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Hosseini EM, Zafarshamspour S, Ghasemi-Rad M, Benndorf G, Rasekhi A, Rafieossadat R. Endoluminal flow diversion as a primary treatment strategy for pediatric traumatic intracranial aneurysms: a case-based review of literature. Childs Nerv Syst 2024; 40:345-357. [PMID: 37750891 DOI: 10.1007/s00381-023-06161-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/15/2023] [Accepted: 09/18/2023] [Indexed: 09/27/2023]
Abstract
BACKGROUND Traumatic intracranial aneurysms (TICAs) constitute a notable portion of pediatric intracranial aneurysms. Their unstable structure dictates a high incidence of rupture or mass effect from enlarging unruptured aneurysms, necessitating prompt diagnosis and treatment. TICAs often lack a true neck or are wide-necked, making them unsuitable for coil embolization and surgical clipping, and their fragile nature poses a risk of rupture during surgical and intrasaccular interventions. Endoluminal flow diverters (FD), deployed without requiring direct access to the aneurysmal sac, have emerged as an appealing sole treatment modality for TICAs. However, the clinical experience with this technique remains limited in the pediatric population. METHOD We describe the successful treatment of a paraclinoid TICA in a 4-year-old female using an endoluminal FD alone. Additionally, we conducted a literature review to assess the safety and effectiveness of this treatment modality in pediatric TICAs. RESULTS Endoluminal flow diversion led to complete aneurysm obliteration in our case, with no observed complication, at the 9-month follow-up. Our review of the previously reported pediatric TICAs managed by standalone flow diversion highlights this technique as safe, efficient, and promising as a sole treatment modality, particularly in the anterior circulation, with a high rate of persistent total obliteration and a low rate of complications. However, the requirement for long-term antiplatelet therapy with the possibility of frequent dose monitoring and adjustments warrants special attention when using endoluminal FDs. Until guidelines specifically addressing optimal antiplatelet therapy in children with intracranial FDs are formulated, adherence to existing protocols is imperative to avoid in-stent thrombosis. CONCLUSION Our literature review and personal experience indicate that endoluminal flow diversion can be a viable treatment approach for pediatric TICAs. However, prospective studies with extensive follow-ups are required to assess the durability of endoluminal FDs in treating pediatric TICAs, considering the long life expectancy of this demographic.
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Affiliation(s)
| | - Saber Zafarshamspour
- Department of Surgery, Rafsanjan University of Medical Sciences, Rafsanjan, Kerman, Iran
| | - Mohammad Ghasemi-Rad
- Department of Interventional Radiology, Baylor College of Medicine, Houston, TX, USA
| | - Goetz Benndorf
- Department of Radiology, University Hospital Rigshospitalet, Copenhagen, Denmark
- Department of Radiology, Baylor College of Medicine, Houston, TX, USA
| | - Alireza Rasekhi
- Department of Radiology, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Reza Rafieossadat
- Department of Neurosurgery, Shiraz University of Medical Sciences, Shiraz, Iran.
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Barchetti G, Di Clemente L, Mazzetto M, Zanusso M, Ferrarese P, Iannucci G. Successful treatment of ruptured multiple fusiform middle cerebral artery aneurysms with Silk Vista Baby flow diverter in a 10-month-old infant. BMJ Case Rep 2022; 15:e017554. [PMID: 36038152 PMCID: PMC9438038 DOI: 10.1136/bcr-2021-017554] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
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.
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Affiliation(s)
| | - Loris Di Clemente
- Neuroradiology Unit, San Bortolo Hospital of Vicenza, Vicenza, Italy
| | - Mauro Mazzetto
- Neurosurgery Unit, San Bortolo Hospital of Vicenza, Vicenza, Italy
| | - Mariano Zanusso
- Neurosurgery Unit, San Bortolo Hospital of Vicenza, Vicenza, Italy
| | - Paola Ferrarese
- Pediatric Intensive Care Unit, San Bortolo Hospital of Vicenza, Vicenza, Italy
| | - Giuseppe Iannucci
- Neuroradiology Unit, San Bortolo Hospital of Vicenza, Vicenza, Italy
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Baz RA, Scheau C, Niscoveanu C, Bordei P. Morphometry of the Entire Internal Carotid Artery on CT Angiography. Medicina (B Aires) 2021; 57:medicina57080832. [PMID: 34441039 PMCID: PMC8398484 DOI: 10.3390/medicina57080832] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2021] [Revised: 08/02/2021] [Accepted: 08/13/2021] [Indexed: 11/16/2022] Open
Abstract
Background and Objectives: Knowledge of the internal carotid artery’s (ICA) morphometric features is influential in outlining surgical and minimally invasive procedures in the neurovascular field. Many studies have shown divisive numbers regarding the ICA’s caliber, with the measuring point of the artery sometimes differing. This study presents ICA dimensions based on computed tomography angiography in each of its seven segments as per Bouthillier’s classification, correlating vascular dimensions with anthropometric parameters. Materials and Methods: A thorough CT angiography analysis was performed on 70 patients with internal carotid vessels unaffected by atherosclerotic disease. The extracranial part of the ICA was measured in four locations—carotid bulb, post-bulbar dilation, at its cervical midpoint, and below its entrance into the carotid foramen. Single landmarks were used for measurements in the intracranial segments. ICA length was assessed in the neck region and also in the cranial cavity. Craniometric measurements were performed on sagittal and coronal CT reconstructions. Patient height was taken into consideration. Results: The largest ICA portion is near its origin in the carotid sinus area (7.59 ± 1.00 mm), with a steep decline in caliber following its extracranial course. Distal ICA presented values somewhat similar to its proximal intracranial segment diameters (4.67 ± 0.47 mm). Dimensions of the ICA in the intracranial segments start from a value of 4.53 ± 0.47 mm and decrease by approximately 40% when reaching the origin of the middle cerebral artery (2.71 ± 0.37 mm), showing a marked decrease in caliber after the emergence of the most critical collateral artery, the ophthalmic branch. The length of the ICA varies between genders, with the male ICA being about 10 mm longer in total length than female ICA; this difference is also correlated with patient height and skull dimensions. Conclusions: Both intra- and extracranial ICA have variable dimensions and length related to gender and anthropometric parameters, with no significant differences obtained concerning side or age.
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Affiliation(s)
- Radu Andrei Baz
- Department of Radiology, Faculty of Medicine, “Ovidius” University, 900470 Constanta, Romania;
| | - Cristian Scheau
- Department of Physiology, “Carol Davila” University of Medicine and Pharmacy, 050474 Bucharest, Romania
- Correspondence: (C.S.); (C.N.)
| | - Cosmin Niscoveanu
- Department of Radiology, Faculty of Medicine, “Ovidius” University, 900470 Constanta, Romania;
- Correspondence: (C.S.); (C.N.)
| | - Petru Bordei
- Department of Anatomy, Faculty of Medicine, “Ovidius” University, 900470 Constanta, Romania;
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Barchetti G, Di Clemente L, Mazzetto M, Zanusso M, Ferrarese P, Iannucci G. Republished: Successful treatment of ruptured multiple fusiform middle cerebral artery aneurysms with silk vista baby flow diverter in a 10-months-old infant. J Neurointerv Surg 2021; 13:e17. [PMID: 34131050 DOI: 10.1136/neurintsurg-2021-017554.rep] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2021] [Accepted: 05/12/2021] [Indexed: 11/03/2022]
Abstract
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.
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Affiliation(s)
| | - Loris Di Clemente
- Neuroradiology Unit, San Bortolo Hospital of Vicenza, Vicenza, Italy
| | - Mauro Mazzetto
- Neurosurgery Unit, San Bortolo Hospital of Vicenza, Vicenza, Italy
| | - Mariano Zanusso
- Neurosurgery Unit, San Bortolo Hospital of Vicenza, Vicenza, Italy
| | - Paola Ferrarese
- Pediatric Intensive Care Unit, San Bortolo Hospital of Vicenza, Vicenza, Italy
| | - Giuseppe Iannucci
- Neuroradiology Unit, San Bortolo Hospital of Vicenza, Vicenza, Italy
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Bhogal P, Hellstern V, AlMatter M, Ganslandt O, Bäzner H, Aguilar Pérez M, Henkes H. Mechanical thrombectomy in children and adolescents: report of five cases and literature review. Stroke Vasc Neurol 2018; 3:245-252. [PMID: 30637131 PMCID: PMC6312071 DOI: 10.1136/svn-2018-000181] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2018] [Revised: 10/01/2018] [Accepted: 10/03/2018] [Indexed: 12/20/2022] Open
Abstract
Background Paediatric arterial ischaemic stroke is an important cause of morbidity and mortality among children. Currently, there are no recommendations regarding mechanical thrombectomy in children despite overwhelming evidence of improved outcomes in adults. Therefore, the need for individual case reports and case series is important to highlight potential advantages and disadvantages in this approach. Case descriptions We retrospectively searched our prospectively maintained database of patients undergoing mechanical thrombectomy for ischaemic stroke. We describe five children, aged between 7 and 17, who underwent mechanical thrombectomy for acute ischaemic stroke. We provide an account of their clinical presentations, operative treatment and postoperative outcome. Discussion Mechanical thrombectomy in children, especially older children, can be performed safely and with existing devices. Although a randomised controlled trial would provide compelling evidence of the potential advantages to this technique, the lack of this should not prevent the use of this procedure by trained neurointerventionists.
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Affiliation(s)
- Pervinder Bhogal
- Department of Interventional Neuroradiology, Royal London Hospital, London, UK
| | - Victoria Hellstern
- Neuroradiological Clinic, Neurocenter, Klinikum Stuttgart, Stuttgart, Germany
| | - Muhammad AlMatter
- Neuroradiological Clinic, Neurocenter, Klinikum Stuttgart, Stuttgart, Germany
| | - Oliver Ganslandt
- Neurosurgical Clinic, Neurocenter, Klinikum Stuttgart, Stuttgart, Germany
| | - Hansjörg Bäzner
- Neurosurgical Clinic, Neurocenter, Klinikum Stuttgart, Stuttgart, Germany
| | - Marta Aguilar Pérez
- Neuroradiological Clinic, Neurocenter, Klinikum Stuttgart, Stuttgart, Germany
| | - Hans Henkes
- Neuroradiological Clinic, Neurocenter, Klinikum Stuttgart, Stuttgart, Germany.,Medical Faculty, University Duisburg-Essen, Duisburg, Germany
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Vijaywargiya M, Deopujari R, Athavale SA. Anatomical study of petrous and cavernous parts of internal carotid artery. Anat Cell Biol 2017; 50:163-170. [PMID: 29043093 PMCID: PMC5639169 DOI: 10.5115/acb.2017.50.3.163] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2016] [Revised: 06/10/2017] [Accepted: 07/12/2017] [Indexed: 11/27/2022] Open
Abstract
The petrous and cavernous parts of internal carotid artery (ICA) are obscure and are not readily accessible to observation/imaging. These parts have broad biological and medical interest because of their peculiar shape. Given the their clinical importance and the scarce data available based mostly on imaging, the present study was aimed at studying these parts of ICA by dissection. The study was carried out on 56 ICAs obtained from embalmed adult cadavers and 10 ICAs from five fetuses. The foetal ICAs were studied in situ. The morphometric analysis of the adult ICA was done after its removal from cranial cavity to gain an insight into the geometry of the vessel, i.e., length, various bends, and diameters at various locations. ICAs in fetuses ran a relatively straighter course taking gentle curves at three positions (two intrapetrous, one cavernous). Adult ICAs were more tortuous and exhibited greater variability in length and angulations. The length of respective portions of the ICA correlate negatively with the measure of angles. The angles in the petrous and cavernous parts were positively correlated to each other. The carotid siphon was positively, highly significantly correlated to other angles. Longer vessels are more tortuous with acute bends. An acute carotid siphon is an indication of more tortuous ICA. The findings of the present study have created a reference data of unsuspected adult population and has potential implications for studying cause/effect relationship of vessel geometry and hemodynamic factors.
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Affiliation(s)
- Manisha Vijaywargiya
- Department of Anatomy, People's College of Medical Sciences and Research Centre, Bhopal, India
| | - Rashmi Deopujari
- Department of Anatomy, People's College of Medical Sciences and Research Centre, Bhopal, India
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Barburoglu M, Arat A. Flow Diverters in the Treatment of Pediatric Cerebrovascular Diseases. AJNR Am J Neuroradiol 2016; 38:113-118. [PMID: 27765738 DOI: 10.3174/ajnr.a4959] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2016] [Accepted: 08/08/2016] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND PURPOSE There is very limited data concerning utilization of flow diverters in children. Our aim is to report results for the treatment of complex intracranial aneurysms and carotid cavernous fistulas by using flow diverters in children. MATERIALS AND METHODS Retrospective review of children (17 years of age or younger) treated with flow diverters between May 2011 and July 2014 was performed. Clinical and laboratory data and angiographic findings were extracted. Seven patients (6 males, 1 female; mean age, 12.7 years; range, 3-16 years) were included. Two presented with posttraumatic fistulas. The remaining patients presented with traumatic aneurysms of the cavernous carotid artery or fusiform aneurysms of the distal vertebral artery, M1, or A2 segments. All patients were premedicated with clopidogrel (75 mg daily for patients with body weights of >45 kg, 37.5 mg daily for 1 small child with a body weight of <45 kg) and aspirin (300 mg daily for ≥45 kg, 100 mg daily for smaller children). RESULTS VerifyNow and Multiplate Analyzer values were higher than expected. No clinical complications were noted. Imaging performed at 7-52 months after the procedure (mean/median, 22.3/14 months) revealed occlusions of all aneurysms and fistulas. One patient had an asymptomatic occlusion of the parent artery; otherwise, no hemodynamically significant parent artery restenosis was observed. There were no clinically significant neurologic events during follow-up. CONCLUSIONS Although flow-diverter placement appears to be safe and effective on midterm follow-up in children, longer follow-up is critical. The current sizes of flow diverter devices and delivery systems cover the pediatric size range, obviating developing flow diverters specific to children.
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Affiliation(s)
- M Barburoglu
- From the Department of Radiology (M.B.), Istanbul University Medical School, Istanbul, Turkey
| | - A Arat
- Department of Radiology (A.A.), School of Medicine, Hacettepe University, Ankara, Turkey.
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