Internal Carotid Artery Bifurcation Aneurysm: Symptomatic Internal Carotid Artery Bifurcation Aneurysm in a Pediatric Patient Treated with Flow Diversion

José E. Cohen, Hosni Abu Al-Hasan, Carlos Candanedo, Moatasim Shweiki, and Gustavo Rajz

Abstract

Intracranial aneurysms are uncommon in pediatric patients and present different characteristics and underlying etiopathogenesis compared to those in adults. The available literature on pediatric aneurysms is surprisingly scarce, but it seems clear that from a therapeutic perspective, there has been a significant shift from microsurgical treatment toward endovascular management due to better outcomes and lower rates of procedural complications. The use of flow diverter stents, initially reserved for adult patients, is also becoming an accepted practice in selected pediatric cases.

We present the case of an 11-year-old boy with an unremarkable medical history who experienced an episode of sudden-onset severe headaches. Over-the-counter analgesics, administered at home, provided partial relief. A day after this, his headaches intensified. The boy vomited repeatedly and experienced general malaise. He was transferred to a primary care hospital. Cranial CT and CTA revealed an irregularly shaped bifurcation aneurysm on the left internal carotid artery (ICA). Its fundus was associated with a spontaneously hyperdense spot, a sign of pseudoaneurysm and contained hemorrhage. No subarachnoid hemorrhage was detected. The anterior communicating artery (AcomA) complex showed a typical configuration.

Lumbar puncture yielded pinkish cerebrospinal fluid (CSF), confirming the minor hemorrhagic leak. The patient was then medicated with stronger analgesics and urgently transferred to our center for treatment. The child could not remain still, and the diagnostic angiogram was performed under general anesthesia. It confirmed an irregularly shaped saccular aneurysm on the left ICA bifurcation and a pseudoaneurysmatic bleb associated with the fundus.

After failed attempts to selectively catheterize the aneurysm with a microcatheter, we administered a loading dose of aspirin and prasugrel via nasogastric tube (NGT). Once it was seen that dual antiplatelet medication had taken effect, a single flow diverter stent was implanted across the aneurysm neck (M1-ICA). The procedure was uneventful, and the patient was discharged home after 7 days. Platelet inhibition was evaluated every 12 hours for the first 3 days after the intervention, and the antiplatelet dose was adapted as necessary.

A follow-up angiogram at 6 months confirmed complete occlusion of the treated aneurysm. The feasibility, safety, and effectiveness of flow diverter stents in pediatric patients, and in the management of bifurcation aneurysms, are the main topics of this chapter.

Keywords:
Internal carotid artery bifurcation · Pediatric aneurysm · Flow diverter stent · Bifurcation aneurysm