Original ArticleMultimodal Treatment of Intracranial Aneurysms in Children: Clinical Case Series and Review of the Literature
Introduction
Compared with aneurysms in adults, pediatric aneurysms are rare and more complex. Lesions may occur in the setting of syndromic disease with unclear implications on natural history. They are less commonly saccular, the posterior circulation is more commonly involved, giant aneurysms are frequent, and fusiform and dissecting pathologic features are common.1 The multiplicity of pediatric intracranial aneurysms (IAs) is similar or lower in frequency compared with adults.2, 3, 4, 5 Pediatric IAs may undergo spontaneous thrombosis with greater frequency (∼8%–16%),3, 5 rendering serial neurovascular imaging a reasonable management option in selected cases.
Children are better able to tolerate subarachnoid hemorrhage (SAH) and its complications (e.g., vasospasm) as a result of their robust collateral leptomeningeal circulation and capacity for neuroplasticity, with better overall outcomes compared with adults.6, 7, 8, 9 However, given frequent pediatric IA complexity and greater anticipated years of life, there exists a higher risk of recurrence and de novo aneurysmogenesis. These factors impact management and follow-up considerations.
Section snippets
Methods
Four institutional databases of neurovascular procedures from 2012 to 2017 were reviewed. Patients <18 years old who were treated for IAs were included. Patient characteristics, aneurysm details, treatment information, and angiographic and clinical outcomes were recorded. The study was approved by each of the local institutional review boards. Owing to the small number of cases, statistical analyses were not performed. In some of the cases, aneurysms were secondary to another underlying primary
Results
Ten cases of IAs in 9 children were identified. There were 7 boys and 2 girls. The mean age was 8.9 years. Management included direct clipping in 1 patient, trapping and bypass in 1, endovascular coil embolization in 1, endovascular vessel sacrifice in 3, flow diversion in 3, and stenting in 1. Of the 10 aneurysms, 3 were ruptured. The mean follow-up time was 24 months, and complete obliteration was achieved in 8 patients (Table 1).
Epidemiology
Pediatric IAs are uncommon, representing 1% to 7% of all IAs; most reports cite the lower end of this range.10, 11, 12, 13, 14, 15 Infant cases are even less frequent, representing 2% of all pediatric IAs.6, 11, 12, 16 Pediatric IAs exhibit overall male predominance (1.5-3:1),2, 3, 5, 17, 18 with female predominance in those <2 years (∼5:1).3, 18, 19
Etiologic Factors
Only one third of pediatric IAs are saccular and the cause is identified in only half of cases.20 Children do not possess the typical adult risk
Conclusion
The spectrum of disease represented by pediatric IAs renders an algorithmic approach to therapeutic decision making challenging. The decision to treat and the selection of therapy require a thorough appreciation, consideration, and careful weighing of all patient and lesion variables, as well as the risks and benefits conferred by available interventions. Therapeutic strategizing, expected outcomes, and contingency plans should be carefully discussed in multidisciplinary fashion by
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Conflict of interest statement: The authors declare that the article content was composed in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.