Figure 1 - uploaded by Azizi Abu Bakar
Content may be subject to copyright.
An axial view of the brain on CT scan showing the giant aneurysm and an extraventricular drain in situ.
Source publication
The incidence of intracranial aneurysm in childhood is rare, especially in infancy. In the literature, most of childhood intracranial aneurysms occur in the posterior and middle cerebral circulation. We report a case of a ruptured giant left distal anterior cerebral artery aneurysm in a 2-month-old baby. This report will discuss the rarity of this...
Context in source publication
Context 1
... non-contrast CT scan of her brain showed a large bifrontal intraparenchymal bleed. A round hyperdense area was seen anterior to the frontal bleed at the midline with extension into the corpus callosum and lateral, third and fourth ventricles with- out significant midline shift. Following this, an external ventricu- lar drain was inserted ( fig. 1 ) and she was subsequently nursed in the Paediatric Intensive Care ...
Citations
... Given the high rate of blister aneurysms and frequent MCA location, we recommend that centers treating these pathologies have both skilled open and endovascular teams. Many authors report good outcomes with clipping or bypass, 9,10 and more recently there have been reports of successful endovascular intervention in neonatal patients. One author reported a successful coiling of an M2 aneurysm without recurrence in 10 months of follow-up. ...
BACKGROUND
Reports of ruptured neonatal aneurysms are rare in neurosurgical literature. Pediatric aneurysms differ from adult aneurysms, notably in morphology, size, number, and risk of rerupture. Many authors report experience with clipping, citing durability and decreased use of radiation as benefits over endovascular intervention. Few authors report extracranial-to-intracranial bypass because small pediatric vessels make this option challenging. The authors discussed a case of a newborn with multiple ruptured aneurysms, one of the youngest reported cases involving extracranial-intracranial bypass.
OBSERVATIONS
A 3-week-old baby presented with hemorrhage from multiple complex middle cerebral artery (MCA) aneurysms. Because of young age, endovascular intervention was not possible; therefore, the patient received craniotomy. Upon exploration, clip reconstruction was impossible; the vessel was trapped, and superficial temporal artery (STA)-MCA bypass was performed. The recipient vessel diameter was 0.3 mm. The postoperative course was complicated by seizures as well as symptomatic vasospasm, which was treated with intraarterial verapamil and ventriculostomy. At last follow-up, the patient was developing normally and was ambulatory with minimal deficit.
LESSONS
This case, one of the youngest patients reported, highlighted details of pediatric aneurysm management, such as propensity for multiple/fusiform aneurysms and high risk of re-hemorrhage, with significant mortality. The authors recommended aggressive, early intervention in pediatric aneurysms at centers with surgeons familiar with both endovascular intervention and cerebral bypass.
... A similar case in a 2-month-old baby with an A3 ruptured aneurysm was treated by clipping with good results. 21 We chose EVT because embolization is the first-line treatment at our institution and results from case-series have demonstrated favorable clinical outcomes when compared with surgery including reconstructive and deconstructive techniques. [7][8][9]11,12,15,22,23 Age and the accessibility to navigate through the vessels were also considered in this case. ...
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.
... В 50% случаев заболевание проявляется псевдотуморозной симптоматикой, в то время как аневризмы меньшего размера манифестируют разрывом (от 54 до 90%, по данным разных авторов [5][6][7][8]). Лишь в 11 наблюдениях гигантских аневризм описан разрыв с формированием субарахноидального, внутрижелудочкового кровоизлияний и внутримозговой гематомы [14,32,33]. В 1 случае заболевание проявилось симптомами транзиторной ишемической атаки [15], в другом -явилось случайной находкой [26]. ...
... В 87% случаев гигантских аневризм прибегают к открытому хирургическому вмешательству, в ходе которого возможно не только выключить из кровотока функционирующую часть аневризмы, но и выполнить декомпрессию нервных образований. Согласно анализу данных литературы [28,32], традиционным доступом можно назвать межполушарный, в 2 публикациях межполушарный доступ был дополнен энцефалотомией. У 4 пациентов при подходе к аневризматическому мешку были выполнены лиги-Сравнительная характеристика перикаллезных и гигантских перикаллезных аневризм на основании анализа данных мировой литературы рование и иссечение верхнего сагиттального синуса и фалькса в передней трети [10,11,19,32]. ...
... Согласно анализу данных литературы [28,32], традиционным доступом можно назвать межполушарный, в 2 публикациях межполушарный доступ был дополнен энцефалотомией. У 4 пациентов при подходе к аневризматическому мешку были выполнены лиги-Сравнительная характеристика перикаллезных и гигантских перикаллезных аневризм на основании анализа данных мировой литературы рование и иссечение верхнего сагиттального синуса и фалькса в передней трети [10,11,19,32]. Ни в одном из этих случаев не было отмечено нарастания неврологического дефицита. ...
Are characterized by Distal giant aneurysms of the anterior cerebral artery are an extremely rare pathology. There are less than 40 cases of this disease described in literature.
Objective:
The aim of the article is to present the clinical observation of a successfully treated giant aneurysm of the pericallosal artery in a 58-year-old man, and also analyze the publications on distal cerebral aneurysms.
Material and methods:
The data of a patient hospitalized with a suspected tumor of the left brain hemisphere spreading to the left lateral ventricle is presented. Repeated MRI suggests a giant subtotal thrombotic aneurysm of the left perical artery, which was confirmed by SCT angiography. The patient underwent aneurysm treping-cliping with dissection of the aneurysm sac. In the analysis of the literature it was shown that the frequency of perical artery aneurysms varies from 5.3-6.0%, and giant aneurysms of this localization are extremely rare and occur in 1-4.5% of all perical artery aneurysms. Unlike distal anterior cerebral artery aneurysms of small and medium size, giant aneurysms are characterized by pseudotumorrhagic symptoms, which causes diagnostic difficulties.
Conclusion:
It is necessary to remember about the diagnostic difficulties caused by the pseudotumorrhosis of the giant aneurysms of the pericallosal artery and the frequent negative angiography data due to total thrombosis of the aneurysmal sac. The gold standard is microsurgical clipping with excision of the aneurysmal sac. The prognosis for this group of patients is favorable.
... 3 Unlike the adult population, there is a male predominance, with a male-to-female ratio of 3:2. 4 The morphology, clinical presentation, and radiological features of aneurysms in infants and children are different from those of aneurysms in adults. 5 They also differ due to the lack of exposure to environmental factors and comorbidities commonly found in adults (for example, smoking, arterial hypertension and excessive chronic alcohol intake), but children with preexisting diseases may be predisposed to the formation of these aneurysms. 2 The location of the aneurysms also differs in children, with the internal carotid artery (ICA) being the most common site, accounting for 13 to 50% of the incidence, while posterior circulation aneurysms are also more frequent in children than in adults. ...
... 3 However, giant aneurysms ( 25 mm) in infants, on the contrary, arise more frequently in the posterior circulation. 5 Treatment options for pediatric ICA aneurysms include conservative management, direct surgical clipping, cerebral revascularization and an endovascular approach. 3 There is no consensus for the management of pediatric aneurysms and its approach remains individualized on a case-by-case basis. ...
... 3 There is no consensus for the management of pediatric aneurysms and its approach remains individualized on a case-by-case basis. 5 In the present study, we report the case of an infant with a giant, partially thrombosed, carotid-ophthalmic aneurysm, which was treated with parent vessel occlusion by endovascular approach, and present a discussion about the epidemiology, etiology, location and treatment options for aneurysms in the pediatric population. ...
Introduction The incidence of intracranial aneurysms in the pediatric population is low, and endovascular treatment is becoming a safe and minimally invasive treatment option. In the present study, the occurrence of special features of cerebral aneurysm in children, in comparison to adults, is also described.
Case Report A 3-month-old female infant presented with progressive proptosis and divergent strabismus at the right eye, in addition to inconsolable crying. Cerebral resonance, angiotomography and angiography exams demonstrated angiodysplasia in the right internal carotid artery with two large paraclinoid dissecting aneurysms with wide neck. The right internal carotid artery was occluded with coils by endovascular approach, without detriment to the perfusion of the ipsilateral hemisphere and without neurological deficits. The patient achieved good recovery, and a late control angiotomography confirmed the exclusion of the aneurysms.
Conclusion Parent artery sacrifice via endovascular approach is an effective therapeutic option, but a long-term follow-up is necessary to avoid recurrence and bleeding.
... Intracranial aneurysms in the pediatric population are rare, with an approximate incidence of 0.5-4.6% of all cerebral aneurysms [2,3,5,22]. Hitherto, the number of reported cases of intracranial saccular aneurysms (ruptured and unruptured) in infants < 1 year of age is less than 200 cases [2,22]. ...
... Hitherto, the number of reported cases of intracranial saccular aneurysms (ruptured and unruptured) in infants < 1 year of age is less than 200 cases [2,22]. Recently, endovascular approaches have been used to treat pediatric intracranial aneurysms with increasing tendency [4,22,23,29]; however, endovascular methods could not alleviate the mass effect caused by large hematoma, which might be ascribed to the neurological deterioration, even death.Craniotomycannot onlydirectlyclipthe aneurysm but alsoevacuate the hematoma.Therefore,openmicrosurgeryis yet a common treatment of these patients [5,11,26,35]. Nevertheless, only a limited number of studies on the long-term outcomes is available due to the rarity of the infantile aneurysms. ...
Objective:
Intracranial aneurysms are extremely rare in infants, especially less than 1 year old. This study aimed to analyze the frequency of infantile intracranial aneurysm in our department and investigate the clinical characteristics, treatment strategies, and outcomes of this disease.
Methods:
Six infants under 1 year old in 4350 patients with intracranial aneurysms were retrospectively analyzed from January 2010 to December 2016.
Results:
The patients (5 females and 1 male) ranged in age from 2 to 11 (mean age, 4.67) months. Four patients presented with generalized seizure and vomiting, 3 showed lethargy, 1 presented eye deviation, and 1 had right-sided hemiparesis. Radiographically, two aneurysms were localized in the middle cerebral artery (MCA) of the M2 segment, two were located in the M3 segment of MCA, one was located at left MCA bifurcation, and one was located at the nonbranching site of the left supraclinoid internal carotid artery. All these lesions were successfully managed with aneurysm clipping or resection, and the improvement of neurological deficits was achieved in all patients.
Conclusion:
Intracranial aneurysms should be considered in the differential diagnosis of infants who present with acute raised intracranial pressure. An improvement of neurological deficits is noted in infants who are managed promptly with microsurgical techniques of clipping during the long-term follow-up.
... Pterional craniotomy is the usual approach to P1 and P1-P2 junction aneurysms, while subtemporal craniotomy is the preferred approach to those in the P2 and P3 segments [9] . Whereas giant aneurysms may present proliferative disease in the vessel wall, trapping with proximal and distal parent vessel clipping followed by surgical excision is considered the best therapy [12] , and could have been an option in this case. Nonetheless, surgery on distal PCA giant aneurysms in children is complex due to their deep location and close relationship to eloquent structures [13] . ...
... Endovascular treatment has been established in the therapeutic arsenal as an effective therapeutic option, especially in cases where surgical access would represent a real technical challenge [4,12] . Although results are improving with new materials and technical evolution, long-term follow-up with surveillance and serial imaging of embolized aneurysms in childhood is indispensable to prevent recurrence and rebleeding [4] . ...
The incidence of intracranial aneurysms in the pediatric population is low, and surgical clipping remains a good long-term treatment option. However, posterior circulation aneurysms are even more complex to manage in children than in adults. We report a case of a giant aneurysm of the posterior cerebral artery in a 10-year-old boy presenting with subarachnoid hemorrhage. Endovascular treatment with platinum coils was performed with total occlusion of the aneurysm and the affected arterial segment without complications. The patient achieved good recovery, and a late control angiogram confirmed exclusion of the aneurysm. Occurrence of special features of cerebral aneurysm in children, in comparison to adults, is also described. Parent artery sacrifice is an effective therapeutic option, but long-term follow-up is necessary to avoid recurrence and rebleeding.
Intracranial aneurysms (IA) in infants are reportedly rare at 0.5% to 4.5% of all aneurysms. Furthermore, subarachnoid hemorrhage in infants younger than three months are even rarer as it has been reported in approximately 20 cases only till date.
A 3-month-old infant with seizures and impaired consciousness was admitted to our hospital. Three-dimensional computed tomography angiography (3D-CTA) revealed a dissecting aneurysm with a maximum diameter of 13 mm in the right M2. Internal trapping using detachable coil were successfully performed, following which he was discharged without significant neurological deficit after one month of onset. Thus, we have reported a rare case of a large ruptured dissecting IA in a 3-month-old infant, in the right middle cerebral artery (MCA), successfully treated with an endovascular therapy, along with a literature review.
Fullsize Image
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.
Aneurysms of vertebral (VA) and posterior inferior cerebellar arteries (PICA) are relatively rare pathologies and account for 3.4% of the total number of intracranial aneurysms.
Material and methods:
The experience of microsurgical treatment of 67 patients with VA and PICA aneurysms in N.N. Burdenko National Medical Research Center for Neurosurgery of the RF Ministry of Health from 2012 to 2017 is presented.
Results:
Most patients underwent reconstructive microsurgical interventions: clipping of the aneurysm neck in 42 (62.7%) patients and complex clipping with the formation of arterial opening - in 10 (14.9%). Exclusion of the aneurysm together with the carrier artery (trapping, proximal clipping) was performed on 10 (14.9%) patients. In 5 (7.5%) patients, deconstruction of the carrier artery of the aneurysm was performed after creating local anastomoses. The radical exclusion of aneurysms in the studied group was 95.5%. Postoperative dysfunction of the caudal group of cranial nerves was detected in 11 (16.4%) patients. There were no lethal outcomes, or cases with vegetative status outcomes.
Conclusion:
Microsurgical intervention is an effective way to treat VA and PICA aneurysms, subject to the principles of patient selection based on existing treatment algorithms as well as adherence to an interdisciplinary approach.
The possibility of segmenting three-dimensional objects by DICOM-series is well known and available both on specialized workstations and on personal computers. The technique, however, is relatively rarely used in clinical practice, and we believe that the benefits of preoperative preparation using segmented 3D models are underestimated. The article is devoted to our experience in using segmentation of anatomical structures based on CT and MRI for preoperative preparation for surgical operations performed in neurosurgical departments on patients with vascular pathology. The paper discusses the types and possibilities of segmentation, provides some examples describing the clinical use of the technique.
