Risk of Recurrent

Aneurysms
International Subarachnoid Aneurysm Trial (ISAT) and the
Cave Carotid Artery Aneurysm
• Flow diversion is not a good option for ruptured aneurysms for at
least two reasons:
(1) antiplatelet treatment is also mandatory as for stenting
(2) aneurysmal thrombosis is progressively obtained in several days or
weeks and that limits the efficacy of this treatment against
rebleeding at the acute phase of bleeding.
Superior Hypophyseal Aneurysm(SHA)
• Ruptured SHA need immediate treatment to prevent risk of rebleeding
• Unruptured but symptomatic SHA aneurysms including patients with visual deficits or pituitary
insufciency should be considered for treatment to improve the symptoms or prevent further
decline
• Based on Barrow Ruptured Aneurysm Trial (BRAT), microsurgical clipping is significantly better
than endovascular coiling in case of aneurysm obliteration, aneurysm recurrence, and retreatment
• Based on International Subarachnoid Aneurysm Trial (ISAT), coiled aneurysms had insignificant
increase on rebleeding comparing to clipped.
• The reported recurrence rate of 3.9% in a large series of SHA aneurysms at follow-up is not much
higher than in clipped aneurysms. The rate of recurrence requiring further intervention was only
1.3%. Coiled SHA aneurysms seem to have the lowest recurrence rate compared to greater than
20% for posterior circulation aneurysms and middle cerebral artery aneurysms, and up to 35% for
posterior communicating artery aneurysms. The recurrence rate for all paraclinoidal aneurysms is
sometimes as high as 12 to 29%. SHA aneurysms seem to be very benign, treated or untreated.
Ophthalmic Artery Aneurysms
• For acute ruptured wide-necked aneurysms in higher grade patients or
those with external ventricular drains, an additional strategy is staged
treatment—partial coiling of the aneurysm, followed by staged flow
diversion or clip ligation after recovery from the SAH
• Partial coiling is performed with the intention of achieving dome
obliteration (i.e., occlusion of the most likely site of rupture), without the
risk to the parent artery of coiling a wide-necked aneurysm
• Validated by Brinjikji et al who noted both safety and efficacy, with no
cases of rebleeding during the interval between coiling and flow
diversion. Have no adverse clinical sequelae with regard to coil mass
effect
Posterior Communicating Artery Aneurysms
• Long-term ISAT data from 2014 reported 17 rehemorrhages from target aneurysms, 4 in the
surgical group and 13 in the endovascular group. The endovascular group rate of rebleeding
was 1.56 per 1,000 patient years compared to 0.49 per 1,000 patient-years in the surgical
group
• The death and disability due to rehemorrhage in the endovascular and surgical group were
0.72 and 0.49 per 1,000 patient-years
• Supplementary data reveal that of the endovascularly treated aneurysms that
rehemorrhaged, 46% were PCoA aneurysms
• A series of 501 endovascularly treated aneurysms where 54.1% were ruptured found
recurrence in 33.6% of patients and retreatment required in 20.7% of patients
• Treatment during the acute phase and incomplete embolization were associated with
recurrence. PCoA aneurysms are difficult to achieve complete obliteration with coils alone
and may require a stent or flow diverter
Anterior Choroidal Artery Aneurysms
• Study of 102 patients (68 presenting with SAH) harboring 106 aneurysms treated by
clipping showed new ischemia in AChA territory in 15 (15%) patients and slightly, but
insignifcantly, more in unruptured aneurysms. None of the treated patients had
rebleeding or aneurysm regrowth during follow-up (mean 18.8 months). Favorable
outcome was achieved in 84 (81%) patients
• Endovascular treatment was evaluated in a study of 88 patients harboring 90 aneurysms
(31 ruptured and 59 unruptured) who were treated in 91 sessions. Procedure-related
ischemic and hemorrhagic complications were encountered in 4 cases (4.4%).
• Complete occlusion was achieved in only 15 (17%) of the aneurysms investigated. Near-
complete occlusion was achieved in 69 aneurysms (77%) and partial occlusion in 6
aneurysms (7%).
• Favorable outcome (Glasgow Outcome Score 4–5) was achieved in 79 (90%) patients.
During follow-up (mean 25 months), no rebleeding was noted and major recanalization
occurred in two cases (supports algorithm steps 4 and 6)
Anterior Choroidal Artery Aneurysms
• A comparison between coiling and clipping was performed in a retrospective
study that included 72 patients harboring 73 aneurysms: 38 aneurysms (23
ruptured and 15 unruptured) were treated by endovascular coil embolization
and 35 (30 ruptured and 5 unruptured) surgically
• Permanent neurological deficit that was due to AChA infarction occurred in four
patients after clipping. After coiling, fve patients sufered from transient deficit
that was due to AChA flow compromise
• There was no rebleeding during follow-up after coiling (mean 27 months) or
clipping (mean 34 months). Aneurysm recurrence was found in 5 cases (out of 29
with follow-up angiography, 17.2%) after coiling: 4 of these occurred during the
frst year after treatment and 1 in the second year. Favorable outcome was
achieved in 31 patients (83.8%) in the clip group and 31 patients (88.6%) in the
coil group
Middle Cerebral Artery Aneurysms
• Traditionally, all MCA aneurysms recommended for treatment have been treated with microsurgical clipping. While
this remains the general rule, several authors have begun to report their experience with endovascular treatment
for both ruptured and unruptured aneurysms (1, 8 in algorithm). The difculty or ease of MCA aneurysm treatment
varies, depending on aneurysm size and confguration, inclusion of the branch vessels in the neck, presence of SAH,
and experience of the surgeon or interventionist ( ►Figs. 26.1 and ►26.2). MCA aneurysms presenting with a large
temporal or sylvian ICH require urgent craniectomy and clot evacuation with exploration and treatment of the
aneurysm simultaneously is the rule. Often the aneurysm can be clipped without removing the clot frst, which then
can be easily and safely removed (2 in algorithm). Many MCA aneurysms are unsuitable for endovascular options
due to several reasons including the higher chance of main branch occlusion and the fact that their classic
bifurcation location makes recurrence more likely. MCA aneurysms are also commonly readily accessible surgically
and therefore they are preferentially clipped at most cerebrovascular centers ( ►Fig. 26.1). There are some reports
of coiling of the aneurysm, followed by clot evacuation. This is considered a nonstandard treatment by experienced
cerebrovascular surgeons. If a craniotomy is undertaken for an ICH, the presence of shift out of proportion to the
hematoma should prompt consideration of a hemicraniectomy. There is controversial practice of coiling the
aneurysm and then taking the patient for a craniotomy for clot evacuation with no attempt at clipping (3 in
algorithm). For those ruptured aneurysms without hematoma, timing of surgery should be as early as reasonably
possible. Since much of the risk of rebleeding is in the frst 24 hours through 2 weeks, the earliest opportune time
should be selected (4 in algorithm).
• The long-term (mean follow-up: 9 years; range: 6–14 years) results of
the ISAT showed an increased risk of recurrent bleeding from a coiled
aneurysm compared with a clipped aneurysm. Twenty-four cases of
rebleeding occurred more than 1 year after treatment, of which 13
rebleeds were from the treated aneurysm (10 in the coiling group and
3 in the clipping group). The risk of death at 5 years was signifcantly
lower in the coiled group than in the clipped group. There were 303
MCA aneurysms (14.1%) included in the trial.
Anterior Cerebral
• Lehecka et al studied outcomes of DACAs in 501 patients treated with
clipping or coiling. This is the largest ACAA series to date. Only 12
aneurysms were treated primarily with coiling. They found that 91% of
the clipped aneurysms were completely occluded (supports algorithm
steps 3, 4, 8, and 9). The most common morbidity associated with
clipping was reversible neurological deficit. Only one patient died in the
series. Once clipped, rebleeding from DACAA occurs in 0.4% of patients
within 10 years postoperatively. From the 12 aneurysms treated with
endovascular therapy, 7 were totally occluded. Four required another
round of coiling and three ended up with clipping. There was no
morbidity or mortality associated with endovascular treatment.
Anterior Communicating
• If the ACoA aneurysm is wide neck and the patient is not a good candidate for clip ligation, an
adjunct can be used. Through a sequel Tuohy, two microcatheters can be advanced near the
ACoA complex. In ruptured cases, a single compliant balloon can be used as a temporary
buttress to minimize the risk of coil prolapse into the ACoA with no need for dual-antiplatelet
agents. More recently, the LVIS Jr. stent (Microvention, Tustin, CA) or the newly developed
Neuroform Atlas (Stryker, Kalamazoo, MI) has been successfully used as a single or Y stent
construct to help buttress the coil mass inside the aneurysm, with jailing of the microcatheter
that goes to the dome of the aneurysm (►Fig. 29.3). Advantages of the LVIS Jr. stent compared
to the traditional Enterprise (Cordis, Dublin, OH) and Neuroform stents include its ability to be
deployed through a small microcatheter (0.017) and ft in small parent vessels (2–3.5 mm). For
complex aneurysms, partial coil embolization followed by more defnitive treatment (e.g., on
dual-antiplatelet agents for ruptured ACoA aneurysms) has been performed safely with no
rebleeding in 6-month and 3-year follow-up (►Fig. 29.5). Small ruptured ACoA aneurysms less
than 3 mm have been shown to have near or complete obliteration with coil embolization
alone in select Japanese studies.
Pericallosal
• Early treatment is ofered in all cases of SAH to prevent the risk of
rebleeding. In cases of SAH with ICH, microsurgical clipping with
hematoma evacuation is standard treatment; however, endovascular
therapy can be considered due to the risk of cortical injury with
cerebral edema and friable tissue. While the theoretical risks of ICH
and herniation associated with ruptured PcaA aneurysms is less than
MCA aneurysms, treatment should be performed urgently
Giant aneurysms of anterior circulation
• Following diagnosis, the natural history of GIAs is poor with a high risk of spontaneous rupture with
substantial accompanying morbidity and mortality. While recent advances in vascular neuroimaging,
neuroanesthesia, neurocritical care, and microsurgical/endovascular techniques have ushered in a dramatic
improvement in clinical outcomes, the large size, complex angioarchitecture, and frequent presence of
atherosclerosis, calcifcation, and/or thrombus within GIAs render them a formidable treatment challenge.
Successful treatment of GIAs is aimed at excluding the aneurysm from the intracerebral circulation to
prevent risk of rupture, preservation of parent and perforating arteries, and decompressing surrounding
neural elements. In general, this is best achieved by open microsurgery, which provides the best chance for a
defnitive, durable cure. Endovascular therapy may be considered for patients who are not ideal candidates
for a craniotomy, and may be the preferred modality for GIAs in certain anatomical locations. However,
endovascular techniques are not considered the standard treatment given the low aneurysm obliteration
rates, high aneurysm rebleeding rates, need for multiple retreatments, and unsatisfactory relief of mass
effect. Major controversies in decision making addressed in this chapter include: 1. Whether or not
treatment is indicated. 2. Microsurgical versus endovascular treatment for ruptured and unruptured GIAs. 3.
Management of GIAs that present with hematomas requiring urgent evacuation. 4. When should adjuvant
microsurgical techniques (e.g., bypass, aneurysmorrhaphy, local or systemic circulatory arrest) be utilized?
• Our understanding of the natural history of GIAs remains incomplete; the preponderance of evidence
suggests that these lesions carry a grave prognosis. Observational studies demonstrate that, after
initial rupture, the cumulative rate of rebleeding for GIAs is 18.4% within the frst 14 days. The
mortality of GIAs is greater than 60% within 2 years. Overall, 80% of patients with symptomatic,
untreated GIAs are dead or incapacitated within 5 years of initial diagnosis from hemorrhage or
cerebral ischemia (1 in algorithm). In the International Study of Unruptured Intracranial Aneurysms
(ISUIA) trial, the investigators determined that GIAs had a rupture rate of 6% in the frst year and a
relative risk of rupture (as compared to an unruptured aneurysm ≤10 mm in size) of 59.0. This study
suggested that GIAs located on the cavernous internal carotid artery (ICA) had a 5-year cumulative
rupture rate of 6.4%, while GIAs on the anterior communicating artery (ACoA), middle cerebral artery
(MCA), and ICA had a 5-year rupture rate of 40%. GIAs residing on the posterior communicating artery
(PCoA) had an even higher cumulative rupture rate of 50% in 5 years. Taken together, these data
suggest that the morbidity and mortality of untreated, symptomatic, intradural GIAs justifes their
aggressive treatment (1 in algorithm). This observation is juxtaposed to the natural history of
extradural (e.g., petrocavernous) GIAs, which appear to have a more benign natural history and may
warrant a more conservative approach.
• All GIAs of the anterior circulation recommended for treatment—both
ruptured and unruptured—were treated traditionally via open microsurgery.
In the early 1990s, the advent of endovascular coiling techniques introduced
another treatment modality. Since then, however, the clinical and
radiographic outcomes for patients with GIAs treated by primary coiling
have been disappointing. Reasons for this include (1) wide aneurysm neck
making complete coil obliteration difcult without parent artery compromise,
(2) complex branching of aferent/eferent arteries, (3) coil compaction with
need for retreatment,(4) coil migration into intraluminal thrombus with
recanalization, (6) regrowth of residual aneurysm neck, (7) need for frequent
angiographic surveillance, (8) higher rate of aneurysm bleeding and/or
rebleeding, and (9) inability to eliminate mass effect.
Dissecting Intracranial Aneurysms of
Anterior Circulation
• As noted earlier, the natural history of these lesions is not well documented.
BTAs are almost always described in the ruptured setting, and short-interval
follow-up vascular imaging suggests that these lesions are dynamic,
demonstrating rapid conformational change suggestive of instability and a
malignant natural history. DPAs were historically implicated as a rare cause
of ischemic symptoms in young patients; however, recent reports suggest
that they are more commonly associated with SAH. When presenting with
SAH, DIAs have been reported to have a higher rate of rebleeding (44%)
compared to saccular aneurysms (14%), and as such the prognosis is worse
in these patients. As such, when a DIA is diagnosed in the setting of SAH, it
should be treated aggressively and promptly (1, 2, 3 in algorithm)
• Endovascular treatment of DIA with traditional coil embolization techniques have been associated with
high recurrence rates. Introduction of a coil mass into dissecting aneurysms can lead to rupture given
the fragility of the aneurysm walls; similarly, manipulation with a microcatheter may also result in
intraprocedural rupture. In cases where the aneurysm is broad based, care must be taken to prevent
coil loop herniation into the parent vessel. In many cases, this would require balloon- or stent-assisted
coiling. The use of such adjuvant techniques may lead to a more satisfactory initial result but ultimately
still have an unacceptably high recurrence and rebleed rate. Another strategy that was developed and
has proven to be more effective and durable is the use of multiple overlapping stents to preferentially
shunt flow down the parent artery and disrupt the inflow at the neck of the aneurysm (8 in algorithm).
Such early “flow-diverting” techniques promoted aneurysm thrombosis over time and, as they did not
involve manipulation of the fragile aneurysm itself, were associated with lower rates of intraprocedural
rehemorrhage. The downside of this strategy is that it requires dualantiplatelet therapy. As the next-
generation strategy to the use of multiple overlapping stents, the development of novel, flow-diverting
stents has allowed for the treatment of dissecting aneurysms without vessel sacrifce or coil packing into
a friable aneurysm (►Fig. 33.2). When associated with a dissection, flow diverters can be used to treat
the underlying injury and remodel the vessel (8 in algorithm).
• Dissecting Pseudoaneurysms There have been reports of unruptured DPAs
resolving on angiographic follow-up. In cases where patients present with
ischemic symptoms, the outcome is good once patients are started on
antiplatelet therapy, and most do not exhibit recurrent ischemic events (4
in algorithm). In contrast, patients presenting with SAH from a ruptured
DPA tend to have a poor prognosis, with a mortality of up to 50%, which
given the complexity of these lesions is not unsurprising. In untreated
cases, rebleeding has been reported to occur in 50% of patients within 14
days, highlighting the need for early intervention (supports algorithm
steps 2, 4, 5, 6). Unfortunately, due to the rarity of these lesions, outcome
data are available only through case reports and case series.
• The malignant natural history of atherosclerotic dissecting aneurysms that
present with SAH both justifes an aggressive approach to treatment and
should give the microsurgeon pause about the same. These aneurysms tend
to have fairly extensive SAHs at presentation and high risk for rebleeding. At
the same time, they are at higher risk for bleeding or thrombosing during
surgery. Where possible, trapping and bypass or primary occlusion should
be the frst choice. Where this is not possible, clip wrapping is an option.
Endovascular deconstruction is an option if it appears that distal ischemia is
not an issue. However, stenting must be approached with caution as the risk
of rehemorrhage is high, and the use of antiplatelet agents in this setting
can therefore pose a problem. Aggressive isolation of the aneurysm is the
best treatment.
Previously coiled recurrent aneurysms of the
anterior circulation
• There is an absence of unequivocal clinical evidence to guide decision making for retreatment
of recurrent aneurysms after endovascular coiling. This leads to substantial variability among
experienced clinicians on whether to re-treat. The decision to re-treat and selection of
appropriate technique requires careful clinical judgment on a caseby-case basis ( ►Fig. 35.1).
Risk of rehemorrhage from residual and/or recurrent aneurysms following endovascular coiling
is not trivial. Published studies—including ISAT, BRAT, and Cerebral Aneurysm Rerupture
Treatment (CARAT)—have suggested that the annual risk for rebleeding after coiling ranges
from 0 to 1.3%, but varies with the timing from initial intervention. For example, in CARAT and
ISAT, rates of rerupture in the frst year following treatment occur in 1.7 and 1.8%, respectively,
across treatment modalities, but may be as high as 3.4% in those treated with endovascular
coiling. After the frst year, the annual risk declines, but remains higher in those treated with
endovascular coiling (endovascular: 1.56 per 1,000 patient-years; microsurgical clipping: 0.49
per 1,000 patient-years). Despite this relative infrequency, rerupture of previously treated
aneurysms is frequently neurologically devastating with a mortality rate up to 58% (1, 2 in
algorithm).
• The identifcation of clues of looming rupture in the context of previously coiled
aneurysms is less well established. Similar to the initial treatment of cerebral aneurysms,
factors to consider are size, location, and morphology of the recurrent aneurysm and
whether it previously ruptured. Additional factors unique to recurrence should also be
considered, including time since initial treatment and degree of aneurysmal occlusion. In
the CARAT study, the risk of rerupture of recurrent aneurysms varied as a function of
initial aneurysm occlusion (overall risk: 1.1% for complete occlusion, 2.9% for 91–99%
occlusion, 5.9% for 70–90%, and 17.6% for <70% occlusion). Given the consequences of
rerupture, we favor retreatment when postcoiling residual or recurrence is detected in
our center. However, desires to treat should be tempered by the patient’s perioperative
risk including age and comorbid conditions, patient preference, surgeon or interventionist
experience, and likelihood of successful intervention, and clinicians should engage in
detailed risk versus beneft discussions with the patient and/or family to carefully design
the most appropriate treatment plan.
• In our clinical series, complete angiographic occlusion with open
microsurgical management was achieved in 89% of previously coiled
residual or recurrent aneurysms. With exclusion of wrapped
aneurysms, microsurgical clipping or bypass led to complete
angiographic occlusion in 95% of cases. The small minority of
aneurysms that were wrapped and followed showed no evidence of
radiographic enlargement. No rebleeding or subsequent recurrence
has been observed (supports algorithm steps 5, 8, 9, and 10).
Previously Clipped Recurrent Aneurysms of
the Anterior Circulation
• Treatment of recurrent aneurysms after clipping may be considered in several scenarios including (►Table 36.1): 1.
Aneurysm remnants that are found immediately after aneurysm clipping in about 5% of patients (1 in algorithm). 2.
Regrowth, hemorrhage, or symptoms such as mass effect from a previously completely clipped aneurysm (2 in algorithm).
3. Growth, hemorrhage, or symptoms from an aneurysm remnant known after clipping (2 in algorithm). 4. New de novo
aneurysms at site(s) distinct from the previously clipped aneurysm (3 in algorithm). This decision is based on assessment
of the risks of treatment balanced against the risk of the natural history of the identifed aneurysm, the natural history risk
being basically the risk of recurrent hemorrhage. Some patients recover well after recurrent hemorrhage but for decision
making, it is reasonable to assume that bleeding or rebleeding after aneurysm repair will lead to an unfavorable outcome.
Surgeons have published retrospective reviews of their cases of craniotomy to clip previously clipped aneurysms.
Morbidity and mortality is about 10%, but this is likely an underestimate and must vary with all of the usual factors that
afect morbidity and mortality after aneurysm surgery. These factors include patient- (age, medical comorbidities,
intracranial atherosclerosis) and aneurysm-related features (ruptured or not, presence of space-occupying intracerebral
hemorrhage, aneurysm size, location, presence of calcifcations and thrombus, presence of daughter loculi, and growth).
Older age and associated medical illnesses increase the risk of complications. Ruptured aneurysms have worse outcome
than unruptured aneurysms. Larger aneurysms and those with calcifcation and/ or thrombus are more complicated to
repair by any method. Increased size, presence of daughter sac, growth of the aneurysm, and posterior circulation
location increase the risk of hemorrhage. When an aneurysm remnant is found after surgery, knowledge of why the
remnant was left, either purposely or not, is important in deciding whether and how to repair (1, 2 in algorithm).
Previously Clipped Recurrent Aneurysms of
the Anterior Circulation
• If the surgeon does the best clipping they can and document a residual aneurysm by
intraoperative means, then they need to decide after the surgery whether to observe the
remnant or to endovascularly coil it. If intraoperative imaging is not done, then unexpected
findings can occur such as flling of the aneurysm distal to the clip blades, presence of a residual
proximal part of the aneurysm, or finding a completely unclipped aneurysm (1 in algorithm).
Aneurysm flling distal to the clip blades carries a high risk of rebleeding for ruptured aneurysms
and alters the hemodynamics of unruptured aneurysms, potentially leading to catastrophic
hemorrhage (1, 5, 8 in algorithm). Therefore, in general, distal flling should be treated
immediately by surgical exploration or endovascular means with the decision based on the
usual factors such as the clinical condition of the patient, the surgeon’s impression as to the
cause of the remnant, and the potential efcacy of repeat clipping or endovascular repair ( ►Fig.
36.1). The same considerations apply to unexpected proximal remnants, although their risk of
rupture is probably low whether or not the initial indication for treatment was hemorrhage or
not and approximates that of unruptured aneurysms (2, 6, 7, 9 in algorithm).
Vertebral artery
• Dissecting VA aneurysms are a rare entity that can present in the form
of SAH or brainstem ischemia. The precise cause of these lesions is
not completely known, although disruption of the internal elastic
lamina leading to vessel dilation and pseudoaneurysm formation is
thought to play a role. Dissecting aneurysms exhibit both a high risk of
rebleeding—more than 71% in some studies—and high operative
morbidity. A variety of treatment strategies, including trapping,
proximal occlusion, and reconstruction using endovascular
techniques, have been used to treat these lesions, and the specifc
approach chosen must be tailored for each individual aneurysm.
• Rehemorrhage rates in the ISAT trial for patients who underwent coiling was
4.2% at 1 year and was signifcantly higher than the rate of rebleeding in the
clipping group. In the BRAT trial, 57.9% of patients who underwent coiling
experienced complete aneurysm obliteration immediately postoperatively,
whereas complete obliteration was obtained in 85.1% of those who
underwent aneurysm clipping. At 3-year follow-up, these numbers were
52.2% for the coiled group and 87.1% for the clipped group. On 6-year
follow-up, despite lower rates of obliteration, no patients sufered rebleeding
events within the endovascular treatment group. Long-term durability data
for newer technologies such as flow-diverting stents are not currently
available, although aneurysm occlusion at early follow-up between 3 and 12
months has been reported in the literature.
Superior cerebellar
• There were no cases of rebleeding reported in SCA aneurysm-specifc
studies across either treatment modality. A meta-analysis of posterior
circulation aneurysms from 2002 found three cases of delayed
hemorrhage occurred among 456 aneurysms treated, giving an
overall rebleed rate of 0.66% and a 0.9% annual risk of SAH after
embolization, which is no diferent from the natural history of these
aneurysms. The 10-year ISAT data published in 2014 showed a greater
number of index aneurysm rebleeds from the endovascular group
than from the surgical group (13/1,073 = 1.21% vs. 4/1,070 = 0.37%, p
= 0.02) (supports algorithm steps 3 and 7).
Anterior inferior cerebellar
• Whether treated surgically or by endovascular means, patients must be
followed up to detect any recurrence of an aneurysm. Although
endovascular treatment generally has lower morbidity than surgery, it also
has a higher rate of recurrence. In the summary literature review of the 150
cases of AICA aneurysms from many small series, two cases that were
treated by coiling were reported to have re-bled a few days following coiling
and required surgical trapping. However, no data are available regarding
recurrence and rebleeding of AICA aneurysms in the long term, whether
following surgery or endovascular treatment. Risk factors for recurrence
include a large aneurysmal neck, large aneurysms, incomplete exclusion of
the aneurysm whether by surgery or endovascular means, and partially
thrombosed aneurysms treated by coiling.
Posterior Inferior Cerebellar Artery
Aneurysms
• As with other intracerebral aneurysms, the rupture risk of a PICA aneurysm goes up with
increasing size and a history of subarachnoid hemorrhage (SAH) from a previous aneurysm
in the same patient. Family history, smoking, and hypertension are also taken into account.
The results of the International Study of Unruptured Intracranial Aneurysms (ISUIA) and
other natural history studies show that PICA aneurysms have a higher risk of rupture than
other types of aneurysms, even at smaller sizes. In ruptured aneurysms, prompt treatment
is paramount, as rebleeding rates can be as high as 78% (1, 3, 4 in algorithm). Case series of
ruptured PICA aneurysms have shown good outcomes even in patients presenting with
poor clinical grades. Ruptured PICA aneurysms frequently present with obstructive
hydrocephalus, which can worsen the Hunt/Hess grade, due to the artery’s proximity to the
ventricular system. Swiftly addressing hydrocephalus can reverse clinical deterioration. In
our practice, most patients with unruptured PICA aneurysms are ofered treatment, unless
there are extenuating circumstances such as a limited life expectancy or prohibitive
comorbidities. Ruptured aneurysms almost always warrant timely intervention.
Fusiform Aneurysms of the Posterior
Circulation
• Fusiform aneurysms are uncommon but remain challenging to neurosurgical treatment.
Fusiform aneurysms of the basilar artery (BA) were frst described in 1922, and since then
several terms have also been used including dolichoectatic aneurysms, transitional
aneurysms, and giant serpentine aneurysms. Posterior circulation fusiform aneurysms
(PCFAs) are rare, with signifcant male predominance (~70%). PCFAs most commonly
present as posterior circulation ischemic strokes. In addition, they may cause cranial
nerve palsies, brainstem compression, and subarachnoid hemorrhage (SAH). Contrary to
the more common saccular aneurysms, fusiform aneurysms are associated with high
rates of rebleeding and morbidity. In this chapter, PCFAs are reviewed, including natural
history, anatomy, pathophysiology, and treatment, with a suggested algorithm for
treatment based on review of the literature. Major controversies in decision making
addressed in this chapter include: 1. Whether treatment is indicated. 2. Open versus
endovascular treatment for ruptured and unruptured PCFA. 3. The role of flow diverters
for PCFA.
• Unlike the case of saccular aneurysms, our understanding of the natural history of
PCFAs is more limited. The natural history of PCFAs depends on the presenting signs
and symptoms. However, it appears to be very poor in symptomatic patients, if left
without treatment. In such cases, the rebleeding rate is high and ranges between
30 and 85%. In addition, untreated ruptured PCFAs are associated with high rates of
mortality, ranging between 23 and 35% in a 5-year follow-up. In a large prospective
study of vertebrobasilar (VB) aneurysms over a 12-year period, the annual rupture
rate of fusiform aneurysms was approximately 2%. Aneurysm enlargement is a
signifcant predictor of lesion rupture. In a series of patients with unruptured
fusiform aneurysms, a diameter of ≥ 10 mm in VB aneurysms was a signifcant risk
factor for aneurysm growth and it was predictive of future rupture. Therefore, the
vast majority of ruptured PCFAs cases should be treated (1, 2, 3 in algorithm).
Additionally, unruptured PCFAs greater than 10 mm also likely warrant treatment.
• Only few classifcation systems attempted to guide clinical decision in fusiform aneurysms
by stratifying patients into risk groups. Mizutani et al’s classifcation system is composed
of four types based on a combination of clinical features, imaging findings, lesional
patterns of the internal elastic lamina (IEL), and the state of the intima. Type I is classic
dissecting aneurysm characterized by disruption of the IEL without intimal thickening,
presentation with SAH, and high rates of rebleeding. Type II is segmental ectasia, with a
benign clinical course compared to type I. This type is pathologically characterized by
extended and/or fragmented IEL with intimal thickening. In addition, the luminal surface
is smooth without thrombus formation. Type III is dolichoectatic dissecting aneurysm.
This type is distinguished pathologically from type II by dissections in the thickened
intima, and organized luminal thrombus. Type III is frequently associated with
hemorrhage and 50% mortality rate. Lastly, type IV is saccular aneurysm. Similar to the
case of types I and III, type IV is associated with high rates of rebleeding and mortality.
• For aneurysms that are not treatable by endovascular methods,
microsurgical treatment should be considered. Generally, clip
reconstruction is difcult and prone to recurrence because there is no
true aneurysm neck. A scenario, however, where clip reconstruction
can be utilized is for patients with SAH secondary to rupture of a
daughter sac arising from a fusiform vessel. The daughter sac can be
completely occluded by the clip and the patient protected from early
rebleeding. The fusiform vessel can be addressed in a delayed fashion
by another method such as FD.
Dissecting Intracranial Aneurysms of the
Posterior Circulation
• Dissecting aneurysms of the posterior circulation constitute a relatively uncommon
subgroup of aneurysms. These aneurysms are sometimes known as “pseudoaneurysms”
and represent around 28% of the posterior circulation aneurysms and 3.3% of all
intracranial aneurysms. Dissecting aneurysms of the posterior inferior cerebellar artery
(PICA) account for 0.5 to 0.7% of all intracranial aneurysms. Posterior circulation
dissecting aneurysms account for 3 to 7% of cases of nontraumatic subarachnoid
hemorrhage (SAH). These are now recognized as a common cause of stroke and SAH in
otherwise healthy young adults. Management of these lesions is still controversial.
Prevention of rebleeding of ruptured dissecting aneurysms of the posterior circulation is
an essential cornerstone of treatment. Major controversies in decision making addressed
in the chapter include: 1. Whether treatment is indicated. 2. Does clinical presentation
stroke/SAH dictate diferent treatment? 3. Open versus endovascular treatment for
ruptured and unruptured dissecting aneurysms of the posterior circulation.
• The guidelines for endovascular treatment of unruptured dissecting aneurysms
presenting with ischemia, headache, and incidental findings remain controversial. The
relatively benign clinical course and outcome reported for unruptured minimally
symptomatic posterior circulation dissecting aneurysms have resulted in conservative
treatment such as anticoagulation being recommended. Also for patients presenting
with a PICA infarct, conservative treatment can be recommended if there are no
obvious angiographic risk factors for hemorrhage such as a pseudoaneurysm. Ruptured
fusiform and dissecting aneurysms of the posterior circulation typically have a poor
prognosis if left untreated. The rebleeding rate is particularly high in the range of 25 to
30% with a mortality rate of around 50% in untreated patients. Rebleeding generally
occurs within the frst 24 hours after rupture onset and is associated with a poor clinical
outcome. Considering the aggressive behavior of ruptured vertebral dissecting
aneurysms, such aneurysms warrant urgent treatment (1, 2, 3, 4, 5 in algorithm).
• When aneurysms are located beyond the origin, in the more distal course of
the PICA, they are usually fusiform; such aneurysms are most often caused
by vessel wall dissections. Probably the most important issue in the
management of PICA-dissecting aneurysms is their site. There is evidence
that patients with distal dissections have better clinical outcome than those
with proximal lesions. Perforating arteries usually arise from the frst three
segments of PICA, which run close to the medulla. The facts that occlusion
of PICA beyond the frst three segments is unlikely to result in brain stem
injury and distal PICA dissections have a low propensity to bleed or rebleed
due to relatively low rate of recanalization make PVO with or without
internal trapping a suitable choice for managing distal PICA aneurysms (12,
13, 14 in algorithm).
• Posterior circulation dissecting aneurysms are difcult to treat because of their location, their morphology, and small
perforators to the brain stem, which are difcult to visualize on the imaging studies with a high incidence of morbidity
and mortality associated in managing those. Posterior circulation dissecting aneurysms can be classifed as follows
based on the location: lesion inferior to the origin of the PICA, lesion superior to the origin of the PICA, lesions
involving the PICA origin, lesions at the VBJ, lesion of the basilar trunk, and lesion in proximal PCA. A variety of
treatment strategies have been applied in patients with such aneurysms, including surgical reconstruction, surgical
ligation, wrapping, endovascular trapping, and various surgical bypass with occlusion strategies. Some of the basic
principles in dissecting aneurysm management apply to both microsurgical and endovascular treatment. • With PVO,
the risk of rebleeding is not completely eliminated due to collaterals and retrograde blood flow. • The point of
dissection needs to be identifed and occluded to eliminate the risk of rebleeding with PVO even when the aneurysm
itself is occluded. • Aneurysm involvement of the PICA or spinal arterial segment such as ASA and posterior spinal
artery precludes a deconstructive treatment such as clip occlusion or coil occlusion of the artery at the aneurysm site.
• Balloon occlusion testing can provide valuable information regarding the safety of proximal occlusion and should be
performed just proximally to the intended site of occlusion. Balloon test occlusion (BTO) should ideally be performed
in a site to simulate best the anticipated therapeutic occlusion, without entering the dissected segment. However,
BTO in the posterior circulation is considered less specifc as compared to the anterior circulation. For distal PICA and
PCA aneurysms, BTO may not be useful as the outcomes with PVO and aneurysmal trapping are generally good,
which practically obviates the need for BTO.
• Although PVO is reported as one of commonly performed treatment
option with good outcomes, the risk of rebleeding is not completely
eliminated due to collaterals and retrograde blood flow. If the
occlusion is far from the aneurysm, thrombosis may be delayed or
never occur, due to the collateral/ retrograde circulation; so, the
occlusion should be performed as close to the aneurysms as possible.
PVO is probably a satisfactory treatment for distal PICA and distal PCA
(distal to P2) aneurysm (12 in algorithm). When the occlusion is
proximal to the telovelotonsillar segment of PICA, lateral medullary
infarction can ensue.
• The alternative endovascular strategies include internal trapping of the
aneurysm with coils, stent-assisted coil embolization, stent alone, and stand-
alone coiling. The selection of the management strategy varies with the
aneurysm morphology, collateral supply, origin of perforators, branch origin
from the aneurysm wall, BTO if performed, and dominance of the VA.
Internal trapping along with PVO afords the greatest beneft in terms of
rebleeding; however, it does pose the risk of infarction if the lesion
incorporates a branch such as the AICA, PICA, or ASA. If the VA aneurysm is
distal to PICA, it does increase the chances of perforator strokes in the lateral
medulla (lateral medullary syndrome). The technical factors that can result in
failure and recurrences include incomplete coverage of the dissected
segment with the stents, coil compaction, and coiling the false lumen.
• The latest addition to the endovascular armamentarium is flow diversion (FD) ( ►Fig.
46.2). The treatment is limited to the unruptured dissecting aneurysms; however, it
is increasingly performed in ruptured aneurysms in selected cases, such as if the
alternative strategies pose higher risk or if the aneurysms morphology is sacculo-
fusiform, the saccular component can be coiled in the acute SAH phase, and fusiform
component can be treated later in about 2 to 3 weeks with FD (9, 13, 15 in
algorithm). One of the limitations with FD alone is delayed occlusion of the
aneurysm as the aneurysm does not immediately obliterate with this technique and
there is a risk of rebleed during the latency interval while the aneurysm progressively
thromboses after flow diversion. Patients with aneurysms in perforator-rich areas
such as mid-distal BA, holo-basilar aneurysms, and aneurysms with signifcant clot
burden have a higher incidence of perforator strokes with FD. However, these
aneurysms are difcult to treat with poor prognosis with any treatment option.
• The most common complications with surgical treatment of posterior
circulation dissecting aneurysms include lower cranial nerve palsies
and brainstem and cerebellar infarcts. In one of the largest series of
24 patients with VAD aneurysms, surgery was performed in 19
patients, the most common technique being clip occlusion of the
proximal VA. There were no postoperative deaths or rebleeding; a
lateral medullary syndrome developed in three patients. Most
common surgical complication was lower cranial nerve palsies (all
improved except one) (supports algorithm steps 6, 9, 11, and 13).
Traumatic Intracranial Aneurysms of the
Posterior Circulation
• Traumatic posterior circulation aneurysms are extremely rare and fall into two distinct
groups: (1) dissecting aneurysms secondary to blunt trauma and (2) pseudoaneurysms
secondary to penetrating injuries. Dissecting aneurysms following blunt trauma often
occur in the vertebral and posterior cerebral arteries due to their proximity to the
craniocervical junction and the rigid tentorium, respectively. They can present with
either ischemic or hemorrhagic manifestation based on the plane of dissection within
the arterial wall. Subintimal dissecting aneurysms usually present with ischemic
symptoms secondary to large vessel or perforator occlusion or due to thromboembolic
phenomenon and are best treated with anticoagulation. Subadventitial dissecting
aneurysms as well as traumatic pseudoaneurysms following penetrating trauma often
present with hemorrhage and carry a devastating natural history. They must be treated
in a timely fashion to prevent rebleeding. These lesions are best treated defnitively, if
possible, with parent vessel sacrifce, either as a stand-alone procedure or in conjunction
with arterial bypass
• Traumatic aneurysms of the posterior circulation fall into two distinct groups with regard
to treatment: (1) dissecting aneurysms secondary to blunt trauma and (2)
pseudoaneurysms secondary to penetrating trauma. Dissecting aneurysms following blunt
trauma often occur in the vertebral and posterior cerebral arteries due to their proximity
to the craniocervical junction and the rigid tentorium, respectively. They can present with
either ischemic or hemorrhagic manifestation based on the plane of dissection within the
arterial wall. Subintimal dissecting aneurysms usually present with ischemic symptoms
secondary to large vessel or perforator occlusion or due to thromboembolic
phenomenon. Although not a defnitive rule, the plane of dissection usually does not cross
from one layer to the next. Thus, dissecting aneurysms presenting with initial ischemic
symptoms rarely go on to hemorrhage and vice versa. These patients are best treated
with anticoagulation. Subadventitial dissecting aneurysms often present with hemorrhage
and must be treated to prevent rebleeding. The treatment strategy for such lesions is
similar to pseudoaneurysms following penetrating trauma.
Previously Coiled/Clipped Recurrent
Aneurysms of the Posterior Circulation
• Rerupture rates in the recent literature following treatment are low. In a study of
over 1,000 patients treated at multiple centers over a 2-year period, rerupture rate
was found to be 1.8%, similar to the 1-year rerupture risk (1.8%) published in ISAT (1,
2 in algorithm). With respect to posterior circulation aneurysms, less than 3% of the
aneurysms in ISAT and 17% of the aneurysms in BRAT were located in the posterior
circulation. This is consistent with the commonly published incidence of aneurysms
within the posterior circulation and explains the lack of literature regarding posterior
circulation aneurysm recurrence. These studies briefy emphasize the problem that
faces vascular neurosurgeons frequently; aneurysm remnants are common and
require continued observation at a minimum (2, 8 in algorithm). More importantly, it
is the role of the vascular neurosurgeon to determine the patients who are at high
risk for rebleeding from the index aneurysm. In other words, who should be
retreated and who can be safely observed?
• Initial angiographic occlusion comes from patience, diligence, and
experience in the angiography suite and operating room and is the
goal whenever possible and safe. However, there are multiple studies
that demonstrate low rebleed risk despite the presence of a neck
remnant/recurrence after endovascular therapy and even lower risk
of recurrence and rebleeding after clip ligation. Based on this
published data, certain anatomical factors and other risk factors can
guide the neurosurgeon as to the aneurysm remnants that should be
retreated and those that can be followed.
• History of rupture is one of the most important factors to consider when deciding whether or not to treat a recurrence (1, 2 in
algorithm); however, anatomical features guide whether or not the recurrence is signifcant or worrisome. The initial
angiographic result, aneurysm type (saccular, fusiform, dissecting), aneurysm location (e.g., at a bifurcation), large aneurysm
size, and wide neck are factors that correlate with aneurysm recurrence (6, 7 in algorithm). However, not all recurrences are
created equally and do not always correlate with the risk of rebleeding. For example, aneurysm flling into the dome of a
ruptured aneurysm intuitively is more dangerous than flling of an electively treated unruptured aneurysm. That said, a large
dome recurrence of a 10-mm incidental aneurysm is likely to be retreated given the fact that the aneurysm was treated due to
its higher risk of rupture in the frst place. The angiographic location of the recurrence is an important factor when reviewing
the angiographic remnant. A small, stable neck remnant, without flling of the dome, could be followed with serial magnetic
resonance angiography (MRA), and with formal angiography at 6 months or with changes in MRA (►Fig. 48.1) (8 in algorithm).
However, a sidewall recurrence, meaning flling of the aneurysm between the coil mass and the side wall of the aneurysm,
should not be followed and should be considered for treatment. Sidewall flling can signal an endovascular leak and portends a
higher rate of rerupture by allowing flling to reach the dome (►Fig. 48.2) (6, 7, 9 in algorithm). Sidewall recurrences should be
treated diligently. Posterior circulation dissecting aneurysms carry a high risk of rupture and any recurrence should be treated.
Length of follow-up and stability of the remnant on angiographic or noninvasive imaging are also factored into whether an
aneurysm remnant requires treatment. For example, an aneurysm remnant that has remained unchanged on MRA and 5-year
follow-up angiography is unlikely to change and rarely requires intervention. Finally, patient comorbidities and history, such as
smoking, poorly controlled hypertension, and strong family history of aneurysms should be observed more closely and for a
longer period of time or should be treated early, depending on the other factors mentioned earlier.
• The BRAT study compared outcomes in SAH patients treated with
either clipping or coiling. With respect to the durability or their
patients, excellent occlusion rates (96%) and low retreatment rates
(4.6%) at 6 years were demonstrated. In this study, 14% of patients
treated with clip ligation had posterior circulation aneurysms. Despite
the low rebleed rate published in this study, interestingly, one of two
patients who re-bled in the frst year was a dissecting PICA aneurysm.
No other rebleeds were reported in subsequent 3- and 6-year results
for surgically treated aneurysms (supports algorithm steps 1, 2, 5, and
8).
• Similarly, there is a paucity of data specifcally looking at the
retreatment of posterior circulation aneurysms after initial
endovascular therapy. However, many studies assess the durability
and recurrence rates following endovascular therapy for all
aneurysms. Follow-up periods have varied from months to years and
the majority of the studies did not limit the patients by aneurysm
location. Some studies quote the rate of recurrence as high as 20%
following endovascular therapy. In comparison, the numbers of
rebleed events in each of these studies are signifcantly lower with
some studies reporting zero rebleeds with follow-up period as long as
14 years (supports algorithm steps 2, 6, 7, and 8).
Myotic Intracranial Aneurysms
• In cases where bypass surgery or vessel sacrifce is being considered,
having endovascular access simultaneously can sometimes be
benefcial during the exploration in case of intraoperative rupture.
According to several case reports, partial clot evacuation tends to be
done prior to finding the aneurysmal dome and treating the
aneurysm directly (1 in algorithm). For ruptured mycotic aneurysms
without large hematomas, treatment should be as early as possible.
Although no natural history exists for rerupture rates for mycotic
aneurysms, it is believed that rebleeding is still highest in the frst 24
hours through 2 weeks, and early treatment is usually employed.
• Mycotic aneurysms can be extremely complex because they can be multiple
and are often located distally. They should be treated with surgical exclusion
of the aneurysm with or without bypass. The risk of progression, rebleeding,
recurrence, or extension without direct treatment is high. Medical
treatment is essential with appropriate antibiotics. In the setting of an
unruptured aneurysm, antibiotics and close observation are reasonable. In
the setting of rupture, I favor a very aggressive surgical approach to these
lesions, including trapping and bypass and assuming that any ruptured
aneurysm and indeed any large or growing aneurysm are high enough risk
that it should be explored and treated. Operating in the setting of infection
causes some surgeons to pause—however, the risk of not operating should
be considered much greater.
Blood Blister–Like Aneurysms
• Blood blister–like aneurysms (BBAs) are small sessile, thin-walled lesions without
an identifable neck located at nonbranching sites of the internal carotid artery
(ICA). Also called blister or dorsal variant aneurysms, BBAs are treacherous lesions
that can enlarge rapidly and rebleed frequently. They have a low prevalence,
comprising 0.3 to 1% of intracranial aneurysms and 0.9 to 6.5% of aneurysms of the
ICA, but have much higher morbidity and mortality than saccular aneurysms. In
contrast to natural history data that suggest that small aneurysms have a minimal
chance of rupture, most cases of BBAs are diagnosed in the setting of subarachnoid
hemorrhage (SAH), and afected patients tend to be younger than those with
ruptured saccular aneurysms. Major controversies in decision making addressed in
this chapter include: 1. Whether or not treatment is indicated. 2. Open vascular
versus endovascular treatment for ruptured and unruptured BBAs aneurysms. 3.
Timing of intervention. 4. Role of flow diverter in ruptured BBAs.
• BBAs are frequently associated with SAH. They can have rapid growth
rates and high rebleeding rates if they are not completely treated.
Expeditious occlusion of the aneurysm via open surgical or
endovascular technique is recommended (1, 2 in algorithm). The
timing of intervention, however, is controversial depending on the
technique chosen. If flow diversion is planned, the requirement for
dual-antiplatelet medications raises concerns of hemorrhagic
complications should the patient require another invasive procedure
(e.g., ventriculoperitoneal shunt placement). Delay of treatment,
however, exposes the patient to the risk of aneurysm rerupture (4 in
algorithm).
• BBAs may be mistaken for saccular aneurysms of the ophthalmic, anterior choroidal, or PCOM
arteries. In the setting of SAH without an obvious source, meticulous angiography should be
performed to look for a BBA as they have a tendency to enlarge rapidly and rebleed. Multiple inte
• Parent vessel reconstruction using clips or clip-wrapping materials has been described. The BBA can
be wrapped in a muslin gauze or Gore-Tex sling, which is then clipped to reinforce the vessel (►Fig.
50.1). A portion of the normal vessel can be included in the wrapping material, which is then
secured tightly with a clip, thereby inducing a mild circumferential narrowing. Clip reconstruction of
the parent artery, however, is generally not effective at completely occluding the aneurysm and
may not prevent future rebleeding events and/or growth of the BBA. This technique may also injure
perforating arteries and small branch vessels. Slits can be made in the wrapping material to
accommodate branch vessels. Some surgeons consider clip-wrapping to be a temporizing measure
for the acute subarachnoid period and not a defnitive treatment; delayed endovascular treatment
can be performed when the patient is at less risk for complications. Others, however, consider clip-
wrapping to be a defnitive treatment (3, 5, 7, 8 in algorithm).rval angiograms may be required to
visualize a BBA.
• Because BBAs are rare lesions, most of the evidence is extrapolated
from case reports and small case series. A multitude of treatment
options are associated with high rates of failure, rebleeding, technical
complications, and the need for retreatment. A literature review of 35
articles including 175 patients with BBAs reported that 30% of
patients had bleeding during treatment, 11% had bleeding after
treatment, and 10% had identifable regrowth. Immediate complete
BBA occlusion is more likely after open surgical treatment, whereas
persistent aneurysm flling on follow-up imaging is not uncommon
after endovascular treatment (supports algorithm step 3–7).
• Although early results with endovascular treatment were generally poor,
flow diversion may provide improved results. It enables immediate
alterations in the flow dynamics of the BBA as well as delayed remodeling
of the diseased vessel segment (2 in algorithm). The remodeling process,
however, requires time. In the interim, the SAH patients remain at risk for
rebleeding. A two-staged approach has also been described with initial clip-
wrapping of the aneurysm during the acute phase followed by endovascular
placement of a FDS at a later date when the patient is at less risk for
bleeding complications and is more likely to tolerate dual-antiplatelet
therapy (►Fig. 50.3) (6–8 in algorithm). Further research is needed to
determine whether this strategy is an effective long-term treatment.
• Without treatment, ruptured BBAs have a very high rate of
rebleeding. Immediate occlusion of a BBA is most likely to occur after
a trapping and bypass procedure. Clip reconstruction of the parent
artery and clip-wrapping procedures have relatively high rates of BBA
recurrence. Delayed aneurysm occlusion may occur after
endovascular flow diversion, but in the interim before vessel
reconstruction occurs, the patient remains at risk for rebleeding.
Long-term studies are needed to determine the durability of flow
diversion and whether the interim risk of rehemorrhage is acceptable.
• Because rapid enlargement and rebleeding is frequent even after
initial surgical or endovascular treatment, short-term angiographic
follow-up is warranted. Although there is no consensus on the
optimal time period, at our institution we obtain follow-up
angiograms 1 week after treatment of a ruptured BBA. The presence
of a residual BBA after either surgical or endovascular treatment will
always remain a source of concern for the treating physician and may
prompt retreatment using another treatment modality (i.e.,
placement of an additional FDS).
Pediatric Intracranial Aneurysms
• Intracranial aneurysms (IAs) in the pediatric patient population are rare and challenging. They
represent 0.5 to 2% of all IAs. They should not be thought of as aneurysms occurring in little
people, but rather regarded as a diferent entity with diferent pathophysiology, natural history,
treatment options applicable to pediatric patients, and long-term outlook for surviving
patients. Caring for pediatric aneurysms, especially very young ones, requires a well-
orchestrated collaborative efort that entails neurosurgeons, interventional neuroradiologists,
pediatric neurointensivists, and pediatric anesthetists all working in specialized, high-volume
neurovascular centers or centers dedicated altogether to caring for pediatric patients. It is
also of paramount importance to have the strong presence of a dedicated social worker and
spiritual service to support the parents of these children during these difcult times. Major
controversies in decision making addressed in this chapter include: 1. Risks of bleeding and
rebleeding in pediatric aneurysms. 2. Treatment strategies stratifed to diferent age groups. 3.
Technical considerations in open and endovascular management of pediatric aneurysms. 4.
Long-term follow-up and screening strategies for pediatric aneurysms.
• Treatment of IA aims to exclude the whole aneurysm from the blood stream without
sacrifcing normal blood supply. A ruptured aneurysm should be treated as soon as
possible to eliminate the risk of rebleeding. Even for unruptured aneurysms, the
highly criticized International Study of Unruptured Intracranial Aneurysms (ISUIA)
could not be applied as the conclusion of not treating aneurysms smaller than 7 mm
is not universally valid. This is because of the longevity expected in these young
children favoring active treatment strategy (1–4 in algorithm). There is a male
predominance throughout the literature in pediatric aneurysm patients although
some investigators suggest that among children younger than 2 years of age, the
incidence of aneurysms was higher in girls (5:1). Aneurysms in infants are extremely
rare. Among patients harboring aneurysms during the frst year of life, 20% were
reported to have comorbidities such as cutaneous vascular disorder, autosomal-
dominant polycystic kidney disease (ADPKD), or brain tumors.