Recovery After Surgery for Intracranial Aneurysms in Children

Postoperative Orders

• Vital signs: Vital signs should be continuously monitored. Concerning blood pressure, the aim is normotension for age in the acute postoperative phase, whereas permissive hypertension might be required at a later phase when potentially expecting vasospasm.
• Activity: Prior to definitive treatment of the aneurysm, bed rest with the head of bed elevated at 30 degrees is recommended.
• 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.
• Medication: Although oral or intravenous nimodipine is a frequent treatment for adults with ruptured aneurysms, this drug should be very carefully administered in children. There are no controlled trials in children, and data from small series suggest a substantial risk of induced arterial hypotension (26). Deep sedation should be avoided whenever possible to allow for neurological assessment.
• Radiology studies: A CT to exclude postoperative hematoma or infarction should be performed within 6–12 hours. Postoperative angiography to confirm complete aneurysm occlusion is recommended.

Postoperative Morbidity

Cerebral vasospasm is considered a major determinant of morbidity after aneurysm rupture (42). It is defined as a narrowing of the cerebral arteries after subarachnoid hemorrhage. In adults, it is detected during angiography after subarachnoid hemorrhage (i.e., angiographic vasospasm) in up to 70% of cases (42). Delayed cerebral ischemia, i.e., manifestation of new neurological deficits due to vasospasm, is encountered in adults in up to 30% of cases (42, 64).

• 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 appears to be rare (8, 28, 39). A proposed explanation for the lower susceptibility of children to vasospasm and delayed cerebral ischemia is the better collateral circulation compared to adults (39).
• 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) (20, 42).