Intracranial Aneurysms in Childhood: Report of 8 Cases and Review of the Literature

Abstract

Objective: Subarachnoid haemorrhage (SAH) due to ruptured cerebral aneurysms is a rare diagnosis in childhood and is believed to differ from that in adults with regard to sex, aneurysm size and location, clinical appearance as well as outcome, suggesting that aneurysms in childhood are a distinct entity.

Patients and Methods: Seven children and young adults with a mean age of 13.6 years suffered from aneurysmal subarachnoid haemorrhage. On admission two patients were Hunt & Hess (HH) grade I, four were grade III and one was grade V. In addition, there was one 14-year-old boy who presented with seizures and was found to have a non-ruptured aneurysm of the basilar tip. Overall, there were two female and six male patients. Anterior circulation aneurysms were diagnosed in five patients whereas three patients suffered from posterior circulation aneurysm. Five large (10–25 mm) aneurysms and three smaller than 10 mm were found. Surgical clipping of the aneurysms was performed in all patients.

Results: Six patients showed no significant disability or no symptoms at all when evaluated with the modified Rankin Scale (mRS 0 or 1). One patient suffered from persisting nerve palsies (mRS 2) and one 6-year-old boy, admitted with HH grade V, died due to the initial poor clinical condition followed by severe brain oedema and secondary complications.

Conclusions: Reviewing the literature, a male predominance, low rate of SAH, high percentage of complex aneurysms and of aneurysms located in the posterior circulation are characteristic features of aneurysms in childhood. Once a cerebral aneurysm is diagnosed in the younger age group, definite therapy should be performed soon as the outcome is expected to be more favourable than in adulthood.

Zusammenfassung

Hintergrund: Die aneurysmatische Subarachnoidalblutung (SAB) im Kindesalter ist eine sehr seltene Diagnose und ist nach Angaben der Literatur hinsichtlich der klinischen Daten, Aneurysmagröße und –lokalisation sowie der therapeutischen Ergebnisse deutlich von denen im Erwachsenenalter zu unterscheiden.

Patienten und Methodik: Sieben Kinder und Jugendliche mit mittlerem Lebensalter von 13,6 Jahren wurden mit einer SAB (Hunt & Hess Grad I bis V) operativ behandelt. Bei einem weiteren Patienten (14 Jahre) mit zerebralen Krampfanfällen wurde ein nicht rupturiertes Basilaris-Kopf-Aneurysma ebenfalls neurochirurgisch versorgt. Aneurysmen des vorderen Kreislaufes wurden bei fünf Kindern, des vertebrobasilären Kreislaufes bei drei Kindern diagnostiziert. 5 von 8 Aneurysmen waren zwischen 10 und 25 mm groß, 3 waren kleiner als 10 mm.

Ergebnisse: Sechs Patienten zeigten nach der Behandlung keine oder nur eine geringe Einschränkung (modified Rankin Scale 0 oder 1), während ein Patient dauerhafte Hirnnervenstörungen erlitt und einer an der Schwere der SAB, Hirnödem mit pulmonalen Komplikationen verstarb.

Schlussfolgerung: Eine Übersicht der Literatur mit mehr als 700 publizierten Fällen zeigt bei Kindern im Gegensatz zu der Gruppe der Erwachsenen eine männliche Dominanz, eine relativ geringe Rate von rupturierten Aneurysmen, einen hohen Prozentsatz von sehr großen oder komplexen Aneurysmen, die zudem weitaus häufiger im hinteren Kreislauf lokalisiert sind. Damit dürfen die Aneurysmen im Kindesalter als eine besondere Entität verstanden werden, die hinsichtlich der Therapie trotz der kritischen Eingangsvoraussetzungen eine sehr günstige Prognose besitzen.

Key words

spontaneous subarachnoid haemorrhage - cerebral aneurysm - childhood

Schlüsselwörter

Subarachnoidalblutung - zerebrale Aneurysmen - Kindesalter

References

• 1 Agid R, Souza MPS, Reintamm G. et al . The role of endovascular treatment for pediatric aneurysms.  Childs Nerv Syst. 2005;  21 1030-1036
• 2 Almeida GM, Pindaro J, Plese P. et al . Intracranial arterial aneurysms in infancy and childhood.  Childs Brain. 1997;  3 193-199
• 3 Al-Qahtani S, Tampieri D, Brassard R. et al . Coil embolization of an aneurysm associated with an infraoptic anterior cerebral artery in a child.  AJNR Am J Neuroradiol. 2003;  24 ((5)) 990-991
• 4 Andrews BT, Edwards MS, Gannon P. Acutely thrombosed aneurysm of the middle cerebral artery presenting as intracranial hemorrhage in a 3-year-old child. Case report.  J Neurosurg. 1984;  60 1303-1307
• 5 Aydin IH, Onder A, Kadioglu HH. Giant intracranial aneurysms in children and adolescents.  Zentralbl Neurochir. 1993;  54 35-38
• 6 Biller J, Toffol GJ, Kassell NF. et al . Spontaneous subarachnoid hemorrhage in young adults.  Neurosurgery. 1987;  21 664-667
• 7 Burke MJ. Occult aneurysmal hemorrhage in a child. Case report and literature review.  Pediatr Neurosurg. 2000;  33 274-277
• 8 Cambria S, Cardia E, Macri E. Giant aneurysm of the sylvian artery in a 4-year old child.  Neurochirurgie. 1976;  22 85-90
• 9 Carillo R, Carreira LM, Prada J. et al . Giant aneurysm arising from a single arteriovenous fistula in a child. Case report.  J Neurosurg. 1984;  60 1085-1088
• 10 Cedzich C, Schramm J, Röckelein G. Multiple middle cerebral artery aneurysms in an infant. Case report.  J Neurosurg. 1990;  72 ((5)) 806-809
• 11 Cheung H, Lee FC. A thrombosed saccular posterior cerebral artery aneurysm in an infant.  Australas Radiol. 1993;  37 90-92
• 12 Cohen JE, Ferrario A, Ceratto R. et al . Reconstructive endovascular approach for a cavernous aneurysm in infancy.  Neurol Res. 2001;  25 ((5)) 492-496
• 13 de Sousa AA, Dantas FL, Neto AP. et al . Giant posterior cerebral artery aneurysm in a 4-year-old child: case report.  Surg Neurol. 1996;  45 31-35
• 14 Deruty R, Mottolese C, Bascoulergue Y. et al . Spontaneous progressive thrombosis and surgical resection of a giant aneurysm of the posterior cerebral artery in an 18-year-old.  Neurol Res. 1987;  9 169-176
• 15 Desai K, Nadkarni T, Muzumdar D. et al . Rupture of a giant posterior inferior cerebellar artery aneurysm in an infant following a ventriculoperitoneal shunt – Case report.  Neurol Med Chir (Tokyo). 2001;  41 ((3)) 127-130
• 16 Diaz A, Taha S, Vinikoff L. et al . Trauma induced arterial aneurysm in childhood. Report of a case and review of the literature.  Neurochirurgie. 1998;  44 46-49
• 17 Dufill J, Lang DA, Dwyer GN. Subarachnoid hemorrhage in a child from an aneurysm of persistent primitive hypoglossal artery.  Br J Neurosurg. 1996;  10 607-610
• 18 Endo M, Ochiai C, Watanabe K. et al . Ruptured peripheral lenticulostriate artery aneurysm in a child: case report.  No Shinkei Geka. 1996;  24 961-964
• 19 Ferrante L, Fortuna A, Celli P. et al . Intracranial aneurysms in early childhood.  Surg Neurol. 1988;  29 39-56
• 20 Fukamachi A, Hirato M, Wakao T. et al . Giant serpentine aneurysm of the posterior cerebral artery.  Neurosurgery. 1982;  11 271-276
• 21 Fulmer BB, Dillard SC, Musulman EM. et al . Two cases of cerebral aneurysms in HIV and children.  Pediatr Neurosurg. 1998;  28 31-34
• 22 Fujita K, Yanaka K, Kamezaki T. et al . Ruptured middle cerebral artery aneurysm with intramural myxoid degeneration in a child.  Pediatr Neurosurg. 2003;  39 ((2)) 108-111
• 23 Gerosa M, Licata C, Fiore DL. et al . Intracranial aneurysms of childhood.  Childs Brain. 1980;  6 295-302
• 24 Gewirtz RJ, Broderick RW, Baumann RJ. et al . Fusiform P1 segment artery aneurysm in a pediatric patient – technical case report.  Pediatr Neurosrug. 1998;  29 218-221
• 25 Hacein-Bey L, Muszynski CA, Varelas PN. Saccular aneurysm associated with posterior cerebral artery fenestration manifesting as a subarachnoid hemorrhage in a child.  AJNR Am J Neuroradiol. 2002;  23 ((8)) 1291-1294
• 26 Heiskanen O. Ruptured intracranial arterial aneurysm of children and adolescents. Surgical and total management results.  Childs Nerv Syst. 1989;  5 66-70
• 27 Heiskanen O, Vilkki J. Intracranial arterial aneurysms in children and adolescents.  Acta Neurochir. 1981;  59 55-63
• 28 Hourihan MD, Gates PC, MacAllister VL. Subarachnoid hemorrhage in childhood and adolescence.  J Neurosurg. 1984;  60 1163-1166
• 29 Huang LT, Shih TY, Lui CC. Posterior cerebral artery aneurysm in a two year old girl.  J Formos Med Assoc. 1996;  95 170-172
• 30 Hulsmann S, Moskopp D, Wassmann H. Management of a ruptured cerebral aneurysm in infancy. Report of a case of a ten-month-old boy.  Neurosurg Rev. 1998;  21 161-166
• 31 Hungerford GD, Marzluff JM, Kempe LG. et al . Cerebral arterial aneurysm in a neonate.  Neuroradiology. 1981;  21 107-110
• 32 Ikeda K, Yamashita J, Higashi S. Giant fusiform aneurysm at the horizontal position of the middle cerebral artery in a child – case report.  Neurol Med Chir. 1994;  34 30-34
• 33 Ishii K, Isono M, Kasai N. et al . Midaortic syndrome in childhood associated with a ruptured cerebral aneurysm: a case report.  Surg Neurol. 2001;  55 209-212
• 34 Ito M, Yoshihara M, Ishii M. et al . Cerebral aneurysms in children.  Brain Dev. 1992;  14 263-268
• 35 Jain PK, Mehta VS. Anterior communicating artery aneurysm in a 3-year-old girl.  Childs Nerv Syst. 2002;  18 ((1–2)) 71-73
• 36 Jones BV, Tomsick TA, Franz DN. Guglielmi detachable coil embolization of a giant midbasilar aneurysm in a 19-month-old patient.  AJNR Am J Neuroradiol. 2002;  23 ((7)) 1145-1148
• 37 Ito T, Kubo H, Kobayashi M. et al . Basilar aneurysm with subarachnoid hemorrhage and hemiparesis in a young male.  Nippon Ika Daigaku Zasshi. 1968;  35 154-158
• 38 Kaplan PA, Hahn FJ. Aneurysms of the posterior cerebral artery in children.  AJNR Am J Neuroradiol. 1984;  5 771-774
• 39 Kasahara E, Murayama T, Yamane C. Giant cerebral aneurysm in an infant: report of a case and review of 42 previous cases in infants with cerebral arterial aneurysm.  Acta Pediatr Jpn. 1986;  38 684-688
• 40 Kato T, Hattori H, Yorifuji T. et al . Intracranial aneurysms in Ehlers-Danlos syndrome type IV in early childhood.  Pediatr Neurol. 2001;  25 ((4)) 336-339
• 41 Krishna H, Wani AA, Behari S. et al . Intracranial aneurysms in patients 18 years of age or under, are they different from aneurysms in adult population?.  Acta Neurochir. 2005;  147 469-476
• 42 Leblanc R, Blundell JE. Aneurysm of the posterior inferior cerebellar artery presenting as intraventricular hemorrhage in a child: report of a case with survival.  Can J Neurol Sci. 1980;  7 301-304
• 43 Ley-Valle A, Vilalta J, Sahuquillo J. et al . Giant calcified aneurysm on the posterior crebral artery in nine-year-old child.  Surg Neurol. 1983;  20 396-398
• 44 Lilova MI, Petkov DL. Intracranial aneurysms in a child with autosomal recessive polycystic kidney disease.  Pediatr Nephrol. 2001;  16 ((12)) 1030-1032
• 45 Mazza C, Pasqualin A, Da Pian R. et al . Intracranial aneurysms and subarachnoid hemorrhage in children and adolescents.  Minerva Med. 1986;  77 1145-1151
• 46 Meyer FB, Sundt TM, Fode NC. et al . Cerebral aneurysms in childhood and adolescence.  J Neurosurg. 1989;  70 420-425
• 47 Morelli RJ, Laubscher F. Intracranial aneurysm in infancy. Case report.  J Neurosurg. 1977;  46 832-834
• 48 Motahashi O, Kameyama M, Imaizumi S. et al . A distal anterior cerebral artery aneurysm in infant: disappearance and reappearance of the aneurysm.  J Clin Neurosci. 2004;  11 86-88
• 49 Nanda A, Drury BT. Posterior circulation aneurysms in a child: clipping of one leads to spontaneous thrombosis of the other.  Pediatr Neurosurg. 1997;  26 41-47
• 50 Norris JS, Wallace MC. Pediatric intracranial aneurysms.  Neurosurg Clin N Am. 1998;  9 557-563
• 51 Orozco M, Trigueros F, Quintana F. et al . Intracranial aneurysms in early childhood.  Surg Neurol. 1978;  9 247-252
• 52 Ostergaard JR, Voldby B. Intracranial arterial aneurysms in children and adolescents.  J Neurosurg. 1983;  58 832-837
• 53 Paoletti P, Pezzotta S, Scotta M. et al . Saccular aneurysm of infancy and early childhood: report of a case.  Acta Neurochir (Wien). 1981;  57 257-267
• 54 Pasqualin A, Mazza C, Cavazzani P. et al . Intracranial aneurysms and subarachnoid hemorrhage in children and adolescents.  Childs Nerv Syst. 1986;  2 185-190
• 55 Proust F, Toussaint P, Garnieri J. et al . Pediatric cerebral aneurysms.  J Neurosurg. 2001;  94 733-739
• 56 Putty TK, Luerssen TG, Campbell RL. et al . Magnetic resonance imaging diagnosis of a cerebral aneurysm in an infant. Case report and review of the literature.  Pediatr Neurosurg. 1990;  16 48-51
• 57 Romero FJ, Tapies C, Ibarra B. et al . Aneurysms of the posterior cerebral artery in children.  Pediatr Radiol. 1988;  18 491-493
• 58 Sano K, Ueda Y, Saito I. Subarachnoid hemorrhage in children.  Childs Brain. 1978;  4 38-46
• 59 Sharma BS, Sinha S, Mehta VS. et al . Pediatric intracranial aneurysms – clinical characteristics and outcome of surgical treatment.  Childs Nerv Syst. 2007;  23 327-333
• 60 Scholten FG, ter Berg HW, Hofstee N. et al . Giant aneurysm of the posterior cerebral artery in a one-year-old child.  Eur J Radiol. 1992;  5 56-58
• 61 Tanabe M, Inoue Y, Hori T. Spontaneous thrombosis of an aneurysm of the middle cerebral artery with subarachnoid hemorrhage in a 6-year-old child: case report.  Neurol Res. 1991;  13 202-204
• 62 Uhlmann O, Kunzel W. Fatal subarachnoid hemorrhage from a ruptured aneurysm of the posterior cerebral artery in a 3-year-old girl.  Padiatr Grenzgeb. 1969;  8 49-56
• 63 Ventureyra EC, Choo SH, Benoit BG. Super giant globoid intracranial aneurysm in an infant. Case report.  J Neurosurg. 1980;  53 411-416
• 64 Ventureyra EC, Higgins MJ. Traumatic intracranial aneurysms in childhood and adolescence. Case reports and review of the literature.  Childs Nerv Syst. 1994;  10 361-379
• 65 Vincent FM, Zimmermann JE. Superior cerebellar artery aneurysm presenting as an oculomotor nerve palsy in a child.  Neurosurgery. 1980;  6 661-664
• 66 Visudhipan P, Chiemchanya S, Somburanasin R. et al . Cause of spontaneous subarachnoid hemorrhage in Thai infants and childrena. A study of 56 patients.  J Neurosurg. 1980;  53 185-187
• 67 Wojtacha M, Bazowski P, Mandera M. et al . Cerebral aneurysms in childhood.  Childs Nerv Syst. 2001;  17 37-41

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