FEATURE


Case presentation: Neuro IR on a pediatric patient


By Anurag Chahal, MD


n September, the monthly Virtual Angio Club opened its doors to Residency Essentials participants to present their challenging and interesting cases.


Anurag Chahal, MD, a PGY-5 diagnostic radiology (ESIR) resident at Washington University, shared his experience and takeaways from an interesting case of a neonate patient with a pial arteriovenous fistula (AVF) that was draining into the vein of Galen.


IRQ: Tell us about this case. Anurag Chahal, MD: This case involved a neonate male who had initially


24 IRQ | WINTER 2024


been diagnosed with a vein of Galen dilatation on prenatal ultrasound and was born at 37 weeks and 4 days via induction of labor for new pericardial effusion. However, when he was delivered, he didn’t have any signs of clinical failure and the shunt in his brain didn’t seem significant enough to cause imminent failure. The care team made the clinical decision to forgo intervention and just monitor him until he was larger, around 5 months old or so. A vein of Galen aneurysmal malformation (VGAM) was the presumptive diagnosis at


birth, although more detailed imaging evaluation revealed secondary dilatation of the vein of Galen due to drainage from a pial AVF.


We worked closely with his pediatrician to schedule timed clinical visits to monitor neurological symptoms and head size, which would serve as a surrogate for elevated intracranial pressure and increasing vascular shunting. We wanted to limit the MR imaging to reduce repeated anesthesia in such a small child. It was crucial to provide longitudinal care and follow-up as part of a multidisciplinary team.


At 5 months, he began to go downhill. His head size increased, and he started to show some behavioral abnormalities. An MRI showed significant increase in the abnormality with increasing size of the shunt and vein of Galen resulting in compression of ventricular outflow, and he started to have hydrocephalus. We took him to angiography and saw several feeders leading to the shunt and one large feeder.


Page 1  |  Page 2  |  Page 3  |  Page 4  |  Page 5  |  Page 6  |  Page 7  |  Page 8  |  Page 9  |  Page 10  |  Page 11  |  Page 12  |  Page 13  |  Page 14  |  Page 15  |  Page 16  |  Page 17  |  Page 18  |  Page 19  |  Page 20  |  Page 21  |  Page 22  |  Page 23  |  Page 24  |  Page 25  |  Page 26  |  Page 27  |  Page 28  |  Page 29  |  Page 30  |  Page 31  |  Page 32  |  Page 33  |  Page 34  |  Page 35  |  Page 36  |  Page 37  |  Page 38  |  Page 39  |  Page 40