Recovery After Surgery for Intracranial Aneurysms in Children

Postoperative Orders

• Vital signs: VS should be continuously monitored. Concerning blood pressure: the aim is normotension for age in the acute postoperative phase, although permissive hypertension might be required at a later phase when anticipating potential vasospasm.
• Activity: In the setting of a ruptured aneurysm, patients are usually kept with HOB elevated to 30 degrees for neuroprotection (to reduce the elevated ICP by facilitating cerebral venous drainage). Most patients are kept on bedrest while awaiting treatment, although this typically occurs within 24 hours. After surgery, patients are generally liberalized to activity as tolerated — the aneurysm has been secured — but they may also be kept on neuroprotective HOB 30-degree elevation if they still have intracranial hypertension. Even when patients have an EVD for hydrocephalus from subarachnoid hemorrhage or intraventricular hemorrhage, they can often have out-of-bed activity as long as heart rate and blood pressure are controlled.
• CSF drainage parameters: If an EVD is in place, the aim should be to maintain a physiological ICP that is appropriate for the patient’s age. Data for this target goal are limited in children with subarachnoid hemorrhage and are usually generalized from adult literature or pediatric severe brain injury literature.
• Medication: Although oral or IV nimodipine is a frequent treatment for adults with ruptured aneurysms, great care must be taken when administering this drug to children. There are no controlled trials in children, and data from small series suggest a substantial risk of induced arterial hypotension (90). Deep sedation should be avoided whenever possible to allow for neurological assessment.
• Radiology studies: A CT or MRI to exclude postoperative hematoma or infarction should be performed within 6 to 12 hours. Postoperative angiography to confirm complete aneurysm occlusion is recommended.

Postoperative Morbidity

Cerebral vasospasm is considered a major determinant of morbidity after aneurysm rupture (120). The pathogenesis is linked to the presence of blood breakdown products in the subarachnoid space (121). In adults, it is detected during angiography after subarachnoid hemorrhage (i.e., angiographic vasospasm) in up to 70% of cases (120). Delayed cerebral ischemia — that is, manifestation of new neurological deficits due to vasospasm — is encountered in adults in up to 30% of cases (120,122).

• Low incidence of vasospasm in children: In children, vasospasm is described in 10% of cases, and most authors observe only angiographic vasospasm in children; symptomatic vasospasm is rare (12,43,78). A proposed explanation for the lower susceptibility of children to vasospasm and delayed cerebral ischemia is the better collateral circulation in children, compared with adults (12).
• Treatment of vasospasm: If treatment is deemed necessary in children, options are hemodynamic therapy, administration of nimodipine, or endovascular intervention (balloon angioplasty and intraarterial papaverine/nimodipine) (120,123).