This document discusses a case of a 3-year-old female child who presented with recurrent seizures over 2 hours followed by loss of consciousness for 2 days. On examination, she had right upper and lower limb weakness, difficulty speaking, and right 7th nerve palsy. Imaging and surgery revealed a ruptured aneurysm at the left ICA bifurcation, which was clipped. The document then reviews characteristics of pediatric intracranial aneurysms, including their etiology, location, presentation, treatment approaches, and outcomes.

1. Dr.Manoranjitha kumari
Prof. R.Arunkumar
Madras Institute Of Neurology
Chennai

2. 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

3.  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

4.  On examination :
child alert
playful
afebrile
no neck stiffness
aphasic
obeys commands

5.  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

6.  Superficial reflexes- normal
 DTR- brisk reflexes in rt side limbs, normal in
the lt side
 Plantar rt- extensor lt- flexor
 Spine and cranium normal

7.  Cardiacevaluation and other blood infection
done at ICH was normal

18. 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

19.  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

20.  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

21.  75 % of patients – SAH
 Giant aneurysms are common in paediatric
age 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

22.  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

23.  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

24.  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

25.  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 paediatric
aneurysms, i.e, in both groups, there is
absence of both internal elastic lamina and
muscularis layer of tunica media

26.  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

27.  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.

28.  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

29.  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

30.  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