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Ruptured AComA aneurysm and asymptomatic bilateral ACA vasospasm in an infant: surgical case report
Cristina Caterina Aldea1, Ioan Alexandru Florian2,3, Teodora Larisa Timiș4
1Clinic of Neurosurgery, Cluj County Emergency Clinical Hospital, Cluj-Napoca, Romania.
Insights
Ruptured intracranial aneurysms (IAs) are rare in infants but treatable with microsurgery. Experienced surgical intervention can lead to favorable outcomes, even with unusual angiographic findings like absent anterior cerebral arteries.
Area of Science:
- Pediatric Neurosurgery
- Cerebrovascular Surgery
Background:
- Intracranial aneurysms (IAs) cause subarachnoid hemorrhage, morbidity, and mortality.
- IAs are rare in infants, with ruptured variants being exceptional.
Observation:
- A 4-month-old infant presented with vomiting and fever, found to have a ruptured anterior communicating artery aneurysm.
- Pre-operative imaging revealed significant vasospasm affecting the anterior cerebral arteries, rendering them nearly invisible.
Findings:
- Emergency external ventricular shunt placement followed by delayed microsurgical clipping of the IA was successfully performed.
- The infant recovered without neurological deficit, despite the unusual angiographic findings of the anterior cerebral arteries.
Implications:
- Microsurgery is a safe and effective treatment for ruptured intracranial aneurysms in infants, provided experienced surgical teams are involved.
- Early and expert management is crucial to prevent long-term neurological deficits in pediatric IA cases.
- Angiographic invisibility of anterior cerebral arteries in infants may not necessarily predict adverse neurological outcomes.
Abstract:
Intracranial aneurysms (IAs) are localized dilations of the cerebral vasculature, representing the leading cause for non-traumatic subarachnoid hemorrhage and an important source of morbidity and mortality. Despite it being a frequent pathology and most often diagnosed incidentally, IAs in infants are a very rare occurrence, and the ruptured variant is exceptional. A 4-month-old boy with a negative family history was brought to our department because of several episodes of incoercible vomiting and fever. Upon examination, the child was somnolent, without any noticeable deficit. Transfontanellar ultrasonography and CT angiography revealed a ruptured aneurysm of the anterior communicating artery (AComA), whereas the pre-clipping MRI showed thin, almost angiographically invisible anterior cerebral arteries (ACAs) on both sides due to vasospasm. We intervened surgically by placing an external ventricular shunt in an emergency setting, followed by clipping of the IA in a delayed manner. The child was discharged a month after admission with no deficit, despite the paradoxical aspect of the ACA. Ruptured IAs can be safely treated via microsurgery, even in infants. However, this requires a great amount of experience and surgical expertise. Furthermore, the lack of proper management would most likely result in a severe deficit in the long term. Lastly, the lack of visibility of the ACA on angiographic studies may not have neurological consequences if they occur in this age group.
