Middle cerebral artery aneurysms in children: case series and review

Abstract

<jats:sec> <jats:title>Object</jats:title> <jats:p>Pediatric intracranial aneurysms are rare lesions that differ from their adult counterparts. Aneurysms involving the middle cerebral artery (MCA) are particularly challenging to treat in children, as they are often fusiform and cannot undergo direct clipping alone. The authors recently treated a patient with a heavily calcified, dysplastic, left-sided MCA aneurysm. The present study was performed to evaluate the authors' previous operative and follow-up experience with these difficult lesions.</jats:p></jats:sec> <jats:sec> <jats:title>Methods</jats:title> <jats:p>The authors performed a review of a prospectively maintained database of all aneurysms treated at Methodist Hospital in Indianapolis, Indiana, from January 1990 through November 2010. Relevant operative notes, clinical charts, and radiological reports were reviewed for all patients 18 years of age or younger.</jats:p></jats:sec> <jats:sec> <jats:title>Results</jats:title> <jats:p>A total of 2949 patients with aneurysms were treated over the study period, including 28 children (0.95%). Seven children harbored MCA aneurysms. Five of these 7 aneurysms (71.4%) were fusiform. Two patients were treated with direct clipping, 2 underwent parent vessel occlusion without bypass, and 3 underwent aneurysm trapping with extracranial-intracranial vessel bypass. Long-term follow-up data were available in 6 cases. All 6 patients had a 1-year follow-up Glasgow Outcome Scale score of 5. Long-term radiological follow-up was available in 4 patients. One patient required a reoperation for a recurrent aneurysm 4 years after the initial surgery.</jats:p></jats:sec> <jats:sec> <jats:title>Conclusions</jats:title> <jats:p>Middle cerebral artery aneurysms in children are often fusiform, giant, and incorporate the origins of proximal artery branches. Direct clipping may not be possible; trapping of the lesion may be required. Children seem to tolerate surgical trapping with or without bypass extremely well. Aggressive therapy of these rare lesions in children is warranted, as even patients presenting with a poor clinical grade may have excellent outcomes. Long-term surveillance imaging is necessary because of the risk of aneurysm recurrence.</jats:p></jats:sec>

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

“…Thus, appropriate surveillance or detection of additional aneurysms is warranted. Middle cerebral artery aneurysms in children have been treated with a host of techniques, including clipping and/or extracranial-to-intracranial (EC-IC) bypass, 1,2,6 endovascular therapy, 7 trapping alone, 8 and bypass combined with endovascular therapy. 13 In children most MCA aneurysms are giant, fusiform, and difficult to treat with direct clipping alone.…”

“…13 In children most MCA aneurysms are giant, fusiform, and difficult to treat with direct clipping alone. 1 They also can be calcified or dysplastic 13 and can involve proximal MCA perforators. Consequently, they are frequently treated by trapping (Hunterian ligation) 8 or flow reversal with potential EC-IC bypass in an attempt to preserve critical perforators.…”

Ruptured Dissecting Vertebrobasilar Aneurysm in Childhood: What Is the Therapeutic Strategy?

“…Interestingly, none of the risk factors traditionally known to be involved in adult aneurysm formation, such as familiarity, smoking, cocaine use, and arterial hypertension, could be identified with the same frequency among the pediatric population, raising the question of a different pathogenesis. Moreover, pediatric aneurysms show peculiar characteristics, differentiating them from adults: predominant male to female ratio (2:1), high rate of posterior circulation lesions, high proportion of carotid bifurcation location for anterior circulation malformations and remarkable frequency of giant aneurysms (>2.5 cm) [15]. Correlation to congenital disorders (polycystic kidney disease, aortic coarctation, sickle cell anemia, Ehlers-Danlos syndrome, type IV collagenopathy) has also been observed, but it was extremely rare in most of the large series [16].…”

Rapid de novo aneurysm formation after clipping of a ruptured middle cerebral artery aneurysm in an infant with an MYH11 mutation

“…3 Pediatric cerebral aneurysms are also more frequently giant, tend to form in the posterior circulation and at the internal carotid artery bifurcation, and have a male preponderance. 19,26,30,33 Fusiform aneurysms are less common in adults, more common in children, 6,11 and frequently occur along the MCA branches. 6 The featured case represents a rare saccular aneurysm arising from the inferior division of M 2 with de novo saccular aneurysm formation at the superior division of M 2 .…”