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 Table of Contents  
CASE REPORT
Year : 2020  |  Volume : 8  |  Issue : 2  |  Page : 130-133

Traumatic distal anterior cerebral artery aneurysm in a 3-year-old child: An uncommon but notable case


Department of Neurosurgery, GIPMER, Delhi, India

Date of Submission07-Sep-2020
Date of Acceptance28-Nov-2020
Date of Web Publication3-Feb-2021

Correspondence Address:
Dr. Piyush Kumar Panchariya
Department of Neurosurgery, GIPMER, Delhi
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jcvs.jcvs_24_20

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  Abstract 


Aneurysm in paediatric population is a relatively less reported vascular pathology. In contrary to degenerative and dysplastic causes as in their adult counterpart, the mechanism lies either in a congenital defect in vessel wall or following some traumatic event. Traumatic intracranial aneurysms (TICA) are again not a common occurrence. TICAs constitute <1% of all intracranial aneurysms. They can occur following blunt or penetrating head trauma and are more common in the paediatric population. Traumatic aneurysms are typically associated with an acute episode of delayed intracranial haemorrhage with an average time from initial trauma to aneurysm haemorrhage of approximately 21 days. The youngest case reported for a traumatic distal anterior cerebral artery (ACA) aneurysm is of a 6-week old child due to shaken baby syndrome. We report an interesting and rare case of a traumatic distal ACA aneurysm in a 3-year-old child.

Keywords: Distal anterior cerebral artery, paediatric aneurysm, traumatic aneurysm


How to cite this article:
Panchariya PK, Singhal G, Jagetia A, Srivastava A K. Traumatic distal anterior cerebral artery aneurysm in a 3-year-old child: An uncommon but notable case. J Cerebrovasc Sci 2020;8:130-3

How to cite this URL:
Panchariya PK, Singhal G, Jagetia A, Srivastava A K. Traumatic distal anterior cerebral artery aneurysm in a 3-year-old child: An uncommon but notable case. J Cerebrovasc Sci [serial online] 2020 [cited 2021 Sep 17];8:130-3. Available from: http://www.jcvs.com/text.asp?2020/8/2/130/308629




  Introduction Top


Trauma is an uncommon but well-known cause of intracranial aneurysms (<1%). Traumatic aneurysms are more common in children. They have been reported in association with both blunt and penetrating trauma. Diagnosing intracranial aneurysm following blunt closed head injury needs a high index of suspicion. Ventureya and Higgins proposed four aetiopathological categories that have been found to be responsible for the formation of traumatic intracranial aneurysms (TICA).[1] These include closed head injury, missile injury, penetrating injury and iatrogenic injury. The various mechanisms working are either direct injury to vessel as in penetrating injuries or injury as a result of skull fracture as may be case with both penetrating or blunt injury and shear strain to vessel against some fixed rigid structure such as falx. The locations for the occurrence of traumatic aneurysms vary from posterior circulation to internal carotid artery (ICA) to distal circulation including distal anterior cerebral artery (ACA) and middle cerebral artery (MCA). Haemorrhage from traumatic aneurysms appears frequently after a delay of several weeks, especially reported in children, indicating that these aneurysms have the potential to evolve with time.[2] The youngest aneurysm case described has been a 6-week infant due to shaken baby syndrome.[3] Here, we report a 3-year-old case of distal ACA aneurysm with typical temporal event of recurrent vomiting, seizures and enlarging haematoma on computed tomography (CT) after 21 days of the initial trauma.[1] A hypothesis of injury to vessel wall from accelerating decelerating process in the setting of non-penetrating blunt closed head injury has been considered.[2]


  Case Report Top


A 3-year-old female child with a history of fall from height of about 15 feets at her home followed by vomiting two episodes with no loss of consciousness. She was taken to a private hospital where CT was done which revealed a small inter-haemispheric bleed slightly more towards right side with undisplaced fracture of right frontal bone and the superior wall of right orbit [Figure 1]. The patient was managed conservatively and discharged uneventful from the hospital. After about 20 days of initial event, the patient developed multiple episodes of vomiting associated a seizure episode and loss of consciousness. The patient was taken to the same hospital where repeat CT revealed a large anterior inter-haemispheric haematoma with adjacent mass effect and extension to frontal horn of right lateral ventricle [Figure 2]. The patient was subjected to a CT angiography, revealing a left distal ACA aneurysm. The aneurysm was located just proximal to pericallosal callosal junction over the main stem of A3 segment of ACA just distal to the rostrum and level of junction of the rostrum with genu [Figure 3]. Then, the patient was referred to our institute. On examination, the patient was conscious and playful with no neurological deficit and categorised as Hess and Hunt Grade 1.
Figure 1: Initial non-contrast computed tomography brain after trauma

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Figure 2: Non-contrast computed tomography brain after about 3 weeks of initial trauma when patient had vomiting and seizures

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Figure 3: Computed tomography angiography brain suggestive of an aneurysm with irregular contour of dome and not a well-defined neck located at left distal anterior cerebral artery at junction of rostrum and genu at main arterial stem proximal to junction of callosal pericallosal artery directing superiorly

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The patient was worked up for the possibility of any associated vasculitis which revealed no positive marker for vasculitis. No other systemic examination revealed possibility of any vasculitis or collagen vascular disease. The patient was planned for craniotomy and clipping and a right side craniotomy decided on the basis of magnetic resonance (MR) venogram with inter-haemispheric approach. Intraoperatively, a haematoma was found in anterior inter-haemispheric region with adhesions present. Proximal trunks of A2-A3 found buried inside the haematoma. Single saccular aneurysm arising from left distal ACA just proximal to junction of callosal pericallosal arteries was found directing superiorly. Aneurysm was clipped with a single UpCurve medium size clip [Figure 4]. The post-operative course of the patient was uneventful. An MR angiography (MRA) was done on post-operated day 3, which was suggestive of no filling of aneurysm sac and normal flow-related enhancement of bilateral ACA distal to clip [Figure 5]. The patient was discharged uneventfully with intact neurological status on day 7 after surgery and is in follow-up with us.
Figure 4: Intra-operative picture of aneurysm with bilateral anterior cerebral artery seen. Aneurysm clipped at neck

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Figure 5: Postoperative magnetic resonance angiography brain suggestive of no aneurysm sac with distal filling of bilateral anterior cerebral arteries

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  Discussion Top


Intracranial aneurysm developing after a closed blunt head injury requires a high degree of suspicion in patients with a history of trauma and a scenario of neurological deficit after few days to few weeks (3–4 weeks) after the initial insult. Traumatic aneurysm comprising <1% of intracranial aneurysm, but about one-third of cases of traumatic intracranial aneurysm occur under the age of 20 years.[4] Traumatic aneurysms are more common in males as compared to females. The various mechanisms reported for TICA include closed head injuries (most common), gunshot injuries, penetrating wounds and iatrogenic injuries. While in rest of the causes, there can be a direct injury to vessel wall, resulting in aneurysm formation in closed head injury might be due to rapid acceleration-deceleration causing sudden brain and arterial movement against stationary structures such as falx or because of injury due to fractured skull segment.[2] In our case, the possible mechanism seems to be indirect injury to ACA against falx. The duration of diagnosis of TICA following initial insult has been reported 3–4 weeks up to many years (9–10 years). In our case, the duration of the presentation is about 3 weeks after the initial trauma. In series of Ventureya and Higgins, the most common location for TICA was anterior circulation with distal anterior cerebral artery (DACA) being the most common followed in decreasing frequency by intracranial ICA, MCA and posterior circulation.[1] Histologically, there may be true or false aneurysm, with false being the common amongst TICA.[5] The clinical presentation of TICA varies from intracranial haemorrhage, epistaxis, cranial nerve palsies, seizures to asymptomatic.[6] In children, neurological deterioration is less encountered. The diagnosis of TICA requires a high index of suspicion in all patients of trauma who presents with a delayed new-onset features of raised ICP or some new-onset neurological deficits. There are no defined protocols at present for routine CT angiography of trauma patients. Any trauma patients or a post-operative patient who present with the following features should undergo a CT angiography: (1) penetrating fragments, especially if they cross the midline or traverse into another dural compartment, (2) delayed neurological deterioration, (3) delayed haemorrhage, (4) new or unexplained intracranial bleed, (5) facio-orbito-pterional injuries, (6) discrepancy between the amount of subarachnoid haemorrhage intraventricular haemorrhage to the severity of the brain injury and (7) unexplained major arterial bleeding during evacuation of the haematoma.[4] Angiographically, features that favour a TICA include ill-defined contour of the sac, delayed filling of sac, absence of defined neck and a peripheral location of sac other than branching point.[4] After diagnosis, TICA can be managed endovascular approach or by surgical clipping, resection or trapping of aneurysm. The aim of treatment is to exclude the aneurysm from the circulation. Both modalities have its own pros and cons, but definitive exclusion of aneurysm with surgery, reconstruction of vessel if required and evacuation of haematoma make surgery to be better choice for accessible TICA. The optimal management is to be tailored on case-to-case basis. In the current case, we clipped the aneurysm in view of young age and hence complete cutoff of aneurysm from the circulation. Outcome of these children with TICA is primarily determined by the extent of traumatic brain injury, preoperative clinical status and the time of diagnosis and definitive treatment.[7],[8] In the current case, our patient was Hess and Hunt Grade 1, with earlier presentation and prompt definitive management and hence discharged uneventful.


  Conclusion Top


There should be a high degree of suspicion in trauma patients, especially with a closed head injury who presents with delayed features after initial trauma for diagnosis of TICA. TICA is to be suspected in the paediatric population too with a low threshold for an MRI/MRA brain in suspected cases. Paediatric patients do well after optimal and prompt treatment may be due to no other associated comorbidities.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Ventureyra EC, Higgins MJ. Traumatic intracranial aneurysms in childhood and adolescence. Case reports and review of the literature. Childs Nerv Syst 1994;10:361-79.  Back to cited text no. 1
    
2.
Henroteaux A, Otto B, Martin D, Scholtes F. Head trauma and distal anterior cerebral artery aneurysm: Potential role of an adhesion to the falx. J Neurol Surg Part A: Central Euro Neurosurg 2014;76:72-5.  Back to cited text no. 2
    
3.
Lam CH, Montes J, Farmer JP, O'Gorman AM, Meagher-Villemure K. Traumatic aneursym from shaken baby syndrome: Case report. Neurosurgery 1996;39:1252-5.  Back to cited text no. 3
    
4.
Raju BS, Purohit AK, Murthy SR, Sundaram C, Sanjay T. Traumatic distal anterior cerebral artery aneurysm in a child: a case report. Neurol India 2001;49:295-8.  Back to cited text no. 4
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5.
Jian B, Hetts S, Lawton M, Gupta N. Pediatric intracranial aneurysms. Neurosurg Clin N Am 2010;21:491-501.  Back to cited text no. 5
    
6.
Garg K, Singh P, Sharma B, Chandra P, Suri A, Singh M, et al. Pediatric intracranial aneurysms – our experience and review of literature. Childs Nerv Syst 2013;30:873-83.  Back to cited text no. 6
    
7.
Sorteberg A, Dahlberg D. Intracranial non-traumatic aneurysms in children and adolescents. Curr Pediatr Rev 2013;9:343-52.  Back to cited text no. 7
    
8.
Wani AA, Behari S, Sahu RN, Jaiswal AK, Jain VK. Paediatric intracranial aneurysms. J Pediatr Neurosci 2006;1:11-5.  Back to cited text no. 8
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    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]



 

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