First brain surgery performed on baby in womb


fetus third trimester pregnancy human development illustration

In a medical breakthrough, researchers successfully performed the first-ever intrauterine surgery to repair a life-threatening fetal brain malformation, preventing postnatal heart failure and brain damage.

Researchers report the first-of-its-kind fetal surgery to repair potentially fatal vascular malformations in the brain and avoid postnatal heart failure and brain damage, published in a journal stroke.

  • Using ultrasound guidance, researchers have successfully repaired a potentially fatal vascular malformation deep in the prenatal fetal brain called Galen’s malformation. This malformation of excessive blood flow often leads to heart failure, severe brain damage, or death shortly after birth.
  • The first intrauterine embolism repair was successfully performed in a fetus at 34 weeks 2 days of gestation. Fetal ultrasonography showed an immediate reduction in abnormal blood flow through the brain malformation, and fetal echocardiography showed significant improvement in cardiac function the day after surgery.
  • Since birth, the infant required no medication to treat heart failure, nor postnatal surgery to treat malformations. Postnatal repeat echocardiography showed marked improvement in cardiac output, and her MRI of the brain showed no brain damage and a normal neurological examination.

For the first time, researchers have shown that by treating an aggressive vascular malformation called Galen’s veins in the fetal brain before birth, a potentially fatal developmental condition can be prevented, according to a new study published May 4. I had a successful intrauterine surgery to repair the. strokethe peer-reviewed flagship journal of the American Stroke Association, a division of the American Heart Association.

Galen Vein Malformation (VOGM) is a rare prenatal condition in which an artery carrying high-flow, high-pressure blood from the heart to the brain connects directly to one of the major collecting veins deep at the base of the brain. rather than the capillaries needed to slow blood flow and deliver oxygen to the surrounding brain tissue. Due to changes in the infant’s vascular physiology during and after birth, the malformed high flow rate has even more severe effects on the postnatal heart and brain, putting greater pressure on the neonatal heart and lungs. , can lead to pulmonary hypertension, heart failure, or other potentially life-threatening conditions. VOGM is most often first seen on prenatal ultrasound and definitively diagnosed by MRI late in the second or third trimester of pregnancy.

The researchers performed intrauterine embolization on a fetus with VOGM at 34 weeks and 2 days gestation as the first treatment patient in an ongoing clinical trial at Boston Children’s Hospital and Brigham and Women’s Hospital, and are now available in the United States. conducted under the supervision of Food and Drug Administration.

“Ongoing clinical trials are using ultrasound-guided transuterine embolization to address Galen malformation veins prenatally. At 6 weeks, the infant is doing very well, taking no medications, eating normally, gaining weight, and going home. We are pleased to report that there have been no indications of adverse effects on the brain,” said lead study author Darren B. Orbach, MD, Ph.D. He is co-director of the Center for Cerebrovascular Surgery and Intervention at Boston Children’s Hospital and Harvard Medical School.

The infant was delivered 2 days later by induced labor due to premature rupture of the membrane during intrauterine embolization. Postnatal echocardiography showed a progressive normalization of cardiac output. In this case, the neonate did not require cardiovascular support or surgery after intrauterine treatment and was observed in the NICU for several weeks after birth due to prematurity before being sent home. , MRI of the brain showed no stroke, fluid accumulation, or hemorrhage.

“While this is our first treatment patient and it is important that we continue the trial to assess safety and efficacy in other patients, this approach is the first of its kind in Galen malformation, which pre-repairs the malformation. “It may represent a paradigm shift in venous management: rather than trying to reverse heart failure after birth, it’s about giving birth and avoiding heart failure before it occurs,” Orbach said. This may significantly reduce the risk of long-term brain injury, disability, or death in these infants.”

VOGM, the most common congenital vascular brain malformation, is estimated to occur in as many as 1 in 60,000 live births. The current standard of care for VOGM is postnatal treatment with embolization. This is a catheter-based procedure that blocks direct connections between malformed arteries and veins, blocking excessive blood flow to the brain and heart. However, embolization itself is risky and is not always successful in reversing heart failure. In addition, severe brain damage may already have occurred, which can lead to lifelong cognitive impairment, life-threatening conditions in young children, and even death.

“The Fetal Intervention Team at Boston Children’s Hospital and Brigham and Women’s Hospital has successfully devised another intrauterine procedure that could be highly impactful for a specific group of patients diagnosed with Galen’s malformation. Director of Pediatric Echocardiography in[{” attribute=””>UCLA Mattel Children’s Hospital and co-director of the UCLA Fetal Cardiology Program and who was not involved with the study. Satou, a pediatric cardiologist, is past chair of the American Heart Association’s Congenital Cardiac Defects committee of Young Hearts Council and a clinical professor in the department of pediatrics at the David Geffen School of Medicine at UCLA. 

“As always, a number of these fetal cases will need to be performed and followed in order to establish a clear pattern of improvement in both neurologic and cardiovascular outcomes,” Satou said. “Thus, the national clinical trial will be crucial in order to achieve adequate data and, hopefully, successful outcomes.”

The procedure was not without its limitations, noted Colin P. Derdeyn, M.D., a neurointerventional radiologist at University of Iowa Health Care who performs VOGM embolizations on neonates and who was not involved with the study. 

“The key advance here is to intervene before the physiologic events of birth can cause life-threatening heart failure. There are caveats; one successful case is not enough experience for us to conclude that the risks of this procedure are worth the benefits. Safety issues may crop up in future procedures, and this approach through the veins may not be consistently successful in preventing heart failure. The procedure described here is designed to reduce the flow through the malformation and not to cure it,” said Derdeyn, the Krabbenhoft Professor of Radiology and chair and department executive officer of the department of radiology at the University of Iowa Health Care Carver College of Medicine and a past chair of the American Heart Association’s Stroke Council.

 “However, the positive hemodynamic changes that they observed in utero and after birth – reduction in flow, reduction in size of the draining vein, reversal of the abnormal reversed flow in the aorta – are really encouraging. These are some of the most exciting and surprising aspects of this case report,” he said. “This is pioneering work being done in a very careful and responsible way.”

For more on this breakthrough achievement, see First-of-Its-Kind, In-Utero Procedure To Fix Deadly Vascular Malformation.

Reference: “Transuterine ultrasound-guided fetal embolization of vein of Galen malformation, eliminating postnatal pathophysiology” by Darren B. Orbach, Louise E. Wilkins-Haug, Carol B. Benson, Wayne Tworetzky, Shivani D. Rangwala, Stephanie H. Guseh, Nicole K. Gately, Jeffrey N. Stout, Arielle Mizrahi-Arnaud and Alfred P. See, 4 May 2023, Stroke.
DOI: 10.1161/STROKEAHA.123.043421

Co-authors are Louise E. Wilkins-Haug, M.D.; Carol B. Benson, M.D.; Wayne Tworetzky, M.B. Ch.B.; Shivani D. Rangwala, M.D.; Stephanie H. Guseh, M.D.; Nicole K. Gately, R.N.; Jeffrey N. Stout, Ph.D.; Arielle Mizrahi-Arnaud, M.D.; and Alfred P. See, M.D. Authors’ disclosures are listed in the manuscript.

The study was funded by a grant from the Sage Schermerhorn Chair for Image-Guided Therapy (DBO) in Boston Children’s Hospital’s Radiology Department.





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