Ruptured intracranial aneurysm in a patient with autosomal recessive polycystic kidney disease

Aneurysmal rupture can result in devastating neurological consequences and can be complicated by comorbid disease processes. Patients with autosomal recessive polycystic kidney disease (ARPKD) have a low rate of reported aneurysms, but this may be due to the relative high rate of end-stage illnesses early in childhood. Authors here report the case of a 10-year-old boy with ARPKD who presented with a Hunt and Hess grade V subarachnoid hemorrhage requiring emergency ventriculostomy, embolization, and decompressive craniectomy. Despite initial improvements in his neurological status, the patient succumbed to hepatic failure. Given the catastrophic outcomes of subarachnoid hemorrhage in young patients, early radiographic screening in those with ARPKD may be warranted.

Pediatric Intracranial Aneurysms: Considerations and Recommendations for Follow-Up Imaging

BACKGROUND

Pediatric intracranial aneurysms (IAs) are rare. Compared with adult IAs, they are more commonly giant, fusiform, or dissecting. Treatment often proves more complex, and recurrence rate and de novo aneurysmogenesis incidence are higher. A consensus regarding the most appropriate algorithm for following pediatric IAs is lacking.

METHODS

We sought to generate recommendations based on the reported experience in the literature with pediatric IAs through a thorough review of the PubMed database, discussion with experienced neurointerventionalists, and our own experience.

RESULTS

Digital subtraction angiography (DSA) was utilized immediately post-operatively for microsurgically-clipped and endovascularly-treated IAs, at 6-12 months postoperatively for endovascularly-treated IAs, and in cases of aneurysmal recurrence or de novo aneurysmogenesis discovered by non-invasive imaging modalities. Computed tomographic angiography was the preferred imaging modality for long-term follow-up of microsurgically clipped IAs. Magnetic resonance angiography (MRA) was the preferred modality for following IAs that were untreated, endovascularly-treated, or microsurgically-treated in a manner other than clipping.

CONCLUSIONS

We propose incidental untreated IAs to be followed by magnetic resonance angiography without contrast enhancement. Follow-up modality and interval for treated pediatric IAs is determined by initial aneurysmal complexity, treatment modality, and degree of posttreatment obliteration. Recurrence or de novo aneurysmogenesis requiring treatment should be followed by digital subtraction angiography and appropriate retreatment. Computed tomography angiography is preferred for clipped IAs, whereas contrast-enhanced magnetic resonance angiography is preferred for lesions treated endovascularly with coil embolization and lesions treated microsurgically in a manner other than clipping.

Extracranial Aneurysms in 2 Patients with Autosomal Recessive Polycystic Kidney Disease

Unlike autosomal dominant polycystic kidney disease (ADPKD), autosomal recessive polycystic kidney disease (ARPKD) is not generally known to be associated with vascular abnormalities. Only 4 cases of ARPKD patients with intracranial aneurysms have been reported previously. We present 2 ARPKD patients with extracranial vascular abnormalities: a young man with infrarenal aortic and iliac artery aneurysms complicated by dissection and a teenage girl with multiple splenic and gastric artery aneurysms and arterial vascular malformations. These cases raise the question of whether vascular integrity and development may be impaired in ARPKD, perhaps through molecular mechanisms overlapping with ADPKD. This possibility is supported by studies in mice that show ARPKD gene expression in the walls of large blood vessels.

Endovascular Treatment of Intracranial Aneurysms in Patients With Autosomal Dominant Polycystic Kidney Disease

BACKGROUND

Little is known about the outcome of endovascular treatment for intracranial aneurysms in patients with autosomal dominant polycystic kidney disease (ADPKD).

OBJECTIVE

To present clinical outcomes in terms of safety, effectiveness, and renal functions to assess contrast-induced nephropathy in endovascular coil embolization for intracranial aneurysms in ADPKD patients.

METHODS

Nineteen ADPKD patients (female:male, 15:4; mean age, 49.8 years; range, 20-67 years) had 26 aneurysms (mean size, 5.86 mm; range, 2.5-11.6 mm) and underwent 22 endovascular treatment sessions from 2001 to 2013. Four patients presented with ruptured aneurysms. Periprocedural complications, clinical outcomes with modified Rankin Scale scores, laboratory findings, and chronic kidney disease (CKD) stage before and after treatment were documented. Acute renal impairment was defined as serum creatinine (Cr) elevation by ≥ 0.5 mg/dL or 25% relative to baseline.

RESULTS

Symptomatic periprocedural complications developed after 1 endovascular procedure (1 of 22, 4.5%), and good clinical outcomes (modified Rankin Scale scores, 0-1) were achieved in 90% of patients (17 of 19). Overall, acute renal impairment occurred in 9.1% of treatment sessions (2 of 22). Acute renal impairment developed in 25% of high-risk patients (baseline Cr > 2.0 mg/dL) and 33.3% of baseline CKD stage 5 sessions but in none of the low-risk patients (baseline Cr ≤ 2.0 mg/dL) and in no CKD stage 1 to 4 sessions.

CONCLUSION

With appropriate management, coil embolization may be safe and effective for intracranial aneurysms in ADPKD. There is a concern about contrast-induced nephropathy in patients with CKD stage 5 or high serum Cr level (>2.0 mg/dL).

Autosomal dominant polycystic kidney disease in children

PURPOSE OF REVIEW

Autosomal dominant polycystic kidney disease (ADPKD) is the most common hereditary renal disease, affecting one in 500 individuals. The cardinal manifestation of ADPKD is progressive cystic dilatation of renal tubules with kidney enlargement and progression to end-stage renal disease in approximately half of cases by 60 years of age. Although previously considered a condition of adults, it is clear that children and young adults are subject to the complications of ADPKD.

RECENT FINDINGS

It has been increasingly recognized that interventions early in life are necessary in order to confer the best long-term outcome in this common condition. Therefore, it is imperative for pediatricians to recognize the manifestations and complications of this disease. Until recently ADPKD management focused on general principles of chronic kidney disease. However, several recent clinical trials in children and adults with ADPKD have focused on disease-specific therapies.

SUMMARY

This review will highlight the clinical manifestations, diagnosis, and appropriate management of ADPKD in childhood and will review recent relevant clinical trials in children and adults with this condition.

Diagnostic characteristics and management of intracranial aneurysms in children

Childhood aneurysms have special characteristics different from adults' aneurysms. Their features were found to significantly differ from aneurysms in adults especially in their gender prevalence, location, morphology and underlying etiology. Treatment options include both surgical and endovascular methods. Whenever possible, endovascular treatment for pediatric aneurysms is the recommended approach, since it offers both reconstructive and deconstructive techniques, durable results and better clinical outcome.

Intracranial aneurysms in children aged under 15 years: review of 59 consecutive children with 75 aneurysms

OBJECTIVE

The objective was to review the clinical aspects and therapeutic strategies in a series of aneurysmal vasculopathies seen in children 15 years or under.

METHODS

From our dedicated neurovascular databank of patients, we reviewed 59 consecutive children who had 75 separate lesions.

RESULTS

The children were divided into four age groups: below 2 years (22%), 2-5 years (24%), 6-10 years (24%) and 11-15 years (30%). Thirty-three children had dissecting aneurysms, 2 had chronic post-traumatic aneurysms, 8 had infectious aneurysms and 16 had saccular lesions. Twenty-seven percent of the lesions were in the posterior circulation, and 21% developed on the middle cerebral artery. Most dissecting lesions were encountered in the vertebrobasilar system, while saccular lesions were present mostly in the anterior circulation. Half of all cases presented with haemorrhage. Haemorrhage in patients below 2 years of age was due to dissecting aneurysms, while saccular aneurysms were responsible for haemorrhage in patients above 5 years of age. Five children had familial disease and 9 presented with multiple aneurysms. Forty-eight children were referred to us for treatment. Thirty-two underwent surgical (21.9%), endovascular (62.8%) or combined (9.3%) treatment. Eleven patients were treated conservatively and in 5 patients the aneurysms had spontaneously thrombosed at admission. Overall, complete or partial spontaneous thrombosis was seen in 10 patients (16.9%). Dissecting aneurysms were frequent in children of all ages with either associated thrombosis or arterial tear with repeated acute haemorrhage and poor outcome. Two types of dissection seem identifiable despite the small number of cases collected: acute segmental arterial tear without thrombosis, acute subarachnoid haemorrhage (SAH) and recurrence before 5 years; and subacute focal dissection with partial thrombosis (or mural haematoma), rare SAH and no early recurrence. The former would require aggressive management whereas the latter often do not require interventional approaches. The mortality in our series of aneurysms is low in the treated group (10.42%). The overall tolerance to haemorrhage seems better than in adults, as already stressed in the literature.

CONCLUSION

The multiple etiologies encountered confirm the heterogenous nature of "aneurysms". The variety of treatments used suggests the need to categorise aneurysms into subgroups in sufficient numbers to fully appreciate the behavior of the lesions and make the appropriate therapeutic decisions.

Tuberous sclerosis complex with an unruptured intracranial aneurysm: manifestations of contiguous gene syndrome

SUMMARY

With the advancement of molecular genetics, the deletion of the TSC2/PKD1 gene at chromosome 16p13.3 has been discovered to be responsible for the tuberous sclerosis complex sharing some of the clinical manifestations of autosomal dominant adult polycystic kidney disease such as multiple renal cysts and intracranial aneurysms. The unruptured aneurysm in tuberous sclerosis complex is far beyond the meaning it has in general population. The risk of aneurysmal hemorrhage in tuberous sclerosis complex may be higher than that in autosomal dominant adult polycystic kidney disease due to the synergistic effect of gene deletion and certainly much higher than that in the general population. For such high-risk patients with intracranial aneurysms doomed to subarachnoid hemorrh age, magnetic resonance angiography plays an important role in screening and follow-up, especially more critically for patients with contiguous gene syndrome. Endovascular coil embolization should be the first choice of treatment for un ruptured intracranial aneurysms.