Microsurgical management of vein of Galen aneurysmal malformations.

No intraoperative mortality, major bleeding, or postoperative neurological deficits occurred in any of the seven microsurgically treated VGAM patients.

• Seven consecutive pediatric patients with VGAM were treated microsurgically between 2014 and 2024 at a single institution.
• The cohort included 4 males and 3 females with a mean age of 11.1 months.
• All patients were alive with normal age-appropriate development at follow-up.
• Follow-up ranged from 10 months to 6 years.

Cardiac symptoms resolved in all patients who presented with heart failure following microsurgical feeder occlusion.

• Three patients presented with heart failure alone, and one presented with both heart failure and hydrocephalus.
• Cardiac symptoms resolved in all four affected patients postoperatively.
• Outcomes were assessed preoperatively, early postoperatively (<24 hours), and at long-term follow-up.

Hydrocephalus resolved after feeder occlusion in the majority of affected patients, with VP shunts required in only three patients.

• Three patients presented with hydrocephalus alone, and one presented with both hydrocephalus and heart failure.
• VP shunts were required in three patients.
• The remainder had resolution of hydrocephalus after feeder occlusion without need for shunting.

Follow-up imaging demonstrated shrinkage of the dilated vein in all seven cases after microsurgical treatment.

• Radiological outcomes were assessed preoperatively, early postoperatively (<24 hours), and at long-term follow-up (10 months to 6 years).
• Shrinkage of the dilated vein was observed in all cases.
• VGAM types treated were Yaşargil type III (n=4), type I (n=2), and type IVB (n=1).

The posterior interhemispheric approach was used as the microsurgical technique for all seven patients in this series.

• This approach was employed across all cases treated between 2014 and 2024.
• Patients were classified according to Yaşargil's system.
• The study was a retrospective review at a single institution.

Microsurgery, once the standard treatment for VGAM, has largely been abandoned due to historically high mortality rates, but this series challenges its exclusion as a primary treatment option.

• VGAMs are rare congenital vascular anomalies typically treated with endovascular embolization in the contemporary era.
• The authors propose reconsideration of microsurgery as a primary treatment option in selected cases.
• Microsurgery may be particularly relevant in centers with appropriate microsurgical expertise or where endovascular therapy is unavailable or anatomically unfeasible.
• Multicenter prospective studies are needed to confirm these findings and refine patient selection.