1. S.Orsola Malpighi Hospital, Bologna
INTRACRANIAL ANEURYSMS AND COARCTATION OF THE AORTA: A MAGNETIC ANGIOGRAPHIC SCREENING IN A PAEDIATRIC POPULATION OF 61 PATIENTS
L.Spinardi, C.Leoni, M.Fabi, L.Faccioli, M. Pastore Trossello Units of Neuroradiology and Paediatric Cardiology
S.Orsola Malpighi Hospital, Bologna

2. COARCTATION OF THE AORTA (CoA)
Relatively common defect that accounts for 5-8% of all congenital heart defects
Usually located in the thoracic aorta distal to the origin of the left subclavian artery at about the level of the ductal structure

3. DIAGNOSIS
The diagnosis of coarctation of the aorta may be missed until the patient develops congestive heart failure (CHF), which is common in infants, or hypertension, which is common in older children

4. ASSOCIATED CLINICALLY SIGNIFICANT DEFECTS
Bicuspid aortic valve and more rarely Mitral valve anomalies
Patent ductus arteriosus, VSD, and aortic stenosis
Coarctation of the aorta as a complicating feature of a more complex heart defect, such as transposition of the great arteries, Taussig-Bing anomaly, double-inlet left ventricle, tricuspid atresia with transposition of the great arteries

5. TREATMENT Surgical approaches:
End-to-end anastomosis (EEA) (the preferred surgical approach for CoA in neonates as it appears to be free from subsequent cardiovascular pathology, at least until 5 years of age, compared to SFR)
Reverse / Subclavian flap angioplasty (SFR)

6. TREATMENT Transcatheter treatments:
Balloon angioplasty (children > 3 months old)
Stent implantation (children > 60 kg)

7. RELATIONSHIP BETWEEN INTRACRANIC ANEURYSM AND AORTIC COARCTATION
Aortic coarctation is often mentioned for a supposed association with brain aneurysms

8. CASE REPORT
Hodes et al 1959
Robinson et al 1967
Serizawa et al 1992
Mercato et al 2002
Harikrishnan et al 2004
Victor et al 2005
Punsar et al 2005
Celik et al 2005
Solinas et al 2006
There are several case reports described in literature on adult patients…

9. ONLY ONE PROSPECTIVE STUDY ON A POPULATION OF 100 ADULT PATIENTS
SUPPORTED THE HIPOTHESYS OF HIGHER FREQUENCY OF IA AMONG PATIENTS WITH COA IN COMPARISON TO NORMAL POPULATION (10% VS 2%)

10. ..HYPERTENSION IS A SINGLE RISK FACTOR FOR DEVELOPING BRAIN ANEURSYMS
BUT..
ALSO IN THIS STUDY MOST OF THE PATIENTS ARE ADULT WITH A LONG HYSTORY OF HYPERTENSION..
..HYPERTENSION IS A SINGLE RISK FACTOR FOR DEVELOPING BRAIN ANEURSYMS

11. RELATIONSHIP BETWEEN INTRACRANIC ANEURYSM AND AORTIC COARCTATION
UNTIL NOW TWO DIFFERENT HIPOTHESYS HAVE BEEN CONSIDERED TO GIUSTIFY THE SUPPOSED ASSOCIATION…
Arterial hypertension
and
cronic haemodinamic
stress
Vascular developmental abnormalities originated from the neural ridge vs

12. J of Paediatrics and Child Health, 2006
IS SCREENING INDICATED IN ASYMPTOMATIC PATIENTS ?
J of Paediatrics and Child Health, 2006

13. OBJECTIVE VERIFY THE ASSOCIATION BETWEEN COA AND IA
IN A PAEDIATRIC POPULATION TREATED FOR COA

14. MATERIAL
61 patients, followed by the Department of Pediatric cardio-surgery of S. Orsola-Malpighi Hospital in Bologna, were included until now in our study:
Mean age at MRA screening: 17 year old
Mean age at diagnosis: 2,5 year old
Mean age at treatment: 2,8 year old (< 18 year old)
Treatment: 82% chirurgical, 18% endovascular (Retreated: 9)
Hypertension: 28% has mild hypertension, controlled with Beta-blockers or ACE-inibitors
Neurological symptoms: headache (6)

15. System 1.5 T GE Medical Systems USA
MRI TECHNIQUE
System 1.5 T GE Medical Systems USA
MR angiography with time of flight technique (TOF) with MIP e VR reconstructions
Sagittal T1 Fast Spin Echo
Coronal T2 FSE
Axial FLAIR sequences
Images were valuated in blind by two neuroradiologists and an interventional neuroradiologist with experience in endovascular treatment of intracranial aneurysms

16. RESULTS MR angiography showed NO EVIDENCE OF INTRACRANIAL ANEURYSM,
in any of our patient treated for aortic coarctation in childhood

17. The real incidence of intracranial aneurysm in children is debated and should be around 1-2 %
Aortic coarctation has always been strictly and directly related to intracranial aneurysms and their rupture
Several case reports in literature in fact support this relationship and, in particular, the prospective study made by Mayo Clinic in 2003 stated that the prevalence of intracranial aneurysms in a population of 100 people with CoA was 10 %
DISCUSSION

18. What we have noticed is that to our knowledge until now no one has actually valued a population of children treated for aortic coarctation in paediatric age, and that most of these studies and case reports described patients who were treated in adulthood and most of which were also severely hypertense, or patients not treated at all and whose diagnosis of the presence of an intracranial aneurysm was the first sign of an unknown coarctation of the aorta
In our study we have analyzed until now 61 pediatric patients all treated in childhood and we found NO evidence of intracranial aneurysms
What we believe is that the direct relationship between aortic coarctation and intracranic aneurysms should be at lest called into question

19. CONCLUSION
In our patients, all treated in childhood, there was no evidence of aneurysm
There is no certain epidemiological and scientific evidence of a DIRECT relationship between CoA and Intracranial aneurysm
A follow up of our population could be interesting and further investigations have to be done