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

Microsurgical clipping of large MCA aneurysm in a 2-month-old child

BACKGROUND

Cerebral aneurysms in children have a low incidence and accounts for less than 4% of all cerebral aneurysms. These aneurysms have been linked to various factors. Severe headache, seizures, and motor-sensory deficits are common presentations.

CASE REPORT

We describe the case of a 2-month-old male patient who presented with generalized tonic-clonic seizures for 4 days. At the hospital, he was stabilized with ventilatory support, sedation, and antiepileptic drugs. A NCCT (Head) showed intraparenchymal hemorrhage in the left fronto-parieto-temporal lobe and subarachnoid hemorrhage. Subsequently a CT angiogram revealed an aneurysm of the left M3 segment of MCA. Successfully, the patient underwent microsurgical clipping of aneurysm and evacuation of hematoma.

CONCLUSIONS

Pediatric cerebral aneurysms differ from their adult counterparts, mainly in their etiology and evolution. As per literature, aneurysmal clipping and neurological endovascular therapy have shown similar results.

Trend of cerebral aneurysms over the past two centuries: need for early screening

OBJECTIVE

Cerebral aneurysms (CAs) are linked to variations in the cerebral basal arterial network (CBAN). This study aimed to find the optimal age for screening to detect brain arterial variations and predict aneurysms before rupture.

DESIGN

An observational, quantitative and retrospective research.

SETTING

The study analysed 1127 cases of CAs published from 1761 to 1938. Additionally, CT angiography images of 173-patients at the Royal Adelaide Hospital (RAH), South Australia between 2011 and 2019 were examined for the presence and the location of aneurysms in CBAN.

PARTICIPANTS

The data were collected from patients at RAH and 407 published sources, including males and females across the entire age range, up to 100 years old.

OUTCOME MEASURES AND RESULTS

Data, CAs cases, from 1761 to 1938 included (526 males, 573 females and 28 unknown sexes). The age of these patients varied from 18 months to 89 years (mean age=42, SD=18). Approximately 11.5% of the CAs occurred in patients aged <20 years. Among the 1078 aneurysms whose location was reported, 76% were located in the internal carotid (IC), middle cerebral (MC) and anterior communicating artery complex (AcomAC) regions, while the remaining 24% were in the vertebrobasilar region. Among 173 patients from RAH aged between 18 and 100 years (male=83 and female=90, mean age=60, SD=16), 94% of the CAs were found in the IC, MC and AcomAC regions. The pattern of aneurysm occurrence, as indicated by values at the 25th, 50th and 75th percentiles, along with the minimum and maximum patient ages, has remained consistent from 1761 to 2019.

CONCLUSION

The distribution pattern of CAs in relation to sex, age and locations in the CBAN, remained steady over the last 260 years resulting in risk of strokes early in life. Therefore, early screening for CBAN segment variations is advised for stroke prevention if possible.

Pediatric brain aneurysms: a review of 1458 brain MR angiograms

PURPOSE

To evaluate clinical and imaging characteristics of pediatric brain aneurysms.

MATERIALS AND METHODS

A retrospective review of 1458 MR angiograms of pediatric patients (≤18 years old) obtained between 2006 and 2021 was performed. A non-infundibular arterial luminal outpouching larger than 1mm in size was identified as an "Intracranial aneurysm." Patient demographics, clinical presentations, and predisposing risk factors, including family history and underlying medical conditions, were reviewed. MRA images were analyzed for aneurysm location, number, maximum diameter, and interval changes on follow-up.

RESULTS

Forty-nine (3.3%) patients (30 females, 19 males) with 64 intracranial aneurysms were identified with an average age of 13.71 ± 3.67 years. Eleven (22.4%) patients had multiple aneurysms. An underlying systemic illness was observed in 81.6% (40/49) cases, with sickle cell disease as the most frequent (25/49, 51%) diagnosis. A first-degree family history of intracranial aneurysms was recognized in 36/1458 (2.5%) patients. However, no intracranial aneurysm was found in this group. While 02/49 (4%) patients presented with acute SAH, headache was the most common (16/49, 32.7%) symptom at presentation in unruptured cases. The majority (47/64, 73.4%) of the aneurysms were located in the anterior circulation, with the ICA ophthalmic segment being most frequently (24/47, 51%) involved. Most (54/64, 84.4%) aneurysms were smaller than 4mm in size at the time of diagnosis. At least one follow-up MRA was obtained in 72.3% (34/47) of the unruptured aneurysms cohort. There was no change in the aneurysm size and morphology in 31/34 (91.2 %) patients over an average imaging follow-up of 39.6 months. Three (6%) patients demonstrated an interval increase in the aneurysm size. SAH patients (n=2) and two unruptured aneurysm patients with an interval increase in size were successfully treated with endovascular techniques.

CONCLUSION

Female predominance with a higher frequency of small and unruptured intracranial aneurysms was recognized in our cohort. A higher incidence of an underlying systemic illness, especially sickle cell disease, was also noted. Most intracranial aneurysms in children appear to remain stable. However, there seems to be the risk of an aneurysm size increase which warrants regular clinical and imaging follow-up.

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.

Paediatric Intracranial Aneurysms: Long-term Angiographic and Clinical Outcomes in a Contemporary Series

Objective

Paediatric aneurysms are rare and difficult to treat. Studies on the long-term angiographic and clinical outcomes conducted within the past decade are lacking. We aimed to investigate the clinical and radiographic outcomes of paediatric aneurysms treated with different strategies in a contemporary series.

Methods

We performed a retrospective medical record review of paediatric patients examined at our institution between 2011 and 2018. Patient charts were retrospectively reviewed for age, presentation, type and location of the aneurysm, modalities of treatment, complications, and clinical and angiographic outcomes. The rates of aneurysm recurrence and de novo formation were determined.

Results

We evaluated 61 patients (mean age, 11.6 years; 23 females, 38 males) with 69 intracranial aneurysms. Their presentations included headache, neurological deficits, aneurysmal subarachnoid haemorrhage, incidental aneurysm, and traumatic subarachnoid haemorrhage. Of the aneurysms, 30 (49.2%) were giant. Forty-five (73.8%) patients underwent treatment for their aneurysms, and 16 (26.2%) patients were managed conservatively. The perioperative morbidity rate was 17.8%. There were no deaths. The long-term morbidity rate was 4.6%. The clinical outcomes were favourable in 82.2 and 95.3% at discharge and follow-up, respectively (mean, 41.5 months; range, 1.5–9 years). For treated aneurysms, 2/43 (4.6%) risk of aneurysm recurrence, 1/43 (2.3%) risk of aneurysm bleeding, 1/43 (2.3%) risk of de novo aneurysm formation. The annual bleeding, recurrence, and de novo formation or growth risk were 0.7, 1.4, and 0.7%, respectively.

Conclusions

In neurovascular centres where microsurgical and endovascular options are available, most children with intracranial aneurysms can be successfully treated with low morbidity and mortality. However, they have higher rates of recurrence and a greater risk of de novo formation or growth than their adult counterparts, which mandates lifelong follow-up.

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.

Intracranial aneurysms in pediatric population: a two-center audit

OBJECTIVE

Intracranial aneurysms (IA) in children are rare, accounting for less than 5% of all IA. Due to their scarcity, the epidemiology is poorly understood and differs from adults in term of clinical presentation, size, location, and origin. Consequently, the treatment strategies are specific and cannot be only based on data from adult series. The aim of our study was to report the characteristics, management, and outcomes of children treated for IA in two university hospitals located in Normandy (France) over the last 17 years and to perform a literature review of this rare pathology.

METHODS

This retrospective study included 18 consecutive children (< 18 years old) admitted with cerebral aneurysm treated in two neurosurgery departments in Normandy, from 2001 to 2018. Computerized tomography and cerebral angiography established the diagnosis. Both endovascular and surgical procedures were discussed in all cases. Data focused on clinical condition at admission, characteristics of the IA, choice of the treatment modalities, and complications. The outcome at follow-up is based on Glasgow outcomes scale (GOS) at 1 year.

RESULTS

During the study period, 18 children (mean age: 12.6 years; sex ratio male/female: 2.3) were admitted with 21 IA. Aneurysms had a mean size of 13.6 mm with 4 giant aneurysms and were mostly located in the anterior circulation (16/21). Clinical presentations at onset were sudden symptoms related to a subarachnoid hemorrhage in 13 patients, headaches in 4 patients with giant aneurysm, and asymptomatic in one patient. Among the 13 patients with ruptured IA, 6 presented in poor preoperative condition (Hunt and Hess Grade ≥ 4). Treatment modalities consisted in embolization in 9 patients and surgery in 9 patients including 2 by-pass surgeries in fusiform aneurysms. Complications were similar in the two groups, but two cases of recanalization were observed in the endovascular group. At 1 year of follow-up, 14 children were in good condition (GOS Score > 4) and one died. Three children presented associated IA treated by the same technique as initial aneurysm.

CONCLUSIONS

Pediatric aneurysm is a different pathology compared with adults, occurring more frequently in male population with a higher proportion of giant aneurysms and aneurysms located in the internal carotid bifurcation. The use of endovascular techniques has progressed in the last years, but surgery was proposed for half of our population.

Screening for cerebrovascular disorder on the basis of family history in asymptomatic children

Background: Cerebrovascular disorders represent a group of uncommon, heterogeneous, and complex conditions in children. We reviewed the screening practice for the detection of cerebrovascular disorder in asymptomatic children referred to our neurovascular service on the basis of a positive family history and parental and/or treating physician concern.Methods: Retrospective case-note review of referrals to our neurovascular service (July 2008-April 2018). Patients were included if the referral was made for screening, on the basis of a positive family history of cerebrovascular disorder. Symptomatic children, those with previous cranial imaging, or children under the care of a clinical geneticist (i.e. due to the child or their relative having HHT or mutations in KRIT1) were not eligible for inclusion.Results: Forty-one children were reviewed, 22 males (Median age 10.7 years, range 0.6-15.6 years). This represented 22% of the total number of referrals over a 10-year period. Twenty-nine children had an MRI/MRA brain. Twenty-eight children were referred due to a family history of intracranial aneurysm and/or subarachnoid haemorrhage, but only two had two first-degree relatives affected. Ten children were referred due to a family history of arteriovenous malformation. Three children were referred due to a family history of stroke. No cerebrovascular disease was detected during the study period (n = 29).Conclusions: Parental and/or physician concern generated a substantial number of referrals but no pathology was detected after screening. Whilst general screening guidance exists for the detection of intracranial aneurysms, consensus guidelines for the screening of children with a positive family history do not, but are required both to guide clinical practice and to assuage parental and/or physician concerns.

Microsurgery for a ruptured intracranial aneurysm in a 3-year-old child: A case report

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Intracranial aneurysms are rare in children, only case reports and case series published.

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Subarachnoid hemorrhage is the most common feature of pediatric intracranial aneurysm with good clinical grade.

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Microsurgical clipping is safe and effective in treatment of pediatric intracranial aneurysms.

Introduction

Pediatric intracranial aneurysms are rare, with some different characteristics from those in adults. Here, we present a case of distal anterior cerebral artery aneurysm which we believe the first case from Vietnam.

Presentation of case

A 3 years old boy presented with headache, lethargic and hemiparesis was diagnosed ruptured distal anterior cerebral artery aneurysm with CTA. 10 days before admission in our hospital, the toddler was admitted in local hospital with diagnosis of SAH without more accurate findings. Clipping microsurgery of aneurysms with left interhemispheric approach was done with good outcome.

Discussion

The epidermiology, presentation and diagnosis and strategy of treatments as well as their outcomes were discussed. We also discussed our thoughts about our case within the limited-resource condition such as in Vietnam.

Conclusion

Pediatric intracranial anerusyms are rare but should be recognised in neurosurgical practice. Surgery is an effective treatment method.

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.

Advanced multimodality neuroimaging of a giant, thrombosed MCA aneurysm complicated by an acute stroke in a pediatric patient

A 17-year-old boy presented to our quaternary hospital because of acute mental status changes following prolonged gastrointestinal illness resulting in dehydration. Neuroimaging studies with computed tomography and magnetic resonance imaging (MRI) revealed a giant thrombosed aneurysm of the left middle cerebral artery (MCA) with acute left MCA stroke. An ischemic penumbra was identified based upon the mismatch between diffusion weighted (DWI) and susceptibility weighted (SWI) MRI matching with the perfusion weighted imaging (PWI). On follow-up MRI, the core of ischemia as identified by DWI progressed into the ischemic penumbra identified by SWI. The patient had permanent moderate right hemiparesis and aphasia on last follow-up. In conclusion, thrombosis is a rare complication of a giant aneurysm in children. Advanced neuroimaging using the combination of DWI and noncontrast enhanced SWI is a valuable alternative or possibly adjunct to PWI to identify tissue at risk for progressing stroke.

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.

Impact of Young Age on the Presentation of Saccular Intracranial Aneurysms: Population-Based Analysis of 4082 Patients

BACKGROUND

Formation and rupture of saccular intracranial aneurysms (sIAs) may have different pathobiologies in patients with younger age at first diagnosis of sIA disease.

OBJECTIVE

To study the phenotype of sIA disease and formation of new (de novo) sIAs in patients below 40 yr.

METHODS

A population-based cohort study was conducted in 613 young (<40 yr) sIA patients with first diagnosis between 1980 and 2014 and total angiographic follow-up of 3768 yr.

RESULTS

Of the 613 sIA patients <40 yr, 508 had aneurysmal subarachnoid hemorrhage (sIA-SAH) and 105 unruptured sIA(s) at first sIA diagnosis. Hypertension was 2 times less common among <40 than >40-yr-old patients (unruptured and ruptured). Smoking was very prevalent in <40-yr-old patients (33% in SAH, 68% unruptured). SAH patients <40 yr more often had family history of sIA, and lower PHASES scores (age omitted, P < .001). Ruptured sIAs were small (<7 mm) in 33% of 39 to 30 yr patients, in 44% of 29 to 20 yr patients, and 57% of <19 yr patients. Their shape was irregular in 90%, 94%, and 95%, respectively. Smoking history (hazard ratio [HR] 2.8, 95% confidence interval [CI] 1.2-7.0), family history for sIAs (HR 3.1, 95% CI 1.3-7.7), and age at presentation (HR .91 per year, 95% CI .85-.98) were risk factors for de novo sIA formation, diagnosed in 4% even after 20 yr (median 11.8 yr).

CONCLUSION

Smoking and family history are risk factors for sIA formation and aneurysmal SAH at young age. Young aneurysmal SAH patients had lower PHASES scores and often rupture from a small sIA, suggesting need for more aggressive management.

Paediatric intracranial aneurysms: a British institutional review

INTRODUCTION

Paediatric intracranial aneurysms are rare, with a differing natural history and thought to account for only up to 7% of all intracranial aneurysms. There is much uncertainty that surrounds the prevalence of unruptured intracranial aneurysms and it is estimated to be anywhere between 2 and 90 per 1000. This is the largest British single-centre analysis of paediatric intracranial aneurysms. We present the patient course from their initial presentations to the outcome of treatment and evaluate a serial assessment of adequacy of aneurysmal obliteration radiologically.

RESULTS

Twenty-two paediatric cases were identified that required treatment. The median age of presentation was 11.3 years (mean 9.9, range 0 to 15.9), 68% (15/22) were male and 77% (17/22) were ruptured on presentation. The majority of aneurysms were located at the anterior circulation (77% (17/22)). The overall median aneurysm size (n = 21) was 7.4 mm (mean 5 mm, range 2.5-19 mm). Twenty patients survived the acute phase and 80% (16/20) underwent coil embolisation and the other patients' surgical clipping. The overall outcomes were available for the 20 patients; on discharge, 90% (18/20) had a favourable clinical outcome (GOS score of 3-5). Treatment-specific clinical favourable outcomes were 88% (14/16) for coil embolisation against 100% (4/4) after surgical clipping. Of the two patients that died in the acute phase, one had sickle cell anaemia. Aneurysm aetiology was unknown in all other cases. None of the patients had a family history of aneurysms.

CONCLUSION

Paediatric intracranial aneurysms while rare should be considered a differential diagnosis of children presenting with unexplained loss of consciousness with or without focal neurological deficit and/or headache. There is a two to one preponderance for males with a larger proportion of aneurysms within the posterior circulation (25%). Coil embolisation is the preferred method of securing a paediatric intracranial aneurysm.

Trends in the Incidence and Treatment of Cerebrovascular Diseases in Korea : Part I. Intracranial Aneurysm, Intracerebral Hemorrhage, and Arteriovenous Malformation

Objective

To analyze the incidence and treatment trends of hemorrhagic stroke (HS), according to HS subtypes, using nationwide data in Korea from January 2008 to December 2016.

Methods

We used data from the national health-claim database provided by the National Health Insurance Service for 2008–2016 using the International Classification of Diseases. The crude incidence and age-standardized incidence of each disease associated with HS, which included intracranial aneurysm (IA), hypertensive intracerebral hemorrhage (ICH), and arteriovenous malformation (AVM), were calculated and additional analysis was conducted according to age and sex. Changes in trends in treatment methods and number of treatments were analyzed for each cerebrovascular disease using the Korean Classification of Diseases procedure codes.

Results

In 2016, the total number of newly diagnosed adult patients with HS was 24169, showing a decrease by 7.0% since 2008; the age-standardized incidence of HS was 46.2 per 100000 person-years. The age-standardized incidence of unruptured IA (UIA) in adults was 71.4 per 100000 person-years—increased by 2.6-fold since 2008—while that of ruptured IA (RIA) was 12.6 per 100000 person-years, which had decreased at a rate of 20.3% since 2008. The number of coil embolization (CE) for UIA increased by 3.4-fold over 9 years and exceeded that of clipping since 2008. With respect to RIA, CE increased by 2.0-fold over 9 years and exceeded that of clipping from 2014. As for spontaneous ICH in adults, the age-standardized incidence was 31.3 per 100000 person-years in 2016—decreased by 34.7% since 2008—and 14.6% of patients diagnosed with ICH were treated in 2016, which was not significantly different from the proportion of patients treated since 2008. The age-standardized incidence of unruptured AVM (UAVM) was 2.0 per 100000 person-year in 2016, while that of ruptured AVM (RAVM) was 2.4 per 100000 person-years in 2016, showing a decreasing rate of 17.2% from 2008. The total number of treated patients with AVM declined since 2014.

Conclusion

In Korea, age-related cerebral vascular diseases, such as RIA, ICH, and RAVM, demonstrated a declining trend in agestandardized incidence; meanwhile, UIA and UAVM demonstrated an increased trend in both crude incidence and age-standardized incidence for 9 years. The increase in the elderly population, management of hypertension, and development of diagnostic and endovascular techniques appear to have influenced this trend.

Pediatric Intracranial Aneurysms: Favorable Outcomes Despite Rareness and Complexity

OBJECTIVE

Pediatric intracranial aneurysms (IAs) are rare and differ from their adult counterparts in terms of their aneurysmal characteristics, presentation, treatment, and outcomes. Their treatment is often more difficult and complex compared with that of adults. However, studies outlining the clinical effect of pediatric IAs remain sparse.

METHODS

We retrospectively reviewed the data from patients aged ≤18 years admitted to our hospital from 2000 to 2017 with a diagnosis of IAs.

RESULTS

From the sample of 8207 patients with an IA diagnosis, 26 patients with 33 IAs were involved. Our cohort included 17 males and 9 females, with a mean age of 12.5 years. The mean follow-up duration was 4 years and 3 months. Seven patients (26.92%) were assumed to have a traumatic origin for their IAs. Ruptured aneurysms were more common than unruptured ones (61.53% vs. 38.46%). Complex features were observed in 14 aneurysms (42.42%). Initially, microsurgical and endovascular treatment were both performed in 10 patients (38.46%). A good recovery was obtained in 16 patients (61.54%) as determined by the Glasgow outcome scale scores at the 6-month follow-up visits. The complete obliteration of aneurysms was observed in 17 patients (65.38%). Endovascular treatment was the initial treatment in 3 patients with incomplete obliteration.

CONCLUSIONS

The treatment of pediatric IAs is challenging and technically demanding owing to their discrete nature compared with adult IAs and the need for greater surgical skills. We found a male predominance, with internal carotid artery bifurcation as the most frequent location of the aneurysms. Despite the greater incidence of ruptured and complex aneurysm cases, many patients had experienced a good recovery at the 6-month follow-up examinations.

Pediatric intracranial aneurysms in Senegal: a series of 10 cases treated in unfavorable socio-economic conditions

OBJECTIVE

The aim of this study is to show the characteristics of pediatric intracranial aneurysms in a sub-Saharan country and to analyze the results of treatment in this challenging medical environment.

METHOD

The authors reviewed retrospectively ten patients ≤ 18 years old between May 2013 and December 2016 in Neurosurgery department of Fann Hospital in Dakar. For each child, clinical features, radiological findings, and outcome were determined with mean follow-up of 22 months.

RESULTS

Ten children were treated for intracranial aneurysm including four boys and six girls. Two patients had evolutive infectious endocarditis with rheumatic heart disease at the time of diagnosis. Neurological signs of deficiency were present in six patients (WFNS ≥ 3). The diagnosis of aneurysm was made by CT angiography in all patients, and in two of them respectively arteriography and angioMRI were performed in complement. The aneurysm was on the middle cerebral artery in six patients, on the internal carotid artery in two others, anterior communicating artery in another, and the last one was located on the anterior cerebral artery on its 3rd segment. The treatment of the aneurysm was surgical in seven patients and endovascular in one of them. The postoperative course was excellent in two patients and good in the five patients. No postoperative worsening was noted. One child died 4 months in the postoperative course from acute cardiac deterioration.

CONCLUSIONS

In Senegal, pediatric aneurysms represent about 8.3% of all intracranial aneurysms. They are most often located on the MCA and have commonly fusiform shape. Despite difficult treatment conditions, overall outcome was good.

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.

Pediatric intracranial distal arterial aneurysms: report of 35 cases

BACKGROUND

Although research on pediatric intracranial aneurysms is well documented, studies of pediatric intracranial distal arterial aneurysms (PIDAAs) remain scarce.

METHODS

All pediatric patients (≤ 18 years) with intracranial aneurysms located distally to the M2 segment of the middle cerebral artery (MCA), A2 segment of the anterior cerebral artery, P2 segment of the posterior cerebral artery, and other cerebral arteries distal to the main branch who were treated at our center between January 2012 and April 2017 were retrospectively reviewed.

RESULTS

Thirty-five PIDAAs were observed in 35 patients with a mean age of 9.2 ± 5.9 years and a male ratio of 71.4% (n = 25). Sudden onset of severe headache was the most common symptom (n = 22, 62.9%), followed by seizures (n = 21, 60%). Twenty-seven patients (77.1%) had ruptured aneurysms, and 18 of them (66.7%) exhibited combined lobe intracerebral hematoma. MCA was the most common site (n = 23, 65.7%). Large or giant aneurysms were observed in 16 patients (45.7%). Eight patients (22.9%) had pseudoaneurysms, six of whom (75%) reported a head trauma history. Thirty patients (85.7%) had favorable outcomes at the end of the 6-month follow-up. Kaplan-Meier 6-month seizure curves revealed a significantly higher decrease in seizure rates in the surgical group than in the endovascular group (P = 0.036).

CONCLUSIONS

PIDAAs constitute a high proportion of pediatric intracranial aneurysms. PIDAAs are associated with an increased risk of seizures, a predilection for the MCA, and a high incidence of pseudoaneurysms with head trauma history. Surgical intervention is of greater benefit than endovascular treatment in controlling the risk of seizures.

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.

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.

Paediatric vertebral artery aneurysms: a literature review

Vertebral artery (VA) aneurysms in the paediatric population are a rare but a serious condition. However, the epidemiology of paediatric VA aneurysms is poorly understood and there is little consensus on what constitutes the appropriate treatment. Although multiple treatment options are available, including surgery, endovascular approaches, coil embolization and parent artery occlusion, there is limited clinical evidence regarding which approach is most optimal. This review outlines the current literature and evidence outlining the epidemiology, presentation, pathogenesis and treatment of paediatric VA aneurysms.

Treatment for Spontaneous Intracranial Dissecting Aneurysms in Childhood: A Retrospective Study of 26 Cases

OBJECTIVE

This study aimed to assess the clinicoradiological features and treatment outcomes of intracranial dissecting aneurysms (IDAs) in childhood.

METHODS

We conducted a retrospective study of pediatric patients who were treated for spontaneous IDAs in our institute between January 2010 and December 2015. The clinical presentation, aneurysm characteristics, treatment modality, and outcome were studied.

RESULTS

We studied 26 pediatric patients (mean age, 13.4 years; range, 4-18 years) with 31 IDAs who comprised 6.9% of all IDA patients treated during the same period. Seventeen (65.4%) patients were males, and nine (34.6%) were females. The incidence of large (≥10 mm in size) or giant aneurysms (≥25 mm in size) was 65.5%. Twenty-one (80.8%) patients underwent endovascular or surgical treatment and five (19.2%) received conservative treatment. Perioperative complications occurred in three patients, in whom two eventually recovered completely with a Glasgow Outcome Scale (GOS) score of 5 and one partially recovered with a GOS score 4. Overall, 25 (96.2%) patients had a favorable outcome and one (3.8%) had an unfavorable outcome at a mean follow-up of 22.8 months (range, 6-60 months).

CONCLUSION

Pediatric IDAs are rare. In this series, endovascular management was a relatively safe and effective method of treatment for pediatric IDAs. However, continued follow-up is required because of the possibility of aneurysm recurrence and de novo aneurysm formation after treatment.

Flow Diverters in the Treatment of Pediatric Cerebrovascular Diseases

BACKGROUND AND PURPOSE

There is very limited data concerning utilization of flow diverters in children. Our aim is to report results for the treatment of complex intracranial aneurysms and carotid cavernous fistulas by using flow diverters in children.

MATERIALS AND METHODS

Retrospective review of children (17 years of age or younger) treated with flow diverters between May 2011 and July 2014 was performed. Clinical and laboratory data and angiographic findings were extracted. Seven patients (6 males, 1 female; mean age, 12.7 years; range, 3-16 years) were included. Two presented with posttraumatic fistulas. The remaining patients presented with traumatic aneurysms of the cavernous carotid artery or fusiform aneurysms of the distal vertebral artery, M1, or A2 segments. All patients were premedicated with clopidogrel (75 mg daily for patients with body weights of >45 kg, 37.5 mg daily for 1 small child with a body weight of <45 kg) and aspirin (300 mg daily for ≥45 kg, 100 mg daily for smaller children).

RESULTS

VerifyNow and Multiplate Analyzer values were higher than expected. No clinical complications were noted. Imaging performed at 7-52 months after the procedure (mean/median, 22.3/14 months) revealed occlusions of all aneurysms and fistulas. One patient had an asymptomatic occlusion of the parent artery; otherwise, no hemodynamically significant parent artery restenosis was observed. There were no clinically significant neurologic events during follow-up.

CONCLUSIONS

Although flow-diverter placement appears to be safe and effective on midterm follow-up in children, longer follow-up is critical. The current sizes of flow diverter devices and delivery systems cover the pediatric size range, obviating developing flow diverters specific to children.

Factors Predicting Poor Outcome in a Surgically Managed Series of Multiple Intracranial Aneurysms

OBJECTIVE

Multiple factors are known to influence outcomes in single-aneurysm subarachnoid hemorrhage, such as Hunt and Hess (H&H) grade, hypertension, etc. We sought to assess the influence of individual risk factors on outcome in surgically managed patients with multiple intracranial aneurysm.

METHODS

A retrospective review of consecutive 780 patients of subarachnoid hemorrhage revealed multiple intracranial aneurysm in 63 patients with 146 aneurysms. Clinicoradiologic features, hospital course, and outcome obtained via use of the Glasgow Outcome Score were noted from hospital records. H&H grade was divided into 2 groups as good and poor whereas Glasgow Outcome Score at 1 month was divided into 2 groups as favorable and unfavorable for analysis. To test association among variables, a χ(2) test/Fisher exact test was used. Risk was calculated in exposure group by the use of univariate logistic regression and multivariate analysis (binary logistic regression model).

RESULTS

A definite female preponderance was observed (male/female ratio: 1:2.71). The most common site was middle cerebral artery bifurcation (overall and male patients, n = 43); in women, it was internal carotid artery bifurcation. Anterior communicating artery aneurysm was the most common to bleed (n = 22). Early presentation resulted in worse outcomes (<4: 4-21: >21days = 44:37:33, P = .844). Vasospasm and infarct incidence was greatest in the group 4-14 days (n = 37). Infarct evolved in 15 patients (8 in territory of aneurysmal dissection/distribution). Factors influencing patient outcomes were age ≥65 years (P = 0.037), H&H grade (P = 0.04), posterior communicating artery distribution of aneurysm (P = 0.03), hypertension (P = 0.03), infarct (P = 0.001), and hydrocephalus (P = 0.01) CONCLUSIONS: Poor H&H grade, hypertension, posterior communicating artery distribution, elderly age, infarct, and hydrocephalus each influenced poor outcomes at 1 month. Hydrocephalus is predictive of poor outcome.

Extent of collateralization predicting symptomatic cerebral vasospasm among pediatric patients: correlations among angiography, transcranial Doppler ultrasonography, and clinical findings

OBJECT

Although the development and prevalence of cerebral vasospasm (CV) has been extensively investigated in adults, little data exist on the development of CV in children. The authors hypothesized that even though children have highly vasoreactive arteries, because of a robust cerebral collateral blood flow, they rarely develop symptomatic CV.

METHODS

The authors retrospectively reviewed their university hospital's neurointerventional database for children (that is, patients ≤ 18 years) who were examined or treated for aneurysmal or traumatic subarachnoid hemorrhage (SAH) during the period 1990-2013. Images from digital subtraction angiography (DSA) were analyzed for the extent of CV and collateralization of the cerebral circulation. Results from transcranial Doppler (TCD) ultrasonography were correlated with those from DSA. Cerebral vasospasm on TCD ultrasonography was defined according to criteria developed for adults. Clinical outcomes of CV were assessed with the pediatric modified Rankin Scale (mRS).

RESULTS

Among 37 children (21 boys and 16 girls ranging in age from 8 months to 18 years) showing symptoms of an aneurysmal SAH (comprising 32 aneurysms and 5 traumatic pseudoaneurysms), 17 (46%) had CV confirmed by DSA; CV was mild in 21% of these children, moderate in 50%, and severe in 29%. Only 3 children exhibited symptomatic CV, all of whom had poor collateralization of cerebral vessels. Among the 14 asymptomatic children, 10 (71%) showed some degree of vessel collateralization. Among 16 children for whom TCD data were available that could be correlated with the DSA findings, 13 (81%) had CV according to TCD criteria. The sensitivity and specificity of TCD ultrasonography for diagnosing CV were 95% and 59%, respectively. The time to CV onset detected by TCD ultrasonography was 5 ± 3 days (range 2-10 days). Twenty-five (68%) of the children had good long-term outcomes (that is, had mRS scores of 0-2).

CONCLUSIONS

Children have a relatively high incidence of angiographically detectable, moderate-to-severe CV. Children rarely develop symptomatic CV and have good long-term outcomes, perhaps due to robust cerebral collateral blood flow. Criteria developed for detecting CV with TCD ultrasonography in adults overestimate the prevalence of CV in children. Larger studies are needed to define TCD ultrasonography-based CV criteria for children.

Patterns of treatment and associated short-term outcomes of unruptured intracranial aneurysms in children

BACKGROUND

The rates and outcomes of treatments for intracranial aneurysms have not been exclusively determined within the pediatric population. We determined the rates of endovascular and microsurgical treatments for unruptured intracranial aneurysms (UIA) and associated rates of favorable outcome in patients aged <18 years.

METHODS

We analyzed data obtained as part of the Kids' Inpatient Database between 2003 and 2009 with primary diagnosis of UIA. Patients undergoing endovascular treatment were compared to those undergoing microsurgical treatment. We determined rates of intracerebral hemorrhage, subarachnoid hemorrhage, neurological complications, and favorable outcome.

RESULTS

There were 818 cases of UIA during the study period. A total of 111 patients (mean age 14 ± 6 years, 37.6 % female) underwent microsurgical treatment, and another 200 patients (mean age 13 ± 7 years, 42.5 % female) underwent endovascular treatment. A high rate of favorable outcome was observed in patients who received either treatment (microsurgical treatment 87.7 % versus endovascular treatment 91.6 %, p = 0.4). There was a trend towards a significantly shorter mean hospitalization stay among those who received endovascular treatment compared with microsurgical treatment (6 ± 12 versus 9 ± 11 days, p = 0.06). There was a significant trend towards higher utilization of endovascular treatment as opposed to microsurgical treatment from 2003 to 2009 (p = 0.02).

CONCLUSIONS

Although outcomes except for length of stay were comparable between endovascular treatment and microsurgical treatment patients, there was a trend towards higher utilization of endovascular treatment among children with UIAs from 2003 to 2009.

Pediatric intracranial aneurysms--our experience and review of literature

PURPOSE

Intracranial aneurysms in children are not as common as in adults and there are many differences in the etiology, demographic variables, aneurysm location, aneurysm morphological characteristics, clinical presentation, and outcome in pediatric and adult intracranial aneurysms.

METHODS

All children (≤18 years) suffering from intracranial aneurysm managed at our center from July 2001 through June 2013 were included in the study, and the details of these patients were retrieved from the computerized database of our hospital.

OBSERVATIONS

A total of 62 pediatric patients were treated for 74 aneurysms during the study period and constituted 2.3% of all intracranial aneurysms treated during the same period. The mean age at presentation was 13.5 years. Headache (82%) was the commonest presenting feature; other symptoms included seizures (21%), ictal loss of consciousness (27%), and motor/cranial nerve deficits (22.6%). Computed tomogram revealed subarachnoid hemorrhage in 58% of patients. Eighty-two percent of aneurysms were in anterior circulation. Sixty-seven percent of aneurysms were complex aneurysms. Fifty-eight percent of patients underwent surgical intervention while 30% underwent endovascular procedures. Twenty-one percent of the patients developed vasospasm. There was no postoperative mortality. Favorable outcome was seen in 72% of the patients.

CONCLUSIONS

Pediatric intracranial aneurysms are uncommon as compared to in adult patients. Seizures and cranial nerve involvement are seen more often as the presenting features in children. Posterior circulation aneurysms are more common in children, as are the internal carotid artery bifurcation aneurysms. There is high incidence of giant, posttraumatic, and mycotic aneurysms in children.

Intracranial aneurysm in childhood and interrupted aortic arch

BACKGROUND

Intracranial aneurysms are very rare in children. Headache and nausea/vomiting are the most prominent clinical findings. The only effective treatment is obliteration of aneurysm by surgical or endovascular techniques. Interrupted aortic arch is also a rare, congenital cardiovascular malformation characterized by the lack of continuity between the ascending and descending thoracic aorta. Aortic interruption is an uncommon cause of intracranial aneurysm. The course of disease is lethal unless effective collateral flow develops. Long-term survival may be possible with surgical repair.

METHOD

We report on a 17-year-old boy affected with interrupted aortic arch disease and associated multiple intracranial aneurysms. Both aneurysms clipped successfully. After patient had recovered, he referred to cardiovascular surgery for further treatment.

CONCLUSION

Surgical or endovascular obliteration remains the main therapy for intracranial aneurysms. Accompanying systemic diseases such as interrupted aortic arch challenge the management of both diseases.