The Galen vein malformation is a rare disease, but here the cystic components of the previous bleeding with obstructive hydrocephalus gave the impression of Galen vein malformation.

The trilateral approach was performed, in case that if the structure is malformation with feeders, the supratentorial combined approach is a must to reach the feeders fro terminal branches of ACA, PCA, SCA and AICA. Most of then cannot be reached subtentorially.

The patient came to the clinic 17-March-2003 with parents, telling that she suffered trauma during birth and was paralyzed for 6 months, after what she started to improve. The last 45 days started to deteriorate with headache and BP was 160/90. Convulsion free. CT-scan done 15-May-1998 showing huge intraventricular hemorrhage with posterior fossa hematoma and dilated ventricle.

On examination: the patient has huge head but no signs of active progressing hydrocephalus.

Setting position. Posterior trilateral approach over the torcula. Infra-tentorial approach was achieved. Inspection of the deep cerebral vein and its branches were normal, but pushed from several cystic components, which were fenestrated and dissected of the veins and surrounding neural structures. IT was possible to see the brain stem and dissect the quadrigeminal cistern to ensure good communication between the supra and infratentorial pathways. Routine closure of the wound

Smooth postoperative recovery. The patient was sent to the ICU for 24 hours monitoring.

The patient the 5th postoperative day became drowsy with left hemiplegia and aphasic, then recovered slowly over time. She came to the clinic 30-April-2003 with clean wound improved motor and sensory functions. Full recovery of motor and sensory functions.

The last time seen 15-October-2008 with recent MRI done 2 days ago showing massive dilatation of the ventricular system. The family advised for redo or VPS but they disappeared.