Tumor bleeding from a de novo aneurysm associated with optic glioma

Aneurysms in children are rare and potentially devastating lesions. The authors report the case of a 16-year-old girl with a complicated medical history related to a chiasmal glioma diagnosed at 18 months of age. She had previously received multiple modalities of radiation treatment, including external beam, proton therapy, and Gamma Knife. She presented with hemorrhage centered in the tumor and extending into the ventricular space. There was no subarachnoid blood. Magnetic resonance imaging demonstrated the hemorrhage and tumor anatomy. Magnetic resonance angiography revealed an aneurysm at the internal carotid artery bifurcation, but the lesion was more clearly delineated on CT angiography. A comparison MR imaging study obtained 6 months earlier, even in retrospect, did not show evidence of an aneurysm. This case illustrates the salient point that the clinician must search for vascular lesions in the patient with spontaneous "tumor bleeding," especially if that patient has risk factors for aneurysm formation. The authors also suggest that a CT angiogram is better at radiographically demonstrating an intratumoral aneurysm than an MR angiogram in this scenario.     

Splenic artery aneurysm: a diagnostic challenge in the setting of extensive portal venous collaterals

We present a 16-year-old boy with autoimmune liver disease and longstanding portal hypertension in whom a CT arteriogram demonstrated a large aneurysm arising from the distal, extra-parenchymal portion of the splenic artery. Because of its location adjacent to multiple venous collaterals, the aneurysm was indistinguishable from splenic varices on initial imaging with Doppler sonography and on portal venous-phase CT. There is an increased risk of rupture of splenic artery aneurysms in the post-liver transplant period, with high associated mortality, and therefore diagnosis of splenic artery aneurysm prior to liver transplantation is clinically important. It is quite possible that the diagnosis of splenic artery aneurysm in this case would have been missed in the absence of dedicated arterial-phase imaging. As radiologists strive to reduce radiation exposure in children, this case highlights a potential diagnostic pitfall of both Doppler sonography and venous or single-acquisition arterial/venous-phase CT angiogram in children with venous collaterals and an undiagnosed splenic artery aneurysm.     

Occult aneurysmal hemorrhage in a child. Case report and literature review

A unique case of the diagnosis and treatment of a ruptured cerebral aneurysm in a 5-year-old male is presented. The child presented with subarachnoid hemorrhage, and initial CT imaging indicated a right posterior communicating artery aneurysm. Cerebral angiography and MRI/MRA were normal. Repeat cerebral angiogram 3 weeks later was also normal. Sixteen months later, an angiogram was performed to evaluate a subtle carotid bruit found on exam. A carotid bifurcation aneurysm pointing inferior and posterior was found. Craniotomy to clip the aneurysm was performed, and marked adherent gliosis around the lesion was found, supporting the fact that this was the causal lesion of his bleed in the past. Albeit a single case report, it underscores the need for very long-term follow-up and evaluation of idiopathic pediatric subarachnoid hemorrhage.     

Septal aneurysm with associated anomalies

A 15-year-old boy had a history of a functional systolic murmur with systolic and diastolic murmurs and radiological evidence of left ventricular hypertrophy. The angiocardiogram demonstrated an aneurysm of the membranous septum, bicuspid aortic valve, dilatation of the left subclavian artery and left common carotid artery. Echocardiography showed a holosystolic prolapse of the mitral valve with mitral insufficiency and a bicuspid aortic valve with insignificant incompetence of the aortic valve. Classical TM mode echocardiography did not show an aneurysm of the membranous septum.     

Renal artery aneurysm in a hypertensive child treated by percutaneous coil embolization

A 16-year-old boy was admitted to our hospital with uncontrolled hypertension. A left renal artery aneurysm was detected on colour Doppler US and CT. Renal arteriography demonstrated the aneurysm and focal renal parenchymal areas of decreased perfusion. The renal artery aneurysm was successfully treated by transcatheter coil embolization.     

Mycotic cervical lymphadenitis following oral mucositis in children with leukemia

Four children developed mycotic cervical lymphadenitis while receiving cytotoxic chemotherapy for acute leukemia. Neutropenia, oral mucositis, and broad-spectrum antibiotic administration preceded the appearance of lymphadenitis in each case. Enlarged tender cervical lymph nodes of mycotic origin were not clinically distinguishable from lymphadenitis of bacterial or viral origin. Although cervical lymphadenitis was the initial clinical manifestation of deep fungal infection, computerized tomography of the chest and abdomen subsequently demonstrated asymptomatic pulmonic, splenic, or hepatic lesions characteristic of fungal abscesses in all four children. These findings demonstrate the importance of microbiologic identification of the etiologic agents of cervical lymphadenitis following mucositis and neutropenia in children with leukemia.     

Stent-assisted coiling treatment of pediatric traumatic pseudoaneurysm resulting from tumor surgery

Background: Traumatic intracranial pseudoaneurysms in children are typically the result of blunt or penetrating head injury. There are isolated reports of pseudoaneurysm as the result of intracranial aneurysm surgery in both adults and children. Treatment of these lesions, both surgically and endovascularly, can be complicated due to the known variability of arterial wall thickness in traumatic pseudoaneurysms. Case Report: We describe a child who underwent successful craniopharyngioma resection following staged surgical procedures. Follow-up imaging 8 months after the operation demonstrated an enlarging pseudoaneurysm of the left supraclinoid carotid artery. The lesion was successfully treated with stenting of the vessel and coil placement between the stent and the aneurysmal segment of the artery. Follow-up angiographic imaging 6 months later revealed complete obliteration of the aneurysm and normalization of the carotid artery lumen. Conclusion: To our knowledge, this is the first report of a pseudoaneurysm secondary to a surgical intervention in childhood that was treated with stent-assisted coiling. This strategy of vascular reconstruction is increasingly used in adults and appears safe to implement in the pediatric population. However, the long-term outcomes and the value of using an antiplatelet regimen in this young population are still to be determined.     

Spontaneous thrombosis of giant cavernous internal carotid artery aneurysm in a neonate. Case report and review of the literature

Neonatal intracranial aneurysms are rare, with only 20 cases being reported in the literature. No case of spontaneous resolution of a giant intracranial cavernous segment aneurysm in a neonate is reported till date. The authors describe a 3-week-old male child who presented with a left-sided tonic seizure episode and was diagnosed as having a right-sided giant cavernous internal carotid artery aneurysm. The aneurysm was found to be totally thrombosed on angiography done before planning definitive treatment. The child is doing well at 2 years of follow-up. Spontaneous thrombosis, an exceptionally rare but fortunate outcome in a rare case of giant neonatal internal carotid artery aneurysm, has led the authors to report this case. The need of repeat imaging or angiography should be considered to rule out this rare outcome, more so if there is any delay between the ictus and treatment.     

Arterial tortuosity and aneurysm in a case of Loeys-Dietz syndrome type IB with a mutation p.R537P in the TGFBR2 gene

We report a 13-year-old girl with Loeys-Dietz syndrome (LDS) caused by a known transforming growth factor beta receptor II (TGFBR2) gene mutation, who developed aortic root dilatation and saccular aneurysm of the internal carotid artery. LDS is a rare, autosomal dominant aortic aneurysm syndrome with multisystem involvement. The disease is typically characterized by the triad of arterial tortuosity and aneurysms, hypertelorism, and bifid uvula/cleft palate. The characteristic LDS symptoms observed in the reported case included craniofacial dysmorphism (hypertelorism, cleft palate, blue sclerae, malar hypoplasia, retrognathia), skeletal deformities (scoliosis, talipes equinovarus, pectus deformity, arachnodactyly), congenital heart defects (patent ductus arteriosus, PDA), and arterial tortuosity and aneurysms. Molecular genetic testing revealed a heterozygous mutation (c.1610 G>C, p.R528C) in the serine-threonine kinase domain of the TGFBR2 gene. Magnetic resonance (MR) angiography showed aortic dilatation, tortuosity of bilateral supraaortic arteries, and saccular aneurysm on the right cervical internal carotid artery. LDS resembles Marfan-related disorders (Marfan, Shprintzen-Goldberg and vascular Ehlers-Danlos syndrome), but arterial tortuosity and aneurysms are characteristic for LDS, so a timely diagnosis of LDS is important for early diagnosis and intervention of aneurysms to prevent vascular events. Here, we describe a LDS patient who presented with arterial tortuosity and saccular aneurysm.     

Magnetic resonance imaging diagnosis of a cerebral aneurysm in an infant. Case report and review of the literature

A posterior cerebral artery aneurysm presented as a seizure disorder in a 7-week-old infant. A small hemorrhage in the posterior thalamus was seen on CT scan. However, magnetic resonance imaging (MRI study) demonstrated an aneurysm and appropriate therapy was carried out. The incidence, natural history, etiology, and surgical treatment of these lesions are reviewed, and the usefulness of MRI in their diagnosis is emphasized.     

Vertebral artery aneurysm--a unique hazard of head banging by heavy metal rockers. Case report.

A 15-year-old drummer in a neighborhood rock music band suffered a traumatic true aneurysm of the cervical vertebral artery from violent head and neck motion. He underwent excision of the aneurysm after distal and proximal ligation of the artery. He is neurologically normal 1 year after surgery. The mechanisms of injury caused by extremes of cervical motion, as well as 5 previously reported cases of extracranial vertebral artery aneurysm from closed trauma, are discussed. Excision of vertebral artery aneurysms in patients with emboli from a mural thrombus is recommended. The consequences of vertebral artery ligation and the indications for distal reconstruction are discussed.     

Horseshoe lung associated with left-lung hypoplasia,left pulmonary artery sling and bilateral agenesis of upper lobe bronchi

Horseshoe lung, a rare congenital anomaly, is almost always associated with unilateral (usually right-sided) lung hypoplasia, and, in most cases, in conjunction with the scimitar syndrome. We present an 8-month-old boy with horseshoe lung associated with left-lung hypoplasia, left pulmonary artery sling and bilateral agenesis of the upper lobe bronchi, diagnosed by multidetector CT (MDCT) imaging. The study also revealed an anomalous origin of the left vertebral artery as the last branch of the aortic arch, distal to the left subclavian artery, and an anomalous origin of the left common carotid artery from the brachiocephalic trunk. A hemivertebral anomaly of the seventh cervical vertebra was incidentally detected. MDCT with high-quality multiplanar and three-dimensional reconstructions is a noninvasive and rapid technique for detecting the complex combination of vascular, tracheobronchial and parenchymal anomalies, and any potential bone anomalies, in one imaging study.     

Occult carotid pseudoaneurysm following streptococcal throat infection

Pseudoaneurysm of the internal carotid artery (PAICA) is a rare complication of neck space infection. An 8-year-old girl presented with odynophagia (painful swallowing), trismus and left peritonsillar swelling. Abscess was suspected, but aspiration was dry. The PAICA was diagnosed on computed tomography. The aneurysm and involved left internal carotid artery were occluded endovascularly. She has made an uneventful recovery.     

Cerebral arteriovenous malformation in a neonate: treatment by embolisation.

A neonate with an aneurysm of the vein of Galen was treated by embolisation using Giant-urco coils. Doppler ultrasound examination showed that blood flow in the internal carotid artery decreased while that in the pericallosal artery increased after occlusion, suggesting a ''steal phenomenon'' with blood directed preferentially towards the aneurysm.     

Cervical thymic cysts: CT appearance of two cases including a persistent thymopharyngeal duct cyst

The differential diagnosis of cervical cysts in children includes common entities such as branchial cleft cysts, thyroglossal duct cysts, and cystic hygromas. Congenital thymic cysts are uncommon and often misdiagnosed as either branchial cleft cysts or cystic hygromas. However, they may have an appearance on CT that can be characteristic. The course of the descent of embryologic thymic tissue in the neck to the mediastinum indicates the potential site of deposition of an ectopic cervical thymic cyst. In a child, a cystic lesion that has an intimate relationship to the carotid sheath is likely to be a thymic cyst. Of the approximately 100 cases of vestigial cervical thymus or thymic cysts that have been reported in children, only 5 cases of a persistent thymopharyngeal duct cyst have been described [1–5]. In two of these five, the persistent thymopharyngeal duct cyst was demonstrated by CT [1, 2]. We report one additional case of a cervical thymic cyst and one case of a persistent thymopharyngeal duct cyst both depicted by CT.     

Ulnar artery aneurysm causing palmar mass in 5-month-old girl

A 5-month-old previously healthy girl presented to the emergency department with a large palpable nontender mass in the hypothenar soft tissues of her left hand. US revealed a well-demarcated nonvascular soft tissue mass. Subsequent MR imaging showed a rim-enhancing mass with heterogeneous intrinsic signal characteristics. Abscess and necrotic tumor were the primary considerations. Surgery demonstrated a thrombosed aneurysm continuous with the ulnar artery system. The aneurysm was resected and the ulnar artery was ligated at the wrist.     

Cervical spine and temporomandibular joint arthritis in a child with Kawasaki disease

Severe neck pain, stiffness, and torticollis in a child with Kawasaki disease commonly represent aseptic meningitis or lymphadenitis. Here we present an unusual case of severe cervical spine and bilateral temporomandibular joint arthritis in a 5-year-old boy with a relapse of Kawasaki disease and coronary artery ectasia. The patient had a favorable response to a second course of intravenous immunoglobulin G and indomethacin therapy, with complete resolution of his symptoms.     

Mycotic intracavernous carotid artery aneurysm in childhood

A mycotic aneurysm of the intracavernous carotid artery which presented in an apparently classical manner during childhood, and was treated by surgery is described. The outcome was satisfactory. The literature relating to this rare condition is reviewed.     

Aneurysm of the superficial femoral artery in an infant

An isolated arterial aneurysm in childhood is extremely rare. We report a 1-year-old girl with an aneurysm of the right superficial femoral artery, presenting as an asymptomatic mass of the thigh. The aneurysm involved the whole superficial femoral artery (9 cm in length), and surgical treatment would have required replacement of the affected artery. Conservative treatment was chosen, influenced by the patient's rapid growth at that time. Non-invasive, 3-D contrast-enhanced magnetic resonance angiography (MRA) was useful as an alternative to conventional angiography for detailed evaluation of the femoral arteries, including the aneurysm.     

Congenital aneurysm presenting as peripheral facial paresis

The incidence of intracranial aneurysms in infancy is relatively rare. They are infrequent in children less than 1 year old, and are an exception in the neonatal period. They usually originate in the internal carotid artery bifurcation, posterior circulation and seldom in the territory of the distal middle cerebral artery distribution. Infants often present with nonspecific symptoms: irritability, lethargy, vomiting, seizures and coma. Sometimes, they may present with unexpected clinical symptoms such as peripheral facial palsy. Subarachnoid hemorrhage is the most frequent presentation in this kind of aneurysms. Intracerebral hematoma is unusual. We present the case of a 10-week-old child harboring a middle cerebral artery aneurysm. To our knowledge, this is the first case of an aneurysm presenting as a peripheral facial paresis in a pediatric patient.