KidsMD Health Topics

Brain Aneurysms


  • Angiogram showing a high-resolution view of an aneurysm. 

     

     

     

     

     

     

     

     

     

     

     

    Sometimes the wall of an artery in the brain develops a weak spot, and the vessel bulges outward. This is known as a cerebral aneurysm. Aneurysms are sometimes found incidentally, during a brain scan for other reasons, but unfortunately, they more often come to light when they burst, causing bleeding in the brain.

    Cerebral aneurysms are very rare in children and may not cause any symptoms until they burst, or rupture. Any of these symptoms may indicate a ruptured aneurysm:

    • an unusually severe headache (the most common symptom)
    • vomiting
    • stiff neck
    • sensitivity to light
    • weakness
    • neurologic impairment
    • seizures
    • loss of consciousness

     

    How we care for cerebral aneurysms at Boston Children's Hospital

     

    Ruptured brain aneurysms can be life-threatening. Once we’ve stabilized the child in the intensive care unit, we treat them immediately to minimize damage to the brain. If the aneurysm has not burst, our approach is based on careful imaging to determine the aneurysm’s location and size and the risks of treatment, as well as the child’s overall health. If an aneurysm is small and imaging studies show nothing worrisome, treatment might pose more of a risk than the aneurysm itself, and the best course of action might be careful observation. The Cerebrovascular Surgery and Interventions Center has pioneered the practice of performing an additional imaging angiogram after treatment, before waking the child from anesthesia, to verify that the aneurysm has been closed off.

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    Blood flows normally after repair of a ruptured aneurysm with embolization coils (see in the original image at left and next to the blue arrow at right). 

     

     

    Although aneurysms can occur with no known cause, aneurysms in children are commonly associated with severe head trauma, connective tissue disorders and infection.

     

    A tendency to develop aneurysms can sometimes run in families or can occur as part of a broader genetic disorder, such as Marfan syndrome, Ehlers-Danlos syndrome or polycystic kidney disease. If your child has not had genetic testing, we may refer her to a geneticist at Boston Children’s.

     

    Read more about how aneurysms are diagnosed and treated by clicking the Tests and Treatments tabs.

  • We use a variety of imaging technologies to diagnose aneurysms, understand their anatomic location and structure, and assess the status of the surrounding arteries and the overall condition of the brain. Specific tests may include:

     

    CT (computed tomography) uses x-ray equipment and powerful computers to create detailed, cross-sectional images (often called “slices”) of the head, neck and brain. Most CT scans are performed in seconds, although it can take 10 minutes or longer to position the child correctly for the exam. It is noninvasive, highly accurate and provides more detailed images of the bony and soft tissue structure of the head and neck than conventional x-rays. Read more.

    Magnetic resonance imaging (MRI) uses a strong magnetic field, radio waves and advanced computer processing to produce 2- and 3-dimensional images of the head, neck and brain. MRI is noninvasive and is critical in helping to evaluate conditions that may not be assessed adequately with other imaging technologies. 

    • MRI uses no x-rays or radiation exposure of any kind.
    • Sometimes a contrast dye is injected through an IV during scanning to get a better image.
    • The child must lie still inside an MRI scanner—a large, tube-shaped magnet—sometimes requiring her to be sedated.
    • In response to the magnetic field and the radio waves of the scanner, water molecules in the body give off tiny pulses of energy. A computer constructs detailed images out of these pulses, showing the head, neck and brain anatomy. Read more.

    Cerebral angiography, sometimes called cerebral arteriography or catheter angiography, produces the most detailed images of the blood vessels of the neck, head and brain, using live x-rays.

    • The neuroradiologist or neurointerventionalist inserts a small needle into the femoral artery in the groin. Then, the specialist introduces a soft, thin wire that guides a catheter up to the arteries leading to the brain region containing the aneurysm.
    • A special dye, injected through the catheter, allows the radiologist to more clearly see the aneurysm, as well as the pattern of arteries and veins surrounding it. The catheter also can be used to deliver treatments from within the vessels.
    • Cerebral angiography can take from 30 minutes to several hours, and in almost all children, it is performed under general anesthesia. After the angiogram, patients lie flat for four hours in the recovery room; during this time, with their parents close by, they can sleep, watch TV or use a handheld device.
    • We ask patients not to do vigorous exercise for several days after the procedure, although they can return to school as soon as they are ready to do so. Read more about angiograms.

    CT angiography (CTA) uses the technology of a conventional CT scan, along with an injected special dye (known as contrast) to generate images of the blood vessels of the upper chest, neck and brain.

    • CTA generates images somewhat similar to those seen with cerebral catheter angiography, but since the dye is injected into a vein through a standard IV, rather than into an artery, CTA is less invasive.
    • During the test, the child must lie still on a table that slides slowly through a donut-shaped device. A computer constructs 3D images of the blood vessels from the CTA images.
    • Young children may need sedation to keep them still.
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    Angiogram (left) showing the coils within an aneurysm

     

     

     

     Fortunately, children’s brains have a remarkable ability to recover from injury, so even children with a burst (ruptured) aneurysm often have an excellent prognosis. At Boston Children’s Hospital, we maintain a comprehensive database of all the children we treat for aneurysms to guide our practice in a truly evidence-based fashion.

    A ruptured aneurysm is a medical emergency. We immediately assess how much damage the child’s brain has sustained, admit the child to the intensive care unit for monitoring, and plan for the optimal mode of treatment as soon as we can safely do so.  

    In all children with an aneurysm, we conduct careful imaging studies to visualize the aneurysm and determine the status of the surrounding arteries and the overall condition of the brain. If the aneurysm has not burst, the care team may decide that it is best to “watch and wait.”

    Generally, one of two procedures is used to treat both ruptured and unruptured aneurysms. After treatment, we perform an additional angiogram, before waking the child from anesthesia, to verify that the aneurysm has been closed off.


    Surgical clipping

    Clipping is exactly as it sounds. A neurosurgeon exposes the aneurysm and the parent artery and, guided by a microscope, places a tiny metal clip at the base of the aneurysm. The clip prevents blood from filling the aneurysm and closes it off from the circulation, but allows the artery to stay open. The clip is left inside the brain.

    Endovascular coiling

    Endovascular coiling is a minimally invasive, catheter-based technique for closing off a brain aneurysm. Guided by x-ray imaging, a catheter (a thin, flexible tube) is advanced through the arteries in the brain until the tip is inside the aneurysm. A smaller microcatheter, threaded through this catheter, then inserts specially designed metal coils. The coils unfold into a 3D shape, closing off and packing the aneurysm from the inside, while keeping the parent artery open.

     

    Coiling is done under general anesthesia by one of our neurointerventional radiologists with the help of specialized anesthesiologists, nurses and technologists. To begin the procedure, the catheter is inserted into an artery in the child’s groin through a tiny incision. Under x-ray guidance, it is advanced up the aorta (the main artery in the middle of the body) to the target artery.

     

    The neurointerventional radiologist then injects a special contrast solution (a dye) through the catheter to visualize the aneurysm and the affected artery, then threads the second catheter through the first and injects the coils. The team then removes the catheters, places a bandage over the insertion site on the groin and transfers the child to the recovery room or to the ICU for observation. The neurointerventionalist will discuss the findings and results of the procedure in depth with the family as soon as the procedure is over.

     

    Though there are some serious risks, complications from coiling are rare. The procedure does require exposing patients to ionizing radiation (x-rays). Because children are more sensitive to radiation exposure than adults, we have adjusted our equipment and procedures to deliver the lowest possible dose.

     

    Preparation and follow-up for aneurysm treatment

    If your child is scheduled to come to Boston Children’s, you will receive specific information on how to prepare. Because these procedures involve general anesthesia, we usually ask patients to refrain from eating, drinking and sometimes from taking medicines for a certain period of time.

     

    Upon arrival, plan to spend about four hours meeting with nurses, the anesthesiologist and the neurointerventionalist. Children can bring a favorite toy or blanket into the procedure room, and parents can stay close by, in the family waiting area, while procedures are being performed. Parents are welcome to stay with their children in the recovery room, the ICU and the hospital floor rooms afterward.

     

    Most children have no pain or other symptoms with coiling, and recovery is usually rapid. Sometimes, if the situation warrants, we will admit the child to the ICU for several days of observation. Most children leave the hospital within a few days and return for a follow-up office visit within a few weeks. Follow up may be in part through video teleconference for patients who live outside the Boston area.

  • The Cerebrovascular Surgery and Interventions Center at Boston Children’s Hospital conducts ongoing research to improve diagnostic and therapeutic approaches to brain aneurysms in children.

    3D printing to model brain and vascular anatomy

    Orbach 3D modelWorking with the Simulator program at Boston Children’s, Edward Smith, MD, and Darren Orbach, MD, PhD, are pioneering the creation of precision 3D models of patients’ brains and blood vessels, using actual data from their brain scans. These models, created with special digitally guided printers, can be used to rehearse tricky operations and catheter-based procedures in advance. Read more.

     

     

     

    CVD Dynamic Database

    Our comprehensive patient database, representing the largest experience with pediatric cerebrovascular disease (CVD) in the world, provides rich source material for ongoing studies of brain aneurysm and other CVD conditions. The database allows us to track long-term patient outcomes, compare the results of different procedures, evaluate newly adopted interventions and improve our quality of care.

    Imaging safely

    New techniques have dramatically improved safety and reduced children’s radiation exposure during diagnostic and neurointerventional (catheter-based) procedures for aneurysm. Working closely with fluoroscopy equipment vendors to adjust and optimize technical factors, we have demonstrated that it is possible to achieve high-quality imaging at low radiation doses. Read more.

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