Pediatric intracranial aneurysms: durability of treatment following microsurgical and endovascular management

Restricted access

Object

Longer life expectancies and differences in the underlying disease in children with aneurysms raise important issues concerning the choice of microsurgical or endovascular therapy. The authors reviewed their experience at one institution regarding patients treated between 1977 and 2003, focusing on the issue of treatment durability.

Methods

Forty-three aneurysms in 32 pediatric patients were identified. The patients ranged in age from 2 months to 18 years (mean 11.7 years). Only seven patients (22%) presented with subarachnoid hemorrhage, and in nine patients (28%) significant medical comorbidities were present. Aneurysm locations included the internal carotid artery (13 lesions), middle cerebral artery (11 lesions), and the basilar artery/vertebrobasilar junction (six lesions). Of the 43 lesions, 17 (40%) were giant aneurysms and 22 (51%) exhibited fusiform/dolichoectatic morphological features. Thirteen patients underwent microsurgery, 16 endovascular treatment, and three observation. Complete aneurysm obliteration rates were 94 and 82% in the microsurgical and endovascular groups, respectively. There were no deaths in either group, and neurological morbidity rates were comparable. Over time, 14% of endovascularly treated aneurysms recurred, and in 19% of these patients de novo aneurysms developed (mean follow-up duration 5.7 years). In contrast, there were no recurrences in the microsurgically treated aneurysms and only one de novo aneurysm (6%).

Conclusions

Both microsurgical and endovascular therapies can be conducted safely to treat pediatric aneurysms. Microsurgery may be more efficacious in completely eliminating the aneurysm and its effects more durable over the extended lifetime of these patients. Parental biases toward nonoperative therapy should be thoroughly addressed before ultimately selecting a treatment strategy.

Abbreviations used in this paper:ACoA = anterior communicating artery; BA = basilar artery; ICA = internal carotid artery; MCA = middle cerebral artery; SAH = subarachnoid hemorrhage; UCSF = University of California at San Francisco; VBJ = vertebrobasilar junction.

Article Information

Address reprint requests to: Michael T. Lawton, M.D., Department of Neurological Surgery, University of California at San Francisco, 505 Parnassus Avenue, M-780C, San Francisco, California 94143-0112. email: lawtonm@neurosurg.ucsf.edu.

© AANS, except where prohibited by US copyright law.

Headings

Figures

  • View in gallery

    Imaging studies obtained in a 15-year-old girl presenting with a seizure. Posterior oblique (A) and posterior (B) computerized tomography angiograms demonstrating a giant dolichoectatic right MCA aneurysm. The aneurysm was exposed via an orbitozygomatic–pterional approach (C) and its dome projected inferiorly into the temporal lobe. The aneurysm had no neck, with the afferent and efferent arteries separated by the body of the aneurysm. The aneurysm was trapped using temporary clips placed proximally and distally, and then punctured to collapse it (D). Multiple fenestrated and straight clips were used to reconstruct a channel from the afferent to the efferent arteries. The patient experienced an excellent outcome; postoperative angiography revealed complete obliteration of her aneurysm.

  • View in gallery

    Imaging studies obtained in a 15-year-old boy presenting with progressive diplopia and headache. A: Digital subtraction angiogram (anteroposterior view) revealing a giant left cavernous ICA aneurysm. B: A left orbitozygomatic–pterional craniotomy was performed, with the petrous ICA exposed proximally by drilling the bone in the Glasscock triangle on the floor of the middle fossa. C: Under electroencephalographic burst suppression, the petrous ICA was trapped between aneurysm clips, opened, and a saphenous vein graft was connected to it using an end-to-side anastomosis. Similarly, the supraclinoid ICA was trapped, arteriotomized (D), and the distal end of the vein graft was connected with an end-to-side anastomosis (E and F). G: The completed bypass courses from the floor of the middle fossa, around the dilated walls of the cavernous sinus, and to the carotid cistern under the frontal lobe. H: Postoperative angiogram demonstrating a patent bypass graft and good flow in the distal hemisphere. The patient experienced an excellent outcome.

  • View in gallery

    Imaging studies acquired in a 17-year-old boy presenting with SAH. A: Digital subtraction angiogram demonstrating a left ICA bifurcation aneurysm. B: The aneurysm was treated by placing endovascular coils, but there was residual aneurysm at the base. C: The aneurysm was exposed via a pterional craniotomy, and the base of the aneurysm still filled. D: A straight clip was placed around this remnant, which was clipped just beneath the coils, and good occlusion was achieved. E: Postoperative angiogram confirming complete aneurysm obliteration. The patient experienced an excellent outcome.

References

  • 1

    Almeida GMPindaro JPlese PBianco EShibata MK: Intracranial arterial aneurysms in infancy and childhood. Childs Brain 3:1931991977

    • Search Google Scholar
    • Export Citation
  • 2

    Amacher ALDrake CGFerguson GG: Posterior circulation aneurysms in young people. Neurosurgery 8:3153201981

  • 3

    Arai HUeki KTakahara Y: Intracranial aneurysm in an infant. Surg Neurol 1:94961973

  • 4

    Batnitzky SMuller J: Infantile and juvenile cerebral aneurysms. Neuroradiology 16:61641978

  • 5

    Burke MJ: Occult aneurysmal hemorrhage in a child. Case report and literature review. Pediatr Neurosurg 33:2742772000

  • 6

    Byard RWBourne AJHanieh A: Sudden and unexpected death due to hemorrhage from occult central nervous system lesions. A pediatric autopsy study. Pediatr Neurosurg 17:88941991

    • Search Google Scholar
    • Export Citation
  • 7

    Dell S: Asymptomatic cerebral aneurysm: assessment of its risk of rupture. Neurosurgery 10:1621661982

  • 8

    Dorfler AWanke IWiedemayer HWeber JForsting M: Endovascular treatment of a giant aneurysm of the internal carotid artery in a child with visual loss: case report. Neuropediatrics 31:1511542000

    • Search Google Scholar
    • Export Citation
  • 9

    Gerosa MLicata CFiore DLIraci G: Intracranial aneurysms of childhood. Childs Brain 6:2953021980

  • 10

    Gewirtz RJBroderick RWBaumann RJStevens JL: Fusiform P1 segment artery aneurysm in a pediatric patient: technical case report. Pediatr Neurosurg 29:2182211998

    • Search Google Scholar
    • Export Citation
  • 11

    Heiskanen OVilkki J: Intracranial arterial aneurysms in children and adolescents. Acta Neurochir (Wien) 59:55631981

  • 12

    Herman JMRekate HLSpetzler RF: Pediatric intracranial aneurysms: simple and complex cases. Pediatr Neurosurg 17:66731992

  • 13

    Huang JMcGirt MJGailloud PTamargo RJ: Intracranial aneurysms in the pediatric population: case series and literature review. Surg Neurol 63:4244332005

    • Search Google Scholar
    • Export Citation
  • 14

    Hulsmann SMoskopp DWassmann H: Management of a ruptured cerebral aneurysm in infancy. Report of a case of a ten-month-old boy. Neurosurg Rev 21:1611661998

    • Search Google Scholar
    • Export Citation
  • 15

    Husson RNSaini RLewis LLButler KMPatronas NPizzo PA: Cerebral artery aneurysms in children infected with human immunodeficiency virus. J Pediatr 121:9279301992

    • Search Google Scholar
    • Export Citation
  • 16

    Iob IScanarini MSalar GOri C: Traumatic cerebral aneurysm in pediatric age. Case report. J Neurosurg Sci 27:1871901983

  • 17

    Jane JA: A large aneurysm of the posterior inferior cerebellar artery in a 1-year-old child. J Neurosurg 18:2452471961

  • 18

    Kanaan ILasjaunias PCoates R: The spectrum of intracranial aneurysms in pediatrics. Minim Invasive Neurosurg 38:191995

  • 19

    Kasahara EMurayama TYamane C: Giant cerebral arterial aneurysm in an infant: report of a case and review of 42 previous cases in infants with cerebral arterial aneurysm. Acta Paediatr Jpn 38:6846881996

    • Search Google Scholar
    • Export Citation
  • 20

    Kassell NFTorner JCHaley EC JrJane JAAdams HPKongable GL: The International Cooperative Study on the Timing of Aneurysm Surgery. Part 1: Overall management results. J Neurosurg 73:18361990

    • Search Google Scholar
    • Export Citation
  • 21

    Kimbell FD JrLlewellyn RCKirgis HD: Surgical treatment of ruptured aneurysm with intracerebral and subarachnoid hemorrhage in a 16-month-old infant. J Neurosurg 17:3313321960

    • Search Google Scholar
    • Export Citation
  • 22

    Kuchelmeister KSchulz RBergmann MSchwuchow RVollmer E: A probably familial saccular aneurysm of the anterior communicating artery in a neonate. Childs Nerv Syst 9:3023051993

    • Search Google Scholar
    • Export Citation
  • 23

    Lansen TAKasoff SSArguelles JH: Giant pediatric aneurysm treated with ligation of the middle cerebral artery with the Drake tourniquet and extracranial-intracranial bypass. Neurosurgery 25:81851989

    • Search Google Scholar
    • Export Citation
  • 24

    Laughlin SterBrugge KWillinsky RAArmstrong DCMontanera WHumphreys RP: Endovascular management of paediatric intracranial aneurysms. Intervent Neuroradiol 3:2052141997

    • Search Google Scholar
    • Export Citation
  • 25

    Lilova MIPetkov DL: Intracranial aneurysms in a child with autosomal recessive polycystic kidney disease. Pediatr Nephrol 16:103010322001

    • Search Google Scholar
    • Export Citation
  • 26

    Lipper SMorgan DKrigman MRStaab EV: Congenital saccular aneurysm in a 19-day-old neonate: case report and review of the literature. Surg Neurol 10:1611651978

    • Search Google Scholar
    • Export Citation
  • 27

    Locksley HB: Natural history of subarachnoid hemorrhage, intracranial aneurysms and arteriovenous malformations. Based on 6368 cases in the cooperative study. J Neurosurg 25:2192391966

    • Search Google Scholar
    • Export Citation
  • 28

    Maggi GRuggiero CPetrone GAliberti F: Giant intracavernous carotid aneurysm in a child. Case report. J Neurosurg Sci 41:3493511997

    • Search Google Scholar
    • Export Citation
  • 29

    Matson DD: Intracranial arterial aneurysms in childhood. J Neurosurg 23:5785831965

  • 30

    Meyer FBSundt TM JrFode NCMorgan MKForbes GSMellinger JF: Cerebral aneurysms in childhood and adolescence. J Neurosurg 70:4204251989

    • Search Google Scholar
    • Export Citation
  • 31

    Nishio ASakaguchi MMurata KEgashira MYamada TIzuo M: Anterior communicating artery aneurysm in early childhood. Report of a case. Surg Neurol 35:2242291991

    • Search Google Scholar
    • Export Citation
  • 32

    Norris JSWallace MC: Pediatric intracranial aneurysms. Neurosurg Clin N Am 9:5575631998

  • 33

    Osenbach RK: Giant aneurysm of the distal posterior inferior cerebellar artery in an 11-month-old child presenting with obstructive hydrocephalus. Pediatr Neurosci 15:3093121989

    • Search Google Scholar
    • Export Citation
  • 34

    Ostergaard JRVoldby B: Intracranial arterial aneurysms in children and adolescents. J Neurosurg 58:8328371983

  • 35

    Pasqualin AMazza CCavazzani PScienza RDaPian R: Intracranial aneurysms and subarachnoid hemorrhage in children and adolescents. Childs Nerv Syst 2:1851901986

    • Search Google Scholar
    • Export Citation
  • 36

    Patel ANRichardson AE: Ruptured intracranial aneurysms in the first two decades of life. A study of 58 patients. J Neurosurg 35:5715761971

    • Search Google Scholar
    • Export Citation
  • 37

    Piatt JH JrClunie DA: Intracranial arterial aneurysm due to birth trauma. Case report. J Neurosurg 77:7998031992

  • 38

    Proust FToussaint PGarnieri JHannequin DLegars DHoutteville JP: Pediatric cerebral aneurysms. J Neurosurg 94:7337392001

    • Search Google Scholar
    • Export Citation
  • 39

    Roche JLChoux MCzorny ADhellemmes PFast MFrerebeau P: L'anévrisme artériel intracranien chez L'enfant. Etude coopérative A propos de 43 observations. Neurochirurgie 34:2432511988

    • Search Google Scholar
    • Export Citation
  • 40

    Sandberg DILamberti-Pasculli MDrake JMHumphreys RPRutka JT: Spontaneous intraparenchymal hemorrhage in full-term neonates. Neurosurgery 48:104210492001

    • Search Google Scholar
    • Export Citation
  • 41

    Sano KUeda YSaito I: Subarachnoid hemorrhage in children. Childs Brain 4:38461978

  • 42

    Schauseil-Zipf UThun FKellermann KMandl-Kramer Sauf der Haar K: Intracranial arteriovenous malformations and aneurysms in childhood and adolescence. Eur J Pediatr 140:2602671983

    • Search Google Scholar
    • Export Citation
  • 43

    Sedzimir CBJones EWHamilton DEdwards R: Management of coarctation of aorta and bleeding intracranial aneurysm in paediatric cases. Neuropadiatrie 4:1241331973

    • Search Google Scholar
    • Export Citation
  • 44

    Solomon RAMayer SATarmey JJ: Relationship between the volume of craniotomies for cerebral aneurysm performed at New York state hospitals and in-hospital mortality. Stroke 27:13171996

    • Search Google Scholar
    • Export Citation
  • 45

    Storrs BBHumphreys RPHendrick EBHoffman HJ: Intracranial aneurysms in the pediatric age-group. Childs Brain 9:3583611982

  • 46

    Takeshita MKagawa MIzawa MKitamura K: Hemorrhagic stroke in infancy, childhood, and adolescence. Surg Neurol 26:4965001986

  • 47

    Tekkök IHVentureyra ECG: Spontaneous intracranial hemorrhage of structural origin during the first year of life. Childs Nerv Syst 13:1541651997

    • Search Google Scholar
    • Export Citation
  • 48

    terBrugge KG: Neurointerventional procedures in the pediatric age group. Childs Nerv Syst 15:7517541999

  • 49

    Uchida KYoshimoto TSuzuki J: [Intracranial saccular aneurysms in the first three decades of life (author's transl).]. No To Shinkei 30:4094141978. (Jpn)

    • Search Google Scholar
    • Export Citation
  • 50

    Vaicys CHunt CDHeary RF: Ruptured intracranial aneurysm in an adolescent with Alport's syndrome—a new expression of type IV collagenopathy: case report. Surg Neurol 54:68722000

    • Search Google Scholar
    • Export Citation
  • 51

    Visudhiphan PChiemchanya SSomburanasin RDheandhanoo D: Causes of spontaneous subarachnoid hemorrhage in Thai infants and children. A study of 56 patients. J Neurosurg 53:1851871980

    • Search Google Scholar
    • Export Citation
  • 52

    Weir BIntracranial aneurysms and subarachnoid hemorrhage: an overview. Wilkins RHRengachary SS: Neurosurgery New YorkMcGraw-Hill1985. Vol 2:13081329

    • Search Google Scholar
    • Export Citation
  • 53

    Yazbak PAMcComb JGRaffel C: Pediatric traumatic intracranial aneurysms. Pediatr Neurosurg 22:15191995

  • 54

    Yoshimoto TUchida KSuzuki J: Intracranial saccular aneurysms in the first three decades. Surg Neurol 9:2872911978

  • 55

    Zee CSSegall HDMcComb JGStanley PLittle FMAhmadi J: Intracranial arterial aneurysms in childhood: more recent considerations. J Child Neurol 1:991141986

    • Search Google Scholar
    • Export Citation

Metrics

Metrics

All Time Past Year Past 30 Days
Abstract Views 79 79 7
Full Text Views 105 105 0
PDF Downloads 58 58 0
EPUB Downloads 0 0 0

PubMed

Google Scholar