1 - Serviço de Neurocirurgia, Centro Hospitalar Universitário de Lisboa Central, Lisboa
2 - Serviço de Neurorradiologia, Centro Hospitalar Universitário de Lisboa Central, Lisboa
3 - Unidade de Neurocirurgia Pediátrica, Hospital Dona Estefânia, Centro Hospitalar Universitário de Lisboa Central, Lisboa
- Poster apresentado no Congresso da European Society of Pediatric Neurosurgery 2018, publicado sobre forma de resumo na revista Child’s Nervous System 2018;34:1056
Resumo:
Introduction: Pediatric intracranial aneurysms are rare. Giant aneurysms (≥25mm) are found more frequently in children than in adults, and favour particularly the vertebrobasilar system.
Case description: A previously healthy 12-year-old boy presented with a 2-month history of progressively worsening headache and intermittent vomiting. Cranial Computed tomography (CT) revealed a circumferential, hyperdense lesion in the third ventricle and associated obstructive hydrocephalus. Brain magnetic resonance imaging (MRI) revealed an aneurysm of the basilar artery compressing the midbrain and the sylvian aqueduct with hyperactive flux. No signs of subarachnoid haemorrhage (SAH) were present. Neurological deterioration occurred with installation of anisocoria and left hemiparesis after 48h without CT scan changes. Cerebral angiography was performed revealing an aneurysm (25,7 x 33,3mm) at the bifurcation of the basilar artery, oriented superiorly and posteriorly. Since it was impossible to identify the origin of the right posterior cerebral artery, partial occlusion of the aneurysm was obtained with coiling. Ventriculoperitoneal (VP) shunting was carried out afterwards using a programmable pressure valve. Control CT scan after endovascular treatment and VP shunt placement showed no signs of SAH and reduction of ventricular size. The patient showed progressive clinical improvement but presented with transient drowsiness and left hemiparesis. Control MRI after 2 months showed adequate control of the hydrocephalus with no signs of hyperdrainage and persistence of residual aneurysmal flow without enlargement of the sac. Bilateral infarct of the cingulate gyrus and corpus callosum area was apparent, probably due to decompression-related vascular lesion after shunting and explaining the transient clinical worsening. A multidisciplinary rehabilitation program was started with progressive improvement and definitive endovascular treatment will be scheduled.
Conclusion: Basilar artery aneurysms with associated hydrocephalus have complex underlying physiological mechanisms. A multimodal treatment including endovascular and neurosurgical is recommended. Life-long follow-up is essential due to high recurrence and “de novo” aneurysm formation rates in pediatric population.
Palavras Chave: Endovascular treatment, Giant basilar tip aneurysm