Recovery for Vein of Galen Malformations in Children

Postoperative Orders

Postprocedurally, patients are often admitted to the ICU for close observation, with the following considerations (79):

• Blood pressure monitoring: During the first 48 hours, avoidance of hypertension prevents cerebral hyperperfusion injury.
• Neurological exam: Perform a general neurological exam to identify alterations in function.
• Monitor non-CNS organ function: Testing of ventilatory status, cardiac function, and renal function with continuous pulse oximetry and appropriate laboratory tests is done.
• Hemostasis: Patients should lie flat for 2 to 4 hours to ensure access-site hemostasis has occurred. Check dorsalis pedis and posterior tibial pulses regularly to ensure thrombosis has not occurred.
• Afterload management: An increase in afterload can be managed with milrinone; this prevents impaired cardiac function after embolization of the previously low resistance, high-flow AV shunt.
• Post-procedural imaging: New focal neurological deficits, worsening hydrocephalus, and seizure activity may be observed post-procedurally and should prompt postoperative imaging with MRI to guide medical management or adjuvant therapies.
• Comprehensive evaluation and monitoring by consultants: Consultation of pediatric cardiologists may be required to assess the patient’s cardiac function. If cardiac overload was an operative indication, then a postoperative assessment of cardiac function such as interval ECG and/or monitoring BNP levels is important.

Postoperative Morbidity

• Altered cerebral hemodynamics: This can result from embolization of the previously low resistance, high-flow shunt; this can result in cerebral hyperperfusion injury and impaired cardiac function (due to increased afterload) if improperly managed (79).
• Venous thrombosis and disseminated intravascular coagulation: If there are significant changes in the shunting through a large venous outflow, then the diminished flow and stasis in the venous outflow may precipitate a propagating thrombus. Rarely, this can lead to disseminated intravascular coagulation; this can be mitigated by cautious modulation of the extent of embolization.