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.
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 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.