Aneurysm is a bulging of the weak spot in the wall of an artery. An artery can become weak and in due course of time, under normal blood pressure, it tends to balloon outward. This may or may not rupture. There are two kinds of Paediatric Aneurysm:
- Saccular Aneurysm: The most common form, it is most likely to rupture and bleed because it bulges outward.
- Fusiform Aneurysm: They are least common. The artery wall is swollen around instead of bulging in a spot. Therefore, it is less likely to rupture and bleed.
In children, Aneurysm is rare but when it does occur, it usually shows in the brain. It is called intracranial or an intracerebral aneurysm. Also, the occurrence is found more frequently in the male child than the female.
Some Aneurysm may be so small that it does not bleed or rupture. The size could be less than 11 millimeter which is like the size of a pencil eraser whereas, the bigger ones could be anything between 11 – 25 millimeters. The biggest ones are greater than 25 millimeters. An aneurysm can be anywhere in the brain.
When the size is small, symptoms may not show until the artery bursts or rupture. If it is ruptured, this causes a life-threatening situation that needs an immediate treatment to prevent further damage to the brain. Bleeding into the brain is called subarachnoid haemorrhage.
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Diagnosis for Paediatric Aneurysm
Paediatric Aneurysm may not be detected until the following occurs:
- Head injury
- Infection due to suppressed immune system
- Genetic disease like connective tissue disorders, polycystic kidney disease, sickle cell anaemia and malformation of the blood vessels.
- Congenial cause resulting in abnormal wall in the artery
- Other unknown causes
A careful observation of your child may be crucial if symptoms do not show especially when there is a family history of aneurysm.
- Severe headache
- Nausea or vomiting
- Stiffness of the neck
- Loss of consciousness
- Eye problems like sensitivity to light, double or blurred vision
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Cerebral Aneurysm is found mostly while scanning the brain for other condition. When a child has a ruptured artery, several emergency tests will be done to determine the symptoms.
- MRI Scan: It is used to scan aneurysm that has not ruptured.
- CT Scan: A preferred scan if a suspected rupture has had happened and there is a bleeding in the brain.
- Lumbar puncture: If there is a strong symptom of a ruptured artery but CT Scan shows negative result, then this method is used. At the base of the spine, a needle is inserted to collect a sample of cerebrospinal fluid to analyse any sign of bleeding in the brain.
- Angiogram: If the scans or lumbar puncture show signs of bleeding or unruptured aneurysm, a further test called Angiogram or Arteriogram is carried out to help plan treatment. A needle is inserted carrying a catheter to inject the arteries in the brain with a special dye to create a shadow to reflect the outline of the blood vessels and aneurysm is seen.
Before proceeding to surgery, an assessment will be done whether a surgery is necessary or not. The assessment is based on:
- Size of the aneurysm
- Location of the aneurysm
- Family history (there is a higher chance of rupture if there is a history of rupture in the family)
- Underlying cause such as polycystic kidney disease, high blood pressure
If the risk of rupture is low, then the doctor recommends an active observation and, advises on regular check-ups. Surgery may not be considered immediately. If there is any possibility of high blood pressure on the child’s health, medications may be given, and lifestyle changes are recommended like lower intake of fat or weight loss.
Surgical Treatment for Paediatric Aneurysm
There are three treatments for aneurysm depending on the type.
- Saccular aneurysm: Neurosurgical clipping and endovascular coiling. These methods stop blood flowing into the aneurysm and prevents rupture.
- Fusiform aneurysm: Bypass surgery. This is a surgical cerebral procedure to repair damaged arteries.
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The following may be done before performing surgery:
- Report of the child’s medical history
- Run scans, lumbar puncture and, angiogram
- Standard tests for surgery
- Risk assessment
- Drinking and eating is prohibited for eight hours before procedure
- Neurosurgical clipping: This is performed under general anaesthetic.
- To access the brain, the neurosurgeon performs craniotomy where a cut is made in the scalp or above the eyebrow to remove a small piece of skull temporarily.
- When the aneurysm is located, a tiny metal clip is used to pinch it off at the neck. This stops the blood from leaking and subsequently, the blood vessel will continue to flow along the normal artery preventing a growth or rupture.
- The bone is replaced, and the scalp is then stitched together. This takes about three to four hours.
- This method is highly effective, aneurysm does not return. When the aneurysm is large or complex (artery is damaged), clipping of the artery of aneurysm is performed. This is called trapping. It is often combined with a bypass surgery.
- Endovascular coiling: This is also done under general anaesthetic.
- A small tube called catheter is inserted up in the artery of the leg or groin. The catheter is guided up into the brain and identifies the aneurysm by means of a dye injected inside.
- Through the catheter, tiny platinum coils are passed through and fills the aneurysm with coils so that blood cannot enter the aneurysm anymore. This inhibits blood flow from the main artery preventing further growth or rupture.
- This surgery takes one and half hour to three hours to perform.
- Coiling is less invasive and although it shows a lower risk of complications in the short term than clipping, but the patient may need more than one procedure.
- Cerebral bypass: Bypass surgery is often done with clipping.
- Under anaesthesia, the surgeon reroutes the blood flow away from the damaged artery. The blood flow around the clamped area of the artery is diverted by grafting a small blood vessel into the artery of the brain.
- If clipping and/or bypass is performed, the child stays in the hospital for about four to six days, but this varies.
- With coiling, it takes a day or two to be hospitalised. Post – surgery monitoring if needed, will increase the stay.
- There will be discomfort in the leg or groin area, but this will disappear after a while.
- Bruises may occur around the incision area, this will heal over time.
- It is normal for the child to feel sad, angry, or nervous.
- There is a possibility of seizure but if this happened, medication will stop further episodes.
- It is common to have headaches for a while.
- Memory loss, confusion, dizziness, or problem with speech may occur but should get better gradually.
Potential Complications after Surgery
Possible risks could arise such as:
- Injury or damage to the aneurysm being treated
- Blood clot resulting in stroke or blockage of blood flow
- Cerebral vasospasm
- Regrowth or enlargement of the aneurysm
- Allergic reaction to dye
- Infection from surgery
If the surgery is performed due to a ruptured aneurysm, the child will stay around two weeks in the hospital to monitor conditions such as Cerebral vasospasm (spasm or narrowing in the brain by the blood vessels), ventilatory issues or Hydrocephalus (presence of too much of fluid in the brain).
In Endovascular coiling, a higher risk of recurrence is found in patients. Therefore, patients are asked to do a follow-up routine and frequently return to perform Angiogram to check any recurrence. This may be done in an in-patient or out-patient basis.
Child patients with history of aneurysm may be advised to do a frequent monitoring.