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

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Intracranial aneurysms in the pediatric population are rare entities. The authors recently treated a 9-month-old infant with a 19-mm recurrent, previously ruptured, and coil-embolized left middle cerebral artery (MCA) pseudoaneurysm, which was treated definitively with single-stage Pipeline-assisted coil embolization. The patient was 5 months old when she underwent resection of a left temporal Grade 1 desmoplastic infantile ganglioglioma at an outside institution, which was complicated by left MCA injury with a resultant 9-mm left M1 pseudoaneurysm. Within a month, the patient had two aneurysmal rupture events and underwent emergency craniectomy for decompression and evacuation of subdural hematoma. The pseudoaneurysm initially underwent coil embolization; however, follow-up MR angiography (MRA) revealed aneurysm recanalization with saccular enlargement to 19 mm. The patient underwent successful flow diversion–assisted coil embolization at 9 months of age. At 7 months after the procedure, follow-up MRA showed complete aneurysm occlusion without evidence of in-stent thrombosis or stenosis. Experience with flow diverters in the pediatric population is still in its early phases, with the youngest reported patient being 22 months old. In this paper the authors report the first case of such a technique in an infant, whom they believe to be the youngest patient to undergo cerebral flow diversion treatment.

ABBREVIATIONS EVD = external ventricular drain; ICA = internal carotid artery; MCA = middle cerebral artery; MRA = MR angiography; PED = Pipeline embolization device; PRU = platelet response units; STA = superficial temporal artery.
Article Information

Contributor Notes

Correspondence Alexander L. Coon: Johns Hopkins University School of Medicine, The Johns Hopkins Hospital, Baltimore, MD. acoon2@jhmi.edu.INCLUDE WHEN CITING Published online August 24, 2018; DOI: 10.3171/2018.6.PEDS18165.Disclosures Dr. Coon is a proctor for the Woven Endobridge (WEB) device (Sequent Medical); a proctor for the Surpass device (Stryker Neurovascular) and a consultant for Stryker Neurovascular; a proctor for the PED (Medtronic Neurovascular) and a consultant for Medtronic; and a proctor for the FRED device (MicroVention) and consultant for MicroVention. Dr. Colby is a proctor for the PED and consultant for Stryker Neurovascular. Dr. Lin is a proctor for the PED (Medtronic Neurovascular), is a consultant for MicroVention, and participates in a clinical trial for Stryker. Dr. Huang reports ownership in Longeviti.

© AANS, except where prohibited by US copyright law.

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References
  • 1

    Abla AAZaidi HACrowley RWBritz GWMcDougall CGAlbuquerque FC: Optic chiasm compression from mass effect and thrombus formation following unsuccessful treatment of a giant supraclinoid ICA aneurysm with the Pipeline device: open surgical bailout with STA-MCA bypass and parent vessel occlusion. J Neurosurg Pediatr 14:31372014

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 2

    Alawi AEdgell RCElbabaa SKCallison RCKhalili YAAllam H: Treatment of cerebral aneurysms in children: analysis of the Kids’ Inpatient Database. J Neurosurg Pediatr 14:23302014

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 3

    Appelboom GKadri KHassan FLeclerc X: Infectious aneurysm of the cavernous carotid artery in a child treated with a new-generation of flow-diverting stent graft: case report. Neurosurgery 66:E623E6242010

    • Search Google Scholar
    • Export Citation
  • 4

    Awad AJMascitelli JRHaroun RRDe Leacy RAFifi JTMocco J: Endovascular management of fusiform aneurysms in the posterior circulation: the era of flow diversion. Neurosurg Focus 42(6):E142017

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 5

    Becske TBrinjikji WPotts MBKallmes DFShapiro MMoran CJ: Long-term clinical and angiographic outcomes following Pipeline Embolization Device treatment of complex internal carotid artery aneurysms: five-year results of the Pipeline for Uncoilable or Failed Aneurysms trial. Neurosurgery 80:40482017

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 6

    Becske TPotts MBShapiro MKallmes DFBrinjikji WSaatci I: Pipeline for uncoilable or failed aneurysms: 3-year follow-up results. J Neurosurg 127:81882017

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 7

    Bender MTColby GPJiang BLin LMCampos JKXu R: Flow diversion of posterior circulation cerebral aneurysms: a single-institution series of 59 cases. Neurosurgery [epub ahead of print] 2018

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 8

    Bender MTColby GPLin LMJiang BWestbroek EMXu R: Predictors of cerebral aneurysm persistence and occlusion after flow diversion: a single-institution series of 445 cases with angiographic follow-up. J Neurosurg [epub ahead of print March 30 2018. DOI: 10.3171/2017.11.JNS171738]

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 9

    Bender MTLin LMColby GPLubelski DHuang JTamargo RJ: P2Y12 hyporesponse (PRU>200) is not associated with increased thromboembolic complications in anterior circulation Pipeline. J Neurointerv Surg 9:9789812017

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 10

    Bender MTWendt HMonarch TLin LMJiang BHuang J: Shifting treatment paradigms for ruptured aneurysms from open surgery to endovascular therapy over 25 years. World Neurosurg 106:9199242017

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 11

    Bhogal PAlMatter MBäzner HGanslandt OHenkes HAguilar Pérez M: Flow diversion for the treatment of MCA bifurcation aneurysms—a single centre experience. Front Neurol 8:202017

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 12

    Burrows AMZipfel GLanzino G: Treatment of a pediatric recurrent fusiform middle cerebral artery (MCA) aneurysm with a flow diverter. J Neurointerv Surg 5:e472013

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 13

    Chalouhi NZanaty MWhiting AYang STjoumakaris SHasan D: Safety and efficacy of the Pipeline Embolization Device in 100 small intracranial aneurysms. J Neurosurg 122:149815022015

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 14

    Çinar CBozkaya HOran I: Endovascular treatment of cranial aneurysms with the pipeline flow-diverting stent: preliminary mid-term results. Diagn Interv Radiol 19:1541642013

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 15

    Cobb MIHZomorodi ARHauck EFSmith TPFernando Gonzalez L: Optimal pediatric dosing of anti-platelet agents for pipeline stent embolization—a case report and review of the literature. Childs Nerv Syst 33:6856902017

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 16

    Colby GPBender MTLin LMBeaty NCaplan JMJiang B: Declining complication rates with flow diversion of anterior circulation aneurysms after introduction of the Pipeline Flex: analysis of a single-institution series of 568 cases. J Neurosurg [epub ahead of print January 12 2018. DOI: 10.3171/2017.7.JNS171289]

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 17

    Colby GPBender MTLin LMBeaty NHuang JTamargo RJ: Endovascular flow diversion for treatment of anterior communicating artery region cerebral aneurysms: a single-center cohort of 50 cases. J Neurointerv Surg 9:6796852017

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 18

    Colby GPLin LMCaplan JMJiang BHuang JTamargo RJ: Immediate procedural outcomes in 44 consecutive Pipeline Flex cases: the first North American single-center series. J Neurointerv Surg 8:7027092016

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 19

    Crowley RWEvans AJKassell NFJensen MEDumont AS: Endovascular treatment of a fusiform basilar artery aneurysm using multiple “in-stent stents”. Technical note. J Neurosurg Pediatr 3:4965002009

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 20

    de Barros Faria MCastro RNLundquist JScrivano ECeratto RFerrario A: The role of the pipeline embolization device for the treatment of dissecting intracranial aneurysms. AJNR Am J Neuroradiol 32:219221952011

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 21

    Delgado Almandoz JECrandall BMScholz JMFease JLAnderson REKadkhodayan Y: Pre-procedure P2Y12 reaction units value predicts perioperative thromboembolic and hemorrhagic complications in patients with cerebral aneurysms treated with the Pipeline Embolization Device. J Neurointerv Surg 5 (Suppl 3):iii3iii102013

    • Search Google Scholar
    • Export Citation
  • 22

    Finkelstein YNurmohamed LAvner MBenson LNKoren G: Clopidogrel use in children. J Pediatr 147:6576612005

  • 23

    Goh CChurilov LMitchell PDowling RYan B: Clopidogrel hyper-response and bleeding risk in neurointerventional procedures. AJNR Am J Neuroradiol 34:7217262013

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 24

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

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 25

    Ikeda DSMarlin ESShaw APowers CJ: Successful endovascular reconstruction of a recurrent giant middle cerebral artery aneurysm with multiple telescoping flow diverters in a pediatric patient. Pediatr Neurosurg 50:88932015

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 26

    Jiang BPaff MColby GPCoon ALLin LM: Cerebral aneurysm treatment: modern neurovascular techniques. Stroke Vasc Neurol 1:931002016

  • 27

    Kakarla UKBeres EJPonce FAChang SWDeshmukh VRBambakidis NC: Microsurgical treatment of pediatric intracranial aneurysms: long-term angiographic and clinical outcomes. Neurosurgery 67:2372502010

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 28

    Kallmes DFBrinjikji WCekirge SFiorella DHanel RAJabbour P: Safety and efficacy of the Pipeline embolization device for treatment of intracranial aneurysms: a pooled analysis of 3 large studies. J Neurosurg 127:7757802017

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 29

    Kan PMokin MPuri ASWakhloo AK: Successful treatment of a giant pediatric fusiform basilar trunk aneurysm with surpass flow diverter. BMJ Case Rep 2015:bcr20150117182015

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 30

    Li JSYow EBerezny KYBokesch PMTakahashi MGraham TP Jr: Dosing of clopidogrel for platelet inhibition in infants and young children: primary results of the Platelet Inhibition in Children On cLOpidogrel (PICOLO) trial. Circulation 117:5535592008

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 31

    Lin NLanzino GLopes DKArthur ASOgilvy CSEcker RD: Treatment of distal anterior circulation aneurysms with the Pipeline embolization device: a US multicenter experience. Neurosurgery 79:14222016

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 32

    Lubicz BCollignon LRaphaeli GPruvo JPBruneau MDe Witte O: Flow-diverter stent for the endovascular treatment of intracranial aneurysms: a prospective study in 29 patients with 34 aneurysms. Stroke 41:224722532010

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 33

    Lyon KAArrey ENHaider ASJeevan DSBenardete EA: Endovascular treatment of a large ruptured middle cerebral artery bifurcation aneurysm in a 5-week-old infant: case report. J Neurosurg Pediatr 20:3573632017

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 34

    Martínez-Galdámez MPérez SVega ARuiz PCaniego JLBárcena E: Endovascular treatment of intracranial aneurysms using the Pipeline Flex embolization device: a case series of 30 consecutive patients. J Neurointerv Surg 8:3964012016

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 35

    Navarro RBrown BLBeier ARanalli NAldana PHanel RA: Flow diversion for complex intracranial aneurysms in young children. J Neurosurg Pediatr 15:2762812015

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 36

    Nossek EChalif DJChakraborty SLombardo KBlack KSSetton A: Concurrent use of the Pipeline Embolization Device and coils for intracranial aneurysms: technique, safety, and efficacy. J Neurosurg 122:9049112015

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 37

    Park MSMazur MDMoon KNanaszko MJKestle JRWShah LM: An outcomes-based grading scale for the evaluation of cerebral aneurysms treated with flow diversion. J Neurointerv Surg 9:106010632017

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 38

    Rajah GNarayanan SRangel-Castilla L: Update on flow diverters for the endovascular management of cerebral aneurysms. Neurosurg Focus 42(6):E22017

  • 39

    Sanai NQuinones-Hinojosa AGupta NMPerry VSun PPWilson CB: Pediatric intracranial aneurysms: durability of treatment following microsurgical and endovascular management. J Neurosurg 104 (2 Suppl):82892006

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 40

    Saraf RShrivastava MSiddhartha WLimaye U: Intracranial pediatric aneurysms: endovascular treatment and its outcome. J Neurosurg Pediatr 10:2302402012

  • 41

    Sastry RAKoch MJGrannan BLStapleton CJButler WEPatel AB: Flow diversion of a recurrent, iatrogenic basilar tip aneurysm in a pediatric patient: case report. J Neurosurg Pediatr 21:90932018

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 42

    Simma BHöliner ILuetschg J: Therapy in pediatric stroke. Eur J Pediatr 172:8678752013

  • 43

    Soman TRafay MFHune SAllen AMacGregor DdeVeber G: The risks and safety of clopidogrel in pediatric arterial ischemic stroke. Stroke 37:112011222006

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 44

    Takemoto KTateshima SGolshan AGonzalez NJahan RDuckwiler G: Endovascular treatment of pediatric intracranial aneurysms: a retrospective study of 35 aneurysms. J Neurointerv Surg 6:4324382014

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 45

    Taylor LIDickerson JCDambrino RJKalani MYSTaussky PWashington CW: Platelet testing in flow diversion: a review of the evidence. Neurosurg Focus 42(6):E52017

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 46

    Vachhani JANickele CMElijovich LKlimo PArthur AS: Flow diversion for treatment of growing A2 aneurysm in a child: case report and review of flow diversion for intracranial aneurysms in pediatric patients. World Neurosurg 96:607.e13607.e172016

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 47

    van Rooij WJSluzewski M: Perforator infarction after placement of a pipeline flow-diverting stent for an unruptured A1 aneurysm. AJNR Am J Neuroradiol 31:E43E442010

    • Search Google Scholar
    • Export Citation
  • 48

    Vargas SADiaz CHerrera DADublin AB: Intracranial aneurysms in children: the role of stenting and flow-diversion. J Neuroimaging 26:41452016

  • 49

    Zarzecka AGory BTurjman F: Implantation of two flow diverter devices in a child with a giant, fusiform vertebral artery aneurysm: case report. Pediatr Neurol 50:1851872014

    • Crossref
    • Search Google Scholar
    • Export Citation
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