Intracranial pediatric aneurysms: endovascular treatment and its outcome

Object The aim of this study was to analyze the location, clinical presentation, and morphological characteristics of pediatric aneurysms and the safety, feasibility, and durability of endovascular treatment. Methods The authors conducted a retrospective study of all cases involving patients 18 years old or younger who underwent endovascular treatment for pediatric aneurysms at their institution between July 1998 and July 2010. The clinical presentation, aneurysm location, endovascular management, and treatment outcome were studied. Results During the study period, 23 pediatric patients (mean age 13 years, range 2 months–18 years) were referred to the authors' department and underwent endovascular treatment for aneurysms. The aneurysms were saccular in 6 cases, dissecting in 4, infectious in 5, and giant partially thrombosed lesions in 8. Fourteen of the aneurysms were ruptured, and 9 were unruptured. Thirteen were in the anterior circulation and 10 in the posterior circulation. The most common location in the anterior circulation was the anterior communicating artery; in the posterior circulation, the most common location was the basilar artery. Saccular aneurysms were the most common type in the anterior circulation; and giant partially thrombosed and dissecting aneurysms were the most common types in the posterior circulation. Coil embolization was performed in 7 cases, parent vessel sacrifice in 10, flow reversal in 3, glue embolization in 2, and stent placement in 1. Immediate angiographic cure was seen in 21 (91%) of 23 patients. Complications occurred in 4 patients, 3 of whom eventually had a good outcome. No patient died. Overall, a favorable outcome was seen in 22 (96%) of 23 patients. Follow-up showed stable occlusion of aneurysms in 96% of the patients. Conclusions Pediatric aneurysms are rare. Their clinical presentation varies from intracranial hemorrhage to mass effect. They may also be found incidentally. Among pediatric patients with aneurysms, giant aneurysms are relatively common. Endovascular management is associated with low rates of complications and is a safe, durable, and effective treatment for pediatric aneurysms.

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Republished: Successful treatment of a giant pediatric fusiform basilar trunk aneurysm with surpass flow diverter

Journal of NeuroInterventional Surgery ◽

10.1136/neurintsurg-2015-011718.rep ◽

2015 ◽

Vol 8 (6) ◽

pp. e23-e23 ◽

Cited By ~ 6

Author(s):

Peter Kan ◽

Maxim Mokin ◽

Ajit S Puri ◽

Ajay K Wakhloo

Keyword(s):

Endovascular Treatment ◽

Successful Treatment ◽

Flow Diverter ◽

Emerging Technology ◽

Posterior Circulation ◽

Parent Vessel ◽

Anterior Circulation ◽

Unique Challenge ◽

Posterior Circulation Aneurysms ◽

Vessel Flow

Fusiform aneurysms present a unique challenge to traditional microsurgical and endovascular treatment because of the lack of a discernible neck and the involvement of parent vessel. Flow diversion has increasingly become the treatment of choice for fusiform aneurysms in the anterior circulation, but its results in the posterior circulation are variable. We report successful treatment of a giant fusiform upper basilar trunk aneurysm with the Surpass flow diverter in an adolescent, and discuss the potential advantages of this emerging technology in the treatment of fusiform posterior circulation aneurysms.

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Important Factors for a Combined Neurovascular Team to Consider in Selecting a Treatment Modality for Patients with Previously Clipped Residual and Recurrent Intracranial Aneurysms

Neurosurgery ◽

10.1227/01.neu.0000053209.61909.f2 ◽

2003 ◽

Vol 52 (4) ◽

pp. 732-739 ◽

Cited By ~ 32

Author(s):

Brian L. Hoh ◽

Bob S. Carter ◽

Christopher M. Putman ◽

Christopher S. Ogilvy

Keyword(s):

Endovascular Treatment ◽

Treatment Modality ◽

Posterior Circulation ◽

Neurological Deficits ◽

Parent Vessel ◽

Surgical Risk ◽

Fatal Hemorrhage ◽

The Mean ◽

Selection Of

Abstract OBJECTIVE Intracranial residual and recurrent aneurysms can occur after surgical clipping, with risks of growth and rupture. In the past, surgical reoperation, which can be associated with higher risk than the initial operation, was the only available treatment. A combined neurovascular team that uses both surgical and endovascular therapies could maximize efficacy and outcomes while minimizing risks in these difficult cases. The indications for which surgical or endovascular treatment should be used to treat patients with residual or recurrent aneurysms, however, have not been elucidated well. We have reviewed the 10-year experience of our combined neurovascular team to determine in a retrospective manner which factors were important to treatment modality selection for patients with these residual and recurrent lesions. METHODS From 1991 to 2001, the combined neurovascular unit at the Massachusetts General Hospital treated 25 residual and recurrent previously clipped aneurysms (15 had been clipped at other centers). Only patients in whom a clip had been placed were included in the study; patients who did not have a clip placed or whose aneurysms were wrapped or coated were excluded. The radiographic studies and clinical data were reviewed retrospectively to determine the efficacy, outcomes, and factors important to the selection of treatment strategy in these patients. RESULTS The patients' clinical presentations were radiographic follow-up, 17 patients; rehemorrhage, 3; mass effect, 3; and thromboembolism, 2. The mean aneurysm recurrence or residual size was 11 mm (range, 4–26 mm). The mean interval until representation was 6.6 years (range, 1 wk–25 yr). Treatment consisted of: coiling, 11 patients; reclipping, 8; proximal parent vessel balloon occlusion, 2; extracranial-intracranial bypass with coil occlusion of aneurysm and parent vessel, 2; extracranial-intracranial bypass with clip trapping, 1; and extracranial-intracranial bypass with proximal clip occlusion of parent vessel, 1. The mean radiographic follow-up period was 11 months. Complete angiographic occlusion was found in 19 aneurysms (76%), at least 90% occlusion was found in 4 aneurysms (16%), intentional partial coil obliteration was found in 1 fusiform lesion (4%), and intentional retrograde flow was found in 1 fusiform lesion (4%). Clinical outcomes were excellent or good in 19 patients (76%). Twenty-one patients (84%) were neurologically the same after retreatment (13 remained neurologically intact, and 8 had preexisting neurological deficits that did not change). Three patients (12%) had new neurological deficits after retreatment, and one patient (4%) died. There were four complications of retreatment (16%), one of which was a fatal hemorrhage in a patient 1 month after intentional partial coil obliteration of a fusiform vertebrobasilar junction aneurysm. Factors important to the selection of treatment modality were recurrence or residual location (all posterior circulation lesions were treated endovascularly), lesion size (lesions larger than 10 mm were treated endovascularly or with the use of combined techniques), and aneurysm morphology (fusiform and wide-necked lesions were treated endovascularly or with the use of combined techniques). CONCLUSION The proper selection of surgical or endovascular treatment for residual and recurrent previously clipped aneurysms can achieve excellent radiographic efficacy with low mortality. Factors important to the selection of treatment by this combined neurovascular team were posterior circulation location, aneurysm size larger than 10 mm, and fusiform morphology, which were treated endovascularly or with the use of combined techniques because of the higher surgical risk associated with these factors. For aneurysms with lower surgical risk, such as some anterior circulation aneurysms and aneurysms smaller than 10 mm, we prefer to perform a reoperation because of superior radiographic cure without compromising the outcome.

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Posterior cerebral artery stenosis and posterior circulation revascularization surgery in pediatric patients with moyamoya disease

Journal of Neurosurgery Pediatrics ◽

10.3171/2018.1.peds17367 ◽

2018 ◽

Vol 21 (6) ◽

pp. 632-638 ◽

Cited By ~ 3

Author(s):

Tomomi Kimiwada ◽

Toshiaki Hayashi ◽

Reizo Shirane ◽

Teiji Tominaga

Keyword(s):

Moyamoya Disease ◽

Cerebral Artery ◽

Pediatric Patients ◽

Posterior Cerebral Artery ◽

Posterior Circulation ◽

Initial Diagnosis ◽

Occipital Artery ◽

Anterior Circulation ◽

Before And After ◽

Revascularization Surgery

OBJECTIVESome pediatric patients with moyamoya disease (MMD) present with posterior cerebral artery (PCA) stenosis before and after anterior circulation revascularization surgery and require posterior circulation revascularization surgery. This study evaluated the factors associated with PCA stenosis and assessed the efficacy of posterior circulation revascularization surgery, including occipital artery (OA)–PCA bypass, in pediatric patients with MMD.METHODSThe presence of PCA stenosis before and after anterior circulation revascularization surgery and its clinical characteristics were investigated in 62 pediatric patients (< 16 years of age) with MMD.RESULTSTwenty-three pediatric patients (37%) with MMD presented with PCA stenosis at the time of the initial diagnosis. A strong correlation between the presence of infarction and PCA stenosis before anterior revascularization was observed (p < 0.001). In addition, progressive PCA stenosis was observed in 12 patients (19.4%) after anterior revascularization. The presence of infarction and a younger age at the time of initial diagnosis were risk factors for progressive PCA stenosis after anterior revascularization (p < 0.001 and p = 0.002, respectively). Posterior circulation revascularization surgery, including OA-PCA bypass, was performed in 9 of the 12 patients with progressive PCA stenosis, all of whom showed symptomatic and/or radiological improvement.CONCLUSIONSPCA stenosis is an important clinical factor related to poor prognosis in pediatric MMD. One should be aware of the possibility of progressive PCA stenosis during the postoperative follow-up period and consider performing posterior circulation revascularization surgery.

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Transcirculation Silk Vista Baby-assisted coiling in half-T configuration for the treatment of posterior communicating artery aneurysms associated with a fetal posterior circulation: An alternative flow diversion strategy

Interventional Neuroradiology ◽

10.1177/1591019920961889 ◽

2020 ◽

pp. 159101992096188

Author(s):

Mario Martínez-Galdámez ◽

Miguel Schüller-Arteaga ◽

Jorge Galván-Fernández ◽

Vladimir Kalousek ◽

Ezequiel Petra ◽

...

Keyword(s):

Flow Diverter ◽

Posterior Circulation ◽

Flow Diversion ◽

Anterior Communicating Artery ◽

Anterior Circulation ◽

Low Profile ◽

Specific Subgroup ◽

Flow Diverter Devices ◽

Profile Flow ◽

Incomplete Occlusion

Flow diverter devices have become a routine first-line option for treatment of an increasing population of intracranial aneurysms at many neurovascular centers. Despite the promising results of flow diverter stents on anterior circulation, incomplete occlusion on the presence of fetal posterior circulation has been described on several reports. Here we describe a novel technical alternative to conventional flow diversion approach for this specific subgroup of aneurysms using the low-profile flow diverter, Silk Vista Baby. The device was selectively placed into the fetal type posterior cerebral artery in half-T configuration for the treatment of a posterior communicating aneurysm using a transcirculation approach through the anterior communicating artery. This represents a useful and effective technique and should be considered when encountering the above-described situation.

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Microstent-Assisted Coiling for Wide-Necked Intracranial Aneurysms

Canadian Journal of Neurological Sciences / Journal Canadien des Sciences Neurologiques ◽

10.1017/s0317167100016917 ◽

2005 ◽

Vol 32 (1) ◽

pp. 71-81 ◽

Cited By ~ 43

Author(s):

Marlise Peruzzo dos Santos Souza ◽

Ronit Agid ◽

Robert A. Willinsky ◽

Michael Cusimano ◽

Walter Montanera ◽

...

Keyword(s):

Endovascular Treatment ◽

Intracranial Aneurysms ◽

Neurological Complication ◽

Posterior Circulation ◽

Technical Failure ◽

Anterior Circulation ◽

Neck Size ◽

Clinical Complications ◽

Class 1

Objective:To describe the results, technical feasibility, efficacy and challenges encountered in our preliminary experience using a self-expandable microstent, optimized for intracranial use, as an adjunct in the endovascular treatment of wide-necked aneurysms.Methods:Only broad-necked aneurysms (dome-to-neck ratio £2, or an isolated neck size > 4.5 mm) were treated with Neuroform microstent from July 2003 to May 2004. The techniques used for stent deployment were either parallel or sequential. Angiographic results were recorded immediately for all patients and classified as Class 1 (complete occlusion), Class 2 (neck remnant) or Class 3 (sac remnant) by three interventional neuroradiologists not involved in the procedure. Follow-up angiography at six months was obtained for one case. Modified Rankin Score scale was assessed for all patients.Results:Seventeen intracranial aneurysms in a total of 18 patients were treated (mean age, 52.2 yr). Eight patients (44.4%) presented with acute subarachnoid hemorrhage. Eleven aneurysms (61.1%) were in the posterior circulation. Average dome size was 10.2 mm (range, 3.7-19.8 mm) and average neck size was 5.36 mm (range, 3.0-10.0 mm). Six out of seven aneurysms of the anterior circulation were approached with parallel technique. Eight aneurysms of the posterior circulation were approached with sequential technique. Average number of coils deployed was 9.64 (range, 4-23 coils). Eleven aneurysms (64.8%) resulted in Class 1 and/or Class 2. One technical failure was observed. Technical complications were recognized in four patients (23.5%), all of them with unruptured aneurysms in the anterior circulation. Two patients (11.7%) presented transient immediate clinical complications. One patient (5.8%) had minor permanent neurological complication. Neither major clinical complications nor death were encountered. Favorable clinical outcome (Modified Rankin Scale score 0-2) was observed in 88.2% of the patients (average follow-up time, 4.72 months).Conclusion:Absence of major permanent complications and satisfactory immediate obliteration degree in our preliminary experience indicates that microstent-assisted coiling technique is useful for the minimally invasive treatment of broad-necked complex aneurysms that are not ideal for conventional endovascular treatment and are at a high risk for conventional surgical treatment.

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ENDOVASCULAR AND SURGICAL TREATMENT OF RUPTURED CEREBRAL ANEURYSMS IN PEDIATRIC PATIENTS

Neurosurgery ◽

10.1227/01.neu.0000327573.42267.cc ◽

2008 ◽

Vol 63 (5) ◽

pp. 859-866 ◽

Cited By ~ 40

Author(s):

Michael F. Stiefel ◽

Gregory G. Heuer ◽

Anuj K. Basil ◽

John B. Weigele ◽

Leslie N. Sutton ◽

...

Keyword(s):

Subarachnoid Hemorrhage ◽

Clinical Condition ◽

Pediatric Patients ◽

Aneurysmal Subarachnoid Hemorrhage ◽

Multidisciplinary Treatment ◽

Cerebral Aneurysms ◽

Posterior Circulation ◽

Anterior Circulation ◽

Fisher Grade ◽

Good Clinical Condition

Abstract OBJECTIVE Pediatric cerebral aneurysms are rare. There are very few recent studies that focus on the multidisciplinary treatment of ruptured aneurysms. We reviewed our pediatric endovascular and surgical experience with ruptured cerebral aneurysms. METHODS Pediatric patients aged 16 years and younger who were admitted with a diagnosis of aneurysmal subarachnoid hemorrhage and treated at the Children's Hospital of Philadelphia were included in this analysis. RESULTS Twelve patients with 13 aneurysms (4 male patients and 8 female patients; age range, 4 months–16 years; mean age, 5.1 years), were admitted with subarachnoid hemorrhage during the past 12 years. The majority of patients were admitted in good clinical condition; 31% were in Hunt and Hess Grade II, and 31% were in Hunt and Hess Grade III. The remaining patients were in poor clinical condition and were in Hunt and Hess Grade IV (23%) or Grade V (15%). Computed tomography revealed that 15% of the patients were in Fisher Grade 2, 23% were in Fisher Grade 3, and 62% were in Fisher Grade 4. Endovascular techniques were used in the treatment of 5 aneurysms, and microsurgery was used in the treatment of 8 aneurysms. In the endovascular group, aneurysm sizes ranged from 2 to 35 mm (mean, 12.6 mm); 3 aneurysms were in the anterior circulation, and 2 were in the posterior circulation. In the microsurgery group, 6 aneurysms were in the anterior circulation, and 2 were in the posterior circulation; sizes ranged from 3 to 15 mm (mean, 6.8 mm). Sixty-nine percent of the patients were independent at follow-up. CONCLUSION Contemporary endovascular and microsurgical techniques can be used effectively to treat ruptured cerebral aneurysms in pediatric patients. In the time period studied, the techniques were equally effective when used in the appropriate patients.

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Endovascular management of fusiform aneurysms in the posterior circulation: the era of flow diversion

Neurosurgical FOCUS ◽

10.3171/2017.3.focus1748 ◽

2017 ◽

Vol 42 (6) ◽

pp. E14 ◽

Cited By ~ 34

Author(s):

Ahmed J. Awad ◽

Justin R. Mascitelli ◽

Reham R. Haroun ◽

Reade A. De Leacy ◽

Johanna T. Fifi ◽

...

Keyword(s):

Natural History ◽

Endovascular Treatment ◽

Coil Embolization ◽

Posterior Circulation ◽

Flow Diversion ◽

Endovascular Management ◽

True Aneurysm ◽

Aneurysm Neck

Fusiform aneurysms are uncommon compared with their saccular counterparts, yet they remain very challenging to treat and are associated with high rates of rebleeding and morbidity. Lack of a true aneurysm neck renders simple clip reconstruction or coil embolization usually impossible, and more advanced techniques are required, including bypass, stent-assisted coiling, and, more recently, flow diversion. In this article, the authors review posterior circulation fusiform aneurysms, including pathogenesis, natural history, and endovascular treatment, including the role of flow diversion. In addition, the authors propose an algorithm for treatment based on their practice.

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Posterior Circulation Ischemia in the Endovascular Era

Neurology ◽

10.1212/wnl.0000000000012808 ◽

2021 ◽

Vol 97 (20 Supplement 2) ◽

pp. S158-S169

Author(s):

Roberta Novakovic-White ◽

Juan Mario Corona ◽

Jonathan A. White

Keyword(s):

Risk Factors ◽

Systematic Review ◽

Endovascular Treatment ◽

Ct Perfusion ◽

Posterior Circulation ◽

Basilar Artery Occlusion ◽

Current Evidence ◽

Anterior Circulation ◽

Limb Weakness ◽

Presenting Symptoms

Background and ObjectivesTo perform literature review of clinical, radiographic, and anatomical features of posterior circulation ischemia (PCI) and systematic review of the literature on the management of basilar artery occlusion (BAO) and associated outcomes.MethodsReview of literature was conducted to identify publications describing the risk factors, etiology, clinical presentation, and imaging for PCI. A systematic review was performed in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analysis statement. PubMed and Ovid MEDLINE were searched from 2009 to 2020 for articles relating to management of BAO. A synthesis was compiled summarizing current evidence on management of BAO.ResultsPCI accounts for 15%–20% of strokes. Risk factors are similar to anterior circulation strokes. Dizziness (47%), unilateral limb weakness (41%), and dysarthria (31%) are the most common presenting symptoms. A noncontrast head CT will identify PCI in 21% of cases; diffusion-weighted MRI or CT perfusion increase sensitivity to 85%. Recent trials have shown endovascular therapy can achieve >80% recanalization of BAO. In select patients, 30%–60% who receive endovascular treatment can achieve favorable outcome vs without. A total of 13% achieve good outcome and there is an 86% mortality rate.DiscussionPCI can present with waxing and waning symptoms or clinical findings that overlap with stroke mimics and anterior circulation ischemia, making diagnosis more heavily dependent on imaging. Recanalization is an important predictor of improved functional outcome and survival. In this endovascular era, trials of BAO are fraught with deterrents to enrollment. Despite limitations, endovascular treatment has shown improved outcome in select patients.

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Comparative study of posterior and anterior circulation stroke in childhood

Neurology ◽

10.1212/wnl.0000000000008837 ◽

2019 ◽

Vol 94 (4) ◽

pp. e337-e344 ◽

Cited By ~ 1

Author(s):

Barbara Goeggel Simonetti ◽

Mubeen F. Rafay ◽

Melissa Chung ◽

Warren D. Lo ◽

Lauren A. Beslow ◽

...

Keyword(s):

Ischemic Stroke ◽

Clinical Presentation ◽

Case Fatality ◽

Posterior Circulation ◽

Stroke Severity ◽

Neurologic Examination ◽

Arterial Ischemic Stroke ◽

Anterior Circulation ◽

Multicenter Observational Study ◽

International Multicenter

ObjectiveTo compare risk factors, clinical presentation, and outcomes after posterior circulation arterial ischemic stroke (PCAIS) and anterior circulation arterial ischemic stroke (ACAIS) in neonates and children.MethodsIn this international multicenter observational study including neonates and children up to 18 years of age with arterial ischemic stroke (AIS), we compared clinical and radiologic features according to stroke location.ResultsOf 2,768 AIS cases, 507 (18%) were located in the posterior circulation, 1,931 (70%) in the anterior circulation, and 330 (12%) involved both. PCAIS was less frequent in neonates compared to children (8.8% vs 22%, p < 0.001). Children with PCAIS were older than children with ACAIS (median age 7.8 [interquartile range (IQR) 3.1–14] vs 5.1 [IQR 1.5–12] years, p < 0.001), and more often presented with headache (54% vs 32%, p < 0.001) and a lower Pediatric NIH Stroke Scale score (4 [IQR 2–8] vs 8 [IQR 3–13], p = 0.001). Cervicocephalic artery dissections (CCAD) were more frequent (20% vs 8.5%, p < 0.001), while cardioembolic strokes were less frequent (19% vs 32%, p < 0.001) in PCAIS. Case fatality rates were equal in both groups (2.9%). PCAIS survivors had a better outcome (normal neurologic examination at hospital discharge in 29% vs 21%, p = 0.002) than ACAIS survivors, although this trend was only observed in children and not in neonates.ConclusionPCAIS is less common than ACAIS in both neonates and children. Children with PCAIS are older and have a higher rate of CCAD, lower clinical stroke severity, and better outcome than children with ACAIS.

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HyperForm balloon remodeling in the endovascular treatment of anterior cerebral, middle cerebral, and anterior communicating artery aneurysms: clinical and angiographic follow-up results in 800 consecutive patients

Journal of Neurosurgery ◽

10.3171/2010.3.jns081131 ◽

2011 ◽

Vol 114 (4) ◽

pp. 944-953 ◽

Cited By ~ 32

Author(s):

H. Saruhan Cekirge ◽

Kivilcim Yavuz ◽

Serdar Geyik ◽

Isil Saatci

Keyword(s):

Endovascular Treatment ◽

Cerebral Artery ◽

Coil Embolization ◽

Neurological Deficits ◽

Anterior Communicating Artery ◽

Severe Bleeding ◽

Negative Consequences ◽

Anterior Circulation ◽

Anterior Communicating Artery Aneurysms

Object The purpose of this paper was to present the safety, efficacy, and clinical/angiographic follow-up results of HyperForm balloon-assisted endosaccular coil occlusion of distal anterior circulation bifurcation aneurysms. Methods Over a 7-year period, the authors treated 864 middle cerebral artery, distal anterior cerebral artery bifurcation, and anterior communicating artery aneurysms by means of coil embolization with HyperForm balloon assistance in 800 patients. In 37 aneurysms, 2 HyperForm balloons were used simultaneously for remodeling. Results The overall mortality rate was 7.1%, including 1.4% procedural mortality. Various neurological deficits were present at discharge in 8.9% of the patients, and 4.4% had permanent disabling morbidity 6 months posttreatment (modified Rankin Scale score ≥ 2). Thromboembolic complications developed during the treatment of 15 aneurysms (1.7%) causing morbidity or mortality in 10 cases (1.3%). There were 14 intraoperative perforations (1.6%). In all 14 cases, the HyperForm balloon saved patients from severe bleeding. The perforation led to morbidity or mortality in 3 cases (0.4%); there were no negative consequences in 11. There were 726 patients with 757 aneurysms (87.6%) available for follow-up. Control angiograms were obtained at 6 months in 386 patients, at 1 year in 267, and at 2 years in 104, revealing an 82% complete obliteration rate according to the most recent follow-up angiograms. Conclusions The satisfactory results obtained in this experience demonstrate that HyperForm balloon remodeling provides strong benefits for the endovascular management of middle cerebral, anterior cerebral, and anterior communicating artery aneurysms without increasing the risk of treatment. Not only does this technique allow for the safe treatment of these aneurysms, but it also expands the indications of endovascular treatment to include aneurysms that otherwise cannot be treated with simple coil embolization.

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