Dr.Manoranjitha kumari

Prof. R.Arunkumar

Madras Institute Of Neurology

Chennai

3 years old female child referred from ICH

h/o recurrent episodes of seizures more than

ten episodes in 2 hours period followed by

which child lost consciousnes

regained consciousness in two days

Difficulty in using right upper and lower

limbs with deviation of angle of mouth

towards left side, and inability to speak since

the ictus

h/o low grade fever

No history of trauma

No history of previous seizures

Ante natal , natal and post natal history – nil

relevant

Past history of chicken pox 1 ½ months ago

On examination :

child alert

playful

afebrile

no neck stiffness

aphasic

obeys commands

Cranial nerves:

rt UMN 7th nerve palsy

all other cranial nerves clinically normal

fundus- normal

Spino motor system:

rt lt

bulk n n

tone ↑↑ n

power 0/5 n

Superficial reflexes- normal

DTR- brisk reflexes in rt side limbs, normal in

the lt side

Plantar rt- extensor lt- flexor

Spine and cranium normal

Cardiac evaluation and other blood infection

done at ICH was normal

Epidural catheter

Lt pterional craniotomy

Durotomy

Frontal and temporal lobes retracted

Sylvian and carotico optic cisterns opened

Bilobed aneurysm – 7mm*8mm, neck -3mm at

lt ICA bifircation

Clipped from anterior to posterior

Aneurysm excised, patent, no thrombus

Journal of Neuropathology & Experimental

Neurology:

May 1996 - Volume 55 - Issue 5 - ppg 664

238:

Pediatric AIDS Presenting As A Ruptured

Cerebral Aneurysm Associated With

Varicella-Zoster Vascuutis

stephen dillert et al

Epidemiology

Intracranial paediatric aneurysms are rare, 1-

2%

In children less than 2 y of age, there is a

male predominance

while in adolescents, there is an equal

incidence of aneurysms in both sexes

75 % of patients – SAH

Giant aneurysms are common in paediatricage group

Incidence of rebleeding 19-29%

Radiological vasospasm– 36%, clinical vasospasm is low in paediatric age group(Proust series)

The children tend to present in a better clinical grade as compared to adults after aneurysmal rupture and seem to be less susceptible to the delayed ischemic deficits due to vasospasm

the incidence of seizures is higher

explanation may be the higher incidence of

intra cerebral bleed in children due to the

frequent location of the aneurysms at ICA

bifurcation or the MCA branches.

higher incidence of giant aneurysm in

children that may manifest as seizures or as

mass effect rather than as SAH

The commonest site of aneurysm in the

paediatric group is ICA bifurcation-20-50%

due to the presence of a wide ICA bifurcation

angle. This exposes a wider area of vessel

wall to the turbulent blood

both congenital and acquired factors

The presence of saccular aneurysms during early years

of life point against degenerative causes in the etio

pathogenesis of aneurysm formation.

Bremer et al. supported the congenital origin of

aneurysms and proposed that aneurysms developed

from remnants of small vascular trunks originating from

arterial bifurcation

Diseases like fibromuscular dysplasia, coarctation of aorta, Marfan's disease, polycystic kidney disease have a high incidence of aneurysm formation

Thus, congenital defects of connective tissue in the vessel wall may be the predisposing factor for aneurysm formation in children.

Histopathological studies, however, show no difference between adults and paediatricaneurysms, i.e, in both groups, there is absence of both internal elastic lamina and muscularis layer of tunica media

Many studies support the presence of acquired causes for aneurysm formation. The degenerative changes may first appear in the intimal pads proximal to the blood vessel bifurcation, which then extend to the media

The increased hemodynamic stress at branching points leads to injury to internal elastic lamina and this initiates the development of aneurysm

Infective – mycotic aneurysm in SABE

In traumatic cases, there may be tears in the internal elastic lamina leading to dissecting aneurysms in large arteries.

Stephens suggested lodgment of bacteria at the site of trauma. The bacteria then multiply in the thrombus at the site of vessel injury leading to aneurysm formation

Ruptured aneurysms , the operative or

endovascular techniques are similar to that

used in adults.

Due to higher incidence of complex

aneurysms in children, more extensive

procedures may often be required to

facilitate clipping.

These include microanastomosis, bypass

procedures and trapping.Endovascular

approach should be chosen with the

indications being similar to that of adults.

infective aneurysms, initial efforts focus on

treating them conservatively using antibiotics

and serial angiograms, with surgery being

reserved for patients who have persistence of

the aneurysm on follow-up angiogram.

The aneurysm is often friable and may not be

amenable to clipping. The surgical treatment

usually consists of occluding the parent vessel

proximal to the aneurysm if the aneurysm is on a

terminal branch in a non-eloquent region.

In proximal aneurysms, due to the risk of

ischemia involved in trapping a major vessel,

reconstruction or trapping with bypass may be

preferred depending on the status of cross

circulation

In the case of traumatic aneurysms, an often

used modality is excision of aneurysm

(because these are usually false aneurysms),

especially when it is situated on a terminal

branch.

In aneurysms on main stem of vessel,

trapping with bypass may be required

Intracranial paediatric aneurysms are

different from adults in having a male

predominance, having ICA as the commonest

site and also in having a higher incidence of

infective, traumatic and giant aneurysms.

The clinical presentation of mass effect or

subtle cognitive dysfunction occurs more

often than in adults.

These patients tend to have lesser incidence

of clinical vasospasm and appear to have a

better outcome as compared to adults