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|Year : 2001 | Volume
| Issue : 3 | Page : 295-8
Traumatic distal anterior cerebral artery aneurysm in a child : a case report.
Raju BS, Purohit AK, Murthy SR, Sundaram C, Sanjay T
Department of Neurosurgery, Nizam's Institute of Medical Sciences, Hyderabad-500 082, India.
Department of Neurosurgery, Nizam's Institute of Medical Sciences, Hyderabad-500 082, India.
Traumatic intracranial aneurysms constitute less than 1% of all intracranial aneurysms. A case of traumatic distal anterior cerebral artery aneurysm in 18 months old child, treated successfully by microsurgical excision of aneurysm is being reported, along with review of the literature.
|How to cite this article:|
Raju B S, Purohit A K, Murthy S R, Sundaram C, Sanjay T. Traumatic distal anterior cerebral artery aneurysm in a child : a case report. Neurol India 2001;49:295
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Raju B S, Purohit A K, Murthy S R, Sundaram C, Sanjay T. Traumatic distal anterior cerebral artery aneurysm in a child : a case report. Neurol India [serial online] 2001 [cited 2023 Dec 1];49:295. Available from: https://www.neurologyindia.com/text.asp?2001/49/3/295/1236
Traumatic intracranial aneurysms (TICA) are rare and constitute less than 1% of all intracranial aneurysms. They are most frequently reported in third decade of life, in males due to blunt or penetrating injury. TICA account for 33% of all paediatric aneurysms. The youngest patient with TICA was reported in a six week old infant with pericallosal aneurysm from shaken baby syndrome. Review of literature revealed about 140 cases of TICA reported in first two decades of life, of which 60 cases are reported in the first decade of life. Magnetic resonance imaging (MRI) in TICA aneurysms is rarely reported. We report a case of TICA aneurysm in an 18 months old child, arising from distal anterior cerebral artery (DACA) along with MRI studies.
An 18 month old male child, slipped and fell down from a moving scooter two months prior to admission in this hospital. He was asymptomatic, except for few abrasions over his forehead. One month after injury, he developed sudden onset of altered sensorium and vomiting followed by repeated episodes of generalised tonic-clonic seizures (GTCS). He was treated by a neurosurgeon in a private hospital and was investigated with a computed tomography (CT) of brain [Figure. 1], which revealed anterior interhemispheric bleed in the region of genu of corpus callosum, both lateral ventricles and 4th ventricle. Contrast study revealed no enhancement. He improved gradually in sensorium with anti-epileptics over next 7 days and was discharged. After 1 month, he again developed sudden onset of unconsciousness and vomiting followed by status epilepticus. He was readmitted for the same and later referred to this hospital for further treatment. MRI of brain [Figure. 2] revealed well defined lobulated hypo-intense lesion on TlWI in the region of distal anterior cerebral artery (DACA). At admission, he was unconscious with a GCS of 8 (E2 Vl M5). A four vessel cerebral angiography [Figure. 3] revealed left sided DACA aneurysm just proximal to its bifurcation into callosomarginal and pericallosal arteries. A repeat CT scan of brain revealed communicating hydrocephalus. A right sided ventriculoperitoneal (VP) shunt was done. Following the surgery, he became more alert with a GCS of E4 V2 M5. On 6th post operative day, left frontal craniotomy and excision of the aneurysm by inter-hemispheric approach was performed. On retraction of the medial surface of the right frontal lobe, the pericallosal arteries were identified distally. They were followed towards the suspected site of aneurysm. The proximal portion of the right pericallosal artery was identified. After having achieved proximal and distal control, the aneurysm was dissected and the neck was identified. There was little ooze, therefore the neck of aneurysm was coagulated and then clip was applied. Suddenly, whole of the aneurysm along with the clip got detached from the parent artery. There was a minimal bleed at the site of detachment which was controlled by cautery and a surgical and muscle strip were put at the site of detachment. Histopathology of the aneurysmal wall was suggestive of pseudoaneurysm [Figure. 4]. Post operative period was uneventful, except for revision of shunt for shunt malfunction. He continued to show neurological improvement at 22 months follow up. He had impaired cognitive functions but no motor weakness.
Since the first report of TICA in 1829, over 500 cases have been reported in the world literature. They represent 33% of the paediatric intracranial aneurysms. Extensive literature review by Ventureyra and Higgins, showed 436 cases of TICA with an overall incidence of 30% (130 cases) in children and adolescents. Till now, about 60 cases of TICA in children below 10 years are reported in the world literature. TICA in children occur more frequently during second decade of life than in the first decade, with male predominance.,, They are seldom multiple and often arise at unusual arterial sites compared to adult TICA. The most common sites of TICA in children, in descending order of frequency include DACA (38%), internal carotid artery (ICA) (29%), distal branches of middle cerebral artery (MCA), (25%) and vertebro-basilar system (8%).
Based upon the mechanism of causation of TICA, these were grouped into 4 categories by Ventureyra and Higgins as closed head injuries (CHI), missile injuries, penetrating head injuries, and iatrogenic injury. In their review of 130 TICA in children, CHI was found to constitute 72% of cases, missile injuries 16%, iatrogenic injury 8%, and penetrating head injury 4% of cases. Minor CHI without fracture or significant initial impairment of consciousness can also produce TICA as in the present case., However, direct neural injuries and associated impairment of consciousness produced by head injury often mask the early symptoms due to TICA, leading to delayed diagnosis., TICA due to CHI can result from rapid deceleration causing sudden brain and artery movement producing vessel wall injury against stationary structures. Thus, trauma to pericallosal artery by the edge of falx often leads to TICA.
Histologically, TICA are classified as true, false or mixed aneurysms. Complete arterial wall disruption produces a false aneurysm, often sealed by haematoma. Incomplete mural injury with subsequent dilatation of intact but weak arterial wall produces a true aneurysm. Rupture of true aneurysms leads to complete disruption producing mixed aneurysms., However, histological classification is of little benefit in clinical management of TICA., Ventureyra and Higgins classified paediatric TICA, into early onset (occurring within 4 weeks after injury) or late onset (occurring beyond 4 weeks). Most reported cases of TICA presented with early onset., Late onset manifestation in paediatric TICA, as in the present case is rare with only about 10 reported cases in literature till date. They often result from CHI and manifest clinically as aneurysmal masses.,, Clinically, childhood TICA usually present as intracranial haemorrhages (subarachnoid haemorrhage, intracerebral haemorrhage, intraventricular haemorrhage). Other presentations may include incidental lesions (14%) and cranial nerve palsies. For early diagnosis of TICA, suspicion should be made in all head injured or post-operative patients with delayed neurological deterioration ii) delayed haemorrhage. iii) unexplained major arterial bleeding during evacuation of the haematoma iv) new or unexplained intracranial bleed v) discrepancy between the amount of subarachnoid haemorrhage (SAH) intraventricular haemorrhage (IVH) to the severity of the brain injury vi) facio-orbito-pterional injuries vii) penetrating fragments, especially if they cross the midline or traverse into another dural compartment.,,, Angiographic features are also helpful in differentiating TICA from congenital aneurysm. These include i) delayed filling and emptying of sac, ii) a peripheral location other than at a branching point, iii) irregular contour of the sac, iv) absence of discrete neck of the aneurysm.,
Currently, magnetic resonance angiography (MRA) has a true-positive diagnostic rate of 86% (when aneurysm of 5 mm are taken as the critical size) with time of flight (TOF) MRA alone or combined with standard spin-echo imaging in the diagnosis of spontaneous intracranial aneurysms., Recently, Ida et al reported a 90% diagnostic rate in detection of spontaneous intracranial aneurysm. However, so far no studies on efficacy of MRI/MRA in diagnosis of TICA have been reported. The reduced accuracy probably reflects the various traumatic intracranial changes like SAH, ICH and IVH masking the detection of TICA. However, MRI and MRA remain valuable screening techniques in suspected cases of TICA. Once diagnosed, management in TICA is mainly directed to prevent recurrent haemorrhage. Improved survival rates have been reported in patients treated surgically. Of the total cases of TICA reported in children, 80% underwent operative management with 87% survival compared to 26% survival in cases treated by non-operative means. Many techniques like aneurysmal clipping, excision of aneurysm with or without arterial bypass, trapping and interventional radiological techniques have been tried success-fully.,,,, However, optimal surgical technique must be individualised for each patient. In present case, we clipped the neck. But, the aneurysm along with clip got detached from parent artery and therefore the procedure became an excision. Outcome of these children with TICA is primarily determined by the extent of traumatic brain injury, pre-operative clinical status and the time of diagnosis and definitive treatment. Delayed diagnosis leads to increased morbidity as in the present case. Thus, a high index of suspicion of TICA should be made in all head injured or post- operative delayed neurological deterioration or those who fails to improve in expected period. If SAH or ICH or IVH are seen in imaging, these patients should be subjected to angiography to exclude traumatic aneurysm. It seems that MRI/MRA may become valuable screening test in diagnosing as seen in the present case.
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