Child’s Nerv Syst (2001) 17:37–41

© Springer-Verlag 2001 O R I G I N A L A RT I C L E

M. Wojtacha Cerebral aneurysms in childhood

P. Bażowski
M. Mandera
I. Krawczyk
A. Rudnik

Received: 12 July 1999
Revised: 7 July 2000
M. Wojtacha (✉) · P. Bażowski
M. Mandera · I. Krawczyk · A. Rudnik
Department of Neurosurgery,
Silesian University School of Medicine,
40-752 Katowice, Poland
Fax: +48-32-2525812
Abstract Objects: The aim of this
work was to ascertain any clinical
and anatomical factors allowing dif-
ferentiation between aneurysms of
childhood and those occurring in
adults by comparing both groups.
Methods: Results obtained in a total
of 17 children and adolescents aged
up to 18 who had been operated on
for cerebral aneurysm in our depart-
ment from 1989 to 1997 (3% of all
patients treated for subarachnoid
haemorrhage resulting from ruptured
cerebral aneurysm in this period)
were compared with those in the
adult group operated on in our de-
partment. In contrast to the situation
in adults, there was a male predomi-
nance in our population. In children
we found only 1 case of middle cere-
bral aneurysm and 1 case of multiple
aneurysms. We also found a high
rate of rebleeding in the paediatric
group. Conclusions: We suggest that
the very good outcome (100% very
good results in patients operated on
early) obtained and the high risk of
rebleeding in children with cerebral
aneurysm allow the recommendation
of early surgery in children with rup-
tured cerebral aneurysms.
Keywords Intracranial aneurysm ·
Subarachnoid haemorrhage ·
Children

Introduction dence of traumatic and infectious lesions was reported

Intracranial aneurysms are rare in childhood, constituting
approximately 0.5–4.6% of all patients admitted to neu-
rosurgical departments with a diagnosis of cerebral aneu-
rysm [7, 10, 18, 19, 20]. In the paediatric population rup-
ture of the aneurysm is a cause of subarachnoid haemor-
rhage (SAH) in 18–52.1% [7, 12). Aneurysms before the
age of 15 are extremely rare, accounting for approxi-
mately 1% of all aneurysms [20]. In the literature, how-
ever, we can find reports of cases of aneurysms even in
infants [8, 18]. Analysis of previously reported cases in-
dicates some distinct characteristics that distinguish an-
eurysms in childhood from those occurring in adults.
Many authors have noted the male predominance in
childhood, in contrast to the female predominance in
adults [7, 12, 18, 19]. Some authors have also noted a
high incidence of posterior circulation aneurysms [18]
and giant aneurysms [18]. In other studies a higher inci-
[1, 6].
The aim of this work was to determine clinical and
anatomical factors that make it possible to distinguish
the aneurysms of childhood from those in adults by com-
paring the two groups.
Materials and methods
Throughout the period 1989–1997, a total of 561 patients with
confirmed saccular aneurysm were treated surgically in the De-
partment of Neurosurgery at the Silesian University School of
Medicine in Katowice. Of this total population, 17 patients were
18 years old or younger. The aneurysms with traumatic or mycotic
aetiology were excluded from this study a priori. We compared the
paediatric group with 358 adults operated on for ruptured aneu-
rysm in our department between January 1989 to June 1995.
On admission, the neurological and consciousness status of all
patients was estimated according to the Hunt-Hess scale [13].
General clinical state was also evaluated. The incidence and the
38

timing of rebleeding were also analysed. In all patients cerebral

angiography was performed. We took into consideration location,
size, and occurrence of multiple aneurysms and the presence of
narrowing of the vessels. Computed tomography (CT) on admis-
sion was performed in all patients admitted early (before 72 h after
initial bleeding) and in several patients admitted after this time. In
CT scans we evaluated the amount of extravasated blood accord-
ing to Fisher’s scale [4], widening of cerebral ventricles using
both Evans’ [2] and Hahn’s [9] indexes, and the presence of intra-
ventricular haemorrhage (IVH). The measurements were estimat-
ed as abnormal if the Evans index score exceeded 0.3 [2] and the
score on Hahn’s index exceeded 36% [9].
All patients were treated surgically, and in all cases the aneu-
rysms were successfully clipped.
The outcome according to the Glasgow Outcome Scale [14]
and the presence of seizures were evaluated in both groups at least Fig. 1 Location of aneurysms in children
1 year after operation.

Results
These 17 children with aneurysm constituted about 3%
of the population with intracranial aneurysms treated
surgically at our department. The youngest patient was
10 years old, and the average age was about 15 years
old. In the adult group the average age was 45.2 years
(SD=11.682). There were 4 girls and 13 boys among
the operated children. The male-to-female ratio was
3.25 to 1 (77.5% of males) in this group. In the adult
group there were 169 men (47.2%) and 189 women
(57.8%).
In 7 cases of surgically treated children we ascer-
tained rebleeding before surgery. Taking into consider-
ation that 12 of our patients were treated on late surgery
(later then 3 days after initial bleeding) we could expect
rebleeding in 60% of cases. In adults rebleeding oc-
curred in 27%.
On admission the Hunt and Hess score in 8 children
after SAH (50%) was evaluated as 1. We classed 3 chil-
dren (18.8%) as grade 2, 1 patient (6.3%) as grade 3, and
four patients (25%) as grade 4. In the adult group grade
1 was observed in 89 patients (28.8%), grade 2 in 125
(40.5%), grade 3 in 62 (20.1%), grade 4 in 32 (10.4%)
and grade 5 in 1 patient (0.3%).
In the children’s group we found systemic arterial hy-
pertension only in 1 case (5.9%), whereas in the adult
patients it was found in 132 cases (36.9%). In the child
with arterial hypertension this was associated with adi-
pose-genital syndrome. The case of anterior communi-
cating artery aneurysm (ACoA) became manifest with
the syndrome of anorexia. In the paediatric population
only 1 case without SAH in a patient showing the neuro-
compressive symptoms on admission was found. Poly-
cystic kidney was also diagnosed in 1 case. We did not
find a positive family history or coexisting aortal coarc-
tation in any case.
In 1 case (5.9%) we found two aneurysms, one locat-
ed on the MCA and the other on the ICA, both on the
right side. In the adult group 17% of patients had multi-
Fig. 2 Location of aneurysms in adults
ple aneurysms. The child with multiple aneurysms also
suffered from systemic arterial hypertension.
In the paediatric group we found no cases of giant an-
eurysm. In the adult group we found giant aneurysms in
4.74% of cases.
In the paediatric population we found aneurysms aris-
ing from the ACoA in 9 cases (50%), while in 8 cases
(44.44 %) the aneurysm was located on the ICA. Only in
1 case (5.56%) was the aneurysm located on the MCA.
We did not find any cases of posterior circulation aneu-
rysm (Fig. 1). In adults we found aneurysms arising from
the ACoA in 148 cases (34.66%), from the MCA in 155
cases (36.30%) and from the ICA in 100 cases (23.42%).
Occasionally, aneurysms were found on the posterior cir-
culation arteries (13 cases; 3.04%), and on the perical-
losal artery (11 cases; 2.58%; Fig. 2).
Hydrocephalus was observed in 1 case (5.9%), and
this patient required a shunting operation. In the adult
group widening of the ventricular system was present in
79 cases (22%), 18 of them requiring shunt surgery.
In children a good outcome (grade I and II according
to GOS) was obtained in 12 cases (70.6%), and in the
adult group a good outcome was noted in 196 cases
(64%). Two children died (11.8%). In the adult group the

Fig. 3 Surgical results by time of surgery in children
Fig. 4 Surgical results by time of surgery in adults
mortality rate was 19% (58 patients). Poor outcomes
were observed in 3 (17.6%) children (grades III and IV
according to GOS), a similar proportion to that in adults
(52 patients – 17%).
Four children were operated on early (up to 72 h after
SAH). The most important cause of delayed surgery was
too-late transfer from the general paediatric unit. In all
cases we obtained a very good outcome (Fig. 3). The re-
sults of treatment in correlation with the time of surgery
in adults are presented in Fig. 4.
Discussion
The incidence of aneurysms is rather low in children
compared with adults and constitutes 0.5–4.6% of all
aneurysm cases [7, 10, 18, 19, 20]. The relatively high
incidence rate of paediatric aneurysms in our patient
population can be explained by the fact that our depart-
ment is the only paediatric neurosurgical centre in a
39
large area, with a catchment population of 7 million in-
habitants.
The male-to-female ratio (3.25 : 1) in our patients
confirms the observations of other authors. In the study
of Meyer et al. [18] the ratio was 2.8 : 1. In many other
studies this predominance was also evident [7, 10, 12,
19]. The female predominance in adult patients with an-
eurysm may be connected to the decreased level of oes-
trogen in this group. The decreased level of oestrogen re-
sults in a decrease of collagen, which plays an important
part in maintaining the strength of the vessel wall [16].
We noted the coexistence of polycystic kidney in only
1 case. Ostergaard et al. also found polycystic kidney in
1 case out of 43 analysed [19]. Other authors did not re-
port polycystic kidney [7, 18, 20].
Systemic arterial hypertension was noted in 1 (5.9%)
of our patients, in whom we also diagnosed adipose-gen-
ital syndrome. In the series reported by other authors the
incidence of arterial hypertension was very low [19].
On analysis of our patient population we were also
unable to confirm the more common occurrence of posi-
tive familial history and aortal coarctation in cases with
cerebral aneurysm. This fact was also noted by other au-
thors [7, 18, 19, 20, 22]. Heiskanen [10] reported the co-
arctation of the aorta associated with cerebral aneurysm
only in 1 case in the paediatric population.
In 1 case we found no SAH, but only the symptoms
of anorexia. We did not find the same symptomatology
in the patients of other authors. Gerosa et al. [7] reported
1 case of ACoA aneurysm with concomitant pituitary
dysfunction and amenorrhoea.
More adults than children were in a poor neurological
condition at the time of admission. In our material 25%
of the children admitted were classed as grade IV and V
according to the Hunt-Hess scale and about 69% of pa-
tients were in a good neurological state (grades I and II
on the Hunt-Hess scale). In the adult group the corre-
sponding proportions were, respectively, 68% and about
11%. In the study of Ostergaard et al. [19] only 58% of
children admitted were classed as grade I and II accord-
ing to the GCS, that is in a good clinical condition.
Gerosa et al. found only 2 patients (about 15%) scored as
grade IV on the Hunt-Hess scale on admission, and an
intracerebral haematoma was present in both these cases
[7].
In children we found that most of the aneurysms arose
from the ACoA and the ICA, and only in 1 case from the
MCA. These localisations are very different from those
found in adults. The common localisation of aneurysms
on the ACoA and on the bifurcation of the ICA has also
been observed by other authors [7, 10, 12, 19, 22]. How-
ever, in some series an appreciable number of MCA an-
eurysms was noted [7, 12, 19].
We did not find posterior circulation aneurysms.
Gerosa et al. also found no posterior circulation aneu-
rysms [7]. In the large series of Pasqualin et al. posterior
40
circulation aneurysm was found only in 3% of cases
[20]. Similarly, in the material of Heiskanen only 1 case
of posterior circulation aneurysm was observed [10]. The
incidence of posterior circulation aneurysm in the large
series of Hourihan and al. was also very low [12]. In the
study of Ostergaard the posterior circulation aneurysms
make up 6% of all aneurysms [19]. In the series of other
authors the number of posterior circulation aneurysms is
very high, found in 35–46% [18, 22].
In contrast to our study, giant aneurysms were reported
in the literature quite often. The proportion of giant aneu-
rysms in other series approached 20–31% [7, 17, 22]. In the
series of Meyer giant aneurysms made up as much as 54%
of all cases [18]. Conversely, Heiskanen [10] did not find
any giant aneurysms at all, and Ostergaard et al. [19] report-
ed only 2 cases of such aneurysms in his population (4.5%).
The giant aneurysms commonly occur in infants [18].
In the report of Lena and Choux, two of four giant aneu-
rysms were found in infants [17]. As surgery of giant an-
eurysms is still very dangerous, the endovascular tech-
nique seems to be the method of choice in such cases
and has been performed with good results [15, 17].
We found only 1 case of multiple aneurysm. The mal-
formation was associated with hypertension and adipose-
genital syndrome in this case. Compared with adults the
incidence of multiple aneurysm is very low in children.
In the patient group of Heiskanen there were no cases of
multiple aneurysm [10]. In the study of Hourihan et al.
only 9.2% of children had multiple aneurysm [12].
Ostergaard et al. reported that only 4 children had diag-
nosed arterial hypertension before admission. Three of
them had multiple aneurysm [19]. Our study also con-
firms that hypertension in children coexists with multiple
aneurysm. The rare incidence of MCA aneurysms, multi-
ple aneurysms and their coexistence with arterial hyper-
tension suggests a different pathogenesis of aneurysm in
childhood. In the congenital theory suggested by Forbus
the developmental deficits in internal elastic membrane
and muscular layer were to be responsible for the devel-
opment of aneurysm [5]. On the other hand, Stehbens
claimed that the acquired nature of this lesion was con-
nected rather with hypertension than with developmental
defects of the vessel wall [21]. Fergusson confirmed this
theory in his excellent experimental work [3].
In our material the rebleeding rate was very high
(60%) in the paediatric group compared with adults
(27%). Ostergaard et al. [19] showed a 13% rebleeding
rate in his study of a paediatric population.
References
1. Bohmfalk G, Story J, Wissinger J, 2. Evans W (1942) An encephalographic
Brown W (1978) Bacterial intracranial ratio for estimating ventricular enlarge-
aneurysm. J Neurosurg 48:369–382 ment and cerebral atrophy. Arch Neu-
rol Psychiatry 47:931–937
It is difficult to compare our results with those in oth-
er reports, because the periods of observation have been
longer in the other works. The techniques of surgery
have changed radically since the 1960s and 1970s. The
surgical mortality reported from the premicrosurgical era
was extremely high. The timing of surgery has also
changed in the case of aneurysmal SAH.
In our series the outcome was better in children than
in adults. The clinical outcome also appeared to be sig-
nificantly better in children than in adults in the studies
of others, especially in the case of patients who were in
good neurological condition on admission [10, 11, 19,
20]. The reversibility of neural injury in young patients
and the low incidence of vasospasm in this age group
could be the explanation for this [10, 19, 20]. The low
incidence of hydrocephalus in the paediatric group could
also have some effect on outcome. This has also been re-
ported in other studies [19, 20].
Our results seem to confirm that early surgery is indi-
cated in the cases of aneurysmal bleeding in childhood.
The number of patients operated on early in the current
study is very low, but the results of surgery obtained are
very good. Early surgery is recommended because of
better tolerance of surgery and the greater risk of re-
bleeding in children than in adults [19, 20].
Epilepsy was occasionally found in children after sur-
gery in our series. In other paediatric series the occur-
rence of epilepsy was infrequent [10]. However, in the
series of Ostergaard et al. the incidence of postoperative
epilepsy was very high. In this material 7 patients [24%]
[19] developed epilepsy in spite of receiving preventive
anticonvulsive therapy.
Conclusions
1. In contrast to the definitive female predominance
found in adults, in paediatric cases of intracranial saccu-
lar aneurysms a male predominance is confirmed. We
did not confirm any predominance of posterior cerebral
circulation aneurysm and giant aneurysm in children.
The low incidence of aneurysms arising from the MCA
and of multiple aneurysms was also shown in our study.
2. The great risk of rebleeding in children and the fact
that children tolerate the surgery very well inclines us to
operate on these patients as soon as possible.
3. Ferguson G (1972) Physical factors in
the initiation, growth and rupture of
human intracranial saccular aneurysms.
J Neurosurg 37:666–677

4. Fisher C, Kistler J, Davis J (1980)
Relation of cerebral vasospasm to sub-
arachnoid hemorrhage visualized by
computed tomographic scanning.
Neurosurgery 6:1-8
5. Forbus W (1930) On the origin of mili-
ary aneurysms of the superficial cere-
bral arteries. Bull Johns Hopkins Hosp
47:239–284
6. Frazee J, Cahan L, Winter J (1980)
Bacterial intracranial aneurysms.
J Neurosurg 53:633–641
7. Gerosa M, Licata C, Fiore D, Iraci G
(1980) Intracranial aneurysms of child-
hood. Child’s Brain 6:295–302
8. Grode M, Saunders M, Carton C
(1978) Subarachnoid hemorrhage sec-
ondary to ruptured aneurysms in in-
fants. J Neurosurg 49:898–902
9. Hahn F, Rim K (1976) Frontal ventric-
ular dimensions on normal CT. AJR
Am J Roentgenol 126:593–596
10. Heiskanen O (1989) Ruptured intracra-
nial arterial aneurysms of children and
adolescents. Surgical and total manage-
ment results. Child’s Nerv Syst
5:66–70
11. Herman J, Rekate H, Spetzler R
(1991–1992) Pediatric intracranial an-
eurysms: simple and complex cases.
Pediatr Neurosurg 17:66–73
12. Hourihan M, Gates P, McAllister V
(1984) Subarachnoid hemorrhage in
childhood and adolescence. J Neuro-
surg 60:1163–1166
13. Hunt W, Hess R (1968) Surgical risk as
related to time of intervention in the re-
pair of intracranial aneurysms. J Neu-
rosurg 28:14–19
14. Jennett B, Bond M (1975) Assessment
of outcome after severe brain damage.
A practical scale. Lancet I:480–484
15. Kanaan I, Lasjaunias P, Coates R
(1995) The spectrum of intracranial an-
eurysms in pediatrics. Minim Invasive
Neurosurg 38:1–9
16. Kongable G, Lanzino G, Germanson T,
Truskowski L, Alves W, Torner J, Kas-
sell N (1996) Gender-related differ-
ences in aneurysmal subarachnoid
hemorrhage. J Neurosurg 84:43–48
41
17. Lena G, Choux M (1985) Giant intra-
cranial aneurysms in children 15 years
old or under. Case reports and literature
review. J Pediatric Neurosci 1:84–93
18. Meyer F, Sundt T, Fode N, Morgan M,
Forbes G, Mellinger J (1989) Cerebral
aneurysms in childhood and adoles-
cence. J Neurosurg 70:420–425
19. Ostergaard J, Voldby B (1983) Intra-
cranial arterial aneurysms in children
and adolescents. J Neurosurg
58:832–837
20. Pasqualin A, Mazza C, Cavazzani P,
Scienza R, DaPian R (1986) Intracrani-
al aneurysms and subarachnoid hemor-
rhage in children and adolescents.
Child’s Nerv Syst 2:185–190
21. Stehbens W, Phil D (1989) Etiology of
intracranial berry aneurysms. J Neuro-
surg 70:823–831
22. Storrs B, Humphreys R, Hendrick E,
Hoffman H (1982) Intracranial aneu-
rysms in the pediatric age-group.
Child’s Brain 9:358–361