Intracranial Non-traumatic Aneurysms in Children and Adolescents

Abstract

An intracranial aneurysm in a child or adolescent is a rare, but potentially devastating condition. As little as approximately 1200 cases are reported between 1939 and 2011, with many of the reports presenting diverting results. There is consensus, though, in that pediatric aneurysms represent a pathophysiological entity different from their adult counterparts. In children, there is a male predominance. About two-thirds of pediatric intracranial aneurysms become symptomatic with hemorrhage and the rate of re-hemorrhage is higher than in adults. The rate of hemorrhage from an intracranial aneurysm peaks in girls around menarche. The most common aneurysm site in children is the internal carotid artery, in particular at its terminal ending. Aneurysms in the posterior circulation are more common in children than adults. Children more often develop giant aneurysms, and may become symptomatic from the mass effect of the aneurysm (tumorlike symptoms). The more complex nature of pediatric aneurysms poses a larger challenge to treatment alongside with higher demands to the durability of treatment. Outcome and mortality are similar in children and adults, but long-term outcome in the pediatric population is influenced by the high rate of aneurysm recurrences and de novo formation of intracranial aneurysms. This urges the need for life-long follow-up and screening protocols.

Keywords: Cerebral vasospasm; giant aneurysm; intracranial aneurysm; outcome; pediatric; subarachnoid hemorrhage..

Fig. (1)

Distribution of age at diagnosis of the intracranial aneurysm in males (light grey columns) versus females (dark grey columns). Scale on the right shows the male/female ratio with values above “1” (dotted line) indicating male predominance. Data from [7, 8, 11, 13, 16-29].

Fig. (2)

Age at aneurysm rupture (data collected from previous reports providing adequate information [7, 8, 11, 13, 16-29]).

Fig. (3)

Clinical grade according to Hunt and Hess [43] in males (light grey) and females (dark grey) with ruptured intracranial aneurysms (data collected from previous reports providing adequate information [7, 8, 11, 13, 17-22, 24, 25, 27, 29]).

Fig. (4)

Age when the aneurysm became symptomatic (non-hemorrhagic, data collected from previous reports providing adequate information [7, 11, 13, 16, 18-21, 23-26]).

Fig. (5)

Localization of 671 pediatric (black columns) and 1021 adult (grey columns) intracranial aneurysms reported [7, 8, 11, 13, 16-29, 33, 36, 37, 39, 40, 44, 46]. Shaded columns indicate posterior circulation localizations. A1: anterior cerebral artery proximal to the anterior communicating artery (AcoA), BA: basilar artery (locations other than terminus), ICA: internal carotid artery (localizations other than terminus), M2 and M3: first and second branching of the middle cerebral artery (MCA), MCA bif: MCA bifurcation, P2/3: first and second branching of the posterior cerebral artery (PCA), PICA: posterior inferior cerebellar artery, SCA: superior cerebellar artery, VA: vertebral artery

Fig. (6)

Most children that were in good clinical grade (Hunt and Hess [43] grades 1-3) had an excellent (GOS5) or good (GOS4) outcome, whereas many of the children presenting in a poor clinical grade (Hunt and Hess grades 4 and 5) died (GOS1) or survived to a dependent life. GOS: Glasgow outcome scale [58]. HH: Hunt and Hess grade.