Abstract
Pediatric cerebral aneurysms are rare, and pediatric anterior choroidal artery aneurysms are very rarely reported. A 14-month-old male with no personal or family history of connective tissue disorders or Moyamoya disease presented with a right temporal intracerebral hemorrhage with intraventricular extension. CTA was negative for vascular pathology, but digital subtraction angiography revealed an anterior choroidal artery aneurysm that was successfully coiled. This case underscores the importance of performing digital subtraction angiography in children presenting with intracerebral hemorrhage concerning for vascular pathology even if non-invasive vascular imaging is negative.
Keywords: Intracranial aneurysm, therapeutic embolization, digital subtraction angiography, malformation, brain vascular, brain vascular disorder
A 14-month-old male with no personal or family history of connective tissue disorders or Moyamoya disease presented with a right temporal intracerebral hemorrhage with intraventricular extension (Figure 1(a)). The appearance of calcification lateral to the acute intracerebral hemorrhage raised concern for a ruptured arteriovenous malformation (Figure 1(a)). Computed tomography angiography (CTA) was negative for arteriovenous malformation or other vascular pathology. He underwent right hemicraniectomy and ultimately left occipital ventriculoperitoneal shunt placement. Digital subtraction angiography was deferred at that time due to the patient’s critical illness and poor surgical candidacy. Weeks after discharge to rehab, he re-presented with seizure and new right intracerebral hemorrhage suggestive of aneurysm rupture on imaging (Figure 1(b)). He underwent a second right hemicraniectomy. Digital subtraction angiography revealed a 4.2 mm by 4.9 mm ruptured aneurysm in the right anterior choroidal artery that was successfully treated with coil embolization (Figure 2).
Figure 1.
Non-contrast computed tomography of the head at initial presentation showed a hyperdensity with calcification lateral to the intracerebral hemorrhage, which was initially concerning for arteriovenous malformation (arrow) (a). Repeat non-contrast computed tomography of the head at re-presentation showed a new hyperdensity with an internal circular hypodensity suggestive of a ruptured aneurysm (arrow) (b).
Figure 2.
Digital subtraction angiography showed a right anterior choroidal artery aneurysm (arrows) before (a), (b) and after coil embolization (c), (d). The right middle cerebral artery fills distal to the skull after two preceding right hemicraniectomies (arrowheads).
Pediatric cerebral aneurysms are rare and represent only 1.6–7% of all intracerebral aneurysms, with anterior choroidal artery aneurysms occurring rarely.1–4 Digital subtraction angiography is the diagnostic gold standard and allows for endovascular treatment in appropriate cases. In an adult population, digital subtraction angiography identifies CTA-negative vascular pathology in approximately 13% of patients, including identification of aneurysms in 5% of patients. 5 Diagnosis and treatment of pediatric cerebral aneurysms is essential because ruptured pediatric cerebral aneurysms that are left open or incompletely treated have higher rates of death due to rebleeding in the first 10 years after initial hemorrhage. 6 This case underscores the importance of performing digital subtraction angiography in children presenting with intracerebral hemorrhage to evaluate for possible vascular pathology even if non-invasive vascular imaging is negative.
Informed consent was obtained from the patient’s parents.
Footnotes
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding: The author(s) received no financial support for the research, authorship, and/or publication of this article.
ORCID iDs
Jonathan R Crowe https://orcid.org/0000-0003-3670-5566
Justin Vranic https://orcid.org/0000-0002-6000-6709
Robert W Regenhardt https://orcid.org/0000-0003-2958-3484
References
- 1.Chen RZS, Zhang S, Xiao A, et al. Risk factors for intracranial aneurysm rupture in pediatric patients. Acta Neurochir 2022; 164(4): 1145–1152. [DOI] [PubMed] [Google Scholar]
- 2.Garrido EMT, Metayer T, Borha A, et al. Intracranial aneurysms in pediatric population: a two-center audit. Childs Nerv Syst 2021; 37(8): 2567–2575. [DOI] [PubMed] [Google Scholar]
- 3.Slator NTS, Talibi SS, Mundil N, et al. Paediatric intracranial aneurysms: a British institutional review. Childs Nerv Syst 2019; 35(7): 1197–1205. [DOI] [PubMed] [Google Scholar]
- 4.Feijoo PG, Gutiérrez JMS, Martínez RF, et al. Management of a ruptured intraventricular aneurysm arising from distal anterior choroidal artery (AChA): pediatric case report. Childs Nerv Syst 2021; 37(5): 1791–1796. [DOI] [PubMed] [Google Scholar]
- 5.Heit JJ, Pastena GT, Nogueira RG, et al. Cerebral Angiography for Evaluation of Patients with CT Angiogram-Negative Subarachnoid Hemorrhage: An 11-Year Experience. AJNR Am J Neuroradiol 2016; 37(2): 297–304. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 6.Koroknay-Pál P, Laakso A, Lehto H, et al. Long-term excess mortality in pediatric patients with cerebral aneurysms. Stroke. Aug 2012; 43(8): 2091–2096. [DOI] [PubMed] [Google Scholar]