High-flow bypass and tandem microsurgical-endovascular occlusion of recurrent proximal middle cerebral artery aneurysms in a pediatric patient

Abstract

<jats:p>The authors report the case of a 7-year-old boy with headaches, in whom CT angiography showed multiple intracranial aneurysms from the terminus region of the right internal carotid artery through the proximal right middle cerebral artery (MCA). Initially, the patient underwent clip reconstruction of the M<jats:sub>1</jats:sub> segment. Multiple microsurgical and endovascular treatments were required because the largest of these aneurysms recurred several times over the next 1.5 years. The first recurrence was treated with stent coiling and the second by microsurgical occlusion of the MCA combined with the use of a radial artery graft in a common carotid artery–to-MCA bypass. The aneurysm again recurred and was treated by proximal coil occlusion 15 months after the first treatment session. At a 7.5-year follow-up examination, the aneurysms remained occluded. This case highlights the benefit of combined endovascular and microsurgical techniques in the treatment of a complex and unusual case of proximal MCA aneurysmal disease. The patient, now 15 years old, is neurologically intact and able to participate in all activities.</jats:p>

Endovascular treatment of pediatric intracranial aneurysms: a retrospective study of 35 aneurysms

“…Concerning the MCA trunk aneurysms, even with the bypass surgery it is thought to be difficult to preserve the critical perforators such as in one of our present cases 36. Although there have been limited studies for the pediatric age group, several reconstructive endovascular techniques have been used since stents became available for this purpose 10 13 14 18 33 37 38. The use of these techniques is expected to increase and will probably become an alternative therapeutic option to the classical PVO in the future.…”

“…In addition, the frequency of patients who harbored multiple aneurysms had a certain level of variability ranging from 8% to 31% (present study 13%). Although it has been reported to be considerably lower than that in adults,3 31 32 some authors recently indicated that multiple aneurysms are common in pediatric patients because they are linked to potential vessel wall dysfunction 23 33. This remains controversial and will need to be analyzed in more patients before any conclusions can be drawn.…”

“…In our series, 15 of 17 fusiform aneurysms were treated by curative PVO with or without bypass surgery. To avoid any infarction from the PVO, some authors advocate the use of complementally bypass surgery when needed 10 33 34. Other authors pointed out that the morbidity and mortality of bypass surgery is considerable in these aneurysms (36%) 35.…”

Revascularization and pediatric aneurysm surgery

“…The case of recurrence requiring retreatment has been previously published. 1 This case highlights the importance of close follow-up in this patient population (Fig. 2) and underscores the likelihood that pediatric and adult aneurysms are associated with different pathological mechanisms.…”

“…1,4,16 These reports suggest that these treatment options are generally well tolerated and result in acceptable outcomes in the majority of patients, but the studies suffer from the effects of small sample size and relatively short follow-up.…”