Mikrochirrugische Klippung eines großen MCA Aneurysmas bei einem 3 Monate alten Säugling: Fallpräsentation und Literatur Review

A case of a 3-month-old infant suffering from spontaneous subarachnoid hemorrhage (SAH) from a 15 mm distal M2 aneurysm is reported.

No history of familiar genetic vascular disease history, infection or trauma was evident. Aneurysm rupture happened in a so far healthy and normally developed 3-month-old female infant. Sudden screaming followed by loss of consciousness lead to urgent hospitalization and performance of head ultrasound, CCT and MRI. SAH and a left insular hematoma was diagnosed. A 15 mm M2 aneurysm at the distal insula was identified by CTA as the origin of the hemorrhage.

Interdisciplinary endovascular- microvascular counselling within our vascular working group was performed and pro and cons as well as risks of endovascular versus open microsurgical therapy were weighted. Open surgery was chosen for aneurysm therapy and after insertion of an EVD, trap ligation and excision of the aneurysm via a fronto-temporal osteoplastic craniotomy was performed. The postoperative course was uneventful and no ICP crises or vasospasm occurred, with daily CSF drainage of about 20 ml. In a postoperative CT scan only a small ischemic brain area at the angular region distal to the excised aneurysm was diagnosed showing no significant brain swelling. Weaning and extubation of the infant was possible 10 days after surgery with no apparent neurological deficits detected. Dismission to the hometown hospital was possible 20 days after surgery.

Aneurysmal SAHs in infants up to 3 months of age are exceedingly rare, only about 20 cases are reported in the literature with the MCA being the most common location. Preservation of the parent vessel is usually not feasible neither by endovascular, nor by open surgical approach, mainly due to aneurysm morphology and a mismatch in size between vessels and aneurysm. Hence, endovascular or surgical trapping of the aneurysm is the treatment of choice. Fortunately, collateral vascularization at this young age seems to be capable to impede large clinically relevant strokes as our case had demonstrated.