Microsurgical management of vein of Galen aneurysmal malformations.

[OBJECTIVE] Vein of Galen aneurysmal malformations (VGAMs) are rare congenital vascular anomalies typically treated with endovascular embolization. Microsurgery, once the standard, has largely been abandoned due to historically high mortality rates. This study evaluates contemporary outcomes of microsurgical VGAM management using the posterior interhemispheric approach and proposes its reconsideration as a primary treatment option in selected cases.

[METHODS] We retrospectively reviewed seven consecutive pediatric patients with VGAM treated microsurgically between 2014 and 2024 at a single institution. Clinical, cardiac, and radiological outcomes were assessed preoperatively, early postoperatively (< 24 h), and at long-term follow-up (10 months-6 years). Patients were classified according to Yaşargil's system.

[RESULTS] The cohort included 4 males and 3 females (mean age 11.1 months). Presentations included hydrocephalus (n = 3), heart failure (n = 3), and both (n = 1). VGAM types were III (n = 4), I (n = 2), and IVB (n = 1). No intraoperative mortality, major bleeding, or postoperative neurological deficits occurred. VP shunts were required in three patients; the remainder had resolution of hydrocephalus after feeder occlusion. Cardiac symptoms resolved in all affected patients. Follow-up imaging demonstrated shrinkage of the dilated vein in all cases. All patients were alive with normal age-appropriate development at follow-up.

[CONCLUSIONS] In this series, modern microsurgical VGAM management achieved safe and durable outcomes, challenging the perception of surgery as solely a salvage option. These findings suggest that microsurgery may still have a role in the treatment of VGAM in carefully selected patients, particularly in centers with appropriate microsurgical expertise or in situations where endovascular therapy is unavailable or anatomically unfeasible. Multicenter prospective studies are needed to confirm these findings and refine patient selection.