Role of Endovascular Treatment in Pediatric Cerebral Aneurysms: A Series of Two Case Reports
A 11-year-old male child presented with 2 episodes of generalized seizures and severe headache for 2 days. On clinical examination, there was no focal neurological deficit (Grade I SAH-Hunt and Hess scale).\nCT scan [] showed hemorrhage in the left frontal lobe with intraventricular extension (Fischer Grade IV). Detailed work up was done as described in Case 1. DSA was done subsequently which revealed a bilobed ICA bifurcation aneurysm on the left side []. There was no vasospasm seen on the angiogram. Endovascular treatment (Balloon-assisted coiling) was planned after discussion with the team of neurosurgeon and neurointensivist. High-risk informed consent was obtained after detailed explanation of the risks versus benefits to the parents.\nUnder general anesthesia, right 5F common femoral was accessed. Standard heparinization (100 units/kg as bolus at the beginning of the procedure followed by 20 units/kg every hour) was given to maintain the activated clotting time of 250 s. Guiding catheter (6F Envoy, cordis) with Nimodipine infusion was placed in the left ICA. Hyper glide occlusion balloon (3 mm ×10 mm, eV3) was placed across the neck of the aneurysm. Microcatheter (Echelon-10, eV3) over microwire (Neuroscout-10, codman) was navigated into the sac of the aneurysm. Subsequently, we started packing the aneurysm with the platinum coils using ‘Balloon remodeling technique’. After placement of the second coil and balloon deflation, a small loop of a previously detached coil was seen projecting into the parent vessel [Figure –] on the check angiogram.\nIn order to secure the aneurysm and prevent untoward effects of the prolapsed coil loop into the parent vessel, we deployed an 4 mm ×22 mm ‘Enterprise’ self-expanding stent (Codman, Johnson and Johnson) across the neck of the aneurysm from the right supraclinoid ICA to M1. Thereafter, the aneurysm was densely packed with further coils. The patient was loaded with antiplatelet drugs before stent deployement through the nasogastric tube (clopidogrel, 225 mg and aspirin, 150 mg) and was also started on infusion of Tirofiban which was continued for 4 hours (till the effect of oral antiplatelet agents took over). Post-procedure angiogram showed complete exclusion of the aneurysm from the circulation. Patient was kept under observation for 3 days in the neurointensive care unit. There were no peri- or post-procedural complications and the patient was discharged on day 7 after operation on double antiplatelet regimen (aspirin,50mg and clopidogrel,75mg). Clinical follow-up of the child after 1 month showed normal results. On the 6-month follow-up, neurological examination was normal and the patient was continued on only aspirin, 50 mg.\nFollow-up angiogram done after 1 year showed stable occlusion of the aneurysm and normal patency of the stented artery. The patient is being monitored to determine any long term effects of the treatment.