pediatric cerebral aneurysms are rare . according to a recent review by rao et al . , these aneurysms constitute 2.9% of all cerebral aneurysms .
incidence of these aneurysms in pediatric patients is more in the posterior circulation than in the anterior , when compared to the aneurysms in adults .
lasjunias et al . , in a report on 20 pediatric aneurysm cases , suggested that these aneurysms must be the expression of various vessel wall dysfunctions , producing transient or permanent failure to repair a partial insult .
we present two case reports of non - giant aneurysms of the anterior circulation in the pediatric group , treated successfully by endovascular technique at our institute .
an 8-year - old female child presented with a complaint of persistent headache for 7 days ( grade i sub - arachnoid hemorrhage ( sah ) ( hunt and hess scale ) ) . on clinical examination
computerized tomography ( ct ) scan revealed fischer grade-3 sah in the prepontine cistern and right sylvian fissure .
pre - procedure routine detailed work was done along with special investigations including antineutrophilic antibody ( ana ) , antineutrophilic cytoplasmic antibody ( anca ) , and antiphospholipid antibody ( apla ) .
detailed screening and imaging were done to rule out any associated conditions , such as autosomal dominant polycystic kidney disease ( adpkd ) , fibro muscular dysplasia , co - arctation of aorta , ehlers syndrome , and marfans syndrome .
digital subtraction angiography ( dsa ) showed the presence of a1saccular aneurysm on the right side [ figure 1 ab ] .
endovascular treatment was planned after analyzing the morphology of the aneurysm and the flow hemodynamics of the aneurysm .
high - risk informed consent was obtained from the parents after detailed explanation of the risks versus benefits of the treatment procedure .
case 1 : ( a ) computerized tomography ( ct ) scan shows subarachnoid hemorrhage ( sah ) ( arrow ) in the prepontine and sylvian fissures and ( b ) pre - procedure digital subtraction angiogram reveals saccular a1 aneurysm ( arrow ) on the right side under 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 ( 5f envoy , cordis ) with nimodipine infusion was placed in the internal carotid artery ( ica ) .
microcatheter ( echelon-10 , ev3 ) over microwire ( expedion 14 , ev3 ) was navigated into the sac of the aneurysm [ figure 1 c , d , and e ] .
post - procedure angiogram showed near total exclusion of the aneurysm from the circulation and excellent filling of all branches of the right ica , anterior cerebral artery , and middle cerebral artery .
postprocedure , the patient was extubated in the cathlab and kept under observation for 3 days in the neurointensive care unit .
there were no intra- , peri- , or post - procedural complications and the child was discharged on day 7 post operation .
control angiogram done after 2 years showed stable occlusion of the aneurysm with coil mass in situ .
( c ) microcatheter is shown positioned in the sac of the aneurysm ( arrow ) and ( d ) the post - procedure angiogram shows exclusion of the aneurysm ( arrow ) from the circulation with ( e ) the coil mass in the aneurysm ( arrow ) 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 ) .
ct scan [ figures 2a ] showed hemorrhage in the left frontal lobe with intraventricular extension ( fischer grade iv ) .
dsa was done subsequently which revealed a bilobed ica bifurcation aneurysm on the left side [ figure 2b ] .
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 .
case 2 : ( a ) computerized tomography ( ct ) scan shows bleeding in the left frontal region with intraventricular extension .
( b ) pre - procedural angiogram reveals internal carotid artery ( ica ) bifurcation aneurysm on the left side . under general anesthesia ,
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 2 c  f ] on the check angiogram .
( c ) magnified image shows the coil loop in the internal carotid artery ( ica ) ( arrow ) ( d ) enterprise stent(white arrows ) deployed from m1 to supraclinoid ica with secured coil mass ( black arrow ) in the aneurysm sac .
( e ) postprocedure angiogram shows complete exclusion of aneurysm ( arrow ) from circulation .
( f ) follow - up angiogram reveals stable occlusion of the aneurysm in 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 .
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 ) .
there were no peri- or post - procedural complications and the patient was discharged on day 7 after operation on double antiplatelet regimen ( aspirin,50 mg and clopidogrel,75 mg ) .
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 .
follow - up angiogram done after 1 year showed stable occlusion of the aneurysm and normal patency of the stented artery .
an 8-year - old female child presented with a complaint of persistent headache for 7 days ( grade i sub - arachnoid hemorrhage ( sah ) ( hunt and hess scale ) ) . on clinical examination
computerized tomography ( ct ) scan revealed fischer grade-3 sah in the prepontine cistern and right sylvian fissure .
pre - procedure routine detailed work was done along with special investigations including antineutrophilic antibody ( ana ) , antineutrophilic cytoplasmic antibody ( anca ) , and antiphospholipid antibody ( apla ) .
detailed screening and imaging were done to rule out any associated conditions , such as autosomal dominant polycystic kidney disease ( adpkd ) , fibro muscular dysplasia , co - arctation of aorta , ehlers syndrome , and marfans syndrome .
digital subtraction angiography ( dsa ) showed the presence of a1saccular aneurysm on the right side [ figure 1 ab ] .
endovascular treatment was planned after analyzing the morphology of the aneurysm and the flow hemodynamics of the aneurysm .
high - risk informed consent was obtained from the parents after detailed explanation of the risks versus benefits of the treatment procedure .
case 1 : ( a ) computerized tomography ( ct ) scan shows subarachnoid hemorrhage ( sah ) ( arrow ) in the prepontine and sylvian fissures and ( b ) pre - procedure digital subtraction angiogram reveals saccular a1 aneurysm ( arrow ) on the right side under 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 ( 5f envoy , cordis ) with nimodipine infusion was placed in the internal carotid artery ( ica ) .
microcatheter ( echelon-10 , ev3 ) over microwire ( expedion 14 , ev3 ) was navigated into the sac of the aneurysm [ figure 1 c , d , and e ] .
post - procedure angiogram showed near total exclusion of the aneurysm from the circulation and excellent filling of all branches of the right ica , anterior cerebral artery , and middle cerebral artery .
postprocedure , the patient was extubated in the cathlab and kept under observation for 3 days in the neurointensive care unit .
there were no intra- , peri- , or post - procedural complications and the child was discharged on day 7 post operation .
control angiogram done after 2 years showed stable occlusion of the aneurysm with coil mass in situ .
( c ) microcatheter is shown positioned in the sac of the aneurysm ( arrow ) and ( d ) the post - procedure angiogram shows exclusion of the aneurysm ( arrow ) from the circulation with ( e ) the coil mass in the aneurysm ( arrow )
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 ) .
ct scan [ figures 2a ] showed hemorrhage in the left frontal lobe with intraventricular extension ( fischer grade iv ) .
dsa was done subsequently which revealed a bilobed ica bifurcation aneurysm on the left side [ figure 2b ] .
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 .
case 2 : ( a ) computerized tomography ( ct ) scan shows bleeding in the left frontal region with intraventricular extension .
( b ) pre - procedural angiogram reveals internal carotid artery ( ica ) bifurcation aneurysm on the left side . under general anesthesia ,
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 2 c  f ] on the check angiogram .
( c ) magnified image shows the coil loop in the internal carotid artery ( ica ) ( arrow ) ( d ) enterprise stent(white arrows ) deployed from m1 to supraclinoid ica with secured coil mass ( black arrow ) in the aneurysm sac .
( e ) postprocedure angiogram shows complete exclusion of aneurysm ( arrow ) from circulation .
( f ) follow - up angiogram reveals stable occlusion of the aneurysm in 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 .
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 ) .
there were no peri- or post - procedural complications and the patient was discharged on day 7 after operation on double antiplatelet regimen ( aspirin,50 mg and clopidogrel,75 mg ) .
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 .
follow - up angiogram done after 1 year showed stable occlusion of the aneurysm and normal patency of the stented artery .
pediatric aneurysms constitute 2.9% of all cerebral aneurysms with common location being the posterior circulation and with higher incidence of large and giant complex aneurysm .
the ica bifurcation is the commonest location in the anterior circulation . during the past decade
, there has been dramatic improvement in endovascular techniques that are increasingly being used in treatment of pediatric age group patients .
large and giant aneurysms are more common in the pediatric age group . both our cases were saccular aneurysms in the anterior circulation with grade i sah on presentation .
xianli et al . , in their series , reported the use of coils in all saccular aneurysms . in case 1 ,
coiling of the sacculara1 aneurysm was done with dense packing and exclusion of the aneurysm from the circulation .
liang et al . , in their series of 24 pediatric patients , concluded that this age group differed in many ways from adults . both microsurgical approaches and endovascular treatment were effective in these cases . in two patients with fusiform giant aneurysms of their series , they used balloon - mounted stents to treat the aneurysm and one of the patients with basilar trunk aneurysm succumbed to bleeding on the 23 day post operation .
in one patient in the series , a 10-year - old female child with basilar apexsaccular aneurysm , stent ( neuroform , boston scientific ) assisted coiling was done with successful outcome ( glasgow outcome scale = 5 ) . in case 2 ,
we used a self - expanding stent as a  bail out measure ( enterprise , johnson and johnson ) to secure the neck of the aneurysm and to achieve dense packing of the aneurysm with coils , we did not encounter any untoward effects .
however , a close long - term follow - up has been planned for this patient to look for any long - term adverse effects of the stent , if any .
pediatric cerebral aneurysms are rare with varying clinical presentation and natural history compared to those encountered in adults .
endovascular method is an elegant and minimally invasive alternative treatment of choice in managing these aneurysms and has promising results .
however , a larger case series is required to better evaluate the safety and efficiency of the treatment method .
 aneurysms in the pediatric age group are rare and have preponderance for the posterior circulation . 
 these aneurysms are more commonly large , giant , and complex . 
 we present two case reports of saccular aneurysms in pediatric patients who were treated successfully by endovascular technique . 
INTRODUCTION
CASE REPORTS
Case 1
Case 2
DISCUSSION
CONCLUSION