Management of Intracranial Aneurysms in Children

Initial Management at Presentation

In addition to the following recommendations, refer to Intervention at Presentation.

Ruptured aneurysms

• Emergency surgery in case of impending herniation: In this setting, emergent surgical treatment of the aneurysm may be required; this allows for evacuation of hematoma to relieve mass effect or decompressive craniectomy to treat intracranial hypertension. An EVD may be required.
• Urgent surgery in other cases: When the initial clinical status is stable, surgery or endovascular treatment within 24 to 72 hours is preferred in ruptured or otherwise acutely symptomatic aneurysms.

Unruptured oligosymptomatic or incidental aneurysms

• Analyze risks versus benefits: Treatment decisions should be based on a risk-benefit analysis and discussion about treatment modalities with parents or legal guardians.

Medical and conservative management

• Antibiotics for infectious aneurysms: Broad-spectrum antibiotics should be initiated immediately for suspected infectious aneurysms (86). Antifungals may be added when fungal mycotic aneurysm is suspected.

Pediatric stroke and fungal mycotic aneurysm: (A) This child experienced MCA stroke with complete occlusion of the right M1 segment (observed on MRA). (B) Stemming from chemotherapy-induced immunosuppression, this child developed disseminated candidiasis and was discovered on MRI to have a mycotic pseudoaneurysm (yellow arrow). (C) Evidence of local inflammation (yellow arrow; observed on MRI) and (D) hemorrhage (yellow arrow; observed on CT) suggested rupture of the pseudoaneurysm. (E) Treatment for the fungal infection and associated mycotic aneurysm was amphotericin B and flucytosine, leading to shrinking of the pseudoaneurysm (yellow arrow), as observed on MRI.

• Anticoagulation for dissecting aneurysms: Antiplatelet or anticoagulant medication may be indicated for dissecting aneurysms (49).
• Supportive management: Supportive management may be considered for moribund patients (49,75).

Adjunctive Therapies

• Endovascular therapies: Endovascular treatment is minimally invasive and may be indicated in select cases (99). Techniques include endovascular coiling, parent vessel occlusion, and deployment of flow diverters (for more detail, see Adjuvant Therapies for Intracranial Aneurysms in Children).

Follow-up

Vigilant follow-up is recommended in children after treatment of an intracranial aneurysm, since both the annual risk of recurrence (2.6%) and the annual risk of de novo aneurysm formation (7.8%) are higher than in adults (100,101). In the absence of guidelines, the following recommendations are based on the available literature:

• Initial visit 4 to 6 weeks postoperatively: The first postoperative office visit should be scheduled 4 to 6 weeks after treatment.
• Annual visits: Thereafter, annual office visits should be scheduled with MRI scans including MRA, especially in coiled aneurysms.
• Angiography at 1 and 5 years: DSA should be discussed 1 and 5 years after treatment.
• Follow-up for unruptured/incidental aneurysms: Continued surveillance of unruptured/incidental aneurysms is important, given the possibility of interval growth. Two examinations within 1 year, a third examination at 1 year, and follow-ups at 2- to 5-year intervals until age 18 have been proposed (102).