PEDIATRIC INTRACRANIAL ANEURYSM : A CASE REPORT DATUK DR MOHD SAFFARI HASPANI DR AZMAN RAFFIQ DR PUNEET NANDRAJOG DR YEE SZE-VOON DEPARTMENT OF NEUROSURGERY , HOSPITAL KUALA LUMPUR Introduction Intracranial aneurysms in the paediatric age group are an uncommon occurrence, with incidences ranging between 0.4% - 5.7%. The occurrences in infants are exceedingly rare. The diagnosis of intracranial aneurysms in paediatric patients is commonly a diagnosis of exclusion. As opposed to adults, paediatric patients present with markedly different symptoms and signs, contributing to the notion of diagnosis by exclusion in most cases. While the adult population present with typical signs of severe headache and radiological features of diffuse subarachnoid hemorrhage, paediatric patients present with less localizing symptoms, such as generalized lethargy, seizure or altered consciousness. A typical CT scan finding is of an intraparenchymal hemorrhage. Common differentials include traumatic bleed, ruptured arterio-venous-malformations, tumoural hemorrhage, venous malformation or germinal matrix hemorrhages. Rarely, aneurysmal rupture is considered as a primary differential diagnosis. On many occasion, the correct diagnosis is only made intra-operatively. This case illustrates the challenges in the diagnosis and management of infantile intracranial aneurysms. Case Report A 5-month-old baby boy was referred from a peripheral hospital after he presented to them with the history of low-grade fever, irritability and generalized lethargy for 3 days. Further history also showed that the patient had history of URTI for the past 3 weeks. The child was born by means of normal, spontaneous vaginal delivery after an uncomplicated pregnancy, and the postnatal period was normal. Upon presentation to the emergency department, the patient was intubated in view of a poor GCS of 8/15 (E2V2M4) and for airway protection. Physical examination prior to intubation disclosed that the patient had right hemiplegia and hyperreflexia over the right limbs A Computed Tomography (CT) scan of the brain was done that showed a left fronto-temporo-parietal intracranial bleed measuring 7cm(L) x 3cm (W) x 5.6cm (H) with subarachnoid haemorrhage and mass effect (Figure 1). The patient was then transferred to our centre for a left decompressive craniectomy and evacuation of clot with ICP catheter insertion. Intra-operatively, we noted that the brain was oedematous upon dura opening and the clot was visible in the Sylvian fissure. During the evacuation of the clot, we encountered a pulsatile mass at the temporal region and a doppler ultrasound confirmed our suspicion of an aneurysm (Figure 2). Following surgery, the patient was then transferred back to the paediatric ICU (PICU) and a cerebral angiogram was arranged for the patient. The cerebral angiogram showed a dumb-bell shaped aneurysm at the M3 segment of the left MCA measuring 12.8mm (w) x 12.9mm (l). The patient was then scheduled for a second surgery where an exploration and excision of the Left distal M3 aneurysm was done, as the pedicle was narrow and easily coagulated after placement of the aneurysm clip. Post operatively patient was admitted in PICU for a total of 8 days after which he was then transferred back to the general ward. His recovery was remarkable and uneventful. He was active and his hemiparesis improved with only minimal neurological deficit post operatively. He was discharged home with a plan for a repeat cerebral angiogram to confirm the absence of any vascular pathology. Discussion Cerebral aneurysms usually occur in the adult age group instead of pediatrics. In infancy or childhood, the common aneurysmal risk factors do not exist and the pathogenesis for aneurysm formation is believed to be different.The diagnostic workup of an infant with a suspected aneurysm is a challenging task.The most helpful clues come from a detailed account of the events by the parents. Especially useful findings are a history of meningismus, seizures, failure to thrive, tense fontanel, or lethargy. A sudden event should prompt the differential diagnosis of a vascular event where an urgent CT scan of the brain is an essential first step in the diagnostic workup. The most common aneurysm site in the pediatric population is the internal carotid bifurcation followed by aneurysms of the posterior circulation, MCA & ACA which differ from the adult population. Aneurysms in paediatric age group commonly tend to be of large or giant types. The saccular aneurysms are the ones that usually present with haemorrhage. Figure 1 Conclusion: Pediatric aneurysms are rare, and children with these lesions benefit most from a multidisciplinary team at an experienced tertiary care center. High index of suspicion is needed and an urgent CT-scan of the brain should be performed and if there is any suspicion of SAH, the patient should subsequently evaluated with a four-vessel cerebral angiography. The choice of surgery or endovascular coiling depends on the lesion, with the most complex aneurysms requiring combination therapy. The results with surgical clipping or endovascular coiling are excellent and have greatly improved the outcome in children With cerebral aneurysms. Vigilant long-term follow-up with appropriate clinical and minimally invasive imaging surveillance is very important. Figure 1 Figure 2