Treatment of a complex posterior fossa aneurysm in a child using side-to-side posterior inferior cerebellar artery-posterior inferior cerebellar artery bypass

Abstract

Endovascular and cerebral bypass therapies are rarely used in children. The authors describe the treatment of a partially coiled giant distal vertebral artery (VA)-posterior inferior cerebellar artery (PICA) aneurysm in a child. They performed a side-to-side PICA-PICA anastomosis followed by endovascular VA aneurysm deconstruction with PICA preservation. A healthy 11-year-old boy developed progressive holocephalic headaches over the course of 2 months. Magnetic resonance imaging and magnetic resonance angiography revealed a large right PICA aneurysm causing brainstem compression. In November 2005, 2 Neuroform stents and Guglielmi detachable coils and Matrix were placed in the aneurysm at an outside institution. In 2006, angiography demonstrated aneurysm enlargement from which the PICA originated, coil compaction, and increased mass effect. The patient underwent a PICA-PICA bypass with intraoperative flow measurements followed by endovascular embolization of the aneurysm and parent VA. An angiogram obtained after the procedure demonstrated filling of the right PICA medullary branch through the bypass and obliteration of the aneurysm. The patient remained neurologically intact. Giant aneurysms of the posterior circulation are rare but do occur in children. With the aid of combined surgical and endovascular strategies the authors were able to safely eliminate the aneurysm from circulation with good outcome. Cerebral bypass and endovascular deconstructive therapies can be used safely in children but should be reserved for cases in which direct treatment carries significant risk. Careful surgical and endovascular planning with intraoperative flow assessment is essential for good outcome.