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|LETTER TO EDITOR
|Year : 2015 | Volume
| Issue : 1 | Page : 112-114
Delayed appearance and rupture of a post-traumatic supraclinoid aneurysm in a 2-year-old child
Vivek Shete1, Amandeep Kumar1, Leve Joseph Devarajan2, Bhawani S Sharma1
1 Department of Neurosurgery, All India Institute of Medical Sciences, New Delhi, India
2 Department of Neuroradiology, All India Institute of Medical Sciences, New Delhi, India
|Date of Web Publication||4-Mar-2015|
Department of Neurosurgery, All India Institute of Medical Sciences, New Delhi
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Shete V, Kumar A, Devarajan LJ, Sharma BS. Delayed appearance and rupture of a post-traumatic supraclinoid aneurysm in a 2-year-old child. Neurol India 2015;63:112-4
Post-traumatic intracranial aneurysms (TICAs) are very rare and constitute less than 1% of all intracranial aneurysms.  They are associated with significant morbidity and a high mortality of up to 50% patients.  Early diagnosis and immediate definitive treatment are therefore of utmost importance in managing these patients. We present a unique case of a post-traumatic supraclinoid internal carotid artery (ICA) aneurysm in a 2-year-old child that developed in a delayed manner and manifested with subarachnoid hemorrhage (SAH).
A 2-year-old child developed a small parietal contusion and linear undisplaced fracture of the parietal bone after the fall from a height of 10 feet. He had transient loss of consciousness after the fall from which he completely recovered. The patient was managed conservatively at another hospital and discharged in a fully conscious and oriented state. He underwent magnetic resonance imaging (MRI) immediately after trauma. The MRI, especially T2W sequence, revealed normal supraclinoid ICA without any evidence of an aneurysm [Figure 1]a and b.
|Figure 1: Immediate post-trauma T2W magnetic resonance imaging (MRI) shows normal cerebral vessels. No obvious aneurysm is seen (a and b). NCCT head done at the time of presentation in emergency department shows subarachnoid hemorrhage (SAH), intraventricular hemorrhage (IVH), and acute hydrocephalus (c and d). Digital subtraction angiography (DSA) revealed a supraclinoid aneurysm directed superiorly and medially (e and f)|
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Three weeks later, the child presented in our emergency department in altered sensorium (Glasgow Coma Sclae [GCS]:E1V1M5). His plain computed tomography (CT) scan revealed subarachnoid hemorrhage (SAH), intraventricular hemorrhage (IVH), and acute hydrocephalus [Figure 1] c and d. He was intubated, and an external ventricular drain (EVD) was placed. His neurological status improved after EVD placement (GCS:E4VtM6). An urgent digital subtraction angiography (DSA) revealed a right supraclinoid ICA aneurysm directed supero-medially [Figure 1] e and f. Stent assisted coiling achieved complete occlusion. A ventriculo-peritoneal shunt was placed for hydrocephalus. The child was discharged after 7 days without any deficits.
TICAs can occur following both blunt and penetrating head trauma. In penetrating injuries, TICAs occur on the vessel that is directly injured. In blunt trauma, these aneurysms result from either stretching or shearing of a vessel against a bone or dural edge, or from direct injury from a fractured bone fragment. TICAs, following blunt trauma, commonly involve the peripheral vasculature and the internal carotid artery. The mechanism of injury determines the location of aneurysm. Supraclinoid ICA aneurysms result from its stretching over the anterior clinoid process. , Similarly, basilar artery and infraclinoid ICA aneurysms are associated with basal skull fractures. , Aneurysms of the distal anterior cerebral artery result when the artery is pressed against the tough anterior falcine edge. 
TICAs commonly present with delayed SAH.  The interval between trauma and the rupture of TICA can vary from hours to weeks; rarely, they may present after years.  Although CT is the first investigation performed after acute trauma, DSA is the gold standard for diagnosing TICAs. TICAs have a rupture rate of around 20% with the mortality reaching up to 50%.  A high level of suspicion should be kept in patients who present with delayed neurological deterioration following head trauma. Microsurgical clipping and endovascular coiling are the treatment options for TICAs. The choice of treatment is tailored according to the location, angiographic features, and patient preference.
To conclude, TICAs are a rare and delayed complication of head trauma. Ruptured TICA should be suspected in any patient of head injury deteriorating in a delayed manner.
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