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

Ruptured Intracranial Aneurysm in a Neonate: Case Report and Review of the Literature

BACKGROUND

Intracranial aneurysms (IAs) are exceptional in neonates accounting for less than 2% of all IAs occurring during the first decade of life. Little is known about this pathology in this specific population. Because of its scarcity and this specific age at onset, the treatment of IA in neonates is challenging. We describe a rare case of aneurysmal subarachnoid hemorrhage in a neonate and review the current literature.

CASE DESCRIPTION

A 21-day-old boy was admitted for hypotonia, vomiting, and seizures. Computed tomography scan revealed a subarachnoid hemorrhage in the sylvian fissure, a frontoparietal subdural hematoma, a left middle cerebral artery (MCA) aneurysm with a diameter of 11 mm, and an infarct of the MCA frontal region. He was successfully treated with endovascular coiling, neuroprotection, and antiepileptic drugs. Immediate postoperative magnetic resonance imaging showed a good aneurysm occlusion without any further ischemia. The outcome was favorable with extubation at day 10. At follow-up, the child experienced normal psychomotor development with no motor deficit.

CONCLUSIONS

Ruptured IAs in neonates are rare. Subarachnoid hemorrhage is the most common presentation. Intracranial aneurysms are frequently larger than 10 mm and located on the MCA. The treatment could be surgical or endovascular depending on the characteristics of the aneurysm. There is no recommendation concerning the prevention or treatment of vasospasm in neonates.

Superior Hypophyseal Artery Ruptured Aneurysm in a 5-Month-Old Child Presenting as an Acute Subdural Hematoma: A Case Report

INTRODUCTION

We present a very rare case of ruptured superior hypophyseal artery (SHA) aneurysm that presented as an acute subdural hematoma (SDH) discussing its initial presentation, diagnosis, and treatment modalities. To our knowledge it is one of very few if any cases of a ruptured aneurysm in infants regarding that specific vascular location.

CASE REPORT

A 5-month-old boy was referred to our department due to acute SDH over the right cerebral hemisphere without significant mass effect nor hydrocephalus. Further evaluation revealed a right internal carotid artery (ICA) aneurysm arising from the SHA segment. Microsurgical clip ligation using a fenestrated, angled clip was performed with simultaneous subdural clot removal and proximal control of the ICA dissected in the neck. Our patient made an excellent recovery without any complicating features.

CONCLUSION

Surgical management seems to be a better option in this subgroup of patients given the long life expectancy and durability of microsurgical clip ligation. We believe that our brief case report would add some insight into the management of this rare subgroup of patients, leading to better decision-making and outcome.

Neonatal intracranial aneurysms: case report and review of the literature

Intracranial aneurysms in the neonate, presenting in the first 4 weeks of life, are exceedingly rare. They appear to have characteristics, including presentation and location, that vary from those found in adults. The authors present a case of a 28-day-old neonate with a ruptured distal middle cerebral artery (MCA) aneurysm. Initial noninvasive imaging with transfontanelle ultrasound and CT confirmed intraparenchymal and subarachnoid hemorrhage. Contrast-enhanced MRI revealed a 14-mm ruptured fusiform MCA aneurysm that was not identified on time-of-flight magnetic resonance angiography (MRA). Microsurgical treatment was performed with partial neurological recovery. A comprehensive review of the literature from 1949 to 2017 revealed a total of 40 aneurysms in 37 neonates, including the present case. The most common presenting symptom was seizure. Although subarachnoid hemorrhage was the most common form of hemorrhage, 40% had intraparenchymal hemorrhage. The median aneurysm size was 10 mm (range 2-30 mm) and the most common location was the MCA, with two-thirds of cases involving the distal intracranial vasculature. Over the last 10 years, there has been a trend of increasing noninvasive diagnosis of ruptured cerebral aneurysms in neonates, with CT angiography and contrast-enhanced MRI being the most useful diagnostic modalities. The use of contrast-enhanced MRI may improve sensitivity over time-of-flight MRA. Microsurgical treatment was the most common treatment modality overall, with increased use of endovascular treatment in the last decade. Most patients underwent microsurgical vessel ligation or endovascular parent vessel occlusion. There were high rates of neurological recovery after microsurgical or endovascular treatment, particularly for patients with distal aneurysms.

Endovascular treatment of a large ruptured middle cerebral artery bifurcation aneurysm in a 5-week-old infant: case report

Ruptured intracranial aneurysms are extremely rare in infants. The optimal treatment strategy is not well established. Both microsurgical and endovascular techniques and strategies have been tried, and in the literature there is a significant variability in outcome. The authors report the presentation and successful endovascular treatment of a large, ruptured, middle cerebral artery bifurcation aneurysm in a 5-week-old girl, one of only a few reported in the literature. Clinical and radiological findings at follow-up are also presented. The authors then review the literature on aneurysmal subarachnoid hemorrhage in infants, with particular regard to outcome after either endovascular or open surgical management. They also provide recommendations for follow-up in pediatric patients whose intracranial aneurysms have been treated with coil embolization.

Middle cerebral artery aneurysm rupture in a neonate with interrupted aortic arch: case report

INTRODUCTION

Arterial cerebral aneurysms in the neonatal population are rare, and while the association of interrupted aortic arch and intracranial aneurysm has been reported in the adult and pediatric population (three cases each), to date, it has not been reported in the neonate.

CASE REPORT

We report the case of a 26-day-old girl who presented with a generalized seizure 2 weeks after undergoing congenital heart surgery. Head CT revealed diffuse SAH with a 1.7 × 2.9-cm frontal intra-parenchymal hematoma with subdural extension producing 3 mm of midline shift. CTA evidenced a 2-mm left MCA bifurcation aneurysm, and the patient was taken to the operating room for clipping. Twenty-four-hour post-operative head CT showed ventriculomegaly and an EVD was placed. It was removed 4 days later without the need for permanent CSF diversion, and after this, her hospital stay was uneventful and she was discharged home. At 25 months of age, she was meeting developmental milestones. At this time, she underwent further heart surgery and expired shortly thereafter due to cardiomyopathy.

CONCLUSION

Here, we report the successful treatment of a ruptured neonatal aneurysm, and the first known case associated with interrupted aortic arch. Given the time and presentation, this patient likely illustrates the role of hemodynamic factors in the rupture of neonatal aneurysms. In reviewing all of the reported cases of neonatal aneurysms, promptly securing the aneurysm by either open clipping, parent vessel occlusion, or endovascular coiling is strongly preferable to no surgical intervention.

Evolution of Management of Intracranial Aneurysms in Children: A Systematic Review of the Modern Literature

Pediatric intracranial aneurysms are rare. Management of their more common adult counterparts was profoundly influenced by recent high-quality clinical studies. The aim of this review was to aggregate the modern pediatric data published in the wake of these studies and to analyze their impact on management of aneurysms in children. A systematic PubMed search identified 135 publications published between 2000 and 2015, accounting for 573 children and 656 aneurysms. Descriptive statistical analyses revealed differences between children and adults concerning demographics and aneurysm characteristics. A significant proportion of patients were treated endovascularly, suggesting endovascular treatment has been established in the therapeutic armamentarium for pediatric aneurysms. However, these data highlight the unique nature of pediatric aneurysms, and neither this review nor generalization from adult data can replace high-quality clinical research. Multicenter registries and controlled trials are required to establish the natural history and evidence-based treatment of pediatric aneurysms.

Management of ruptured dissecting intracranial aneurysms in infants: report of four cases and review of the literature

BACKGROUND

Intracranial cerebral aneurysms in the pediatric population are infrequent, and those occurring in infants less than 1 year old are extremely rare. Of intracranial aneurysms in children, dissecting aneurysms are the most common type seen. While spontaneous dissecting aneurysms usually present with ischemia, hemorrhage can also occur.

METHODS

A retrospective review of our patients revealed that from July 1, 2007 to June 30, 2012, four infants were treated for ruptured distal dissecting intracranial aneurysms at Texas Children's Hospital. Mycotic aneurysms and collagen vascular disorder were excluded in all four cases. All patients presented in our series presented with subarachnoid hemorrhage, and three had intraventricular hemorrhage. All patients underwent conventional catheter angiography for diagnosis. All patients in this series were managed in the acute or subacute period with surgical or endovascular trapping without distal bypass procedures. All four patients tolerated sacrifice of the parent vessels feeding these distal aneurysms well.

CASE REPORT AND REVIEW OF LITERATURE

We describe the presentation and management of these rare cases and then review the current literature on the management of these dissecting aneurysms in infants.

A thrombosing, giant, distal posterior cerebral artery aneurysm in a newborn infant

Intracranial aneurysms are extremely rare in infancy. No consensus has yet been developed about the exact treatment of this rare situation. The authors report the case of a 47-day-old male infant who had multiple seizures on the same day, leading to the diagnosis of an intracranial aneurysm. The case was managed conservatively with close imaging follow-up, and the patient had a good recovery. The results of neurological examination were completely normal at the 5-year follow-up visit. These rare lesions may be suspected on the basis of clinical findings and correctly diagnosed with current neuroradiological imaging modalities. The authors believe this report contributes valuable imaging data on rare childhood aneurysms to the literature, as well as emphasizing the importance of clinical and imaging information in therapeutic decision making in children with intracranial vascular problems.

Ruptured dissecting cerebral aneurysms in young people: report of three cases

Intracranial arterial aneurysms in the pediatric population are rare. Among these, dissecting aneurysms are the most frequent, followed by saccular, infectious, and posttraumatic. It is widely known that aneurysmal rupture is uncommon in the first two decades of life. Spontaneous dissecting aneurysms (SDAs) of the middle cerebral artery (MCA) affecting young individuals most frequently present as occlusive syndrome with ischemia, although bleeding and subarachnoid hemorrhage can also occur. Between March 2006 and January 2008, three young patients (20 months, 8 and 20 years old) were surgically treated for MCA SDA in the Neurosurgical Department of "12 de Octubre" Hospital of Madrid. These patients showed hemorrhage as primary radiological finding, and all of them underwent surgical operation. Aneurysms were always treated by trapping, with aneurysmectomy in one case, but no distal extra-intracranial (EC-IC) bypass was performed. In two cases, the histological examination of the aneurysm's wall evidenced signs of subintimal dissection with widespread disruption of the internal elastic lamina and media with neointima formation and intramural hemorrhage. Although bleeding is an uncommon presenting sign of SDAs, they should be suspected in young people showing hemorrhage at CT scan. Early surgical treatment and, if possible, preoperative neuroimaging evaluation of intracranial vessels should be performed to reduce the mortality in these patients despite a higher postoperative morbidity. From a technical point of view, surgical trapping of the aneurysm seems to be a reasonable treatment strategy especially in an emergency basis. However, whenever possible, an EC-IC bypass could help diminish the ischemic morbidity associated with these aneurysms.

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.

Rupture of intracranial arterial aneurysms in neonates: case report and review of the literature

The rupture of cerebral arterial aneurysm is an extremely rare cause of intracranial hemorrhage in infants. Brain magnetic resonance imaging is an excellent technique commonly used to suggest the diagnosis. In this article, we propose color flow Doppler ultrasound as a useful, simple, inexpensive, noninvasive, and accessible option for confirming the lesion.We report one case of cerebral aneurysm in a neonate admitted to our unit. Furthermore, we performed a thorough review of the literature on cerebral aneurysm that led us to the observation that the vast majority of untreated patients suffered a second bleeding that caused death. Thus, we insist on the benefits of a timely treatment.

Spontaneous thrombosis of giant cavernous internal carotid artery aneurysm in a neonate. Case report and review of the literature

Neonatal intracranial aneurysms are rare, with only 20 cases being reported in the literature. No case of spontaneous resolution of a giant intracranial cavernous segment aneurysm in a neonate is reported till date. The authors describe a 3-week-old male child who presented with a left-sided tonic seizure episode and was diagnosed as having a right-sided giant cavernous internal carotid artery aneurysm. The aneurysm was found to be totally thrombosed on angiography done before planning definitive treatment. The child is doing well at 2 years of follow-up. Spontaneous thrombosis, an exceptionally rare but fortunate outcome in a rare case of giant neonatal internal carotid artery aneurysm, has led the authors to report this case. The need of repeat imaging or angiography should be considered to rule out this rare outcome, more so if there is any delay between the ictus and treatment.

Pediatric intracranial aneurysms-clinical characteristics and outcome of surgical treatment

OBJECT

Intracranial aneurysms are rare in children and have different epidemiological, clinical, and morphological characteristics and outcome from those in adults.

MATERIALS AND METHODS

We analyzed demographic, clinical, radiologic features, treatment, and outcome in 55 patients <18 years of age, treated from Jan 1995 through December 2005.

RESULTS

Intracranial aneurysms in children below 18 years constituted 4% of all intracranial aneurysms. Internal Carotid artery (ICA) bifurcation was the commonest location. About half of the aneurysms were complex. Three-fourth of the patients required surgical treatment. Two patients died, constituting 5% mortality. Two patients (5%) had poor outcome, whereas the majority (90%) had a favorable outcome.

CONCLUSIONS

Pediatric aneurysms have male predominance, higher incidence of clinical features of mass effect or seizures, high incidence of large, traumatic/mycotic aneurysms, associated illnesses and ICH/IVH and hydrocephalus, better Hunt and Hess grades at presentation, ICA bifurcation as the commonest site, and better outcome than their adult counterparts.

Intracranial aneurysms in children under 1 year of age: a systematic review of the literature

OBJECTIVE

Intracranial aneurysms are very rare in early childhood. Because the location, morphology as well as the clinical and radiological presentation of these aneurysms seem to be different from those in adults, we performed a systematic review of the literature to discuss the clinical, morphological, and radiological features of intracranial aneurysms in the first year of life.

MATERIALS AND METHODS

A computerized search of both Pubmed and EMBASE from before 1966 to 2005 was performed. Included were all articles that dealt with cases in which an intracranial aneurysm was demonstrated in children under 1 year of age.

RESULTS

We found 110 articles in which 131 cases of an intracranial aneurysm in children under 1 year were presented. The mean age at diagnosis of the aneurysm was 4.9+/-3.5 months with a male to female ratio of 1.1. There was a hemorrhagic presentation in 73% (n=96). The patients presenting with a hemorrhage were younger (mean 4.3 vs 6.7 months, P<0.001) and tended to have smaller-sized (i.e.<2.5 cm) aneurysms (P=0.07). The aneurysm was defined as traumatic or infectious in 15 and 13 cases, respectively. In 21% (n=27), there was various vascular or congenital co-morbidity. In 76%, the aneurysm was located in the anterior circulation. The prevalence of aneurysms on the middle cerebral artery (MCA) was nearly three times higher than on any other vessel. The mean aneurysm size was 1.8+/-1.4 cm, with 30 giant aneurysms (>2.5 cm). The giant aneurysms were significantly more often located in the posterior circulation (43 vs 16%, P=0.01). The mean period of follow-up was 13.6+/-24.8 months. The Glasgow Outcome Scale (GOS) could be derived in 106 cases: 50% had an excellent outcome (GOS of 5).

CONCLUSIONS

The presentation of arterial aneurysms in children under the age of 1 year differs from that in adults with a significantly higher prevalence of giant aneurysms in the posterior circulation. The prevalence of aneurysms on the MCA is nearly three times higher than on any other vessel. The patients presenting with a hemorrhage were younger and tended to have smaller-sized aneurysms. Our study did not confirm the male predominance that has thus far been associated with pediatric aneurysms. The outcome is comparable or slightly better than in adults.