Neuro-Interventions for the Neonates with Brain Arteriovenous Fistulas: With Special Reference to Access Routes

Abstract

Neonatal neuro-intervention is challenging. The purpose of this article is to report the neuro-intervention for the neonates with brain arteriovenous fistulas (AVFs), with special reference to access routes. Fifteen neonates (12 boys and 3 girls) who underwent neuro-intervention within the first 14 days of life were included. Their diagnoses included vein of Galen aneurysmal malformation (6), dural sinus malformations with arteriovenous (AV) shunts (6), pial AVF (2), and epidural AVF (1). Birth weight ranged from 1,538 g to 3,778 g (mean 2,525 g). Neuro-interventions, especially access routes, in the neonatal periods (< 1 month) were retrospectively reviewed. All neonates presented with severe cardiac failure. In total, 29 interventions (mean 1.9) were performed within 1 month. Although 12 neonates with birth weight more than 2,700 g could be treated through transfemoral arterial routes, 3 neonates with birth weight less than 2,200 g could not be treated successfully by femoral arterial routes. Interventions were performed through 19 femoral arterial, 3 femoral venous, 2 umbilical arterial, 3 umbilical venous, 3 transcardiac, and 2 direct carotid routes. Their overall outcomes were six good recovery, one moderate disability, two severe disabilities, one vegetative state, and five deaths with a mean follow-up period of 7 years 2 months. Neuro-intervention for the neonates with birth weight more than 2,700 g can be performed by femoral arterial routes using a 4F sheath. For those with birth weight less than 2,200 g, however, alternative access routes are required.

Prenatal Diagnosis of Vein of Galen Aneurysmal Malformation Allows Early Transumbilical Endovascular Treatment

“…1 The transfemoral approach is commonly used for transarterial embolization; however, catheterization of the femoral artery can be difficult in neonates due to small vessels diameter. 8 Furthermore, it may cause thromboembolic complications or arterial occlusion, and maintenance of a vascular sheath several days for repeated interventional procedures is associated to leg ischemia. 8 Otherwise, the transumbilical arterial approach is technically easier and safer than other methods.…”

“…8 Furthermore, it may cause thromboembolic complications or arterial occlusion, and maintenance of a vascular sheath several days for repeated interventional procedures is associated to leg ischemia. 8 Otherwise, the transumbilical arterial approach is technically easier and safer than other methods. 8 The umbilical cord has three vessels: one larger oval umbilical vein, with thin wall, running to the left portal vein; and two smaller, round umbilical arteries, with thick wall, originated from the internal iliac arteries and enabling direct access to aorta.…”

“…8 The umbilical cord has three vessels: one larger oval umbilical vein, with thin wall, running to the left portal vein; and two smaller, round umbilical arteries, with thick wall, originated from the internal iliac arteries and enabling direct access to aorta. 8 The umbilical arteries suffer prompt constriction after delivery; thus, its cannulation should be conducted immediately after birth; and although it can be performed later, it becomes almost impossible after the 4th postnatal day. 8 Transvenous embolization can be done through direct sinus puncture, jugular, femoral, or umbilical approaches.…”

Coil and Onyx embolization of a torcular herophili dural arteriovenous fistula in a full-term neonate with advanced heart failure using a transumbilical approach

“…Varying birth weights have been described to delineate when femoral access may be difficult. 9,17 Femoral vessel catheterization can be difficult in neonates of preterm status and of especially low birth weight (< 1500 g), making alternative vascular access points preferable. 18 Additionally, transfemoral cannulation of the neonate is associated with stenosis, occlusion, and thrombosis of the iliofemoral vessels more than any other age group.…”

“…2,8 Given the successful treatment of our patient, as well as several others presented in additional studies, the transumbilical approach may be a safer option than transfemoral in neonates, regardless of birth weight. 9,17 Challenges of the umbilical artery approach include vessel tortuosity and the angle of entry requiring the utilization of flexible catheters and wires for the intervention. The risks and benefits of utilizing the transumbilical approach in neonatal endovascular therapy must be weighed against those involved when attempting to cannulate the femoral vessels.…”