Childhood subarachnoid hemorrhage associated with fibromuscular dysplasia

Pediatric primary intraventricular hemorrhage: A case report of isolated fourth ventricle hemorrhage in a 10-year-old boy

Key Clinical Message

Primary intraventricular hemorrhage (PIVH) is a rare condition in pediatric patients, presenting with headache, vomiting, and altered mental status. Surgical interventions, such as external ventricular drain placement, followed by ventriculoperitoneal shunting, show promising outcomes. Further research is needed to enhance understanding and optimize management strategies for pediatric PIVH.

Abstract

This case report describes a 10-year-old boy with isolated primary intraventricular hemorrhage (PIVH) in the fourth ventricle, shedding light on its clinical presentation and management challenges. The patient presented with headache, vomiting, and altered sensorium, and was subsequently diagnosed with obstructive hydrocephalus due to intraventricular bleeding. Emergency external ventricular drain (EVD) insertion was performed, followed by ventriculoperitoneal shunt placement, resulting in a favorable outcome. The etiology of PIVH in children differs from that in adults, with arteriovenous malformations, Moyamoya disease, and aneurysms being commonly implicated causes. Management strategies for pediatric PIVH are challenging due to limited research, but EVD placement and surgical interventions have shown promise.

Internal Trapping of a Growing Ruptured Dissecting Aneurysm of the A1 Segment: A Case Report and Literature Review

A 47-year-old man presented with sudden-onset headache and Fisher group 3 subarachnoid hemorrhage. The World Federation of Neurological Surgeons grade was II. Digital subtraction angiography (DSA) only showed a vessel wall irregularity in the A1 segment of the right anterior cerebral artery (ACA), but an obvious bleeding source was not detected. Repeat angiography showed a tiny aneurysmal dilatation in the A1 segment with an intimal flap. The aneurysm enlarged on subsequent angiograms. Dissecting aneurysm was diagnosed, and the patient underwent internal trapping of the A1 segment to prevent rerupture. Postoperative DSA showed complete obliteration of the dissected segment. Magnetic resonance imaging showed a clinically silent cerebral infarction in the territory of the A1 segment perforators. Parent vessel occlusion for a dissected A1 segment can be effective, provided that sufficient collateral blood flow from the contralateral ACA is observed. We recommend endovascular trapping in this setting and hope that fellow clinicians select this approach for this rare pathology.

Indocyanine Green Videoangiography for Surgery of a Ruptured Dissecting Aneurysm in the Precommunicating Anterior Cerebral Artery: A Technical Case Report

BACKGROUND AND IMPORTANCE

Indocyanine green videoangiography (ICG-VA) is an important intraoperative adjunct for saccular aneurysm surgery, but its efficacy in surgery for dissecting aneurysms has rarely been reported. The authors describe the usefulness of preclipping ICG-VA in a rare case of a ruptured dissecting aneurysm located at the precommunicating (A1) segment of the anterior cerebral artery.

CLINICAL PRESENTATION

A 52-year-old woman, with no history of connective tissue diseases or vascular disorders, presented with sudden headache and convulsion. The CT scan showed that the patient had subarachnoid hemorrhage. Angiography showed a dissecting aneurysm in the left A1 segment of the anterior cerebral artery. Thus, the patient underwent trapping of the dissecting aneurysm. ICG-VA was used as an intraoperative adjunct before and after clipping. The preclipping ICG-VA showed the heterogeneously bright dissecting aneurysm and branching arteries even in the presence of hematoma.

CONCLUSION

Preclipping ICG-VA may enhance the advantage of direct surgery for dissecting aneurysm by allowing visualization of the extent of the dissected vascular wall and the related branching arteries. ICG-VA can be an indispensable adjunct to minimize the compromise from the surgical treatment for intracranial dissecting aneurysms.

Low frequency of cervicocranial artery involvement in Japanese with renal artery fibromuscular dysplasia compared with that of Caucasians

BACKGROUND

Fibromuscular dysplasia (FMD), which usually affects the renal artery, also affects the carotid, vertebral, and intracranial arteries. Previous studies have shown a high prevalence of concomitant renal artery and cervicocranial lesions in FMD patients. However, the analyzed subjects were mostly Caucasians in Western countries.

METHOD

We performed a retrospective analysis to examine the prevalence of cervicocranial vascular lesions in Japanese FMD patients with renal artery involvement at a single institution. The presence of cervicocranial lesions was evaluated by Doppler echography and magnetic resonance angiography. We compared this prevalence with that reported in the literature.

RESULT

Thirty-one Japanese FMD patients with renal artery lesions were studied. The mean age was 30 ± 12 years, 71% were women, and 16% were smokers; all patients were Asians and had hypertension. Multifocal, tubular, and unifocal types of renal lesions were found in 52, 35, and 13% of patients, respectively. Bilateral renal lesions were found in 13% of patients. None of the patients had a cervical vascular lesion associated with FMD. Only two patients (8%) had a lesion in the intracranial artery, of which one was a known case of moyamoya disease.

CONCLUSION

These findings suggest that cervical artery involvement and intracranial artery involvement are not common in renal FMD patients in Japan, which is in contrast to the data reported for Caucasian patients in Western countries. Ethnic differences could influence the occurrence of cervicocranial lesions. A study with a larger sample size should be performed to validate these findings.

Ruptured dissecting aneurysms of the A1 segment of the anterior cerebral artery: three case reports and a review of the literature

Dissecting aneurysms in the anterior cerebral artery (ACA), although rare, can cause ischemic and/or hemorrhagic stroke. Hemorrhagic dissecting aneurysms in the A1 portion of the ACA are often associated with a poor prognosis. We retrospectively investigated three rare cases of hemorrhagic dissecting aneurysms in the A1 portion. Dissecting aneurysms were diagnosed by carotid angiography or computed tomography angiography to visualize morphological changes in the vessel. All patients presented with diffuse subarachnoid hemorrhage. In one case, computed tomography angiography performed at the onset of the subarachnoid hemorrhage revealed fusiform dilatation at the right ACA (A1), which did not appear on a magnetic resonance angiogram obtained 1 year prior to the onset of the subarachnoid hemorrhage. In the other two cases, A1 dissecting aneurysms were diagnosed from a growing aneurysmal bulge revealed at a non-bifurcated site via repeated carotid angiography. Two patients underwent surgical intervention (trapping or clipping), and their outcome was favorable, whereas the third patient died of delayed rebleeding before receiving surgical treatment. Hemorrhagic dissecting aneurysms in the A1 portion cause severe subarachnoid hemorrhage. Surgical treatments that include revascularization are necessary to prevent rebleeding, and direct surgery is recommended, particularly at the A1 portion.

Fibromuscular Dysplasia Complicated With Cerebral Stroke in a Child With Congenital Dyserythropoietic Anemia Type II

Congenital dyserythropoietic anemia type II belongs to a subtype of bone marrow failure syndrome, which is characterized by monolineage involvement and typical morphologic abnormalities in erythroid precursor cells resulting in different degrees of hyporegenerative anemia. Moreover, reticulocytosis, which is not corresponding to the degree of anemia, with jaundice and splenomegaly are major diagnostic criteria. Causative gene is located at SEC23B. Although stroke among children is rare, it can cause significant morbidity and mortality. Herein we present a 3-year-old male with congenital dyserythropoietic anemia type II who presented with stroke-like symptoms, and was diagnosed with fibromuscular dysplasia.

Fibromuscular Dysplasia of Cervical and Intracranial Arteries

Fibromuscular dysplasia is an uncommon, segmental, nonatherosclerotic arterial disease of unknown aetiology. The disease primarily affects women and involves intermediate-sized arteries in many areas of the body, including cervical and intracranial arteries. Although often asymptomatic, fibromuscular dysplasia can also be associated with spontaneous dissection, severe stenosis that compromises the distal circulation, or intracranial aneurysm, and is therefore responsible for cerebral ischaemia or subarachnoid haemorrhage. Fibro-muscular dysplasia affects middle and distal portions of the internal carotid and vertebral arteries, and occasionally, intracranial arteries. Several pathological and angiographic patterns exist. The most frequent pathological type is medial fibromuscular dysplasia, which is associated with the ‘string of beads' angiographic pattern. Unifocal lesions are less common and can be associated with several pathological subtypes. The pathophysiology of the disease is widely unknown. Fibromuscular dysplasia may in fact result from various causes and reflect a non-specific response to different insults. The poor knowledge of the natural history and the lack of randomised trials that compared the different treatment options do not allow any satisfactory judgement to be made regarding the need for or the efficacy of any treatment.

Intrathecal aspergillosis and fusiform arterial aneurysms in an immunocompromised child: a clinico-pathological case report

CASE REPORT

We describe a 12-year-old boy with subarachnoid hemorrhage. Cerebral angiography revealed multiple fusiform intracranial arterial aneurysms. Surgical therapy other than ventricular drainage was not feasible due to the extent and pattern of pathological changes. Aspergillus antigen was found in the cerebrospinal fluid (CSF). However, cultures of urine, CSF, and samples from the upper airways were negative for Aspergillus and other fungi. The boy was immunocompromised due to prophylactic antibiotic therapy for recurrent pneumonia and continuous steroid therapy for his hemolytic anemia. There were Aspergillus antigens but no evidence of ongoing infection with the fungus was found. The patient suffered recurrent intraventricular hemorrhage and died on the 31st day after admission.

PATHOLOGICAL EXAMINATION

Pathological examination showed multiple fusiform aneurysms, hypertrophy of the intima, and destruction of the internal elastic membrane of the cerebral arteries. No fungus infiltration was detected. We speculate that the patient had previously had an Aspergillus infection, causing segmental destruction of the internal elastic membrane. However, we cannot rule out noninfectious vasculitis as possible etiology.

CONCLUSIONS

In the immunocompromised child, fusiform segmental intracranial arterial aneurysms may be secondary to the destruction of the internal elastic membrane by fungus infection. The condition may present with aneurysm rupture and subarachnoid hemorrhage. In this patient group, surgical therapy is rarely an option and the prognosis is poor.

External Carotid Artery Aneurysm Developing After Embolization of a Ruptured Posterior Inferior Cerebellar Artery Aneurysm in a Patient With Cervicocephalic Fibromuscular Dysplasia-Case Report-

A 30-year-old man presented with an aneurysm of the left posterior inferior cerebellar artery manifesting as subarachnoid hemorrhage and cerebellar infarction. Angiography demonstrated string-of-beads sign typical of fibromuscular dysplasia (FMD) in the extracranial carotid and vertebral arteries. The aneurysm and the parent artery were successfully embolized with Guglielmi detachable coils. Severe vasospasm developed 1 week after admission, and was treated several times by selective injection of vasodilator. A new aneurysm of the left external carotid artery became evident 1 month later, whereas only slight dilation had previously been apparent. This angiographic sequence demonstrated a new arterial dissection. Despite the possibility of damage to the artery during multiple catheterizations, arterial wall changes caused by FMD appear to have been primarily responsible. This case emphasizes the need for particular care in performing vascular interventional procedures in the presence of FMD.

Cerebrovascular complications of fibromuscular dysplasia

Patients with cerebral ischemia or hemorrhage due to fibromuscular dysplasia (FMD) should be admitted to a monitored hospital bed and receive supportive stroke care. Based on our personal clinical experience, we recommend antiplatelet agents for future stroke prevention in patients with symptomatic FMD. In patients with watershed stroke due to hemodynamically significant FMD, our opinion is that hypertensive, hypervolemic therapy should be initiated immediately. Additionally, we suggest that potential revascularization therapies, such as intraoperative or primary percutaneous angioplasty, should be discussed.