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Case Reports
. 2020 Dec 8;12(12):e11974.
doi: 10.7759/cureus.11974.

Onyx Embolization of a Distal Middle Cerebral Artery Pseudoaneurysm in a Five-Week-Old: A Case Report and Review of Current Treatment Options

Yasmeen Elsawaf  1 , Maryam Zeinomar  2 , Andrea Scherer  3 , Ravi H Gandhi  4
Affiliations
Case Reports

Onyx Embolization of a Distal Middle Cerebral Artery Pseudoaneurysm in a Five-Week-Old: A Case Report and Review of Current Treatment Options

Yasmeen Elsawaf et al. Cureus. .

Abstract

Intracranial pseudoaneurysms secondary to traumatic birth are a rare finding in infants. Definitive diagnosis of such findings is challenging, and no standard management is delineated for management of pseudoaneurysms in the pediatric population. Commonly attempted treatments include endovascular embolization or surgical clipping. A 5-week-old female presented with a two day history of right hand focal seizures. The patient was found to have a dysplastic superficial intra-axial aneurysm arising from the distal left middle cerebral artery (MCA) branch in the setting of a left posterior frontal lobe hemorrhage noted on brain magnetic resonance imaging/magnetic resonance angiography (MRI/MRA). The patient underwent diagnostic cerebral angiogram demonstrating a left distal MCA pseudoaneurysm, which was treated with Onyx embolization. Post-embolization period was complicated by recurrent left central localized seizures and a left hemispheric temporoparietal hemorrhagic infarction. The patient was managed on levetiracetam, phenytoin, phenobarbital with stable seizure control. Herein, we highlight the youngest case to date of a 5-week-old infant with a left distal MCA pseudoaneurysm treated with Onyx embolization. Pseudoaneurysmal incidence, diagnosis and accepted management is discussed.

Keywords: middle cerebral artery infarct; pediatric vascular malformation; pseudoaneurysm.

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Conflict of interest statement

The authors have declared that no competing interests exist.

Figures

Figure 1
Figure 1. Pre-embolization MRI of the brain
MRI of the brain depicting a dysplastic superficial intra-axial aneurysm arising at the distal left middle cerebral artery (MCA) branch with hemorrhage of the left posterior frontal lobe anterior to the central sulcus (white arrow)
Figure 2
Figure 2. Pre-embolization digital subtraction angiography images obtained upon injection into the right internal carotid artery (ICA)
a: right ICA injection demonstrating normal anatomy. b: left middle cerebral artery (MCA) pseudoaneurysm is not visualized.
Figure 3
Figure 3. Pre-embolization digital subtraction angiography image obtained upon injection into the left internal carotid artery (ICA)
Left ICA injection revealing the left middle cerebral artery (MCA) distal pseudoaneurysm (black arrow)
Figure 4
Figure 4. Pre-embolization digital subtraction angiography images obtained upon injection into the left middle cerebral artery (MCA); arterial phase
a-c: Left MCA injection revealing the left MCA distal pseudoaneurysm (black arrow); arterial phase.
Figure 5
Figure 5. Pre-embolization digital subtraction angiography images obtained upon injection into the left middle cerebral artery (MCA); venous phase
a-c: Left MCA injection revealing the left MCA distal pseudoaneurysm (black arrow); venous phase
Figure 6
Figure 6. Post-embolization digital subtraction angiography images obtained upon injection into the left internal cerebral artery (ICA); arterial phase
a, b: Left ICA injection revealing left middle cerebral artery (MCA) distal pseudoaneurysm (black arrow) in the arterial phase post-embolization
Figure 7
Figure 7. Post-embolization digital subtraction angiography images upon injection into the left internal carotid artery (ICA); venous phase
a, b: Left ICA injection with visualization of the left middle cerebral artery (MCA) distal pseudoaneurysm (black arrow) in the venous phase post-embolization
See this image and copyright information in PMC

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