Pediatric Intracranial Aneurysms. Experience of 47 cases.

Alexandru Vlad Ciurea MD, PhD1,2 , Aurel Mohan MD,PhD3,4 Andrei Voicu MD5, Vicentiu Saceleanu
MD,PhD6,7, Mihai-Stelian Moreanu8, Horia Ples, MD, PhD9,10

1. Chief of Neurosurgery Department, Sanador Clinical Hospital, Bucharest, Romania.

2. Professor of Neurosurgery at “Carol Davila” University of Medicine and Pharmacy, Bucharest,
Romania.
3. Department of Neurosurgery, Bihor County Emergency Hospital, Oradea, Romania.
4. Associate Professor of Neurosurgery at University of Oradea, Faculty of Medicine and Pharmacy,
Oradea, Romania
5. Resident of Neurosurgery at Bucharest Emergency Teaching Hospital, Bucharest, Romania.
6. Chief of Neurosurgery Department at Sibiu County Emergency Hospital, Sibiu Romania.
7. Lecturer at „Lucian Blaga” University of Medicine and Pharmacy, Sibiu, Romania.
8. Medical Student at “Carol Davila” University of Medicine and Pharmacy, Bucharest, Romania.
9. Professor Habil of Neurosurgery at Timis County Emergency Hospital, Head of Neurosurgical
Department
10. Professor Habil of Neurosurgery at “Victor Babes” University of Medicine and Pharmacy,
Timisoara, Romania

Corresponding author:

Mihai-Stelian Moreanu - moreanumihai@yahoo.com

Abstract:

Purpose: Pediatric aneurysms are rare, under 5% of cases, and their clinical presentation, rupture
probability, location and outcome are different from those in adults. In older pediatric patients’
symptoms are more similar to those in adults. Materials & Methods: The authors present 47 cases
of children operated between January 1999 and January 2019 - 20 years – multicenter study. Our
retrospective operated cases study is elaborated based on medical reports and imaging. Treatment
approach consists of open microsurgical dissection – clipping and endovascular embolization –
coiling. Results: The mean age is 14.3 years – ranging from 5 months to 16 years, with 28 boys
(59.5%) and 19 girls (40.4%). In our series, pediatric aneurysms represent 6.1% of all intracranial
aneurysms (771 cases). Clinical features are dominated by headache (45 cases- 95.7%), neck stiffness
(43 cases – 91.4%) and vomiting (42 cases – 89.3%). Most frequent location are anterior
communicating artery (17 cases, 36.1%), middle cerebral artery (12 cases, 25.5%) and internal
carotid artery bifurcation (9 cases, 19.1%). Glasgow outcome scale at six months shows good
recovery in 36 cases (76.5%), moderate disability in 9 cases (19.1%), severe disability in 1 patient
(2.1%) and (preoperative) death in 1 patient (2.1%). Conclusion: IA in children is a very rare
pathologic entity. Early neuro-imagistic diagnosis and microsurgical approach is mandatory and has
excellent results.

Abbreviations:

IA – Intracranial Aneurysm; H&H - Hunt & Hess Scale; ICA – Internal Carotid Artery; MCA – Middle
Cerebral Artery; ACoA – Anterior Communicating Artery; PCoA – Posterior Communicating Artery;

1
VA – Vertebral Artery; GOS – Glasgow Outcome Scale; SAH – Subarachnoid hemorrhage; GCS –
Glasgow Coma Scale.

Introduction We report 47 consecutive cases of pediatric (≤

Intracranial aneurysms (IA) usually form at the
bifurcation of an artery where the
hemodynamic stress is high. In order to grow
and be distinguished, aneurysms require time.
Pediatric aneurysms are rare - under 5% of
cases, and their clinical presentation, rupture
risk, location and outcome are different from
those in adults[1]. In older pediatric patients
symptoms are more similar to those in adults.
However, in neonates or younger children
symptoms are non-specific or even lacking.
The proportion of ruptured aneurysms
decrease with the age, being under 1% in
patients under 15 years. Yet, children present
better clinical aspects than adults after IA
rupture. Male to female ratio of 2:1 contrast
with the female predominance found in adult
IA[2].
The purpose of our study is to analyze the
etiology, clinical aspects and surgical
outcomes in children taking in consideration
Table 1. Clinical status at admission
Symptoms No. Cases (%)
Headaches 45 (96%)
Neck Stiffness 43 (91%)
Vomiting 42 (89%)
Neurological deficits 21 (45%)
Impaired 17 (36%)
consciousness
Comatose status 9 (23%)
Seizures 21 (45%)
16 years old) aneurysms operated on a period
of 20 years from 1999 to 2019 at three
medical centers in Romania: “Bagdasar –
Arseni” Teaching Hospital, Sanador Medical
Center Hospital and Timis County Emergency
Hospital. Most of the cases (40) were
operated in Bagdasar Arseni – Pediatric
Neurosurgical Department.
Admission clinical status was assessed using
H&H scale. Our retrospective consecutive
operated cases study was elaborated based
on medical reports and Imagistics. Regarding
the primary investigations, we consider Digital
subtraction angiography (DSA) to be the main
tool in diagnosing aneurysms. CT or Angio CT
were also used in diagnostic of SAH and
aneurysm location and in the postoperative
control assessment.
Treatment approach consisted of open
microsurgical dissection – clipping and
endovascular embolization – coiling. Our
policy for patient management includes
follow-up at every 6 months with neurological
and ophthalmological examination with a
follow-up CT scan. Follow-ups were assessed
ranging from 6 months to 8 years.
Table 2. Hunt & Hess Scale
H&H GCS
2 25 (53%) 13 - 14 (w/o
focal deficit
3 9 (17%) 13 – 14 (with
focal deficit)
4 3 (8%) 7-12
5 0 (0%) 3-6
Total 47 (100)

Fever 16 (34%) Results

Patients age ranges from neonates – the

the primary factors that lead to long-term
youngest case was 5 months, to 16 years with
good results.
the mean age of 14.3 years. There were 28
Materials & Methods boys (58.7%) and 19 girls (41.2%). 78%
patients admitted presented SAH.

2
 experience in endovascular approach. In our
case series we reported 37 patients (78.5%)
We report 47 cases of pediatric IAs with
with good recovery, 8 patients (17.2%) with
headache (45 cases - 96%), neck stiffness (43
moderate recovery, 1 patient (2.1%) with
cases - 91%) and vomiting (42 cases - 89%).
severe disability and 1 death (2.1%). No
Table 3. Aneurysms Location vegetative state has been reported (Table 4).
Artery No. Cases (%)
ICA 9 (19.5%)
MCA 12 (25%) Discussions
ACoA 17 (36%)
Pediatric aneurysms differ from those
PCoA 6 (17.5%)
encountered in adults having male
Basilary Top 1 (2.5%)
predominance[3], supported by the findings of
VA 1 (2.5%)
this study. The female predominance in adults
Multiple 1 (2.5%)
may be associated with low levels of
Total 47 (100%)
estrogens that lead to low vessel resistance
Most common neurological deficits were causing aneurysm formation.
hemiparesis and speech disorders, The most common risk factors in adults are
hemianopia with oculomotor paresis (21 cases systemic hypertension, smoking,
– 45%) and seizures (21 cases – 45%) (Table hypercholesterolemia, diabetes mellitus and
1). 75% of patients (35 cases) were in good cardiopathy[4]. However, in children aneurysm
clinical status at admission and 10 cases (22%) etiology is more often associated with
presented with grade 1 H&H and 25 (53%) congenital malformations of blood vessel wall
patients with grade 2 H&H (Table 2). (if the aneurysms appear in the first 2 years of
life) or with a vascular syndrome, heart and
aortic malformation (if it appears later)[4].
Anterior Communicating Artery (ACoA) was
the most common location – 17 cases (36%), Development of aneurysms may be caused by
then Middle Cerebral Artery (MCA) – 12 cases trauma, infection or it can be associated with
(25%), followed by Internal Carotid Artery a vasculopathy or an alteration of vessel wall
(ICA) – 9 cases (19.5%) (Table 3). structure [5]. Genetics may play an important
role in aneurysms development when
Open microsurgical dissection under associated with heritable disorders (Ehlers–
Table 4. Postoperative GOS at 6 months Danlos Types IV, Marfan syndrome, Osler-
Weber-Rendu Syndrome, fibromuscular
Status No. Cases (%)
dysplasia and polycystic kidney disease) or
Good recovery 37 (78.5) congenital malformations[6][7]. Systemic
arterial malformations of the aorta could lead
Moderate Recovery 8 (17.2)
to high cerebral pressure that will cause a
Severe disability 1 (2.1) focal degeneration of the internal lamina of
Vegetative state 0 (0) the cerebral vessels. In such situations to
prevent the endovascular manipulation of the
Death 1 (2.1) systemic malformation and to remove the
Total 47 (100) possible hemorrhage open clipping is the
elected treatment[8].
intraoperative monitoring was performed in
Most commonly, pediatric IA are found on the
46 cases (97%) and endovascular embolization
imagistic examination – SAH, especially in
in 1 case (3%). Authors do not have enough

3
younger patients where headache is difficult
to be objectifiied[9], in accordance with our
study findings. SAH is better tolerated in
children than in adults, associating a low-rate
of vasospasm, lower postoperative
administration of anti-ischemic medication
and better long-term outcomes – Table 5.
Children also associate better preoperative
grades, fewer comorbidities, higher brain
plasticity and lower levels of
atherosclerosis[10]. An important role in
decreasing the effect of vasospasm is also
attributable to the high-potential
leptomeningeal circulation[11]. Aneurysm
rebleeding after SAH appears in 52-60% cases
and divides opinions on outcome [12][13]. One
study presents it as the primary causes of
mortality - 76% of total deaths [12], while in
other case series study approximatively 80%
of rebleeding were associated with good
postoperative outcomes[14].

Higher incidence in posterior circulation was

also reported in children than in adults [15]. In
our series, most of the aneurysms belonged to
the anterior circulation. This feature was
similar with adult series where ACoA is the
most common aneurysm site[16]. Studies have
reported a direct relationship between the
age of the patients and the location of the
aneurysms showing up that aneurysms in the
young patient tend to arise more often in the
MCA. The early embryological development
with associated vascular pathology may play
an important role in aneurysm development
after birth [17].

4
Surgical approaches vary – clipping, proximal
vessel occlusion, wrapping, trapping, bypass
alone, endovascular treatment. The selected
treatment however depends also on location,
aneurysm size and patient preoperative
status. We consider clipping to be the elective
choice when dealing with ruptured aneurysm
or associated systemic pathology that lead to
hypertension. Depending on location,
vertebral tip aneurysm is preferred to be
treated by coiling[18] while MCA aneurysms is
treated more often with clipping because of
the arterial branches that may arise directly
from the MCA aneurysm.
Studies are not in consensus regarding
recurrence rate. Some reported high-
recurrence when ICAs were treated with
Figure 1,2. : Preoperative and postoperative angiographies of a 12-years-old girl admitted in our
department
coiling[19], but some stated that endovascular
treatment alone showed good long-term
outcomes[19]. Immediate higher postoperative
mortality and longer hospital stay is more
frequently associated with clipping than
embolization[20]. Recurrence rate is between
12-36%[16] and depends on aneurysm size.
5
Although endovascular approach showed
good results, the rate of re-intervention is
high especially in complex or giant aneurysm.
Hence, bypass surgery combined with artery
clipping reported good results and therefore
should be used[21].
Moreover, anatomical variations in the Willis
polygon - aneurysms associated with arterial
aplasia or asymmetric vessel organization,
tend to recur more often[22].
Long-term outcome depends on the
preoperative status of the patients. Those
admitted with good GCS showed a better
recovery. In addition, absence of vasospasm
and complete obliteration of aneurysm play
an important role in patient recovery [23]. Both
clipping and coiling were associated with good
outcome in 69-91% of cases [3][22][23]. Findings
of our study supports the aforementioned
statement, reporting low postoperative
vegetative state and mortality. Moreover, no
perioperative mortality and recurrence after
clipping was reported.
Treatment of pediatric cases faces big A 12-years-old girl with headaches and altered
challenges. Newly formation of aneurysms general status was admitted the neurosurgical
after surgery is greater in children than in department. At presentation she had SAH
adults[24]. Thus, our policy recommend that with H&H Score 1. Other symptoms were neck
the elective treatment should be chosen stiffness, vomiting and impaired
separately according to the complexity of the consciousness. The first Angiography showed
case and neurosurgeon experience. a large MCA Aneurysms (Figure 1). The case
was microsurgically approached. A clip was
Table 5. Pediatric patients series published placed at the neck of the aneurysms. At the
starting from year 2000
postoperative control angiography, general
Age SAH status was improved and symptoms were
Author Year No.
(yrs) (%) ameliorated (Figure 2).
Current
47 ≤16 78 Conclusions
Study
Proust et Al. IA is a rare pathology in pediatric
[25] 2001 22 ≤16 95
neurosurgery. Pediatric aneurysms are usually
Lasjaunias et
2005 59 ≤15 51 large and singular in pediatric population,
al. [11]
frequently located on carotid bifurcation. Our
Agid et al. [26] 2005 33 ≤17 36 series of 47 consecutive operated cases
Krishna et al. illustrates the clinical aspects, most frequent
[27] 2005 22 ≤18 91 location - ACoA and surgical outcomes in
Huang et al. children taking in consideration the primary
[28] 2005 19 ≤18 58 factors that lead to long-term good results.
Sharma et al. Clinical presentation on admission, especially
[29] 2007 55 ≤18 78
in patients younger than 3 years represents a
Stiefel et al. major challenge for physicians. A
[18] 2008 12 ≤16 100
multidisciplinary approach is needed to
Vaid et al. [4] 2008 27 ≤18 100 effectively overcome this pathology.

Liang et al. [30] 2009 24 ≤14 46

Disclaimer
Jordan et al.
[31] 2009 15 ≤19 100
No conflict of interests. Original study. No
Songsaeng et financial support.
2009 8 <16 25
al. [22]
Refferences:
Sanai et al. [19] 2010 32 ≤17 44
1. Regelsberger J, Heese O, Martens T, Ries T,
Kakarla et al.
[24] 2010 48 ≤18 17 Kunkel P, Westphal M. Intracranial aneurysms
Koroknay et in childhood: Report of 8 cases and review of
2012 114 ≤18 78 the literature. Zentralbl Neurochir.
al. [23]
2009;70(2):79-85.
Garg et. al [9] 2014 62 ≤18 58
2. Proust F, Toussaint P, Garníri J, et al.
Current
47 ≤16 78 Pediatric cerebral aneurysms. J Neurosurg.
Study
2001;94(5):733-739.

3. Wojtacha M, Bazowski P, Mandera M,

Illustrative case
Krawczyk I, Rudnik A. Cerebral aneurysms in

6
childhood. Child’s Nerv Syst. 2001;17(1-2):37- 13. Pinto FCG, Valiengo L, Santos PPML,
41. Matushita H, Plese JPP. Intracranial arterial
aneurysms in childhood: case report. Arq
4. Vaid VK, Kumar R, Kalra SK, Mahapatra AK,
Neuropsiquiatr. 2006;64(3 A):676-680.
Jain VK. Pediatric intracranial aneurysms: An
institutional experience. Pediatr Neurosurg. 14. Mehrotra A, Nair AP, Das KK, Srivastava A,
2008;44(4):296-301. Sahu RN, Kumar R. Clinical and radiological
profiles and outcomes in pediatric patients
5. Hetts SW, Narvid J, Sanai N, et al.
with intracranial aneurysms: Clinical article. J
Intracranial aneurysms in childhood: 27-Year
Neurosurg Pediatr. 2012;10(4):340-346.
single-institution experience. Am J
Neuroradiol. 2009;30(7):1315-1324. 15. Garg M, Shambanduram S, Singh PK, et al.
Management of Pediatric Posterior Circulation
6. Sorteberg A, Dahlberg D. Intracranial Non-
Aneurysms—12-Year Single-Institution
Traumatic Aneurysms in Children and
Experience. World Neurosurg. 2018;116:e624-
Adolescents. Curr Pediatr Rev. 2013;9(4):343-
e633.
352.
16. Pruvot AS, Curey S, Derrey S, Castel H,
7. Mohan D, Munteanu V, Coman T, Ciurea
Proust F. Giant intracranial aneurysms in the
AV. Genetic Factors Involves In Intracranial
paediatric population: Suggested
Aneurysms--Actualities. Journal Of Medicine
management and a review of the literature.
And Life. 2015;8(3):336-341.
Neurochirurgie. 2016:62(1) : 20-24.
8. Hidalgo J, Dickerson JC, Burnsed B, Luqman
17. Fulkerson DH, Voorhies JM, Payner TD, et
A, Shiflett JM. Middle cerebral artery
al. Middle cerebral artery aneurysms in
aneurysm rupture in a neonate with
children: Case series and review - Clinical
interrupted aortic arch: case report. Child’s
article. J Neurosurg Pediatr. 2011;8(1):79-89.
Nerv Syst. 2017;33(6):999-1003.
18. Stiefel MF, Heuer GG, Basil AK, et al.
9. Garg K, Singh PK, Sharma BS, et al. Pediatric
Endovascular and surgical treatment of
intracranial aneurysms - Our experience and
ruptured cerebral aneurysms in pediatric
review of literature. Child’s Nerv Syst.
patients. Neurosurgery. 2008;63(5):859-865.
2014;30(5):873-883.
19. Sanai N, Auguste KI, Lawton MT.
10. Moftakhar P, Cooke DL, Fullerton HJ, et al.
Microsurgical management of pediatric
Extent of collateralization predicting
intracranial aneurysms. Child’s Nerv Syst.
symptomatic cerebral vasospasm among
2010;26(10):1319-1327.
pediatric patients: Correlations among
angiography, transcranial Doppler 20. Alawi AWS, Edgell RC, Elbabaa SK, et al.
ultrasonography, and clinical findings. J Treatment of cerebral aneurysms in children:
Neurosurg Pediatr. 2015;15(3):282-290. Analysis of the Kids’ Inpatient Database. J
Neurosurg Pediatr. 2014;14(1):23-30.
11. Lasjaunias P, Wuppalapati S, Alvarez H,
Rodesch G, Ozanne A. Intracranial aneurysms 21. Kalani MYS, Elhadi AM, Ramey W, et al.
in children aged under 15 years: Review of 59 Revascularization and pediatric aneurysm
consecutive children with 75 aneurysms. surgery: Clinical article. J Neurosurg Pediatr.
Child’s Nerv Syst. 2005;21(6):437-450. 2014;13(6):641-646.

12. Amelot A, Saliou G, Benichi S, et al. Long- 22. Songsaeng D, Geibprasert S, Willinsky R,
term outcomes of cerebral aneurysms in Tymianski M, Terbrugge KG, Krings T. Impact
children. Pediatrics. 2019;143(6):e20183036. of anatomical variations of the circle of Willis
on the incidence of aneurysms and their

7
recurrence rate following endovascular
treatment. Clin Radiol. 2010;65(11):895-901.

23. Koroknay-Pál P, Lehto H, Niemelä M,

Kivisaari R, Hernesniemi J. Long-term outcome
of 114 children with cerebral aneurysms:
Clinical article. J Neurosurg Pediatr.
2012;9(6):636-645.

24. Kakarla UK, Beres EJ, Ponce FA, et al.

Microsurgical treatment of pediatric
intracranial aneurysms: Long-term
angiographic and clinical outcomes.
Neurosurgery. 2010;67(2):237-249.

25. Proust F, Toussaint P, Garniéri J, et al.

Pediatric cerebral aneurysms. J Neurosurg.
2001;94(5):733-739.

26. Agid, R, Souza MPS, Reintamm G et al. The

role of endovascular treatment for pediatric
aneurysms. Childs Nerv Syst. 2005; 21:1030–
1036.

27. Krishna H, Wani AA, Behari S, Banerji D,

Chhabra DK, Jain VK. Intracranial aneurysms in
patients 18 years of age or under, are they
different from aneurysms in adult
population?. Acta Neurochir (Wien).
2005;147(5):469-476.

28. Huang J, McGirt MJ, Gailloud P, Tamargo

RJ. Intracranial aneurysms in the pediatric
population: case series and literature review.
Surg Neurol. 2005;63(5):424-433.

29. Sharma P, Kyriakides C. Surveillance of

patients post-endovascular aneurysm repair.
Postgrad Med J. 2007;83(986):750-753.

30. Liang J, Bao Y, Zhang H, et al. The clinical

features and treatment of pediatric
intracranial aneurysm. Childs Nerv Syst.
2009;25(3):317-324.

31. Jordan LC, Johnston SC, Wu YW, Sidney S,

Fullerton HJ. The importance of cerebral
aneurysms in childhood hemorrhagic stroke: a
population-based study. Stroke.
2009;40(2):400-405.