Intracranial berry aneurysms in infancy

Intracranial aneurysms in pediatric population treated with flow diverters: A single-center experience

Background:

Pediatric intracranial aneurysms (PIAs) are uncommon. Flow diverters (FDs) have shown to be effective on treatment of selected aneurysms.

Methods:

We describe 10 cases of PIAs treated with FDs at one medical center in Mexico, from April 2015 to April 2020.

Results:

Out of 230 patients treated with FDs, 10 (4.3%) were pediatric. Average age was 9.4 years old (R: 6–15). Two patients (20%) had subarachnoid hemorrhage, 3 had epilepsy (30%), 3 (30%) had clinical signs of cranial nerve compression, and 4 (40%) had only headache. Two patients were in 1a grade of Hunt and Kosnik scale. Out of the nonruptured aneurysms, 7 (70%) were in 15 points of Glasgow Coma Scale and 1 patient (10%) was in 13 points. Treatment was performed without complications; nevertheless, appropriate distal deployment was not achieved in one case. At discharge, nine patients had 5 points of Glasgow Outcome Scale. All patients underwent computed tomography angiography or digital subtraction angiography at 1, 3, 6, and 12 months, 2 patients (20%) had a 2-year follow-up, and 3 patients (30%) had a 3-year follow-up. According to Kamran grading scale, 9 patients (90%) were classified as Grade 4 and 1 patient (10%) as Grade 3.

Conclusion:

Even though it is a small series, as this is an uncommon disease, we may suggest that FDs are useful to treat properly selected PIAs. Our study has consecutive imaging assessment at least a year of follow-up in which aneurysm stable occlusion was observed in 90% of patients.

Histological Differences of the Vascular Wall Between Sites With High and Low Prevalence of Intracranial Aneurysm

Intracranial aneurysms (IAs) develop more often on bifurcations compared with the rest of the circle of Willis (CoW). We investigated histological differences between 2 high IA prevalence sites (anterior communicating artery [AcomA] and basilar tip) and 2 corresponding low IA prevalence sites (anterior cerebral artery [ACA] and basilar artery [BA]) using histological sections of 10 CoWs without IAs. Medial defect density in the AcomA was 0.24 medial defects/mm compared with 0.02 for the A1 part and 0.03 for the A2 part of the ACA. In the basilar tip we found 0.15 medial defects/mm compared with 0.14 in the BA. Vascular smooth muscle cells (VSMCs) were more often disorganized in both high-prevalence sites (AcomA: 10/10, basilar tip: 5/10) compared with low-prevalence sites (both ACA and BA: 1/10). Intima thickening was more severe in the high-prevalence sites. Vascular wall thickness was not significantly different between high- and low-prevalence sites, but had a larger variance in high- compared with low-prevalence sites (AcomA vs ACA: p = 6.8E-12, basilar tip vs BA: p = 0.02). Disorganized VSMCs at high-prevalence sites likely result in a higher susceptibility to hemodynamic stress, leading to more vascular remodeling (such as intima thickening), which could increase the likelihood of IA formation.

Blister aneurysms of the internal carotid artery: Surgical treatment and management outcome from a single center experience

OBJECTIVE

Blood-blister aneurysms (BBAs) of the internal carotid artery (ICA) are rare entities, but clinically important cause of subarachnoid hemorrhage (SAH). Several surgical and endovascular strategies have been attempted for these heterogeneous lesions. In this study, the authors analyzed the treatment strategy and outcomes in a series of cases of ICA blister aneurysms treated microsurgically.

PATIENTS AND METHODS

We retrospectively reviewed 15 consecutive cases of patients harboring ruptured BBAs, microsurgically treated at our institution between 2014 and 2018. We performed an analysis of the clinical and surgical aspects, as well as post-operative angiograms and outcomes.

RESULTS

Fifteen patients were identified; 9 (60%) were female. The mean age of presentation was 43,8 years. Most patients presented in good clinical conditions (Hunt-Hess 1-3 = 86%). The most common Fisher grade at presentation was 3 (60% of cases). All patients underwent digital subtraction angiography (DSA), revealing broad-based aneurysms at non-branching sites on the dorsal wall of the ICA. Intraoperatively, BBAs were confirmed in all cases. The lesions were approached through pterional (11-73%) or lateral supraorbital (4-27%) craniotomy. Direct clipping was performed in all but one lesion, in which case the clip-wrapping technique was used. Final angiographic control revealed complete occlusion in 14 cases. One patient required reoperation due to residual aneurysm filling. At discharge, a good outcome (Glasgow Outcome Scale [GOS] 4 or 5) was observed in 12 (80%) patients. Three patients were discharged with a GOS of 3.

CONCLUSION

Blood-blister-type aneurysms are rare and challenging lesions. Preoperative knowledge and careful surgical planning can prevent poor clinical outcomes. Surgical treatment remains an effective and safe option in this context.

Clinical and radiological profiles and outcomes in pediatric patients with intracranial aneurysms

OBJECT

Intracranial aneurysms are extremely uncommon in the pediatric population, their characteristics are not well studied, and certain features make them unique. The authors analyzed pediatric patients with aneurysms to try to understand their clinical, radiological, and outcome profile.

METHODS

Sixty-three pediatric patients (≤ 18 years of age) with ages ranging from 4 to 18 years and features (clinical and radiological) suggestive of aneurysm presented to, and were treated at, the authors' center in the past 20 years (1991-2011). Included in the present study were only those patients who underwent surgical intervention, and thus data for 57 patients were analyzed.

RESULTS

Seventy-three aneurysms in 57 patients were surgically treated. There was a slight female predominance (M/F 1:1.2), and the mean age among all patients was 12.69 ± 3.75 years. Fifty patients (87.72%) presented with subarachnoid hemorrhage, 4 (7.02%) with mass effect, and 3 (5.26%) with seizure. On presentation the majority of patients (45 [78.95%]) had a good clinical grade. Eleven patients had multiple aneurysms. The internal carotid artery (ICA) bifurcation was the most common aneurysm site (18 cases [24.66%]), followed by the middle cerebral artery (MCA) bifurcation (11 cases [15.07%]). At a mean follow-up of 18.58 ± 10.71 months (range 1.5-44 months), 44 patients (77.19%) had a favorable outcome, and 5 patients had died.

CONCLUSIONS

Pediatric patients with intracranial aneurysms most commonly presented with subarachnoid hemorrhage, and there was a slight female predominance. The ICA bifurcation followed by the MCA bifurcation was the most common aneurysm site. The incidence of posterior circulation and giant aneurysms is higher in pediatric patients than in the adult population. Children tend to present with better clinical grades and have better overall survival results and good functional outcomes.

Pathomechanisms and treatment of pediatric aneurysms

Pediatric aneurysms are rare diseases distinct from classical adult aneurysms and therefore require different treatment strategies. Apart from saccular aneurysms that are more commonly found in older children, three major pathomechanisms may be encountered: trauma, infection, and dissection. The posterior circulation and more distal locations are more commonly encountered in children compared to adults, and there is an overall male predominance. Clinical findings are not only confined to subarachnoid hemorrhage but may also comprise mass effects, headaches or neurological deficits. In traumatic aneurysms, the skull base and distal anterior communicating artery are commonly affected, and the hemorrhage occurs often delayed (2-4 weeks following the initial trauma). Infectious aneurysms are mostly bacterial in origin, and hemorrhage occurs early after a septic embolic shower. Dissecting aneurysms are the most often encountered aneurysm type in children and can lead to mass effect, hemorrhage, or ischemia depending on the fate of the intramural hematoma. Treatment strategies in pediatric aneurysms include endosaccular coil treatment only for the "classical berry-type" aneurysms; in the other instances, parent vessel occlusion, flow reversal, surgical options, or a combined treatment with bypass and parent vessel occlusion have to be contemplated.

Neonatal ruptured intracranial aneurysms: case report and literature review

INTRODUCTION

Intracranial aneurysms are exceptional in neonatal patients: There are only 16 cases previously reported. We describe the first case of neonatal posterior inferior cerebellar artery (PICA) aneurysm and review the literature.

CASE REPORT

A 7-day-old girl presented with irritability, anorexia, fever and abnormally enlarging head circumference. Computed tomography (CT) and magnetic resonance (MR) imaging demonstrated intraventricular haemorrhage, secondary hydrocephalus and a pontine cistern haematoma. A PICA aneurysm was suspected on the CT angiogram (CTA) and the diagnosis was confirmed by conventional cerebral angiography. She was successfully treated by surgical clipping of the parent vessel and excision of the aneurysm. Postoperatively, she experienced transient swallowing difficulties and required a ventriculo-peritoneal shunt for hydrocephalus. Histopathological evaluation demonstrated a calcified arterial wall with thrombosis, signs of prior haemorrhage and the absence of the internal elastic lamina.

CONCLUSION

Neonatal intracranial aneurysms are rare. Clinical presentation of subarachnoid haemorrhage in this age group is often non-specific. First-line investigation should start with transfontanelle cranial ultrasound, followed by MR angiography then CTA if necessary. Posterior circulation aneurysms and large or giant aneurysms are more frequent in neonates and children than in adults. Early diagnosis and treatment are important for improved outcome. Surgery is better tolerated than in adults.

Management of intracranial aneurysm in children: clipped and coiled

OBJECTIVES

The objective was to describe the clinical features of intracranial aneurysm in children and evaluate the efficacy and safety of different treatment approaches for children with intracranial aneurysms.

MATERIALS AND METHODS

Clinical data of 13 child patients with intracranial aneurysms that were diagnosed and treated in our hospital in the past 16 years were reviewed. Long-term follow-up data were also collected and reported.

RESULTS

Direct surgical treatment was performed on eight out of all 13 patients; among them, seven achieved good recovery and one died. The remaining five patients were treated with Guglielmi detachable coils (GDC). The aneurysm was successfully sealed off in one case and achieved good postoperative recovery. Residual aneurysm was detected in two cases; a second resection surgery was performed on one patient who died after the operation and on another with neck occlusion who recovered well. Two cases experienced aneurysm recanalization after interventional therapy; among them, one was treated with a second embolotherapy but had recanalization once again and was finally cured by aneurysm resection surgery.

CONCLUSION

Aneurysmal surgery is proved to be a safe and effective treatment for children with intracranial aneurysm. Although requiring a long-term follow-up period to determine the clinical outcome, GDC is also shown to be safe for a child having acute bleeding. Once a residual aneurysm or recanalization occurs, microsurgery is recommended.

History of surgery for cerebrovascular disease in children. Part I. Intracranial arterial aneurysms

✓ Intracranial aneurysms are rare in children, and their origins and treatment methods tend to be different from those in these same entities in adults. These lesions tend to be congenital or to have an infectious or traumatic origin. In the current paper the authors trace the historical evolution of the diagnosis and treatment of intracranial aneurysms in children. Based on the literature, these lesions appear to occur in children in less than 3% of all series. The literature also supports the suggestion that symptoms from these aneurysms are often from mass effect and that giant aneurysms and lesions in the posterior cranial fossa are relatively more common in children than in adults. The termination of the carotid artery and the anterior cerebral artery seem to be disproportionately common sites of aneurysm formation in this cohort. Interestingly, surgical outcomes in children appear to be moderately better than in adults. Based on the literature, the claim can be made that a multidisciplinary approach to the management of such aneurysms can yield good outcomes in a very high percentage of children treated.

A distal anterior cerebral artery aneurysm in infant: disappearance and reappearance of the aneurysm

The incidence of intracranial aneurysms in childhood is rare, especially in infancy. Spontaneous thrombosis of a cerebral aneurysm in a child is very rare, particularly in a non-giant aneurysm. We report a case of a 1-month-old girl with a distal anterior cerebral artery aneurysm which disappeared spontaneously after subarachnoid hemorrhage and reappeared 6 months later. Surgical resection of the aneurysm was performed and she discharged uneventfully 10 days later. Histological examination revealed an aneurysm with a fibrous muscular layer, absence of the internal elastic lamina and partial hypertrophy of the intimal layer. Though the pathogenesis of this aneurysm is uncertain, two hypotheses are discussed.

Rupture of middle cerebral artery aneurysm in a neonate: case report and review of the literature

Intracranial hemorrhage because of rupture of a cerebral aneurysm is extremely rare in the neonatal period. Delayed diagnosis contributes to high mortality and morbidity. The authors report an extremely rare case of a middle cerebral artery aneurysm diagnosed and treated shortly after birth. Extensive review of the literature is presented. The patient died 4 years after surgery.

Pediatric cerebral aneurysms

Object. The exceptional pediatric aneurysm can be distinguished from its adult counterpart by its location and size; however patient outcomes remain difficult to evaluate based on the published literature.

Methods. Twenty-two children, all consecutively treated in three neurosurgery departments, were included in this study. Each patient's preoperative status was determined according to the Hunt and Hess classification. Routine computerized tomography scanning and angiography were performed in all children on the 10th postoperative day. Each patient's clinical status was evaluated 2 to 10 years postoperatively by applying the Glasgow Outcome Scale (GOS).

Twenty-one children presented with a subarachnoid hemorrhage (SAH) and one child harbored an asymptomatic giant aneurysm. Thirteen patients were in good preoperative grade (Hunt and Hess Grades I to III) and eight in poor preoperative grade (Hunt and Hess Grade IV or V). The symptomatic aneurysms were located on the internal carotid artery bifurcation (36.4%); middle cerebral artery (36.4%), half of which were found on the distal portion; anterior communicating artery (18.2%); and within the vertebrobasilar system (9.1%). A giant aneurysm was observed in 14% of patients. Overall outcome was favorable (GOS Score 5) in 14 children (63.6%) and death occurred in five (22.7%). Causes of unfavorable outcome included the initial SAH in four children, a complication in procedure in three children, and edema in one child.

Conclusions. Pediatric aneurysms have a specific distribution unlike that of aneurysms in the adult population. The incidence of giant aneurysms and outcomes were similar to those in the adult population. The major cause of poor outcome was the initial SAH, in particular, the high proportion of rebleeding possibly due to a delay in diagnosis.

Subarachnoid haemorrhage: diagnosis, causes and management

The incidence of subarachnoid haemorrhage (SAH) is stable, at around six cases per 100 000 patient years. Any apparent decrease is attributable to a higher rate of CT scanning, by which other haemorrhagic conditions are excluded. Most patients are <60 years of age. Risk factors are the same as for stroke in general; genetic factors operate in only a minority. Case fatality is approximately 50% overall (including pre-hospital deaths) and one-third of survivors remain dependent. Sudden, explosive headache is a cardinal but non-specific feature in the diagnosis of SAH: in general practice, the cause is innocuous in nine out of 10 patients in whom this is the only symptom. CT scanning is mandatory in all, to be followed by (delayed) lumbar puncture if CT is negative. The cause of SAH is a ruptured aneurysm in 85% of cases, non-aneurysmal perimesencephalic haemorrhage (with excellent prognosis) in 10%, and a variety of rare conditions in 5%. Catheter angiography for detecting aneurysms is gradually being replaced by CT angiography. A poor clinical condition on admission may be caused by a remediable complication of the initial bleed or a recurrent haemorrhage in the form of intracranial haematoma, acute hydrocephalus or global brain ischaemia. Occlusion of the aneurysm effectively prevents rebleeding, but there is a dearth of controlled trials assessing the relative benefits of early operation (within 3 days) versus late operation (day 10-12), or that of endovascular treatment versus any operation. Antifibrinolytic drugs reduce the risk of rebleeding, but do not improve overall outcome. Measures of proven value in decreasing the risk of delayed cerebral ischaemia are a liberal supply of fluids, avoidance of antihypertensive drugs and administration of nimodipine. Once ischaemia has occurred, treatment regimens such as a combination of induced hypertension and hypervolaemia, or transluminal angioplasty, are plausible, but of unproven benefit.

A giant dissecting aneurysm mimicking serpentine aneurysm angiographically. Case report and review of the literature

Intracranial dissecting and giant serpentine aneurysms are rare vascular anomalies. Their precise cause has not yet been completely clarified, and the radiological appearance of such lesions can be different in each case according to the effect of hemodynamic stress on a pathologic vessel wall. For berry aneurysms, available evidence overwhelmingly favors their causation by hemodynamically induced degenerative vascular disease and there is an obvious need to determine the hemodynamic parameters most likely to induce the precursor atrophic lesions. In this study, a case of a giant dissecting aneurysm angiographically mimicking serpentine aneurysm of the right ophthalmic artery is reported and the relevant literature is reviewed to investigate the pathological characteristics and pathogenesis of this lesion. In the present case, radiological investigation of the lesion suggested a serpentine aneurysm, but the diagnosis was corrected to dissecting aneurysm subsequent to the pathological examination of the resected aneurysm. A giant dissecting aneurysm angiographically mimicking serpentine aneurysm and developing as the result of a circumferential dissection located between the internal elastic lamina and media is of particular interest when the etiology of these aneurysms is considered. To our knowledge this is the first report on intracranial dissecting aneurysm mimicking serpentine aneurysm angiographically. Our case illustrates the importance of careful serial section studies for a better understanding of the vascular pathology underlying the processes involved in intracranial serpentine aneurysms. We conclude that serpentine, dissecting and berry aneurysms may all arise by way of similar pathophysiological mechanisms.

Traumatic intracranial aneurysms in childhood and adolescence. Case reports and review of the literature

We report four pediatric traumatic intracranial aneurysms occurring before the age of 10 years. Two of these aneurysms were the result of closed head injury. The remaining two were iatrogenic aneurysms which occurred in unusual circumstances. These four children represent 33% of the pediatric intracranial aneurysms seen at the Children's Hospital of Eastern Ontario from 1974 to 1992. Diagnosis of traumatic intracranial aneurysms requires a high index of suspicion: any head-injured or postoperative child who experiences delayed neurologic deterioration, or who fails to improve as expected following treatment, should promptly undergo diagnostic intracranial imaging. Documented subarachnoid hemorrhage, intracerebral or intraventricular hemorrhage, or subdural haematoma in this clinical setting should be further investigated by cerebral angiography to exclude a traumatic aneurysm or other vascular lesion. Traumatic aneurysms typically arise at the skull base or from distal anterior or middle cerebral arteries or branches consequent to direct mural injury or to acceleration-induced shear. Reported traumatic aneurysms account for 14%-39% of all pediatric aneurysms. Iatrogenic aneurysms also occur with unexpected frequency during childhood and adolescence. Pediatric traumatic cerebral aneurysms may present early or late. Most present early with intracranial hemorrhage. Late presentation occurs infrequently, typically as an aneurysmal mass. Once diagnosed, these aneurysms should be promptly treated by craniotomy employing routine microsurgical techniques, or in some cases, by endovascular detachable balloon techniques. Delay in operative treatment entails significant risks of repeated hemorrhage and death. Outcome in these children is primarily determined by the extent of traumatic cerebral injury and the preoperative clinical status. The latter directly depends upon diagnosis of the aneurysm prior to either initial or repeated hemorrhage.

Giant aneurysm of internal carotid artery in a four-year-old child: a case report

A case of giant saccular aneurysm in early childhood is reported. An internal carotid aneurysm presenting with episodic headache was successfully clipped with complete relief of symptoms. The patient was also investigated for a possible collagen deficiency which proved negative. Clinical features and pathogenesis of this rare lesion are discussed.

Intracranial arterial aneurysm due to birth trauma. Case report

The authors present what is believed to be the first description of an intracranial arterial aneurysm attributable to birth trauma. A male neonate, the product of a precipitious, instrumented, footling breech delivery, exhibited seizures at the age of 18 hours. A computerized tomography scan of the head showed hemorrhage along the tentorium with a globular component at the incisura. Transfontanel Doppler ultrasound examination detected pulsatile arterial flow within the globular mass. Cerebral angiography demonstrated a 1.5-cm saccular aneurysm arising from a small distal branch of the superior cerebellar artery. The pathogenesis of aneurysms in children is obscure and controversial. Birth trauma may be responsible for some pediatric aneurysms that are currently classified as idiopathic or congenital, particularly aneurysms in the region of the tentorial incisura.

[Aneurysm of the distal portion of the posterior and inferior cerebellar artery in a child]

The case of a 7-year-old boy presenting with recurrent episodes of subarachnoid hemorrhage due to a distal posterior inferior cerebellar artery aneurysm (PICA), successfully operated, is reported. The low incidence of intracranial aneurysms in the first decade of life and the rare occurrence of distal PICA aneurysms are unusual features of this case. The theories regarding the origin of intracranial berry aneurysms are discussed.

Etiology of intracranial berry aneurysms

The congenital theory of the etiology of intracranial berry aneurysms has been widely accepted for many years. Review of the supporting evidence indicates that it is not based on sound scientific data but on unscientific and unsubstantiated allegations. There is no evidence of a congenital, developmental, or inherited weakness of the vessel wall. The most plausible explanation is that the aneurysms are acquired degenerative lesions--the effect of hemodynamic stress. The mural atrophy leading to aneurysmal dilatation is an acquired lesion which can be produced experimentally by hemodynamics alone. Hypertension and connective tissue disorders associated with acquired loss of tensile strength of the connective tissues are not essential: they appear to be aggravating rather than causal factors. Occlusion of one or more feeding vessels may enhance the possibility of aneurysm formation at large arterial forks subjected to the augmented hemodynamic stress associated with collateral flow.

Cerebral aneurysms in childhood and adolescence

In this study, 24 aneurysms occurring in 23 patients under the age of 18 years (mean 12 years) are analyzed. The male:female ratio was 2.8:1, and the youngest patient was 3 months old. Mycotic lesions and those associated with other vascular malformations were excluded. Forty-two percent of the aneurysms were located in the posterior circulation, and 54% were giant aneurysms. Presenting symptoms included subarachnoid hemorrhage in 13 and mass effect in 11. Several of these aneurysms were documented to rapidly increase in size over a 3-month to 2-year period of observation. All aneurysms were surgically treated: direct clipping was performed in 14; trapping with bypass in four; trapping alone in four; and direct excision with end-to-end anastomosis in two. The postoperative results were excellent in 21 aneurysms (87%), good in two (8%), and poor in one. The pathogenesis of cerebral aneurysms is reviewed.

Features of intracranial aneurysms in infants and report of a case

An 11-month-old girl presented with seizures, papilledema and a left hemiparesis. Radiographic examination revealed a saccular right middle cerebral-artery aneurysm. Clipping was performed 16 days after admission. At follow-up a year later there was no residual neurological deficit. Aneurysms occurring in infants are relatively large and more peripheral in location compared with adults, and frequently are accompanied by seizures. Infants' aneurysms also tend to occupy the anterior circulation distribution, and their peripheral location may make them more amenable to surgical intervention.

Risk factors for the development and rupture of intracranial berry aneurysms

Risk factors for the development and rupture of intracranial saccular (berry) aneurysms were identified in a case-control study of autopsy subjects. The development of berry aneurysms was positively correlated with increased frequencies of systemic arterial hypertension (p less than 0.001), cerebral artery atherosclerosis (p less than 0.05), and marked asymmetry of the cerebral vessels comprising the circle of Willis (p less than 0.005). In addition, patients with berry aneurysms more frequently had histories of persistent headache (p less than 0.001), pregnancy-induced hypertension (p less than 0.01), long-term use of analgesics (p less than 0.001), especially aspirin (p less than 0.05), and a family history of stroke (p less than 0.05). Factors associated with a decreased risk of berry aneurysms included treatment with insulin to control diabetes mellitus (p less than 0.005), leanness (p less than 0.05), chronic pancreatitis (p less than 0.001), malignant tumors (p less than 0.001), and moderate or severe coronary or renal atherosclerosis (p less than 0.05). Rupture of berry aneurysms was positively correlated with size (p less than 0.05) and the presence of multiple aneurysms (p less than 0.005), but also with long-term analgesic usage (p less than 0.05), excessive ethanol consumption (p less than 0.01), and fatty metamorphosis of the liver (p less than 0.01). The factors that predispose to rupture of berry aneurysms are interrelated in the sense that several of them are known to cause a decrease in the synthesis of prostaglandin E, whereas one of the factors that appears to be protective has the opposite effect. Marked and abrupt lowering of serum prostaglandin levels would cause dilatation of cerebral vasculature and increased cerebral blood flow; in the setting of hypertension, focal defects in cerebral arteries could develop, leading to the formation and subsequent rupture of berry aneurysms.

Giant calcified aneurysm on the posterior cerebral artery in a nine-year-old child

We report the case of a 9-year-old child in whom, after a plain x-ray examination of the skull was performed for a suppurating otitis in the left ear, a calcified lesion was discovered in the left temporal region. Angiographic study showed it to be an aneurysm of the left posterior cerebral artery. The rarity of these lesions is discussed, as well as the successful surgical treatment in this case.