title: Revascularization and pediatric aneurysm surgery.
abstract: OBJECTIVE
  Aneurysms are relatively rare in the pediatric population and tend to include a greater proportion of large and giant lesions. A subset of these large and giant aneurysms are not amenable to direct surgical clipping and require complex treatment strategies and revascularization techniques. There are limited data available on the management of these lesions in the pediatric population. This study was undertaken to evaluate the outcome of treatment of large and giant aneurysms that required microsurgical revascularization and vessel sacrifice in this population.
  
  
  METHODS
  The authors retrospectively identified all cases in which pediatric patients (age < 18 years) with aneurysms were treated using cerebral revascularization in combination with other treatment modalities at their institution between 1989 and 2013.
  
  
  RESULTS
  The authors identified 27 consecutive patients (19 male and 8 female) with 29 aneurysms. The mean age of the patients at the time of treatment was 11.5 years (median 13 years, range 1-17 years). Five patients presented with subarachnoid hemorrhage, 11 with symptoms related to mass effect, 2 with stroke, and 3 with seizures; in 6 cases, the aneurysms were incidental findings. Aneurysms were located along the internal carotid artery (n = 7), posterior cerebral artery (PCA) (n = 2), anterior cerebral artery (n = 2), middle cerebral artery (MCA) (n = 14), basilar artery (n = 2), vertebral artery (n = 1), and at the vertebrobasilar junction (n = 1). Thirteen were giant aneurysms (45%). The majority of the aneurysms were fusiform (n = 19, 66%), followed by saccular (n = 10, 34%). Three cases were previously treated using microsurgery (n = 2) or an endovascular procedure (n = 1). A total of 28 revascularization procedures were performed, including superficial temporal artery (STA) to MCA (n = 6), STA to PCA (n = 1), occipital artery to PCA (n = 1), extracranial-intracranial (EC-IC) bypass using radial artery graft (n = 3), EC-IC using a saphenous vein graft (n = 7), STA onlay (n = 3), end-to-end anastomosis (n = 1), and in situ bypasses (n = 6). Perioperative stroke occurred in 4 patients, but only one remained dependent (Glasgow Outcome Scale [GOS] score 3). At a mean clinical follow-up of 46 months (median 14 months, range 1-232 months), 26 patients had a good outcome (GOS score 4 or 5). There were no deaths. Five patients had documented occlusion of the bypass graft. The majority of aneurysms (n = 24) were obliterated at last follow-up. There was a single case of a residual aneurysm and one case of recurrence. Angiographic follow-up was unavailable in 3 cases.
  
  
  CONCLUSIONS
  Cerebral revascularization remains an essential tool in the treatment of complex cerebral aneurysms in children.
authors.affiliation: Division of Neurological Surgery, Barrow Neurological Institute, Saint Joseph's Hospital and Medical Center, Phoenix, Arizona.
authors.forename: M Yashar S
authors.initials: MY
authors.lastname: Kalani
authors.forename: Ali M
authors.initials: AM
authors.lastname: Elhadi
authors.forename: Wyatt
authors.initials: W
authors.lastname: Ramey
authors.forename: Peter
authors.initials: P
authors.lastname: Nakaji
authors.forename: Felipe C
authors.initials: FC
authors.lastname: Albuquerque
authors.forename: Cameron G
authors.initials: CG
authors.lastname: McDougall
authors.forename: Joseph M
authors.initials: JM
authors.lastname: Zabramski
authors.forename: Robert F
authors.initials: RF
authors.lastname: Spetzler
mesh_terms: D000293:Adolescent; D002343:Carotid Artery, Internal / Q000473:pathology; D002533:Cerebral Angiography; D002548:Cerebral Revascularization / Q000379:methods*; D002648:Child; D002675:Child, Preschool; D003131:Combined Modality Therapy; D057510:Endovascular Procedures / Q000379:methods; D005260:Female; D005500:Follow-Up Studies; D023261:Glasgow Outcome Scale; D006801:Humans; D007223:Infant; D002532:Intracranial Aneurysm / Q000175:diagnosis* / Q000000981:diagnostic imaging / Q000473:pathology / Q000601:surgery*; D018810:Magnetic Resonance Angiography; D008297:Male; D008866:Microsurgery / Q000379:methods; D019635:Neurosurgical Procedures / Q000379:methods; D012189:Retrospective Studies; D016896:Treatment Outcome; D014654:Vascular Patency
keywords: ACA = anterior cerebral artery; BA = basilar artery; CVA = cerebrovascular accident; EC-IC = extracranial-intracranial; GOS = Glasgow Outcome Scale; ICA = internal carotid artery; MCA = middle cerebral artery; OA = occipital artery; PCA = posterior cerebral artery; SAH = subarachnoid hemorrhage; STA = superficial temporal artery; VA = vertebral artery; VBJ = vertebrobasilar junction; aneurysm; bypass; cerebral revascularization; clipping; complex; endovascular; extracranial-to-intracranial; intracranial-to-intracranial; vascular disorders