This document discusses the case of a 12-year-old boy who presented with sudden severe headache, vomiting, right-sided weakness and difficulty speaking. Imaging revealed an aneurysm at the bifurcation of his internal carotid artery. The document then provides background information on intracranial aneurysms in pediatric patients, noting they are rare but can occur in unusual locations compared to adults. Risk factors also differ, with few of the common adult risk factors applying to children. The document outlines treatment approaches for different types of pediatric aneurysms and notes management aims to treat the cause while minimizing risk given children's developing physiology. In this case, the team opted for microsurgical clipping and decompressive craniectomy to address the boy's int

1. DR AMIT GHOSH
CONSULTANT NEUROSURGEON
Institute of Neurosciences Kolkata

2. 12Years old boy
Sudden severe headache. Vomiting, right sided weakness, difficulty in speaking

3. ICA
bifurcatio
n
aneurysm

4. Intracranial aneurysms are rare in childhood. Approximately
0.5%–4.6% of intracranial aneurysms occur in patients 18
years of age or younger
Aneurysms in this population exhibit features that differ
significantly from those in adults and higher incidence of
unusual anatomic locations such as the posterior circulation
and internal carotid bifurcation, and greater numbers of
giant aneurysms.
The commonest site of aneurysm in the paediatric group is
ICA bifurcation, while in adults, the commonest site is anterior
communicating artery complex

5. Risk factors for the formation of intracranial aneurysms have been identified in
adults (family history, age older than 50 years, smoking, cocaine use, and
hypertension), in childhood most of these risk factors do not exist
Aneurysm morphology and etiology can be separated into 4 categories:---
1) Infectious (often termed “mycotic”
2) Posttraumatic
3) Nontraumatic noninfectious fusiform,
4) Nontraumatic noninfectious saccular.
Vasculopathy

6. Paediatric patients constitute most of the reported
cases of traumatic aneurysms.
Infective or mycotic aneurysms have a higher
incidence in children with the commonest
predisposing factors being infective endocarditis
and septicaemia
Etiology--
Other causes–Vasculopathy– Connective tissue disorder,
collagen vascular disease etc.( Diseases like fibromuscular
dysplasia, coarctation of aorta, Marfan's disease have a
high incidence of aneurysm formation)

7. Wani A A, Behari S, Sahu R N, JaiswalA K, Jain
V K. Paediatric intracranial aneurysms. J
Pediatr Neurosci 2006;1:11-5 (22 patients)
Hetts, S.W. et al "Intracranial Aneurysms in Childhood:
27-Year Single-Institution Experience." American Journal
of Neuroradiology 30.7 (2009): 1315-1324. (77 patients)
(University of California San Francisco [UCSF] Medical Center and UCSF Children's
Hospital)

8. Management
Incidental aneurysms need to be treated early because the chances of rupture are
higher due to the increased period of risk in paediatric patients.The incidence of
SAH due to the presence of a previously existing unruptured aneurysm in a 20-year-old
person is 16.6% according to one study.
In the case of ruptured aneurysms , the operative or endovascular techniques are
similar to that used in adults. Infants have a poorly developed thermoregulatory
mechanism and a disproportionately more surface area as compared to weight.Thus,
special precautions are needed to prevent hypothermia. The blood volume in
children is less, hence one has to take extreme care during surgery to prevent
aneurysm rupture. 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.

9. In the case of 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 preferred depending on the status of cross circulation.
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
Management--

12. In view of intracerebral hematoma and
mass effect and also anatomical nature, we
( neurosurgeon and endovascular) decided
jointly to go for
Microsurgical clipping and decompressive
craniectomy

14. POST –OPERATIVE DSA

16. Vasospasm
After intra-arterial
nimodipine injection

18. THANK
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