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      Paediatric subarachnoid haemorrhage and severe vasospasm secondary to traumatic pseudoaneurysm of a fenestrated vertebral artery: a case report and review of the literature

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          Abstract

          Paediatric intracranial aneurysms are rare entities accounting for less than 5% of all age intracranial aneurysms. Traumatic aneurysms are more common in children and have an association with anatomical variations such as arterial fenestrations. Here, we present a case of a child initially presenting with traumatic subarachnoid haemorrhage who returned to baseline and was discharged home only to return within 2 weeks with diffuse subarachnoid and intraventricular re-haemorrhage. A dissecting aneurysm of a duplicated (fenestrated) V4 vertebral artery segment was identified as a rare cause of rebleeding. We describe a course complicated by severe vasospasm delaying aneurysm detection and treatment. Dissecting aneurysms in children should be considered in all cases of delayed post-traumatic cranial rebleeding, particularly where there is anomalous arterial anatomy.

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          Most cited references29

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          Intracranial aneurysms in children aged under 15 years: review of 59 consecutive children with 75 aneurysms.

          Siddharta Wuppalapati, Pierre Lasjaunias, Hortensia Álvarez Díaz … (2005)
          The objective was to review the clinical aspects and therapeutic strategies in a series of aneurysmal vasculopathies seen in children 15 years or under. From our dedicated neurovascular databank of patients, we reviewed 59 consecutive children who had 75 separate lesions. The children were divided into four age groups: below 2 years (22%), 2-5 years (24%), 6-10 years (24%) and 11-15 years (30%). Thirty-three children had dissecting aneurysms, 2 had chronic post-traumatic aneurysms, 8 had infectious aneurysms and 16 had saccular lesions. Twenty-seven percent of the lesions were in the posterior circulation, and 21% developed on the middle cerebral artery. Most dissecting lesions were encountered in the vertebrobasilar system, while saccular lesions were present mostly in the anterior circulation. Half of all cases presented with haemorrhage. Haemorrhage in patients below 2 years of age was due to dissecting aneurysms, while saccular aneurysms were responsible for haemorrhage in patients above 5 years of age. Five children had familial disease and 9 presented with multiple aneurysms. Forty-eight children were referred to us for treatment. Thirty-two underwent surgical (21.9%), endovascular (62.8%) or combined (9.3%) treatment. Eleven patients were treated conservatively and in 5 patients the aneurysms had spontaneously thrombosed at admission. Overall, complete or partial spontaneous thrombosis was seen in 10 patients (16.9%). Dissecting aneurysms were frequent in children of all ages with either associated thrombosis or arterial tear with repeated acute haemorrhage and poor outcome. Two types of dissection seem identifiable despite the small number of cases collected: acute segmental arterial tear without thrombosis, acute subarachnoid haemorrhage (SAH) and recurrence before 5 years; and subacute focal dissection with partial thrombosis (or mural haematoma), rare SAH and no early recurrence. The former would require aggressive management whereas the latter often do not require interventional approaches. The mortality in our series of aneurysms is low in the treated group (10.42%). The overall tolerance to haemorrhage seems better than in adults, as already stressed in the literature. The multiple etiologies encountered confirm the heterogenous nature of "aneurysms". The variety of treatments used suggests the need to categorise aneurysms into subgroups in sufficient numbers to fully appreciate the behavior of the lesions and make the appropriate therapeutic decisions.
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            Traumatic intracranial aneurysms.

            D R Parkinson, Lyndon West (1980)
            Eleven cases of traumatic intracranial aneurysms, six saccular and five arteriovenous, are presented with an operative mortality of 22.2%, which compares favorably with the few reports in the literature. These lesions are usually associated with serious head injuries. The diagnosis is often delayed or overlooked as the surgeon's attention is distracted by the presence of an accompanying intracranial hematoma. With increasing replacement of angiography by computerized tomography in aneurysm diagnosis, these aneurysms are even more likely to escape detection. They should be suspected in any patient who deteriorates within 2 weeks of the trauma. Conservative management carries a mortality rate of about 50%. Because of their superficial location, they are amenable to successful surgical extirpation. Improved mortality depends on early recognition and surgical obliteration.
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              Cerebral aneurysms in childhood and adolescence.

              Thoralf M. Sundt, I W G Forbes, Karolin F Meyer … (1989)
              In this study, 24 aneurysms occurring in 23 patients under the age of 18 years (mean 12 years) are analyzed. The male:female ratio was 2.8:1, and the youngest patient was 3 months old. Mycotic lesions and those associated with other vascular malformations were excluded. Forty-two percent of the aneurysms were located in the posterior circulation, and 54% were giant aneurysms. Presenting symptoms included subarachnoid hemorrhage in 13 and mass effect in 11. Several of these aneurysms were documented to rapidly increase in size over a 3-month to 2-year period of observation. All aneurysms were surgically treated: direct clipping was performed in 14; trapping with bypass in four; trapping alone in four; and direct excision with end-to-end anastomosis in two. The postoperative results were excellent in 21 aneurysms (87%), good in two (8%), and poor in one. The pathogenesis of cerebral aneurysms is reviewed.
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                Author and article information

                Contributors
                Adikarige Haritha Dulanka Silva: dulanka.silva@gosh.nhs.net
                Journal
                Journal ID (nlm-ta): Childs Nerv Syst
                Journal ID (iso-abbrev): Childs Nerv Syst
                Title: Child's Nervous System
                Publisher: Springer Berlin Heidelberg (Berlin/Heidelberg )
                ISSN (Print): 0256-7040
                ISSN (Electronic): 1433-0350
                Publication date (Electronic): 10 May 2023
                Publication date PMC-release: 10 May 2023
                Publication date (Print): 2023
                Volume: 39
                Issue: 8
                Pages: 2187-2193
                Affiliations
                [1 ]GRID grid.420468.c, Great Ormond Street Hospital for Sick Children, ; London, England
                [2 ]GRID grid.420468.c, Department of Paediatric Neurosurgery, , Great Ormond Street Hospital for Children, ; London, England
                [3 ]Department of Radiology, Physics Group, London, England
                [4 ]Paediatric Interventional Neuroradiology, London, England
                Article
                Publisher ID: 5894
                DOI: 10.1007/s00381-023-05894-4
                PMC ID: 10390618
                PubMed ID: 37162521
                SO-VID: 65aa30a7-7539-4e42-870b-1d447d62adf9
                Copyright © © Crown 2023
                License:

                Open AccessThis article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/.

                History
                Date received : 15 November 2022
                Date accepted : 20 February 2023
                Categories
                Subject: Case Report
                Custom metadata
                issue-copyright-statement © Springer-Verlag GmbH Germany, part of Springer Nature 2023

                ScienceOpen disciplines: Neurology
                Keywords: vertebral artery fenestration,paediatric traumatic aneurysm,paediatric aneurysmal subarachnoid haemorrhage,vasospasm
                Data availability:
                ScienceOpen disciplines: Neurology
                Keywords: vertebral artery fenestration, paediatric traumatic aneurysm, paediatric aneurysmal subarachnoid haemorrhage, vasospasm

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