Endovascular Management of Pediatric Aneurysms- Focus on Outcomes Emam Saleh, M.D Robert C. Dawson, III, M.D. Professor of Radiology and Neurosurgery Louisiana State University New Orleans

DECLARATIONS No Conflicts of Interest No specific off-label use of devices c

BACKGROUND Surgery has been the main therapeutic option in treating pediatric aneurysms Surgical mortality rates are reported to be in the 20% range (4%-40%); Myers et al 1989; Humphreys 1989b; Choux et al. 1992.

BACKGROUND In a cooperative study, Roche et al. (1988) reported that: 63.4% of the children were cured without any sequelae, 19.5% were 1 year behind at school. 4.8% severely handicapped 12.3% postoperative mortality

BACKGROUND A limited number of series described the role of endovascular treatment for childhood intracranial aneurysms: Agid et al. (2005), Lasjaunias et al. (2005), (53 aneurysms, under 18Y, follow up 13Y) Nader et al (2006)., (23 aneurysms, 18Y and under, follow up 6Y)

METHODS Retrospective chart review of children admitted for endovascular treatment of cerebral aneurysms between 1999 and 2010 The age group included in the study are children under 18

RESULTS 12 Patients 17 Aneurysms Age ranged from 17 months to 17 years. One aneurysm recurred (1/17) or (5 %) One death during post operative period (1/12) or (8%)

Aneurysms by Location ICA ACom PCom VB 5 2 1 9

Features of the Aneurysms Multiplicity One patient had two aneurysms Two patients each had three aneurysms Nine patients had one aneurysm Size Twelve aneurysms were large or giant

Anterior circulation aneurysms 8 aneurysms/ 6 patients 5 intra cavernous aneurysms\ 4 giants 2 anterior communicating artery aneurysms\ same patient 1 posterior communicating artery aneurysm

Anterior circulation aneurysms The communicating artery aneurysms Treated by Coils - ablated The Intra cavernous aneurysms Two treated by sacrifice of the parent vessels. Three were stented and coiled

Anterior circulation aneurysms No mortality No disability No recurrence Follow up 7 years plus

Posterior circulation aneurysms 9 aneurysms\ 7 patients One patient had 3 aneurysms one basilar and two intra cavernous aneurysms One patient had a vertebrobasilar junction aneurysm Four patients had a single basilar artery aneurysm

Posterior circulation aneurysms One death/ post op (1/7) (14%) One aneurysm recurred (1/9) (11%) No disability due to intervention Follow up ranged from 2 years to 7 years

Posterior circulation aneurysms One Death in post operative period

Posterior circulation aneurysms This Aneurysm recurred Before coiling Immediately after coiling 6 Month after coiling Surgery after recurrence resulted in third nerve palsy + Loss of hearing on one side

Posterior circulation aneurysms Basilar artery aneurysm in 17 month old boy Endovascular treatment can be done in small children

Therapeutic strategies It is not “Clip versus Coil” It is “Clip and Coil” Treatment should be tailored to the individual characteristics of each patient and aneurysm.

Therapeutic strategies Deconstuctive strategy – 4 Reconstuctive strategy – 13 ANATOMY MAY FORCE REVASCULARIZATION

DECONSTRUCTION

TECHNICAL ISSUES Staff training for all team members must be constant and specific to the planned intervention The plan must be worked out prior to the onset Materials must be size-compatible, and at hand; double-checked in advance Contrast limits should be predetermined; strict attention to fluids, temperature, blood loss , especially in smaller children

Conclusion Endovascular treatment can have less mortality and postoperative complications than surgery Results and treatment options depend on location and specific anatomy Allows treatment of multiple aneurysms with less trauma Can be used in small children Long term follow up studies are needed to assess durability of endovascular treatment over the extended lifetimes of these patients

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