The vein of Galen malformations continue to be challenging lesions for the neurosurgeon. Evolving therapies, including transvenous and transarterial embolotherapies, have dramatically changed our approach to these lesions over the past 5 years. The neurosurgeon remains the physician in charge of the care of these individuals. In neonates suffering from severe progressive cardiac failure, about a 50% survival rate can be expected. Those patients demonstrating significant injury to the central nervous system prior to therapy should probably be excluded from the aggressive treatment category. Low morbidity and mortality can be expected in the infant and older childhood group of patients harboring vein of Galen malformations treated interventionally. The tendency today is toward a combined transvenous transarterial approach to these lesions, no matter which clinical category is treated. Aggressive therapy is indicated in the control of hydrocephalus and seizures before, during, and after treatment. The overall philosophy, especially in the transvenous approach to these lesions, remains the careful and repeated embolization of these lesions in a staged fashion to encourage a graded thrombosis in an attempt to minimize the risk of hemorrhage and injury to the central nervous system. The overall prognosis is difficult to predict at this time, but it would appear to be better than with standard surgical treatment of these lesions. These therapies are evolving, and further improvements in the techniques and outcome are anticipated.