Background:
Patients with vein of Galen aneurysmal malformation (VGAM) present with cardiac failure or raised intracranial pressure. Treatment usually involves medical mangement and embolising the arteriovenous shunt (1). We present an unreported severe vasorespiratory disturbance during a VGAM embolisation.

Case report:
A 10 month old girl presented for reembolization of her VGAM. Under general anaesthetic, cerebral angiograms were obtained via the internal carotid artery (ICA) and a microcatheter was advanced into the posterior choroidal artery. A sudden fall in lung compliance, severe hypotension and tachycardia was seen. The patient required multiple boluses of a crystalloid and infusions of adrenaline and noradrenaline. Other causes were ruled out clinically and by imaging. On withdrawing the catheter, the vasorespiratory disturbance resolved completely and the patient was extubated.

After five days, the patient had a repeat embolisation. When her VGAM was approached via the vertebral artery, she had a transient fall in lung compliance but was haemodynamically stable.

Discussion:
Autonomic reactions have been reported during superselective ophthalmic arterial chemotherapy for retinoblastoma treatment and included bradycardia, hypotension and a fall in respiratory compliance. They occurred when the catheter was in the ICA or the ophthalmic artery (2,3). These may be due to stimulation of trigeminal afferents (3) and abrupt changes in peripheral pulmonary vascular resistance (3).

We did not note any bradycardia. Approaching the VGAM via the vertebral artery led to a fall in compliance but no haemodynamic disturbance.

References:
1. Jun Yan et al.Outcome and complications of endovascular embolization for vein of Galen malformations: a systematic review and metaanalysis. J Neurosurg.2015 Oct
2. Phillips,T. J. et al(2013).Autonomic cardiorespiratory reflex reactions and superselective ophthalmic arterial chemotherapy for retinoblastoma. Paediatr Anaesth, 23: 940945.
3. Kato, M. A. et al(2015).A retrospective analysis of severe intraoperative respiratory compliance changes during ophthalmic arterial chemosurgery for retinoblastoma. Paediatr Anaesth, 25: 595602.

Learning points:
1.Lifethreatening vasorespiratory disturbance can happen during ICA catheterisation which may resolve with removal of the catheter.
2. An autonomic pathway linking intracranial vasculature and the respiratory system needs further investigation.

An unreported life-threatening vaso-respiratory disturbance during endovascular embolisation of vein of Galen malformation - a case report