Intracranial aneurysms in the youngest patients: characteristics and treatment challenges

Clinical characteristics and individualized treatment of intracranial aneurysms in young adults: a single-center experience

This study aimed to investigate the clinical characteristics of intracranial aneurysms in young adults and summarize our treatment experiences. We performed a retrospective review of young patients (15-24 years old) with intracranial aneurysms examined in the Fifth Ward of the Neurosurgery Department of Tianjin Huanhu Hospital between January 2015 and November 2022. Data was reviewed for age, sex, presentation, type and size, treatment modalities, location, postoperative complications, and clinical and imaging outcomes. Among the 23 patients, there were 11 males and 12 females (1:1.09). Their presentations included headache, neurological deficits, aneurysmal subarachnoid hemorrhage, incidental or asymptomatic aneurysm, and traumatic subarachnoid hemorrhage. Twenty-five cases of intracranial aneurysms in 25 patients were identified. The aneurysms were saccular (32%, 8/25), dissecting (52%, 13/25), and fusiform (16%, 4/25) in shape. Treatment modalities included direct clipping, embolization, bypass, trapping, resection, coarctation of internal carotid artery (ICA), and endovascular vessel sacrifice. Of the 25 aneurysms, 16 (64%, 16/25) aneurysms were located in anterior circulation, and 9 (36%, 9/25) were located in the posterior circulation, while multiple aneurysms were identified in two patients. A preoperative magnetic resonance perfusion (MRP) examination was performed in 15 patients with unruptured complex aneurysms, of whom 13/15 (86.67%) showed hypoperfusion. Eighteen (78.26%, 18/23) patients had no postoperative complications, temporary complications occurred in 4 (17.39%, 4/23) patients, and 1 patient died postoperatively. The intracranial aneurysms in young adults (15 ~ 24 years old) are rare. The posterior circulation is more commonly involved than adults, giant and huge aneurysms are frequent, and fusiform and dissecting pathologic features are common. Headache is the most common clinical manifestation. Individualized treatment should be performed, and bypass is an effective treatment for young patients with intracranial aneurysms.

Endovascular treatment of pediatric basilar artery aneurysms: case series and literature review

PURPOSE

Pediatric basilar artery aneurysms are rare and challenging to treat. Microsurgical options and standard endovascular coiling are often undesirable choices for treatment of this pathology. Additional endovascular strategies are needed.

METHODS

Presentation, diagnosis, and management of pediatric basilar aneurysms were reviewed, with an emphasis on endovascular treatment strategies. Our case series of 2 patients was presented in detail, one treated with flow diversion and vessel sacrifice and one treated with stent-assisted coiling. An extensive review of the literation was performed to find other examples of pediatric basilar artery aneurysms treated with endovascular techniques.

RESULTS

Twenty-nine studies met inclusion criteria. Fifty-nine aneurysms in 58 patients were treated using endovascular techniques. Mortality rate was 10.3% (6/58) and a poor outcome (GOS 1-3) occurred in 15.5% (9/58). There were 4 reported recurrences requiring retreatment; however, only 46.5% of patients had reported follow-up of at least 1 year. 71.1% (42/59) were dissecting aneurysms.

CONCLUSION

Basilar artery aneurysms in the pediatric population are rare, commonly giant and fusiform, and often not amenable to microsurgical or coiling techniques. The surrounding vasculature, location, size, and morphology of the aneurysm along with the durability of treatment must be considered in treatment decisions. With proper patient selection, stent-assisted coiling and flow diversion may increase the durability and safety of endovascular treatment in this population.

Low-memory shape coils for intracranial aneurysm coiling: Initial and single-center experience with the i-ED coil

Background

Endovascular aneurysmal coiling is a preventative alternative to clipping to avoid aneurysmal rupture. In the literature and our own experience, some common coiling challenges which arise include: (1) microcatheter kickback, (2) detachment zone rigidity, (3) intrasaccular compartmentalization of coils on deployment, and (4) attainability of high-density and effective packing with as few coils as possible.

Methods

We retrospectively reviewed a consecutive case series of 15 intracranial aneurysm patients who received Kaneka i-ED Coils since their initial use in our practice (December 2020) till May 2022.

Results

Of the 14 saccular aneurysm patients treated with i-ED coils, 2/14 (14.3%) achieved a Raymond-Roy (RR) score of 3A (internal remnant), 4/14 (28.6%) achieved RR 2 (slight neck remnant) and 8/14 (57.1%) achieved RR 1. One MoyaMoya patient (5.9%) with a fusiform aneurysm also achieved a complete occlusion by parent artery takedown in this series. Aneurysm volumes ranged from 8.15 mm 3 to 315.5 mm 3 with an average packing density of 36.23% and a standard deviation 8.87%. At 30 days, most of our cohort scored a 0 on the modified Rankin scale (mRS) (11/15), with two patients scoring at an mRS score of 1, one at an mRS score of 4, and one at an mRS score of 6. Low-memory shape, coil cases achieved a significantly higher packing density (P < 0.01) and PD/Coils-used ratio (P < 0.05) than other cases in our practice.

Conclusion

Our initial experience with i-ED coils has shown that they are a feasible strategy in a number of differently sized and shaped aneurysms. While fewer coils overall were not a statistically significant finding in this study, the future studies with larger cohorts are necessary and in progress.

Intracranial aneurysms in the infant population: an institutional case series and individual participant data meta-analysis

OBJECTIVE

Infantile intracranial aneurysms are exceedingly rare. The goal of this study was to evaluate an institutional case series of infantile intracranial aneurysms, as well as those reported in the contemporary literature, to determine their demographics, presentation, management, and long-term outcome.

METHODS

A comprehensive literature review from 1980 to 2020 was performed to identify individual cases of intracranial aneurysms in the infantile population ≤ 2 years of age. Additional cases from the authors' institution were identified during the same time period. An individual participant data meta-analysis (IPDMA) was performed, abiding by the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Patient demographic, radiographic, and clinical information was obtained. Descriptive statistical data were recorded, and multivariate logistic regression analyses were performed.

RESULTS

Patient data were obtained for 133 patients from 87 articles in the literature. Ten additional patients at the authors' institution were also identified, for a total of 143 patients included in the IPDMA. The majority (72.7%) of this cohort consisted of idiopathic aneurysms, while 13.3% were posttraumatic pseudoaneurysms, 9.8% were infectious mycotic aneurysms, and 4.2% were aneurysms associated with a systemic connective tissue disorder or vasculitis. The mean age at presentation was 6.6 months. The majority of infants (97.9%) harbored only 1 aneurysm, and hemorrhage was the most common presenting feature (78.3%). The mean aneurysm size was 14.4 mm, and giant aneurysms ≥ 25 mm comprised 12.9% of the cohort. Most aneurysms occurred in the anterior circulation (80.9%), with the middle cerebral artery (MCA) being the most commonly affected vessel (51.8%). Management strategies included open surgical aneurysm ligation (54.0%), endovascular treatment (35.0%), surgical decompression without aneurysm treatment (4.4%), and medical supportive management only (13.9%). Surgical aneurysm ligation was more commonly performed for MCA and anterior cerebral artery aneurysms (p = 0.004 and p = 0.015, respectively), while endovascular techniques were favored for basilar artery aneurysms (p = 0.042). The mean follow-up period was 29.9 months; 12.4% of the cohort died, and 67.0% had a favorable outcome (Glasgow Outcome Scale score of 5).

CONCLUSIONS

This study is, to the authors' knowledge, the largest analysis of infantile intracranial aneurysms to date. The majority were idiopathic aneurysms involving the anterior circulation. Surgical and endovascular techniques yielded equally favorable outcomes in this cohort. Long-term outcomes in the infantile population compared favorably to outcomes in adults.

Ruptured AComA aneurysm and asymptomatic bilateral ACA vasospasm in an infant: surgical case report

Intracranial aneurysms (IAs) are localized dilations of the cerebral vasculature, representing the leading cause for non-traumatic subarachnoid hemorrhage and an important source of morbidity and mortality. Despite it being a frequent pathology and most often diagnosed incidentally, IAs in infants are a very rare occurrence, and the ruptured variant is exceptional. A 4-month-old boy with a negative family history was brought to our department because of several episodes of incoercible vomiting and fever. Upon examination, the child was somnolent, without any noticeable deficit. Transfontanellar ultrasonography and CT angiography revealed a ruptured aneurysm of the anterior communicating artery (AComA), whereas the pre-clipping MRI showed thin, almost angiographically invisible anterior cerebral arteries (ACAs) on both sides due to vasospasm. We intervened surgically by placing an external ventricular shunt in an emergency setting, followed by clipping of the IA in a delayed manner. The child was discharged a month after admission with no deficit, despite the paradoxical aspect of the ACA. Ruptured IAs can be safely treated via microsurgery, even in infants. However, this requires a great amount of experience and surgical expertise. Furthermore, the lack of proper management would most likely result in a severe deficit in the long term. Lastly, the lack of visibility of the ACA on angiographic studies may not have neurological consequences if they occur in this age group.

Epidemiology and outcomes of pediatric intracranial aneurysms: comparison with an adult population in a 30-year, prospective database

OBJECTIVE

Pediatric intracranial aneurysms are rare. Most large series in the last 15 years reported on an average of only 39 patients. The authors sought to report their institutional experience with pediatric intracranial aneurysms from 1991 to 2021 and to compare pediatric patient and aneurysm characteristics with those of a contemporaneous adult cohort.

METHODS

Pediatric (≤ 18 years of age) and adult patients with one or more intracranial aneurysms were identified in a prospective database. Standard epidemiological features and outcomes of each pediatric patient were retrospectively recorded. These results were compared with those of adult aneurysm patients managed at a single institution over the same time period.

RESULTS

From a total of 4500 patients with 5150 intracranial aneurysms admitted over 30 years, there were 47 children with 53 aneurysms and 4453 adults with 5097 aneurysms; 53.2% of children and 36.4% of adults presented with a subarachnoid hemorrhage (SAH). Pediatric aneurysms were significantly more common in males, more likely giant (≥ 25 mm), and most frequently located in the middle cerebral artery. Overall, 85.1% of the pediatric patients had a modified Rankin Scale score ≤ 2 at the last follow-up (with a mean follow-up of 65.9 months), and the pediatric mortality rate was 10.6%; all 5 patients who died had an SAH. The recurrence rate of treated aneurysms was 6.7% (1/15) in the endovascular group but 0% (0/31) in the microsurgical group. No de novo aneurysms occurred in children (mean follow-up 5.5 years).

CONCLUSIONS

Pediatric intracranial aneurysms are significantly different from adult aneurysms in terms of sex, presentation, location, size, and outcomes. Future prospective studies will better characterize long-term aneurysm recurrence, rebleeds, and de novo aneurysm occurrences. The authors currently favor microsurgical over endovascular treatment for pediatric aneurysms.

Early Treatment of Ruptured Blood Blister-Like Aneurysms of the Internal Carotid Artery With Flow Diverters Using Single Antiplatelet Therapy: A Single-Center Experience With Long-Term Follow-Up

Background and Purpose: Blood Blister-like aneurysms (BBAs) of the internal carotid artery (ICA) are rare entities of cerebral aneurysms. FD use in acutely ruptured aneurysms, timing of treatment and antiplatelet regimen are main debate topics in clinical practice when the treatment decision is flow diversion. The aim of this study is to report the safety and efficacy of a single-center FD treatment for ruptured BBAs in the early phase of SAH using the SAPT regimen.

Material and Method: This study involved a retrospective analysis of a prospectively collected database. Records of patients admitted to our clinic and treated by endovascular route on ruptured BBA between January 2013 and December 2020 were reviewed. Ruptured supraclinoid ICA BBAs treated with FD devices with SAPT within 48 h from ictus of SAH are included. BBA of atypical anatomic locations, other endovascular techniques performed, and delayed admissions (>48 h) were excluded from the study. Demographic, clinical and angiographic features of patients and aneurysms, FD types and numbers, periprocedural complications, immediate and follow-up angiographic and clinical outcomes were recorded.

Results: A total of six patients with ruptured BBAs treated via FDs within 48 h and used SAPT were included in the study. The mean age was 41.6 years (range from 34 to 45 years), and four of six patients were female. All patients were treated within 48 h after ictus, and the mean treatment day was 1.33 days. One patient received ticagrelor, and five patients received prasugrel as SAPT for one year after treatment. No procedure-related death and rebleeding were recorded. One (16.7 %) treatment responsive procedure-related complication occurred (transient ischemia). Overall good outcome rate was 83.3%. One patient died due to pneumonia. The immediate control angiograms showed complete occlusions of BBAs in one patient (16.6%). The complete occlusion rate was 100 % for five survivors at the control angiogram. The median follow-up was 49.5 months.

Conclusion: This single-center experience suggests that early treatment (<2 days) within SAH of ruptured BBAs with FDs using SAPT is safe and effective in terms of clinical and radiological long-term outcomes.

Intracranial Vascular Abnormalities in Children

Intracranial vascular abnormalities rarely are encountered in primary care. Many of the pathologies are occult and prognosis varies widely between inconsequential variants of anatomy to acutely life-threatening conditions. Consequently, there often is a great deal of anxiety associated with any potential diagnosis. This article reviews anatomic intracranial vascular lesions, including vascular malformations (arteriovenous malformations/arteriovenous fistulae and cavernous malformations), structural arteriopathies (aneurysms and moyamoya), and common developmental anomalies of the vasculature. The focus includes a general overview of anatomy, pathology, epidemiology, and key aspects of evaluation for the primary care provider and a review of common questions encountered in practice.

Endovascular Treatment of a Ruptured Distal Anterior Cerebral Artery Aneurysm Using Coils and N-Butyl-Cyanoacrylate in a 5-Month-Old Baby

Intracranial aneurysms in pediatric population are rare and differ in several features with their adult counterpart. Clipping and endovascular therapy have both demonstrated favorable clinical outcomes with reconstructive and deconstructive techniques. We present the case of a 5-month-old infant who was admitted to the emergency with interhemispheric and sylvian subarachnoid hemorrhage. CT angiography and three-dimensional digital subtraction angiography revealed a ruptured left pericallosal aneurysm with morphological features of a dissecting aneurysm. Coiling and N-butyl-cyanoacrylate administration were employed to occlude the aneurysm without complications. Endovascular therapy is an effective and safe option in cases of ruptured intracranial aneurysms in pediatric patients with favorable clinical and radiological outcomes.

Telescoping flow diverters for a pediatric fusiform distal anterior cerebral artery aneurysm: technical case report

BACKGROUND AND IMPORTANCE

Pediatric intracranial aneurysms are rare, with fusiform aneurysms of the distal anterior circulation even more so. A limited number of prior reports detail the management of this pathology.

CLINICAL PRESENTATION

We report a case of a 15-year-old boy presenting with new-onset headache found to have a 3.1 cm × 1.4 cm × 1.4 cm fusiform partially thrombosed aneurysm of the A2 segment of the left anterior cerebral artery. Subsequent treatment with flow diversion resulted in the placement of five telescoping PEDs (2.5 mm × 20 mm, 2.75 mm × 20 mm, 2.75 mm × 20 mm, 3 mm × 25 mm, and 3 mm × 20 mm) from the left pericallosal artery to the left A1 segment. Catheter-based angiography at 6 months post-placement indicated normal vessel caliber, no residual aneurysm, and no in-stent stenosis. The patient's headache resolved after treatment.

CONCLUSION

Telescoping PEDs are a feasible low-risk treatment option for long-segment fusiform distal ACA aneurysms in children that can have optimal clinical and radiographic outcomes.

Endovascular treatment of intracranial vascular malformations in children

Paediatric intracranial vascular malformations are rare and different from adult ones in vascular anatomy, pathophysiology, and symptoms. Their impact on the brain and their symptoms will differ in the antenatal period, in neonates, infants, and children. Clinical presentation includes seizures, focal neurological deficit, haemorrhage, congestive heart failure, hydrovenous disorder, and developmental delays. These malformations are thus associated with a poor prognosis if left untreated. Therefore, aggressive management is generally recommended and must be performed by a multidisciplinary team with extensive experience. Endovascular treatment is the first-choice treatment for most paediatric intracranial vascular malformations. Indication and timing for treatment should be decided on the basis of a careful assessment of neurological symptoms, growth and development, cardiac and other systemic manifestations, and imaging of the malformation and the brain tissue. WHAT THIS PAPER ADDS: Paediatric intracranial vascular malformations are rare, but their prognosis is poor if left untreated. Improved clinical, anatomical, and pathophysiological understanding of these complex lesions has improved prognosis.

Risk factors for preoperative seizures in pediatric patients with intracranial aneurysms

OBJECTIVE

Seizures are common complications following intracranial aneurysms and present a greater risk to pediatric patients than adults. Though the risk factors of seizures in adults with intracranial aneurysms have been well documented, the risk factors in pediatric patients remain unknown. The aim of this study was to evaluate the risk factors for preoperative seizures and the effect of the treatment approach on postoperative seizures in pediatric patients with intracranial aneurysms.

PATIENTS AND METHODS

The data of 64 pediatric patients (mean age 11.4 ± 5.7 years; 68.8 % of males) with intracranial aneurysms were retrospectively analyzed from January 2012 to April 2017. Comparisons were made between patients with preoperative seizures (case group) and those without (control group).

RESULTS

Twenty-four patients (37.5 %) had preoperative seizures, and 15 patients (23.4 %) had postoperative seizures. Multiple logistic regression analysis revealed that younger age (0-5 years), head trauma history, ruptured aneurysms, lobe hematomas, modified Fisher grade 3-4, giant aneurysms, pseudoaneurysms and distal arterial aneurysms were independently associated with the increased risk of preoperative seizures. Patients in the surgical and endovascular groups did not differ significantly in the rates of preoperative seizures or early postoperative seizures (within 1 month) (P > 0.05). However, a significantly lower incidence of late postoperative seizures (1-3 months and 3-6 months) was observed in the surgical group compared with the endovascular group (P < 0.05).

CONCLUSION

Pediatric patients with intracranial aneurysms are at high risk for seizures. Risk factors for preoperative seizures included younger age (0-5 years), head trauma history, lobe hematomas, modified Fisher grade 3-4, giant aneurysms, pseudoaneurysms and distal arterial aneurysms. Compared with the endovascular treatment, surgical intervention provided more benefits with regard to reducing the risk of late postoperative seizures.

Intracranial Aneurysms in Sickle Cell Disease

Background:

The exact causes of intracranial aneurysms (IAs) are still unknown. However, certain diseases are known to be associated with IAs.

Objective:

To analyze the differences in IA characteristics in the general population and in individuals with sickle-cell disease (SCD).

Methods:

We systematically searched PubMed, Scopus, Web of Science, and Cochrane Library for Data on SCD patients with IAs. We compared IA characteristics of SCD patients with those from 2451 healthy IA carriers from our observational cohort.

Results:

129 SCD patients with IAs were identified in 42 studies. The SCD patient cohort was characterized by younger age (mean 27.1 vs 54.9 years, p<0.0001) and lower female prevalence (57.7% vs 68.4%, p=0.0177). The prevalence (47% vs 34.5%, p=0.004) and the number (3.02 vs 2.56 IAs/patient, p=0.004) of multiple IAs were also higher in the SCD cohort. Unruptured IAs (3.27 vs 6.16 mm, p<0.0001), but not ruptured IAs (7.8 vs 7.34 mm, p=0.9086) were significantly smaller in the SCD cohort. In addition, IAs were more frequently located in the internal carotid artery (45% vs 29%, p<0.0001) or posterior circulation (43% vs 20%, p<0.0001). Higher age (≥30 years, p=0.007), IA size ≥7 mm (p=0.008), and location in posterior circulation (p=0.01) were independently associated with subarachnoid hemorrhage in SCD.

Conclusion:

There is a distinct demographic and radiographic pattern of IA in SCD. Risk factors for IA rupture in SCD are mostly congruent with those in healthy individuals.

Nonsaccular aneurysms: A wide comparison between the four main types

Background:

The present study aims to present the most important considerations when it comes to patients features, clinical presentation, localization, morphology, pathogenesis, and the best treatment for each type of the nonsaccular aneurysms.

Methods:

We performed a literature review using PubMed. The search was limited to the studies published in English, from 2010 to 2017.

Results:

Data about the clinical presentation; the aneurysm pathogenesis, morphology, and localization; the patient features; and about the surgical or endovascular approach were analyzed for the four types of nonsaccular aneurysms presented.

Conclusion:

All types of nonsaccular aneurysms have a higher prevalence in young adults. Men are more affected by fusiform and mycotic aneurysms while women suffer more with blister-like aneurysms (BLAs). The mycotic and the BLAs affect more the anterior circulation while the fusiform affects more the posterior circulation. Mycotic and blister-like has as its major complication and clinical presentation the hemorrhage; however, the fusiform aneurysms usually present ischemia and/or mass effect. The reconstructive endovascular techniques for all types of nonsaccular aneurysms presented as the treatment with the best outcomes. Among this technique, the flow diversion presented good results in all types of aneurysms and it seems to promote the best outcomes.

Onyx embolization of a ruptured anterior inferior cerebellar artery in a neonate

Aneurysmal subarachnoid hemorrhage (SAH) is rare in neonates. The authors present a unique report of a neonate with SAH from anterior inferior cerebellar artery (AICA) aneurysm rupture that was successfully treated with Onyx embolization. This case report demonstrates the utility of Onyx embolization for posterior circulation aneurysms in neonates and the successful management of SAH in this population.

Fusiform aneurysms: A review from its pathogenesis to treatment options

Background

This study aims to present the most important considerations when it comes to patients features, clinical presentation, localization, and morphology of the aneurysm and the treatments outcomes of the fusiform aneurysms.

Methods

We performed a literature review using PubMed. The search was limited to the studies published in English, from 2003 to 2017.

Results

The studies analyzed that showed data about the patient features, clinical presentation, the aneurysm localization, morphology, and pathogenesis didn't present much divergence. The surgical and the endovascular approach showed similar treatments outcomes. The reconstructive techniques seem to be safer than the deconstructive. The flow diversion is a technique that showed great results.

Conclusion

Most of the patients are men, younger than 50 years old, pediatric patients are the most affected. Surgical procedures still have an important place in this field. Reconstructive and deconstructive techniques are both effective; the reconstructive techniques are possibly safer than deconstructive techniques. The most important feature of an aneurysm to predict a bad prognose is to determine if the aneurysm is ruptured. The reconstructive EVT accompanied by dual antiplatelet after and before the procedure showed the best results to treat the basilar fusiform aneurysms. Deconstructive treatment including posterior inferior cerebellar artery occlusion should be considered.

Pediatric intracranial aneurysms: changes from previous studies

PURPOSE

To develop a better understanding of pediatric intracranial aneurysms (PIAs).

METHODS

All PIAs treated in our center from January 2012 to April 2017 were retrospectively included. Clinical data, treatment summaries, and follow-up outcomes were retrieved and analyzed.

RESULTS

A total of 66 PIAs were found in 64 patients with a mean age of 11.4 ± 5.7 years, 68.8% of whom were male. The most common symptoms were seizure (n = 7, 63.6%) for the 0-5 age group and headache (n = 38, 71.7%) for the 6-18 age group. Fifty-one PIAs (77.3%) were located in the anterior circulation, with the middle cerebral artery (MCA) being the most common site (n = 28, 42.4%). Fifteen patients (23.4%) had PIAs that were pseudoaneurysms, and nine of them (60%) had a combined history of head trauma. Thirty-five patients (54.7%) had distal arterial aneurysms, and 21 of them (60%) presented with seizure. During a mean follow-up time of 1.6 ± 1.2 years, 79.7% of patients (n = 51) had favorable outcomes, 5 patients (7.8%) died, and the remaining 8 patients (12.5%) had unfavorable outcomes with severe neurological deficits.

CONCLUSION

Apart from characteristics consistent with previous studies, several new findings regarding PIAs were reported, including a difference in the most common symptoms in different age groups, the MCA as the predominant location of PIAs, the high ratio of pseudoaneurysms and their head trauma etiology, and the incidence of distal arterial aneurysms and their relationship with the risk of seizures.

Treatment of pediatric intracranial aneurysms: case series and meta-analysis

Background

There are limited outcome data to guide the choice of treatment in pediatric patients with cerebral aneurysms.

Objective

To describe our institutional experience treating pediatric patients with cerebral aneurysms and to conduct a meta-analysis of available studies to provide the best current evidence on treatment related outcomes.

Methods

We identified pediatric patients with cerebral aneurysms evaluated or treated at our institution using a comprehensive case log. We also identified studies to include in a meta-analysis through a systematic search of Pubmed, SCOPUS, EMBASE, and the Cochrane Database of Systematic Reviews. As part of both the local analysis and meta-analysis, we recorded patient characteristics, aneurysm characteristics, management, and outcomes. Statistical analysis was performed using Fisher’s exact test and the two tailed Student’s t test, as appropriate.

Results

42 pediatric patients with 57 aneurysms were evaluated at our institution, and treatment specific outcome data were available in 560 patients as part of our meta-analysis. Endovascular and surgical treatments yielded comparable rates of favorable outcome in all children (88.3% vs 82.7%, respectively, P=0.097), in children with ruptured aneurysms (75% vs 83%, respectively, P=0.357), and in children with unruptured aneurysms (96% vs 97%, respectively, P=1.000).

Conclusion

Endovascular and surgical treatment yield comparable long term clinical outcomes in pediatric patients with cerebral aneurysms.

Emergency Neurological Life Support: Intracerebral Hemorrhage

Intracerebral hemorrhage (ICH) is a subset of stroke due to spontaneous bleeding within the parenchyma of the brain. It is potentially lethal, and survival depends on ensuring an adequate airway, proper diagnosis, and early management of several specific issues such as blood pressure, coagulopathy reversal, and surgical hematoma evacuation for appropriate patients. ICH was chosen as an Emergency Neurological Life Support (ENLS) protocol because intervention within the first hours may improve outcome, and it is critical to have site-specific protocols to drive care quickly and efficiently.

Successful microsurgical treatment of intracranial aneurysms in infants: a retrospective study and literature review

OBJECTIVE

Intracranial aneurysms are extremely rare in infants, especially less than 1 year old. This study aimed to analyze the frequency of infantile intracranial aneurysm in our department and investigate the clinical characteristics, treatment strategies, and outcomes of this disease.

METHODS

Six infants under 1 year old in 4350 patients with intracranial aneurysms were retrospectively analyzed from January 2010 to December 2016.

RESULTS

The patients (5 females and 1 male) ranged in age from 2 to 11 (mean age, 4.67) months. Four patients presented with generalized seizure and vomiting, 3 showed lethargy, 1 presented eye deviation, and 1 had right-sided hemiparesis. Radiographically, two aneurysms were localized in the middle cerebral artery (MCA) of the M2 segment, two were located in the M3 segment of MCA, one was located at left MCA bifurcation, and one was located at the nonbranching site of the left supraclinoid internal carotid artery. All these lesions were successfully managed with aneurysm clipping or resection, and the improvement of neurological deficits was achieved in all patients.

CONCLUSION

Intracranial aneurysms should be considered in the differential diagnosis of infants who present with acute raised intracranial pressure. An improvement of neurological deficits is noted in infants who are managed promptly with microsurgical techniques of clipping during the long-term follow-up.

Acute Obstructive Hydrocephalus due to a Giant Posterior Cerebral Artery Aneurysm in a Pediatric Patient

INTRODUCTION

Intracranial aneurysms are very rare in children. Although subarachnoidal hemorrhage (SAH) is by far the most common presentation of aneurysms in the majority of the pediatric case series, it is not rare for an unruptured aneurysm to present with a mass effect. Acute hydrocephalus is a common finding following aneurysmal SAH. However, this malady may develop even in the absence of SAH but secondary to direct obstruction by a giant aneurysm. This situation is extremely rare in children, with only a few known case reports in the literature.

CASE REPORT

We report the case of a 10-year-old girl who presented with signs and symptoms of acute hydrocephalus; further radiological evaluation revealed obstructive hydrocephalus and a giant posterior cerebral artery aneurysm. Following endovascular treatment of the aneurysm, hydrocephalus was completely resolved, and the patient was symptom free.

CONCLUSION

Although they are very rare, giant intracranial aneurysms must be kept in mind during the differential diagnosis of pediatric acute hydrocephalus cases. Hydrocephalus may resolve spontaneously after the successful treatment of these aneurysms.

Endovascular Management of Multiple Dysplastic Aneurysms in a Young Man with an Unknown Underlying Cause: A Case Report and Review of the Literature

BACKGROUND

Intracranial aneurysms are the leading cause of nontraumatic subarachnoid hemorrhage and are most commonly associated with the anterior cerebral artery (ACA) and anterior communicating artery complex. We describe the presentation and management of a 27-year-old man with concurrent bilateral A1-2 junction aneurysms and fusiform intraorbital ophthalmic artery (OA) aneurysms.

CASE DESCRIPTION

A 27-year-old man with no past medical history presented with 3 months of headaches. Imaging showed a large dysplastic left A1-2 junction aneurysm and a smaller saccular right A1-2 junction aneurysm, with potentially adherent domes. Two fusiform aneurysms of the intraorbital segment of the left OA were also identified. The patient underwent coil-assisted pipeline embolization of the left A1-A2 aneurysm, with complete obliteration and reconstitution of the normal parent vessel. The patient underwent coil embolization of the right A1-2 aneurysm 3 weeks later, which was found to have grown significantly at the time of treatment. Three-month follow-up showed spontaneous resolution of the OA aneurysms, persistent obliteration of the left aneurysm, and significant recurrence of the right aneurysm, which was treated with stent-assisted coil embolization. A second recurrence 3 months later was successfully treated with repeat coiling. At the time of this treatment, the patient was also found to have 2 de novo distal middle cerebral artery and ACA dysplastic aneurysms, which were not treated. Follow-up angiography 6 weeks later showed stable complete obliteration of the right A1-2 aneurysm and interval complete resolution of the dysplastic middle cerebral artery aneurysm. The distal ACA aneurysm was observed to have minimally increased in size; however, the parent vessel showed signs of interval partial thrombosis with contrast stasis within the aneurysm. This final aneurysm is being followed with serial imaging. The patient remains neurologically intact with complete resolution of his headaches.

CONCLUSIONS

We report the case of a young man with no past medical history who presented with multiple dysplastic aneurysms. Successful staged endovascular intervention resulted in obliteration of aneurysms with spontaneous obliteration of the intraorbital OA aneurysms observed at 3 months. We present this case to review the multiple challenges of managing complex ACA aneurysms and to highlight the usefulness of endovascular intervention in their treatment.

Rapid de novo aneurysm formation after clipping of a ruptured middle cerebral artery aneurysm in an infant with an MYH11 mutation

The authors report the case of a previously healthy 6-month-old girl who presented with right arm and leg stiffening consistent with seizure activity. An initial CT scan of the head demonstrated acute subarachnoid hemorrhage in the basal cisterns extending into the left sylvian fissure. Computed tomography angiography demonstrated a 7 × 6 × 5-mm saccular aneurysm of the inferior M₂ division of the left middle cerebral artery. The patient underwent left craniotomy and microsurgical clip ligation with wrapping of the aneurysm neck because the vessel appeared circumferentially dysplastic in the region of the aneurysm. Postoperative angiography demonstrated a small remnant, sluggish distal flow, but no significant cerebral vasospasm. Fifty-five days after the initial aneurysm rupture, the patient presented again with an acute intraparenchymal hemorrhage of the left anterior temporal lobe. Angiogram revealed a circumferentially dysplastic superior division of the M₂ branch, with a new 5 × 4-mm saccular aneurysm distinct from the first, with 2 smaller aneurysms distal to the new ruptured aneurysm. Endovascular parent vessel occlusion with Onyx was performed. Genetic testing revealed a mutation of the MYH11. To the authors' knowledge, this is the first report of rapid de novo aneurysm formation in an infant with an MYH11 mutation. The authors review the patient's clinical presentation and management and comprehensively review the literature on this topic.

Emergency Neurological Life Support: Intracerebral Hemorrhage

Intracerebral hemorrhage (ICH) is a subset of stroke due to bleeding within the parenchyma of the brain. It is potentially lethal, and survival depends on ensuring an adequate airway, reversal of coagulopathy, and proper diagnosis. ICH was chosen as an Emergency Neurological Life Support protocol because intervention within the first critical hour may improve outcome, and it is critical to have site-specific protocols to drive care quickly and efficiently.

Interventional neuroradiology in children: diagnostics and therapeutics

PURPOSE OF REVIEW

To highlight the spectrum of pediatric neurovascular conditions typically referred for diagnostic or interventional neuroangiography, the range of techniques available in contemporary pediatric neurointerventional practice, and the specific considerations relating to radiation and contrast dosing applicable to pediatric neurointerventional procedures.

RECENT FINDINGS

Neurointerventional procedures are increasingly utilized in children for a variety of indications, with continuous emphasis on improving safety and treatment effectiveness. Numerous steps can be taken to mitigate the potential risks of pediatric neurointerventional procedures, with recent data from high-volume centers suggesting similar, if not lower, complication rates in children compared with adults. Judicious patient selection and clarity of goals are critically important, however, because children undergoing complex and lengthy neurointerventional procedures are particularly vulnerable to the effects of ionizing radiation, vessel injury, and contrast overload.

SUMMARY

With continued advances in endovascular technology, neurointerventionalists stand to play an important and expanding role in the multidisciplinary management of pediatric neurovascular disease.