Clipping of a ruptured cerebral aneurysm in a toddler: a case report and review of aneurysmal treatment in children

Abstract

Background: Pediatric intracranial aneurysms account for 5% of all aneurysms and less than 10% of all aneurysms cause non-traumatic intracranial hemorrhage in children. They are most commonly secondary to trauma, infection, or genetic etiologies; however, case reports have described iatrogenic intracranial aneurysms. We describe a case of a ruptured aneurysm with an associated intracranial hematoma that was treated by surgical clipping and clot evacuation.

Case description: The patient was a 15-month-old boy without a history of trauma or infection, who developed acute-onset nausea and subsequent neurological deterioration and status epilepticus. Imaging demonstrated a 13-mm saccular anterior cerebral artery aneurysm with accompanying large left frontal intraparenchymal hematoma and intraventricular hemorrhage. He was treated with urgent craniotomy for surgical clipping and clot evacuation. An external ventricular drain was placed to treat the hydrocephalus. The patient subsequently received a ventriculoperitoneal shunt with rehabilitation disposition. There was a family history of intracranial aneurysms and cavernous malformations; however, genetic testing was negative. One year later, he is developing his speech and has ambulated independently.

Conclusions: We highlight the importance of expeditious care in toddlers with rapidly deteriorating neurological examination results and associated intracranial findings. We demonstrate the rarity of intracranial aneurysms in a toddler and the need for further study on this topic, as there is no clear etiology for this finding in this patient.

Keywords: Cerebral aneurysm; case report; cerebrovascular; neurosurgery.

Figure 1

Computed tomography head non-contrasted axial (left) and sagittal (right) imaging demonstrates the large left frontal hematoma with diffused intraventricular hemorrhage and ventriculomegaly.

Figure 2

Computed tomography angiography of the head axial (left) and sagittal (right) demonstrated a saccular aneurysm in the inferior frontal region in close association with intraparenchymal hematoma.

Figure 3

Postoperative computed tomography of 3-dimensional reconstruction with bilateral external ventricular drains with bioabsorbable plating system seen.

Figure 4

Postoperative computed tomography angiography of the head axial (left) and sagittal (right) with clips and no further aneurysm contrast opacification, suggestive of complete obliteration. An external ventricular drain is observed within the right frontal horn.

Figure 5

Magnetic resonance imaging T2 axial image showing encephalomalacia in the medial left frontal lobe with mild ventriculomegaly. The external ventricular drain was removed, and a permanent cerebrospinal fluid diversion was placed with a ventriculoperitoneal shunt.