Vein of Galen malformations (VGM's) are uncommon, but present dramatically during early childhood, and continue to be challenging to manage. This infant presented at birth with high-output cardiac failure and multiple organ failure. The above image is a sagittal maximum-intensity projection from a CT cerebral angiogram. It shows an aneurysmal deep venous structure which drains to the vein of Galen, and then to an abnormal falcine sinus. The posterior part of the superior sagittal sinus is enlarged, as are the transverse and sigmoid sinuses. Feeding arteries are multiple, dilated and tortuous. They attach directly to the aneurysm without an intervening nidus. The patient was treated by endovascular occlusion of the larger feeding vessels. An intraprocedural arterial bleed was rapidly controlled. In the immediate postprocedural period the cardiovascular status improved. Ongoing high-output state will necessitate further procedures on a staged basis. Case courtesy of Dr Laughlin Dawes, Radiopaedia.org
