Traumatic aneurysm from shaken baby syndrome: case report

What Do Confessions Reveal About Abusive Head Trauma? A Systematic Review

Although confessions related to abusive head trauma (AHT) are reported, no detailed analysis exists. Therefore, we systematically reviewed studies of AHT confessions and examined the details, including country of origin, mechanisms and perpetrators' characteristics [PUBLISHER - THE PRECEDING UNDERLINED TEXT IS FOR THE MARGIN]. Employing 36 search terms across three search engines, we searched Medline and CINAHL from 1963 to 2018. All relevant studies underwent two independent reviews and data extraction. Descriptive statistics were used to characterise the sample; chi square and Fisher's exact tests were used to assess differences in demographic and clinical characteristics. Of 6759 identified studies, 157 full texts were reviewed and 55 articles from 15 countries spanning four continents were included. Included articles contained 434 confessions. The mechanisms of abuse included shaking alone (64.1%), impact alone (17.1%), shaking plus impact (18.0%) and other (0.9%). There was no statistically significant difference in the percentage of confessions reporting shaking alone when comparing continents: North America (64.0%), Europe (64.2%) and Oceania (60.0%; P=.92), or when comparing circumstances in which the confession was obtained: medical evaluation (74.6%) vs police or judicial investigations (63.4%; P=.11). Of 119 cases with identified perpetrators, 67.2 per cent were cases with males alone. Confessions reveal striking similarities in the mechanism of AHT (predominantly shaking) and occur across the globe.

Surgical treatment of traumatic distal anterior cerebral artery aneurysm: a report of nine cases from a single centre

BACKGROUND

Traumatic distal anterior cerebral artery (dACA) aneurysm is rare and can be easily neglected and misdiagnosed in patients with trauma. The aim of this study was to explore the radiologic characteristics of and therapeutic strategies for traumatic dACA aneurysm and to improve our understanding of unusual complications after trauma.

METHODS

The clinical data of nine cases of traumatic dACA aneurysm from our neurosurgical department from July 1, 2010, to July 1, 2018, were retrospectively analysed.

RESULTS

All 9 patients had a history of brain trauma. The initial computed tomography scan immediately after trauma showed subarachnoid haemorrhage in 8 cases. Among these cases, delayed intracranial haemorrhage occurred in 7 cases. The average interval between injury and diagnosis was 13.67 ± 9.43 days. All 9 cases were confirmed as traumatic dACA aneurysm by computed tomography angiography (CTA) and/or digital subtraction angiography. According to Lehecka's classification system, traumatic dACA aneurysm located in the A3 and A4 segment was found in 3 and 6 cases, respectively. Surgical treatment was performed in 8 cases, including neck clipping, with or without wrapping in 3 cases, trapping in 4 cases, aneurysm excision and suturing in 1 case and conservative treatment in 1 case. Three patients required a ventriculoperitoneal shunt due to severe hydrocephalus. According to the Glasgow Outcome Scale scoring system, good recovery was achieved in 4 cases, moderate disability in 2 cases, severe disability in 1 case, and death in 2 cases.

CONCLUSION

Traumatic dACA aneurysm is a rare complication of brain trauma. Delayed intracranial haemorrhage and the sudden deterioration of neurologic function were the typical characteristics in patients with traumatic dACA aneurysm. CTA is the first-line screening modality for patients who present with intracerebral haemorrhage in the corpus callosum after trauma, particularly for patients who are older, in a poorer or critical condition. When the aneurysm is located in the A4 segment or involves a small branch, surgical trapping is the preferred definitive therapy to prevent further growth and disastrous bleeding. Early diagnosis and prompt treatment could help to improve clinical outcomes.

Case Report: Traumatic anterior cerebral artery aneurysm in a 4-year old child

Traumatic intracranial aneurysm in the proximal part of the anterior cerebral artery in the pediatric population has not been documented so far. Here we report the case of a 4 year-old child who developed a pseudo-aneurysm after minor head trauma and was managed successfully with trapping of the aneurysm. A ventriculo-peritoneal shunt was placed as the child became dependent on extraventricular drain during the post-operative period. The patient made excellent recovery in neurological status within 1 month of post-operative clinical follow up.

Neonatal intracranial aneurysm rupture treated by endovascular management: a case report

Pediatric intracranial aneurysm rupture is rare, and is traditionally managed by surgical clipping. To the best of our knowledge, endovascular embolization of aneurysms in neonates has not previously been reported in Taiwan. We report a 9-day-old boy with intracranial aneurysms who underwent endovascular embolization, representing the youngest reported case in Taiwan. The 9-day-old boy presented with non-specific symptoms of irritable crying, seizure and respiratory distress. Computed tomography disclosed intraventricular hemorrhage, subarachnoid hemorrhage and focal intracranial hemorrhage around the right cerebellum. Subsequent computed tomographic angiography showed two sequential fusiform aneurysms, measuring 3 mm, located in the right side posterior inferior cerebellar artery (PICA). The patient underwent endovascular embolization because of the high risk of aneurysm re-rupture and the impossibility of surgical clipping due to the fusiform nature of the aneurysms. A postembolization angiogram revealed complete obliteration of the right distal PICA and proximal aneurysm. The distal PICA aneurysm was revascularized from the collateral circulation, but demonstrated a slow and delayed filling pattern. The patient's condition remained stable over the following week, and he was discharged without anticonvulsant therapy. No significant developmental delay was noted at follow-up at when he was 3 months old. This case emphasizes the need for clinical practitioners to consider a diagnosis of intracranial hemorrhage in neonates with seizure and increased intracranial pressure. Neonatal intracranial aneurysms can be treated safely by endovascular treatment.

Traumatic false aneurysm of the left gastric artery

We present a patient with a false aneurysm of the left gastric artery, associated with anomalous hepatic artery anatomy, following suspected non-accidental blunt abdominal trauma. We postulate that the anomalous anatomy contributed to the pathogenesis of the lesion by restricting the mobility of the left gastric artery during upward movement of the liver. Trans-catheter embolization of the offending vessel was successful.

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.

Intracranial vertebral artery dissection with subarachnoid hemorrhage following child abuse

Child abuse is often suspected based on particular patterns of injury. We report a case of intracranial vertebral artery dissection with subarachnoid hemorrhage (SAH) in a 3-month-old boy following child abuse. The mechanisms of injury and the clinical and imaging findings are discussed. This particular pattern of injury has rarely been reported in association with child abuse. We hope to raise physician awareness of child abuse when faced with these imaging findings.

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.

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.

Case Analysis of Brain-Injured Admittedly Shaken Infants

The English-language medical case literature was searched for cases of apparent or alleged child abuse between the years 1969 and 2001. Three-hundred and twenty-four cases that contained detailed individual case information were analyzed yielding 54 cases in which someone was recorded as having admitted, in some fashion, to have shaken the injured baby. Individual case findings were tabulated and analyzed with respect to shaking as being the cause for the injuries reported. For all 54 admittedly-shaken-infant cases, the provided details regarding the shaking incidents and other events are reported. Data in the case reports varied widely with respect to important details. Only 11 cases of admittedly shaken babies showed no sign of cranial impact (apparently free-shaken). This small number of cases does not permit valid statistical analysis or support for many of the commonly stated aspects of the so-called shaken baby syndrome.

Endovascular treatment of traumatic intracranial aneurysm in an infant. A case report

SUMMARY

Traumatic intracranial aneurysms in children are rare and mostly related to skull fracture or rapid decelerating closed head injury.We report the case of an infant who developed intracranial aneurysm after minor head trauma and managed by endovascular treatment. A seven-month-old infant presented with delayed intracranial hemorrhage following minor head trauma. Cerebral angiography disclosed a multilobulated fusiform aneurysm involving the right anterior cerebral artery (ACA) distal to the anterior communicating artery. Endovascular treatment of the aneurysm was performed and the infant made an excellent recovery during six months clinical and radiological follow-up. Delayed presentation of intracranial hemorrhage with acute deterioration in the infant after head trauma warrants angiography for proper diagnosis and management of the traumatic aneurysm, which has a high mortality rate after rupture and rebleeding. Endovascular treatment of traumatic aneurysm is feasible in infants, and occlusion of distal intracranial arterial aneurysms can be safely and precisely achieved using current coil technology.

Minimally invasive management of a traumatic artery aneurysm resulting from shaken baby syndrome

Based on our review of the literature, we present the first use of coiling in an infant with a traumatic artery aneurysm that resulted from shaken baby syndrome. Computed tomography (CT) scans showed a skull fracture, hemorrhagic subdural collections, multiple parenchymal contusions, and intraventricular and subarachnoid hemorrhages in a 3-week-old infant who presented with lethargy, poor feeding, and seizure. These multiple injuries were consistent with shaken baby syndrome. After closed-head injury medical management, including subdural taps, the baby was discharged home. When increasing seizures and hydrocephalus developed 8 months later, CT angiographic scans showed a pseudoaneurysm of the anterior cerebral artery. We successfully occluded the aneurysm with pushable coils placed via a microcatheter and treated the obstructive hydrocephalus with endoscopic third ventriculostomy. We show that minimally invasive radiological and surgical techniques may be effective in managing the sequelae of trauma in children.

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.

Development of intracranial complications following transoral stab wounds in children. Report of two cases

Sharp penetrating trauma to the skull and brain is uncommon in children. The related pediatric literature consists mainly of cases involving penetrating stab wounds to the face or scalp resulting from assaults or accidents. Herein, we present two cases of perioral intracranial penetration. The first case was a 2-year-old boy who presented with septic complications and developed a brain abscess. The second case was a 2-year-old girl who presented with a subarachnoid hemorrhage and developed a traumatic pericallosal artery aneurysm. After craniotomy and clipping, both patients made a satisfactory recovery. A high index of suspicion, liberal use of neuroimaging and early operative intervention are important points in the successful management of such cases.

"Early" apoplexy due to traumatic intracranial aneurysm--case report

A 76-year-old man presented with a traumatic aneurysm of the left internal carotid artery which caused repeated subarachnoid hemorrhages within 20 hours of a fall from a height. Early computed tomography (CT) detected no brain abnormalities, but repeat CT found subarachnoid hemorrhage. Internal carotid angiography detected a pseudoaneurysm, which was not treated because of his poor clinical condition. He died of multiple organ failure. Early detection of a traumatic intracranial aneurysm is important for the prevention of aneurysmal rupture, or "delayed" apoplexy. Review of 171 cases with traumatic aneurysms from the literature found that false negative angiography occurred only in three cases on post-trauma day 7 and thereafter. Early diagnostic angiography within a week of the initial trauma is indicated if traumatic aneurysm is suspected to detect early signs of irregularity, spasm, and narrowing of the arterial wall. Repeat angiography is indicated if aneurysmal formation is still highly suspected in spite of negative initial angiography.

Parenchymal perianeurysmal cystic changes in the brain: report of five cases

PURPOSE

To describe parenchymal perianeurysmal cystic changes in the brain.

MATERIALS AND METHODS

Among 247 patients with cerebral aneurysms described in the medical or radiologic records in three institutions, five had perianeurysmal cystic changes. These were evaluated with computed tomography or magnetic resonance (MR) imaging and were categorized according to size, appearance, and the presence of hemosiderin deposit. Confirmation at stereotactic needle biopsy was available in one case.

RESULTS

Perianeurysmal cysts comprised multiple clustered cysts in three cases and a unilocular cyst in two, and diameters were 1.5-3.5 cm. Hemosiderin was depicted at MR imaging in one unilocular cyst. Associated aneurysms had diameters of 0.7-4.0 cm, and prominent aneurysmal thrombosis and calcifications were seen in two cases. Findings at stereotactic needle biopsy were of mild reactive gliosis. At long-term follow-up in two patients, the cystic regions were stable.

CONCLUSION

Parenchymal perianeurysmal cysts are rare and may display various morphologic characteristics from unilocular to multilocular. Since there may or may not be evidence of previous hemorrhage, other mechanisms such as abnormal angiogenesis factors may play a role.

Sudden death in an infant caused by rupture of a basilar artery aneurysm

Ruptured aneurysms of the cerebrovasculature in infancy and early childhood, except for "giant" aneurysms and arteriovenous malformations, are rare. Seizures, loss of consciousness, and apnea are the usual presenting signs in infancy; symptoms such as headache or visual disturbances and signs such as cranial nerve compression or meningeal irritation commonly found in older children or adults are absent in infants. However, the morphologic findings (i.e., subarachnoid and retinal hemorrhage, and occasionally subdural hemorrhage) may be mistaken for inflicted trauma, especially if the aneurysm is not identified. Sudden death caused by rupture of a cerebral aneurysm has not been previously described in an infant. This report outlines the investigation and autopsy findings in a 7-month-old infant who died unexpectedly as a result of rupture of a complex basilar artery aneurysm.

Sudden death in an infant caused by rupture of a basilar artery aneurysm

Ruptured aneurysms of the cerebrovasculature in infancy and early childhood, except for "giant" aneurysms and arteriovenous malformations, are rare. Seizures, loss of consciousness, and apnea are the usual presenting signs in infancy; symptoms such as headache or visual disturbances and signs such as cranial nerve compression or meningeal irritation commonly found in older children or adults are absent in infants. However, the morphologic findings (i.e., subarachnoid and retinal hemorrhage, and occasionally subdural hemorrhage) may be mistaken for inflicted trauma, especially if the aneurysm is not identified. Sudden death caused by rupture of a cerebral aneurysm has not been previously described in an infant. This report outlines the investigation and autopsy findings in a 7-month-old infant who died unexpectedly as a result of rupture of a complex basilar artery aneurysm.