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

Iatrogenic Pseudoaneurysm-Associated Cerebral Hemorrhage: A Rare Complication of Burr Hole Drainage - A Case Report

BACKGROUND

Nontraumatic intracranial hemorrhage occurs most commonly due to hypertension and is treated nonoperatively. Iatrogenic pseudoaneurysm from prior neurosurgical therapy represents a rarely described etiology for intracranial hemorrhage that may require emergent surgical therapy.

CASE REPORT

An elderly female patient was brought to the emergency department with fatigue but no recent trauma. Subsequent computed tomography of the brain revealed a right-sided intraparenchymal hematoma. Her history included burr hole drainage of a subdural hematoma near the site, so additional imaging was performed and revealed an arteriovenous malformation, later discovered on operative findings to be a pseudoaneurysm, as the cause of the current bleeding episode. Why Should an Emergency Physician Be Aware of This? Awareness of prior neurosurgical treatment, even including minor procedures, in patients with apparent spontaneous intracranial bleeding should prompt angiographic evaluation for arteriovenous malformation. If found, these lesions are more likely to benefit from surgical treatment.

Flow diverter stenting for intracranial aneurysms in the pediatric population: Two case reports and literature review

The Pipeline Embolization Device (PED) is a flow-diverting intraluminal device that is approved for use in adults 18 years or older with internal carotid artery aneurysms. However, it can also be used off-label in pediatric patients with aneurysms that cannot be resolved with traditional endovascular treatments. Herein, we present two cases of flow diversion in the pediatric population with complete obliteration of the aneurysm and excellent outcomes. Flow diversion has been shown to be a safe endovascular option in treating complex aneurysms in children. Larger-sized, multicenter trials are encouraged to compare outcomes between flow diversion and other aneurysm treatment options given the rarity of pediatric aneurysms.

Endovascular Management of Pediatric Traumatic Intracranial Pseudoaneurysms: A Systematic Review and Case Series

OBJECTIVE

This study aims to systematically review the management and outcomes of pediatric patients who develop intracranial pseudoaneurysm (IPA) following head trauma or iatrogenic injury.

METHODS

Following Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, a systematic literature review was performed. Additionally, a retrospective analysis was conducted on pediatric patients who underwent evaluation and endovascular treatment for IPA originating from head trauma or iatrogenic injury at a single institution.

RESULTS

Two hundred twenty-one articles in the original literature search. Fifty-one met inclusion criteria resulting in a total of 87 patients with 88 IPAs including our institution. Patients ranged in age from 0.5 months to 18 years. Parent vessel reconstruction was used as first-line treatment in 43 cases, parent vessel occlusion in 26, and direct aneurysm embolization (DAE) in 19. Intraoperative complications were observed in 3.00% of procedures. Complete aneurysm occlusion was achieved in 89.61% of cases. 85.54% of cases resulted in favorable clinical outcomes. The mortality rate after treatment was 3.61%. The DAE group had higher rates of aneurysm recurrence than other treatment strategies (P = 0.009). Patients with SAH had overall worse outcomes compared to patients who did not (P = 0.024). There were no differences in favorable clinical outcomes (P = 0.274) or complete aneurysm occlusion (P = 0.13) between primary treatment strategies.

CONCLUSIONS

IPAs were successfully obliterated, and favorable neurological outcomes were achieved at a high rate regardless of primary treatment strategy. DAE had a higher rate of recurrence than the other treatment groups. Each described treatment method in our review is safe and viable for the treatment of IPAs in pediatric patients.

'Y'-Shaped Palmar Common Digital Artery Interposition Bypass in the Treatment of an Infantile M2 Large Aneurysm and Literature Review

OBJECTIVE

Both craniotomy and interventional embolization are difficult and risky to treat complex middle cerebral artery (MCA) aneurysms in infants. Trapping with revascularization is a therapeutic option for giant aneurysms that cannot be clipped or coiled alone.

METHOD

We describe a technical method using revascularization with a natural Y-shaped palmar common digital artery interposition graft that provides a normal variation for a complex MCA aneurysm in an infant with intracerebral hemorrhage at 37 days of age. Conservative treatment was performed at that time. Seven months later, the patient was re-admitted to the hospital and was confirmed a large aneurysm in the M2 segment of the right MCA by cerebral angiography. A natural artery palmar common digital artery Y-graft was used as the graft and anastomosed to the M2 and both M3 trunks.

RESULT

The symptoms improved after surgery, and the mRS score of the patient was 1 after 5 years of follow-up.

CONCLUSION

The palmar common digital artery can be an option for intracranial revascularization bypass in complex intracranial aneurysms.

Initial experience with Pipeline embolization of intracranial pseudoaneurysms in pediatric patients

OBJECTIVE

Flow-diverting devices have been used successfully for the treatment of complex intracranial vascular injuries in adults, but the role of these devices in treating iatrogenic and traumatic intracranial vascular injuries in children remains unclear. The authors present their experience using the Pipeline embolization device (PED) for treating intracranial pseudoaneurysms in children.

METHODS

This single-center retrospective cohort study included pediatric patients with traumatic and iatrogenic injuries to the intracranial vasculature that were treated with the PED between 2015 and 2021. Demographic data, indications for treatment, the number and sizes of PEDs used, follow-up imaging, and clinical outcomes were analyzed.

RESULTS

Six patients with a median age of 12 years (range 7-16 years) underwent PED placement to treat intracranial pseudoaneurysms. There were 3 patients with hemorrhagic presentation, 2 with ischemia, and 1 in whom a growing pseudoaneurysm was found on angiography. Injured vessels included the anterior cerebral artery (n = 2), the supraclinoid internal carotid artery (ICA, n = 2), the cavernous ICA (n = 1), and the distal cervical ICA (n = 1). All 6 pseudoaneurysms were successfully treated with PED deployment. One patient required re-treatment with a second PED within a week because of concern for a growing pseudoaneurysm. One patient experienced parent vessel occlusion without neurological sequelae.

CONCLUSIONS

Use of the PED is feasible for the management of iatrogenic and traumatic pseudoaneurysms of the intracranial vasculature in children, even in the setting of hemorrhagic presentation.

Successful treatment of ruptured multiple fusiform middle cerebral artery aneurysms with Silk Vista Baby flow diverter in a 10-month-old infant

We report the successful treatment of multiple ruptured fusiform middle cerebral artery (MCA) aneurysms in a 10-month-old girl. This previously healthy infant presented with subarachnoid hemorrhage and was found to have multiple irregular dilatations of the superior division branch of the right MCA. Cerebral angiography was performed and confirmed the presence of multiple fusiform aneurysms of the MCA. After discussion with the multidisciplinary team, it was decided to treat the aneurysms with a endovascular approach, using a flow diverter. Microsurgical clipping was deemed risky because of the high likelihood of parent artery occlusion, and expectant management was also considered inappropriate because of the risk of rebleeding. Dual antiplatelet therapy was started, and a flow diverter was successfully delivered in the superior division branch of the right MCA. The postoperative course was uneventful, MRI at 12 months did not show any sign of recurrence, and at 3 years of age the patient had a normal neurological examination.

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.

Vertebral artery dissection and associated ruptured intracranial pseudoaneurysm successfully treated with coil assisted flow diversion: A case report and review of the literature

Dissecting intracranial pseudoaneurysms (IPs) are associated with a high incidence of rupture and poor neurologic outcomes. Lesions in the posterior circulation are particularly malignant and pose even greater management challenges. Traditional management consists of microsurgical vessel sacrifice with or without bypass. Flow diversion (FD) in the setting of subarachnoid hemorrhage (SAH) represents a reconstructive treatment option and can be paired with coil embolization to promote more rapid thrombosis of the lesion. We report a case of a ruptured dissecting vertebral artery (VA) IP successfully acutely treated with coil-assisted FD. A 53-year-old male presented with a right V4 dissection spanning the origin of the posterior inferior cerebellar artery and associated ruptured V4 IP. The patient was treated with coil-assisted FD. Oral dual-antiplatelet therapy (DAPT) was initiated during the procedure, and intravenous tirofiban was used as a bridging agent. Immediate obliteration of the IP was achieved, with near-complete resolution of the dissection within 48 h. The patient made a complete recovery, and angiography at 6 weeks confirmed total IP obliteration, reconstruction of the VA, and a patent stent. The use of FD and DAPT in the setting of acute SAH remains controversial. We believe that coil-assisted FD in carefully selected patients offers significant advantages over traditional microsurgical and endovascular options. The risks posed by DAPT and potential for delayed thrombosis with FD can be effectively mitigated with planning and the development of protocols. We discuss the current literature in the context of our case and review the challenges associated with treating these often devastating lesions.

Republished: Successful treatment of ruptured multiple fusiform middle cerebral artery aneurysms with silk vista baby flow diverter in a 10-months-old infant

We report the successful treatment of multiple ruptured fusiform middle cerebral artery (MCA) aneurysms in a 10-month-old girl. This previously healthy infant presented with subarachnoid haemorrhage and was found to have multiple irregular dilatations of the superior division branch of the right MCA. Cerebral angiography was performed and confirmed the presence of multiple fusiform aneurysms of the MCA. After multidisciplinary team discussion, it was decided to treat the aneurysms with endovascular approach, using a flow-diverter. Microsurgical clipping was deemed risky because of the high likelihood of parent artery occlusion and expectant management was also considered inappropriate because of the risk of re-bleeding. Dual antiplatelet therapy was started, and a flow-diverter was successfully delivered in the superior division branch of the right MCA. The post-operative course was uneventful, MRI at 12 months did not show any sign of recurrence and at 3 years of age the patient had a normal neurological examination.

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.

Intracranial Pseudoaneurysms: Evaluation and Management

Intracranial pseudoaneurysms account for about 1% of intracranial aneurysms with a high mortality. The natural history of intracranial pseudoaneurysm is not well-understood, and its management remains controversial. This review provides an overview of the etiology, pathophysiology, clinical presentation, imaging, and management of intracranial pseudoaneurysms. Especially, this article emphasizes the factors that should be considered for the most appropriate management strategy based on the risks and benefits of each treatment option.

Endovascular Treatment of a Traumatic Middle Cerebral Artery Pseudoaneurysm with the Pipeline Flex Embolization Device

OBJECTIVE

Traumatic pseudoaneurysms of the proximal middle cerebral artery (MCA) segments are challenging to treat. We describe the management of traumatic internal carotid artery and MCA pseudoaneurysms with flow diversion.

CASE DESCRIPTION

A 19-year-old man had sustained a gunshot wound to the head. Delayed digital subtraction angiography showed de novo formation of the left internal carotid artery ophthalmic segment and left MCA M2 segment pseudoaneurysms. We had initially performed coil embolization of the left MCA pseudoaneurysm. However, it had recurred 2 weeks later. We treated both pseudoaneurysms with flow diversion using the Pipeline Flex embolization device. The patient has continued with dual antiplatelet therapy of aspirin and ticagrelor. Follow-up digital subtraction angiography at 6 months showed complete obliteration of both pseudoaneurysms with patent parent vessels. The patient remained neurologically intact.

CONCLUSIONS

Flow diversion can be an efficacious treatment of traumatic MCA pseudoaneurysms in appropriately selected cases. The risks versus benefits of dual antiplatelet therapy must be weighed in trauma settings.

Flow Diversion for Treatment of Intracranial Aneurysms in Pediatric Patients: Multicenter Case Series

BACKGROUND

Though the Pipeline Embolization Device (Medtronic) is approved for use in adults 22 yr and older, the high efficacy and long-term durability of the device is attractive for treatment of intracranial aneurysms in younger patients who often have aneurysms less amenable to traditional endovascular treatments.

OBJECTIVE

To report technical, angiographic, and clinical outcomes in patients aged 21 or below undergoing flow-diversion treatment for intracranial aneurysms.

METHODS

Retrospective review across 16 institutions identified 39 patients aged 21 or below undergoing 46 treatment sessions with Pipeline Embolization Device placement between 2012 and 2018. A total of 50 intracranial aneurysms were treated. Details regarding patient demographics, aneurysm characteristics, treatment considerations, clinical outcomes, and aneurysm occlusion were obtained and analyzed in a multicenter database.

RESULTS

A total of 70% of patients were male. Nonsaccular morphology was seen in half of identified aneurysms. Six aneurysms were giant, and five patients were treated acutely after ruptured presentation. Eight patients were younger than 10 yr of age. Complete aneurysm occlusion was seen in 74% of treated aneurysms. Three aneurysms (6%) were retreated. A total of 83% of patients had a modified Rankin Scale scores of ≤2 at last clinical follow-up. There were 2 early mortalities (4.3%) in the immediate postprocedure period because of rerupture of a treated ruptured aneurysm. No recanalization of a previously occluded aneurysm was observed.

CONCLUSION

Flow-diversion treatment is a safe and effective treatment for intracranial aneurysms in patients younger than 22 yr. Rates of complete aneurysm occlusion and adverse events are comparable for rates seen in older patients.

Tiny Pipes: 67 Cases of Flow Diversion for Aneurysms in Distal Vessels Measuring Less Than 2.0 mm

BACKGROUND

Flow diversion is increasingly used for off-label treatments of distal circulation aneurysms. Reports of use in sub-2.0-mm vessels are scant.

METHODS

A prospectively collected, institutional review board-approved cerebral aneurysm database was reviewed to identify patients who underwent flow diversion with a 2.5-mm diameter Pipeline embolization device.

RESULTS

Sixty-seven aneurysms were treated in 67 procedures (66 [99%] successful, 64 [96%] single device, 2 [3%] with 2 devices) in 57 patients. Average age was 56 years and 60% were female. Aneurysm location was 51 (76%) anterior cerebral artery, 14 (21%) middle cerebral artery, and 2 (3%) posterior cerebral artery. Aneurysm size was 4.1 ± 3.0 mm (1-20 mm). Safety outcomes included 3 major strokes (4.5%) resulting in permanent neurologic deficit (modified Rankin Scale score 6,4,4), including 1 mortality (1.5%). Acute stent thrombosis was observed intraprocedurally or within 24 hours of each stroke. There were 2 small-volume (<10 cm³, 40 cm³) dependent intracerebral hemorrhage (3.0%) that resolved without permanent neurologic deficit. For effectiveness, 71% of patients underwent follow-up angiography. Complete occlusion was achieved by 88% at 6 months, 86% at 12 months, and 89% at last follow-up. A slight vessel diameter reduction was apparent on average 6.9 months after the procedure, which was statistically significant at the proximal (P = 0.001) but not distal (P = 0.317) device end. Preoperative average parent vessel diameter was 1.9 mm proximally (range, 1.1-2.6 mm) and 1.7 mm distally (range, 1.0-2.3 mm) of the Pipeline embolization device. Follow-up average vessel diameter was 1.7 mm proximally (range, 0.7-2.4 mm) and 1.6 mm distally (range, 0.6-2.1 mm). Flow delay associated with vessel diameter reduction occurred once. There were no cases of asymptomatic vessel occlusion.

CONCLUSIONS

Flow diversion can be safe and effective for aneurysms originating from vessels <2.0 mm in diameter. Heightened vigilance for the prevention and management of acute stent and vessel thrombosis is warranted in these cases.