1. 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

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

3. 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

4. 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

5. 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)

6. 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

7. 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%)

8. Aneurysms by Location
ICA
ACom
PCom VB 5 2 1 9

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

10. 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

11. 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

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

13. 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

14. 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

15. Posterior circulation aneurysms
One Death in post operative period

16. 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

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

18. 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.

19. Therapeutic strategies
Deconstuctive strategy – Reconstuctive strategy – ANATOMY MAY FORCE REVASCULARIZATION

20. DECONSTRUCTION

21. 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

22. 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

23. THANK You