Pediatric intracranial distal arterial aneurysms: report of 35 cases

A rare case of pediatric distal middle cerebral artery aneurysm

Pediatric middle cerebral artery aneurysms are often complicated by subsequent rupture and subarachnoid hemorrhage. Unruptured middle cerebral artery aneurysms are rare in infancy. Here, we present a rare case of a 13-month-old male who underwent clip ligation for the treatment of an incidental M3 aneurysm.

Combining Endovascular Coiling and Open Evacuation for a Delayed-Onset Ruptured Post-traumatic Pseudoaneurysm of the Distal Paracentral Pericallosal Artery Branch

Cerebrovascular pseudoaneurysm development and rupture is a rare, delayed sequelae of trauma. We present a case of a female patient in her sixties who presented after a fall without evidence of vascular injury on imaging. However, after one week, repeat imaging due to an abrupt change in mental status revealed a ruptured pseudoaneurysm, which was treated with a combination of coil embolization and open surgical evacuation of associated intracranial hematoma. This case illustrates the importance of continued surveillance beyond the acute traumatic period to identify late-onset complications in trauma patients requiring emergent treatment.

Intraparenchymal brain hemorrhage due to rupture of aneurysm in infants: report of two cases

Background

Cerebral or brain hemorrhage due to the rupture of intracranial aneurysms is extremely rare in pediatric population. The aim of our work is to describe two cases in children and to review the existent bibliography about this issue.

Case presentation

Both of our patients presented with nonspecific symptoms and subsequent neurological deficit. The brain imaging test revealed intraparenchymal hemorrhage. In both cases, the aneurysm was located at the distal portion of the middle cerebral artery. Surgical intervention was needed, clipping the aneurysm due to the impossibility of intravascular embolization. After the surgery, one patient presented with persistent hydrocephalus secondary to intraventricular hemorrhage, requiring the placement of a cerebrospinal fluid shunt. Over time, the child presented with refractory epilepsy compatible with West syndrome. The second patient did not present postoperative complications but died suddenly 2 months after.

Conclusions

Our two patients presented with a middle cerebral artery aneurysm at the distal level, which seems to be the most frequent location according to literature. The correct diagnosis can be delayed because of the nonspecific initial symptoms, as occurred in one of our patients with a delay of 3 days from the onset of symptoms. In both patients, surgical treatment was preferred over endovascular treatment, due to the anatomical characteristics of the aneurysm and the patient’s age.

Torpid evolution is also described, with one of our patients dying at 2 months, probably due to rebleeding, and the other suffering right hemiparesis and epilepsy compatible with West syndrome.

Clinical characteristics of intracranial aneurysms in elderly patents over 70 years old: a retrospective observational study

Background

Although the characteristics of intracranial aneurysms (IAs) in different age groups have been well documented, they remain relatively unclear in elderly patients due to a lack of large sample studies.

Methods

Data from IA patients aged more than 70 years who were treated in our centre from January 2016 to January 2020 were retrospectively collected.

Results

A total of 290 elderly patients (75.9% female) with a mean age of 74.0 ± 4.7 years were analysed. Rupture occurred in 60.7% of patients, 38.6% of whom presented with meningeal irritation, and seizures were noted in 2.3%. A total of 48.9% of the patients with ruptured IAs had initial symptoms presenting with slow development, and the mean delay from ictus was prolonged to 264.2 ± 914.0 hours. In addition, 61.9% of the patients with ruptured IAs had lesions with a maximum diameter of less than 5 mm. A total of 30.3% of the patients had multiple aneurysms, 35.5% had aneurysms with irregular shapes and 54.8% had cerebrovascular atherosclerotic stenosis (CAS). Pulmonary infection (n = 138, 47.6%), hydrocephalus (n = 72, 24.8%), and thrombosis (n = 35, 12.1%) were common complications during hospitalization. By the end of the 1-year follow-up, 22.1% of the patients had unfavourable clinical outcomes, and the mortality rate was 23.4%.

Conclusions

Several characteristics regarding IAs in elderly patients were reported, including an obvious female predominance; mild, slow initial symptom development causing prolonged admission delay; a low incidence of meningeal irritation and seizures due to decreased electrophysiological activity of the neurons; increased percentages of CAS, multiple aneurysms, and aneurysms with daughter sacs causing a high risk of rupture even for small lesions; a high risk of complications during hospitalization; and relatively poor clinical outcomes.

Risk factors for intracranial aneurysm rupture in pediatric patients

BACKGROUND

Intracranial aneurysm (IA) rupture in pediatric patients is a rare but fatal condition. Although risk factors for aneurysm rupture in adults have been well documented, they remain unknown in pediatric patients.

METHODS

Data for 94 pediatric patients with IAs were retrospectively analyzed. The patients were divided into ruptured and unruptured groups. Risk factors for aneurysm rupture were analyzed through univariable and multiple logistic regression analyses. Typical patients with risk factors were described.

RESULTS

Univariable analyses showed that the unruptured group had significantly higher percentages of giant aneurysms (43.2% vs 12.3%, P = 0.002), wide-neck aneurysms (67.6% vs 29.8%, P = 0.001), and aneurysms located in the internal carotid artery (40.5% vs 3.5%, P < 0.001), while the ruptured group had significantly higher percentages of patients younger than 5 years old (28.1% vs 5.4%, P = 0.013) and aneurysms located in the anterior cerebral artery (24.6% vs 5.4%, P = 0.032), posterior cerebral artery (14.0% vs 0%, P = 0.045), and distal arterial region (DAR) (46.8% vs 27.0%, P < 0.001). Multiple logistic regression analysis confirmed that age 0-5 years (OR = 6.844, P = 0.042) and IAs located in the DAR (OR = 4.162, P = 0.029) were independently related to an increased risk of rupture. Wide-necked aneurysms (OR = 0.235, P = 0.047) were independently associated with a lower risk of rupture.

CONCLUSIONS

Among pediatric patients, age younger than 5 years and lesions located in the DAR are independent risk factors for IA rupture, while an IA with a wide neck acts as a protective factor.

Reported incidence and treatment modalities of giant cerebral aneurysms in the pediatric population: A systematic review and illustrative case report

Giant intracranial aneurysms represent a complex pathology that pose challenges for management, especially in the pediatric population. With emerging endovascular techniques, combined endovascular and open surgical approaches may be a favorable alternative for complex cases. In this systematic review, we characterize the treatment modalities of giant aneurysms in the pediatric population and provide an update on the number of giant aneurysms reported in the literature by anatomic location. We conducted a literature search of PubMed, Embase, and Medline databases with the following terms: 'pediatric' AND 'giant' AND 'intracranial aneurysm.' Studies were included if data on treatment modality and aneurysm location were available for pediatric patients with giant intracranial aneurysms. The literature search yielded a total of 188 papers, with 82 pediatric patients from 33 articles ultimately meeting inclusion criteria. There were significantly more male than female patients (p = 0.011), with 52 and 29 respectively. Patients presenting with a ruptured aneurysm were significantly younger than patients presenting without rupture (p = 0.018), with a median age of 8.0 and 12.0 years, respectively. There were 45 giant aneurysms reported in the anterior circulation and 37 in the posterior circulation. Anterior aneurysms were most often treated with surgical approaches, while posterior aneurysms were typically treated with endovascular interventions (p = 0.002). Although combined surgical and endovascular approaches were the least frequently utilized, we suggest a combined approach may be particularly useful for patients with complex cases that require a management plan tailored to their needs.

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.

Onyx Embolization of a Distal Middle Cerebral Artery Pseudoaneurysm in a Five-Week-Old: A Case Report and Review of Current Treatment Options

Intracranial pseudoaneurysms secondary to traumatic birth are a rare finding in infants. Definitive diagnosis of such findings is challenging, and no standard management is delineated for management of pseudoaneurysms in the pediatric population. Commonly attempted treatments include endovascular embolization or surgical clipping. A 5-week-old female presented with a two day history of right hand focal seizures. The patient was found to have a dysplastic superficial intra-axial aneurysm arising from the distal left middle cerebral artery (MCA) branch in the setting of a left posterior frontal lobe hemorrhage noted on brain magnetic resonance imaging/magnetic resonance angiography (MRI/MRA). The patient underwent diagnostic cerebral angiogram demonstrating a left distal MCA pseudoaneurysm, which was treated with Onyx embolization. Post-embolization period was complicated by recurrent left central localized seizures and a left hemispheric temporoparietal hemorrhagic infarction. The patient was managed on levetiracetam, phenytoin, phenobarbital with stable seizure control. Herein, we highlight the youngest case to date of a 5-week-old infant with a left distal MCA pseudoaneurysm treated with Onyx embolization. Pseudoaneurysmal incidence, diagnosis and accepted management is discussed.

Posttraumatic cerebrovascular injuries in children. A systematic review

INTRODUCTION

Posttraumatic craniocervical vascular injuries in pediatric traumatic brain injury (TBI) are rare, and children-specific, evidence-based standards on screening and therapy of posttraumatic carotid-cavernous fistula (CCF), craniocervical artery dissections (CCAD), traumatic aneurysms (TA), and posttraumatic sinus venous thrombosis (SVT) is lacking. The aim of this review is to summarize the data on epidemiology, clinical presentation, and treatment of these traumatic lesions in a systematic manner.

METHODS

We performed a systematic PubMed search for records of CCF, CCAD, TA, and SVT related to pediatric TBI published until June 2019.

RESULTS

After screening 2439 records, 42 were included in the quantitative analysis. Incidences for CCAD in blunt TBI were 0.21% (range 0.02-6.82%). 11.7% (range 1.69-15.58%) of pediatric aneurysms were found to be traumatic of origin, whereas 38.2% (range 36.84-40%) of all pediatric SVT were due to blunt TBI. For all of the posttraumatic cerebrovascular pathologies, we found a clear male predominance with 68.75% in CCF, 63.4% in CCAD, 60% in TA, and 58.33% in SVT. Clinical presentation did not differ from the adult population with exception of young child. While there is only recommendation for the therapy of CCAD and SVT in the pediatric population, no such recommendation exists for the treatment of CCF's and TA's, and data from randomized controlled trials is lacking.

CONCLUSION

While these results show that posttraumatic CCF, CCAD, TA, and SVT are rarely encountered in children, misdiagnosis may have potentially drastic consequences due to a longer lifetime burden in the pediatric population. Awareness, early recognition, and prompt initiation of the appropriate therapy are essential to avoid morbidity and mortality. Further studies should focus on the development of clinical and radiological screening criteria of posttraumatic vascular lesions in children.

De novo distal middle cerebral artery aneurysm post-excision of intracerebral arteriovenous malformation in an 8-year old

Cerebral arteriovenous malformations (AVMs) are frequently associated with concurrent aneurysms. These aneurysms are commonly haemodynamically related to the AVM and can be classified into extranidal or intranidal in reference to the AVM nidus. An aneurysm arising from an artery that does not angiographically contribute to the blood flow to the AVM is uncommon. A distal middle cerebral artery (dMCA) aneurysm itself is also a rare presentation, especially in paediatric population. We present a rare case of dMCA aneurysm that was noted after successful surgical management of a ruptured AVM in an 8-year-old child and its management. BACKGROUND: About 10-30% of patients with cerebral arteriovenous malformation (AVM) have an associated artery aneurysm. The majority of these aneurysms are flow-related to the malformation. These aneurysms can be classified into extranidal or intranidal in reference to the AVM nidus Rammos et al Am J Neuroradiol 37:1966-1971, [1]. An aneurysm arising from a different artery that does not angiographically contribute to the blood flow associated with the AVM is less common and would generally be regarded as unrelated to the AVM. Distal cerebral artery aneurysm itself is also a rare presentation, comprising of 1-7% of all middle cerebral artery aneurysm. In children, mycotic infection and dissection are the two most common causes for aneurysm in this location. Unlike in adults, berry aneurysms are uncommon in children. We describe a young patient who was found to have distal middle cerebral artery (dMCA) aneurysm in follow-up DSA (Digital Subtraction Angiogram) after the initial successful surgical treatment for a cerebral frontal AVM. In this particular case, endovascular repair is thought to be the best strategy to treat the aneurysm. However, there still remains a lack of consensus of the best management strategy (surgery or endovascular) in treating flow-related aneurysms in general. This is usually based on an individual case scenario and the treatment is tailored depending on various factors including the expertise of the treating team.

Characteristics and Treatment Outcome of Intracranial Aneurysms in Children and Adolescents

Objective

Intracranial aneurysms are not common in young age patients. We sought to find the characteristics of the intracranial aneurysms in patients under 20 years of age.

Methods

We reviewed 23 consecutive patients ≤20 years of age treated for their intracranial aneurysms during the period from 1995 to 2017. From medical records and imaging studies, we gathered data on age, sex, presentation, associated medical condition, location and characteristics of aneurysms, treatment and clinical outcomes.

Results

The patients’ ages ranged from 13 months to 20 years (median, 14 years). There were 16 males and seven females (male to female ratio, 2.3 : 1) with 31 aneurysms. Clinical presentations included sudden severe headache in 61%, followed by altered mentality in 17% and seizure in 17%. More than one-fourth patients had specific medical conditions related to the development of the cerebral aneurysms. The majority of aneurysms occurred in the anterior circulation (71%), and were saccular (71%). There were each three patients with false aneurysms (13%) and giant aneurysms (13%), and only one patient with multiple aneurysms (4%). We treated 22 patients : 21 aneurysms with the endovascular methods, three with open surgery, and one with combined treatment. Good functional outcome could be achieved in 86% during the follow-up period.

Conclusion

In this series, the young-age patients with intracranial aneurysms were characterized by male predominance, related specific medical conditions, low incidence of multiple aneurysms, high incidence of giant aneurysms and good functional outcome after treatment.