Giant vertebral artery aneurysm in a child treated with endovascular parent artery occlusion and coil embolization

Therapeutic dilemmas regarding giant aneurysms of the intracranial vertebral artery causing medulla oblongata compression

BACKGROUND

Giant aneurysms of the intracranial vertebral artery are very rare cerebrovascular lesions. Due to the rarity of these aneurysms, we know little about them.

METHODS

We performed a systematic review of the English literature by searching the PubMed database. The inclusion criteria were as follows: (a) the full text was available and (b) complete clinical data were available.

RESULTS

A total of 45 articles were identified, containing 53 patients (53 aneurysms). The patients were aged from 5 to 77 years (48.8 ± 20.8 years). Four patients receiving conservative treatment died. The remaining 49 patients were divided into the aneurysm removal group (n = 17) and the aneurysm reserve group (n = 32). The outcomes of the 49 treated cases could be obtained in 45 cases, 31 of which (68.9%, 31/45) had a Glasgow outcome scale score of 4-5.

CONCLUSIONS

It is still difficult to treat intracranial giant vertebral artery aneurysms, regardless of the treatment selected. Because of the malignant natural history, aggressive treatment is still advocated.

[Successful combination treatment of giant bicameral fusiform partially thrombosed vertebral artery aneurysm at 12-year-old patient (practical case and literature review)]

Giant cerebral aneurysms are diagnosed more often in children than in adults. Treatment of giant aneurysms is carried out both by endovascular and microsurgical methods. Literature information on combination of microsurgical and endovascular operations of cerebral aneurysms at children is little. A clinical case of the combined treatment of a giant bicameral fusiform partially thrombosed aneurysm of the right vertebral artery at a 12-year-old patient and a literature review on this topic are presented. The patient underwent several complex neurosurgical interventions during two operations: 1) microsurgery including revascularization of the right posterior lower cerebellar artery, thrombectomy and trapping of the larger chamber of fusiform aneurysm of the right vertebral artery, and 2) endovascular, which consists in the installation of redirecting stent from the left vertebral artery to main artery. The uniqueness of the case which we presented lies in the fact that the tactics of stage combined treatment for a complex aneurysm at child was originally planned and successfully implemented. The treatment allowed to ensure a complete shutdown of aneurysm and to exclude postoperative cerebral complications.

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.

[Giant vertebral artery aneurysm in a pediatric patient]

OBJECTIVE

To describe the case of a pediatric patient with a giant vertebral artery aneurysm treated with microsurgical clipping.

MATERIALS AND METHODS

Sixteen patients were treated in our institution in the past 5 years. Only two cases were vertebral artery aneurysms. We describe the case of an 11-year-old patient with history of hiccups episodes. He also complained of horizontal diplopia. Magnetic resonance angiography and digital subtraction angiography (DSA) were performed to assess diagnosis. We decided to perform a modified far-lateral approach without condyle drilling to surgically clip the lesion. There was complete resolution of symptoms and DSA showed aneurysm completely occluded.

CONCLUSION

Giant vertebral artery aneurysm treatment required to exclude the lesion permanently and diminish mass effect. Surgical clipping is an effective option to assure permanent exclusion of circulation and complete resolution of the lesion.

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.