Large Intracranial Aneurysms in a 2-month-old Female: A Rare Occurrence with Serious Anesthetic Challenges

INTRACRANIAL aneurysms in the pediatric population are rare and account for 0.005 to 2% of all diagnosed aneurysms.¹  The accompanying image illustrates two rapidly expanding intracranial arterial aneurysms of the left posterior cerebral artery (A) and left internal carotid artery (B) in a 4.7-kg, 2-month-old, full-term female with SCALP (sebaceous nevus syndrome, CNS malformations, aplasia cutis congenita, limbal dermoid, and pigmented nevus) syndrome.

Intracranial aneurysms in pediatric patients, particularly neonates, present significant airway and hemodynamic challenges for the anesthesiologist.²  Difficult airway management in a neonate may lead to hypoventilation with subsequent hypercarbia and acidosis, which may contribute to unwanted augmentation of cerebral blood volume. Hypoxia during such periods also may increase intracranial pressure by vasodilatation and cerebral edema. Meticulous hemodynamic stability, particularly during induction, is challenging, and any lability in blood pressure may compromise the integrity of the arterial wall, leading to increased risk of rupture or enlargement of the intracranial aneurysm. The use of narcotics in addition to induction agents can be useful to blunt any untoward hemodynamic responses during induction. In addition, the potential for cerebral vasospasm is a significant concern. The incidence of vasospasm resembles that of adult patients undergoing intracranial aneurysm coiling; however, based on the limited available information, pediatric patients seem to better tolerate cerebral vasospasm with better outcomes. Prophylaxis and therapy throughout the perioperative period may include maintenance of cerebral perfusion pressure, normovolemia, and administration of calcium channel blockers.³