Paediatric cerebral aneurysm


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Paediatric cerebral aneurysm

  1. 1. Dr.Manoranjitha kumari Prof. R.ArunkumarMadras Institute Of Neurology Chennai
  2. 2. 3 years old female child referred from ICH h/o recurrent episodes of seizures more than ten episodes in 2 hours period followed by which child lost consciousnes regained consciousness in two days Difficulty in using right upper and lower limbs with deviation of angle of mouth towards left side, and inability to speak since the ictus
  3. 3.  h/o low grade fever No history of trauma No history of previous seizures Ante natal , natal and post natal history – nil relevant Past history of chicken pox 1 ½ months ago
  4. 4.  On examination : child alert playful afebrile no neck stiffness aphasic obeys commands
  5. 5.  Cranial nerves: rt UMN 7th nerve palsy all other cranial nerves clinically normal fundus- normal Spino motor system: rt lt bulk n n tone ↑↑ n power 0/5 n
  6. 6.  Superficial reflexes- normal DTR- brisk reflexes in rt side limbs, normal in the lt side Plantar rt- extensor lt- flexor Spine and cranium normal
  7. 7.  Cardiacevaluation and other blood infection done at ICH was normal
  8. 8. Epidural catheterLt pterional craniotomyDurotomyFrontal and temporal lobes retractedSylvian and carotico optic cisterns openedBilobed aneurysm – 7mm*8mm, neck -3mm at lt ICA bifircationClipped from anterior to posteriorAneurysm excised, patent, no thrombus
  9. 9.  Journal of Neuropathology & Experimental Neurology: May 1996 - Volume 55 - Issue 5 - ppg 664 238: Pediatric AIDS Presenting As A Ruptured Cerebral Aneurysm Associated With Varicella-Zoster Vascuutis stephen dillert et al
  10. 10.  Epidemiology Intracranial paediatric aneurysms are rare, 1- 2% In children less than 2 y of age, there is a male predominance while in adolescents, there is an equal incidence of aneurysms in both sexes
  11. 11.  75 % of patients – SAH Giant aneurysms are common in paediatric age group Incidence of rebleeding 19-29% Radiological vasospasm– 36%, clinical vasospasm is low in paediatric age group(Proust series) The children tend to present in a better clinical grade as compared to adults after aneurysmal rupture and seem to be less susceptible to the delayed ischemic deficits due to vasospasm
  12. 12.  the incidence of seizures is higher explanation may be the higher incidence of intra cerebral bleed in children due to the frequent location of the aneurysms at ICA bifurcation or the MCA branches. higher incidence of giant aneurysm in children that may manifest as seizures or as mass effect rather than as SAH
  13. 13.  The commonest site of aneurysm in the paediatric group is ICA bifurcation-20-50% due to the presence of a wide ICA bifurcation angle. This exposes a wider area of vessel wall to the turbulent blood
  14. 14.  both congenital and acquired factors The presence of saccular aneurysms during early years of life point against degenerative causes in the etio pathogenesis of aneurysm formation. Bremer et al. supported the congenital origin of aneurysms and proposed that aneurysms developed from remnants of small vascular trunks originating from arterial bifurcation
  15. 15.  Diseases like fibromuscular dysplasia, coarctation of aorta, Marfans disease, polycystic kidney disease have a high incidence of aneurysm formation Thus, congenital defects of connective tissue in the vessel wall may be the predisposing factor for aneurysm formation in children. Histopathological studies, however, show no difference between adults and paediatric aneurysms, i.e, in both groups, there is absence of both internal elastic lamina and muscularis layer of tunica media
  16. 16.  Many studies support the presence of acquired causes for aneurysm formation. The degenerative changes may first appear in the intimal pads proximal to the blood vessel bifurcation, which then extend to the media The increased hemodynamic stress at branching points leads to injury to internal elastic lamina and this initiates the development of aneurysm Infective – mycotic aneurysm in SABE In traumatic cases, there may be tears in the internal elastic lamina leading to dissecting aneurysms in large arteries. Stephens suggested lodgment of bacteria at the site of trauma. The bacteria then multiply in the thrombus at the site of vessel injury leading to aneurysm formation
  17. 17.  Ruptured aneurysms , the operative or endovascular techniques are similar to that used in adults. Due to higher incidence of complex aneurysms in children, more extensive procedures may often be required to facilitate clipping. These include microanastomosis, bypass procedures and trapping.Endovascular approach should be chosen with the indications being similar to that of adults.
  18. 18.  infective aneurysms, initial efforts focus on treating them conservatively using antibiotics and serial angiograms, with surgery being reserved for patients who have persistence of the aneurysm on follow-up angiogram. The aneurysm is often friable and may not be amenable to clipping. The surgical treatment usually consists of occluding the parent vessel proximal to the aneurysm if the aneurysm is on a terminal branch in a non-eloquent region. In proximal aneurysms, due to the risk of ischemia involved in trapping a major vessel, reconstruction or trapping with bypass may be
  19. 19.  In the case of traumatic aneurysms, an often used modality is excision of aneurysm (because these are usually false aneurysms), especially when it is situated on a terminal branch. In aneurysms on main stem of vessel, trapping with bypass may be required
  20. 20.  Intracranial paediatric aneurysms are different from adults in having a male predominance, having ICA as the commonest site and also in having a higher incidence of infective, traumatic and giant aneurysms. The clinical presentation of mass effect or subtle cognitive dysfunction occurs more often than in adults. These patients tend to have lesser incidence of clinical vasospasm and appear to have a better outcome as compared to adults