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

Ruptured Middle Cerebral Artery Aneurysm in an Infant: Case Report and Literature Review

Intracranial aneurysms (IA) in infants are reportedly rare at 0.5% to 4.5% of all aneurysms. Furthermore, subarachnoid hemorrhage in infants younger than three months are even rarer as it has been reported in approximately 20 cases only till date. A 3-month-old infant with seizures and impaired consciousness was admitted to our hospital. Three-dimensional computed tomography angiography (3D-CTA) revealed a dissecting aneurysm with a maximum diameter of 13 mm in the right M2. Internal trapping using detachable coil were successfully performed, following which he was discharged without significant neurological deficit after one month of onset. Thus, we have reported a rare case of a large ruptured dissecting IA in a 3-month-old infant, in the right middle cerebral artery (MCA), successfully treated with an endovascular therapy, along with a literature review.

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.

Extracranial-intracranial bypass in a neonate with multiple ruptured middle cerebral artery aneurysms: illustrative case

BACKGROUND

Reports of ruptured neonatal aneurysms are rare in neurosurgical literature. Pediatric aneurysms differ from adult aneurysms, notably in morphology, size, number, and risk of rerupture. Many authors report experience with clipping, citing durability and decreased use of radiation as benefits over endovascular intervention. Few authors report extracranial-to-intracranial bypass because small pediatric vessels make this option challenging. The authors discussed a case of a newborn with multiple ruptured aneurysms, one of the youngest reported cases involving extracranial-intracranial bypass.

OBSERVATIONS

A 3-week-old baby presented with hemorrhage from multiple complex middle cerebral artery (MCA) aneurysms. Because of young age, endovascular intervention was not possible; therefore, the patient received craniotomy. Upon exploration, clip reconstruction was impossible; the vessel was trapped, and superficial temporal artery (STA)-MCA bypass was performed. The recipient vessel diameter was 0.3 mm. The postoperative course was complicated by seizures as well as symptomatic vasospasm, which was treated with intraarterial verapamil and ventriculostomy. At last follow-up, the patient was developing normally and was ambulatory with minimal deficit.

LESSONS

This case, one of the youngest patients reported, highlighted details of pediatric aneurysm management, such as propensity for multiple/fusiform aneurysms and high risk of re-hemorrhage, with significant mortality. The authors recommended aggressive, early intervention in pediatric aneurysms at centers with surgeons familiar with both endovascular intervention and cerebral bypass.

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.

Clinical Characteristics and Microsurgery Treatment of Anterior Cranial Fossa Dural Arteriovenous Fistula

Anterior cranial fossa dural arteriovenous fistulas (DAVFs) represent 6% of all intracranial DAVFs and have a high risk of intracranial hemorrhage. To analyze the clinical characteristics and microsurgery treatment of anterior cranial fossa DAVFs, a retrospective review of 21 patients with anterior cranial fossa DAVFs undergoing microsurgery was performed, including 8 bleeding patients and 13 non-bleeding patients. The Glasgow coma scale (GCS) scores were used to evaluate the conscious states of 8 bleeding patients before and after operation. All patients had no obvious complications and the clinical symptoms were improved after operation. No abnormal fistulas and drainage veins were detected by digital subtraction angiography postoperatively. The GCS scores of 8 bleeding patients showed that the conscious states became better than pre-operation. Of the 21 patients, 9 patients were followed up without recurrence. Taken together, microsurgery is an effective method for the treatment of anterior cranial fossa DAVFs and it is very important for the improvement of bleeding patients' conscious states.

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.

Pipeline-assisted coil embolization of a large middle cerebral artery pseudoaneurysm in a 9-month-old infant: experience from the youngest flow diversion case

Intracranial aneurysms in the pediatric population are rare entities. The authors recently treated a 9-month-old infant with a 19-mm recurrent, previously ruptured, and coil-embolized left middle cerebral artery (MCA) pseudoaneurysm, which was treated definitively with single-stage Pipeline-assisted coil embolization. The patient was 5 months old when she underwent resection of a left temporal Grade 1 desmoplastic infantile ganglioglioma at an outside institution, which was complicated by left MCA injury with a resultant 9-mm left M1 pseudoaneurysm. Within a month, the patient had two aneurysmal rupture events and underwent emergency craniectomy for decompression and evacuation of subdural hematoma. The pseudoaneurysm initially underwent coil embolization; however, follow-up MR angiography (MRA) revealed aneurysm recanalization with saccular enlargement to 19 mm. The patient underwent successful flow diversion-assisted coil embolization at 9 months of age. At 7 months after the procedure, follow-up MRA showed complete aneurysm occlusion without evidence of in-stent thrombosis or stenosis. Experience with flow diverters in the pediatric population is still in its early phases, with the youngest reported patient being 22 months old. In this paper the authors report the first case of such a technique in an infant, whom they believe to be the youngest patient to undergo cerebral flow diversion treatment.

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.

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.

Radiologic Characteristics and High Risk of Seizures in Infants with Ruptured Intracranial Aneurysms: Case Report and Review of the Literature

OBJECTIVE

To evaluate the parameters related to the high risk of preoperative seizures in infants (1 year or younger) with ruptured intracranial aneurysms.

METHODS

Infants with ruptured intracranial aneurysms treated at our institution from January 2012 to January 2018 were retrospectively analyzed. Seventeen similar cases of infant patients with seizures reported in published studies were reviewed.

RESULTS

The mean age of the 7 infant patients treated at our institution was 4.1 ± 3.3 months (range, 28 days to 11 months), with 2 male and 5 female subjects. One patient (14.3%) had an internal carotid artery aneurysm with subarachnoid hemorrhage, and the remaining 6 patients (85.7%) had middle cerebral artery (MCA) aneurysms in the distal arterial region with lobe hemorrhage. Five of the 7 infants (71.4%) had seizures, 4 of whom (4/5, 80.0%) had MCA distal arterial aneurysms with lobe hemorrhage. Management was successful for all patients with aneurysm clipping or resection surgery, and one patient experienced postoperative seizures. Of the 17 reviewed cases of infant patients with seizures, 10 patients (58.8%) exhibited the typical distal arterial aneurysm with lobe hemorrhaging, and 6 (60%) of them had aneurysms in MCA.

CONCLUSIONS

Infant patients with ruptured intracranial aneurysms have a high risk of preoperative seizures. The typical radiologic finding of distal arterial aneurysm with lobe hemorrhage was frequently observed in the MCA, and it might be related to the high risk of preoperative seizures in this population. Microsurgical techniques effectively control postoperative seizures in infants with ruptured intracranial aneurysms.

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.