For the first time, US doctors have performed a successful brain surgery on an unborn baby to prevent heart failure and brain injury after birth.
The in-utero surgery, described in the journal in Stroke, was performed on a foetus with a gestational age of 34 weeks and 2 days. It was done to repair a potentially deadly developmental condition by treating an aggressive vascular malformation, called vein of Galen malformation.
The baby girl Denver Coleman was born two days post-surgery with no birth defects and limited complications at 1.9 kg. She is doing well now, and is not on any medication, said the team from Boston Children’s Hospital and Brigham and Women’s Hospital, who performed the surgery — in-utero embolisation — as part of a clinical trial, and with oversight from the US Food and Drug Administration.
“In our ongoing clinical trial, we are using ultrasound-guided transuterine embolisation to address the vein of Galen malformation before birth, and in our first treated case, we were thrilled to see that the aggressive decline usually seen after birth simply did not appear,” said lead study author Darren B. Orbach, co-director of the Cerebrovascular Surgery & Interventions Centre at the Boston Children’s Hospital.
“We are pleased to report that at six weeks, the infant is progressing remarkably well, on no medications, eating normally, gaining weight and is back home. There are no signs of any negative effects on the brain,” added Orbach, who is also an associate professor of radiology at Harvard Medical School.
Due to premature rupture of membranes during the in-utero embolisation, the infant was delivered by induction of vaginal birth two days later.
Echocardiography after birth showed progressive normalisation of cardiac output. In this case, the newborn did not require any cardiovascular support or surgery following the in-utero treatment and was watched in the neonatal intensive care unit for several weeks after birth because of prematurity before being sent home.
During that time, the newborn had a normal neurological exam and showed no strokes, fluid buildup or haemorrhage on brain MRI.
It is estimated that VOGM, the most common congenital vascular brain malformation, occurs in as many as one in every 60,000 births.
VOGM is most often first seen on a prenatal ultrasound and is definitively diagnosed by MRI during the late second or third trimester of pregnancy.
However, the procedure was not without its limitations, said Colin P. Derdeyn, a neurointerventional radiologist at University of Iowa Health Care, who performs VOGM embolisations 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.
“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 added.
“This is pioneering work being done in a very careful and responsible way.”
