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World-first brain surgery on foetus corrects abnormal blood vessel

For the first time, surgery has corrected an abnormal blood vessel in the brain of a foetus. The baby – who has a rare condition called Vein of Galen malformation – was born without complications, indicating the procedure could safely treat infants.

Vein of Galen malformation forms before birth when arteries in the brain connect back to the organ’s central vein. This expands this vein and lets more blood rush through, placing pressure on the heart and lungs and depriving the brain of oxygen. Babies with the condition commonly develop heart failure and stroke-like symptoms within days of birth.

“There are a lot of patients we cannot help even with the best standard of care,” said Darren Orbach at Boston Children’s Hospital in Massachusetts. New Scientist reports that before infants with this condition are born, the placenta helps mitigate some of the pressure. Once they are born, it may be too late to perform surgery.

“They unfortunately die despite our best efforts, or they’re left with severe brain injuries,” he said.

Orbach and his colleagues conducted surgery to fix the malformation in a foetus at 34 weeks and two days’ gestation. MRI scans revealed that the central vein was greater than 14mm in diameter.

“When the width of the vein is 8m or larger, then we know with 90% certainty that the baby is going to get very sick after birth,” he said. “This was one of the more aggressive malformations we’ve ever seen.”

The pregnant woman received spinal anaesthesia before the surgery and the foetus also received an anaesthetic via injection to prevent movement during the procedure. A needle was then inserted through the uterus. Ultrasound imaging helped aim it at the back of the foetus’ head, at the site of the malformation.

The surgeons gently pushed the needle tip into the vein, before a catheter placed through the needle was then used to insert special metal coils into the extra space created by the malformation. These coils decrease the amount of blood flowing through the vein. The surgery lasted less than two hours.

An ultrasound one day later showed a 43% decrease in the amount of blood pumped by the foetus’ heart. MRIs taken before and after the surgery also revealed the vein shrank by almost 5mm in diameter.

The baby was born prematurely two days later with no complications. She didn’t require heart medications or additional surgery.

“It was remarkable because these babies are usually so dramatically sick,” Orbach said, adding that the infant, now seven-weeks-old, still appears to be healthy.

This surgery is a promising approach to preventing brain injury and death in infants with Vein of Galen malformations who cannot be treated after birth, said Courtney Wusthoff at Stanford University in California.

“The downside is that anytime you’re doing a foetal procedure, there is a risk of complications and, in particular, preterm birth,” she said.

“It’s obviously very exciting to have this result in the first patient, but it’s literally the first patient. We have to do the science and demonstrate that it works across patients,” said Orbach, who is planning to conduct the surgery in an additional 19 participants.

Study details

Transuterine Ultrasound-Guided Foetal Embolisation of Vein of Galen Malformation, Eliminating Postnatal Pathophysiology

Darren Orbach, Louise Wilkins-Haug, Carol Benson, Wayne Tworetzky, Shivani Rangwala, Stephanie Guseh, Nicole Gately, Jeffrey Stout, Arielle Mizrahi-Arnaud and Alfred See.

Published in Stroke on 4 May 2023

Abstract not yet available

 

Stroke Journal article – Transuterine Ultrasound-Guided Foetal Embolisation of Vein of Galen Malformation, Eliminating Postnatal Pathophysiology (Open access)

 

New Scientist article – Brain surgery before birth fixes abnormal blood vessel in foetus (Open access)

 

See more from MedicalBrief archives:

 

Groundbreaking operation on spina bifida foetus

 

US team led by SA-trained doctor in an African first

 

 

 

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