Abstract Number ‐ 139: Endovascular Management of Intracranial Pediatric Traumatic Pseudoaneurysms: A Case Series and Systematic Review
Authors: Brake Aaron , Fry Lane , Brake Aaron , Heskett Cody , Lei Catherine , De Stefano Frank , Chatley Kevin , Peterson Jeremy , Ebersole Koji 
Published: April 2023

Introduction
Intracranial pseudoaneurysms (IPA) are rare and potentially life‐altering lesions. Although IPAs represent less than 1% of all intracranial aneurysms, they account for more than 19% of pediatric intracranial aneurysms. The goal of this study was to systematically review the management and outcomes of pediatric patients who developed pseudoaneurysms following head trauma.

Methods
Following PRISMA guidelines, a systematic literature review was performed using PubMed, EMBASE, OVID Medline and Web of Science databases from date of database inception to May 2022. Studies were selected based on predetermined inclusion and exclusion criteria. Simultaneously, a retrospective analysis was conducted on pediatric patients who underwent endovascular evaluation and treatment for intracranial pseudoaneurysms originating from head trauma at a single institution.

Results
A total of 221 articles were identified in our review, 51 studies met inclusion criteria. A total of 80 patients were treated for 81 intracranial traumatic pseudoaneurysms, including 5 cases from our institution, with 46 males, 28 females, and a mean age of 9.90 years (range 0.04 ‐18 years). 71 total pseudoaneurysms were the result of external trauma while 10 resulted from iatrogenic trauma. Vessels of the anterior circulation were injured in 75.3% (61/81) of cases. Posterior circulation was involved in 24.7% (20/81) of cases. The internal carotid artery was the most impacted vessel at 45.7% (37/81). The next most common territory injured was the anterior cerebral artery and its distal branches, including the pericallosal and callosomarginal arteries, at 17.3% (14/81). The basilar artery was the third most affected artery, representing 12.3% (10/81) of cases. Hemorrhage was present in 41 patients (51.3%). Subarachnoid hemorrhage was present in 33.8% (27/80), while intracerebral hemorrhage and interventricular hemorrhage (IVH) were present 22.5% and 18.8% of cases, respectively. A total of 92 procedures were performed, with only 8 patients requiring more than 1 procedure for treatment. Only 1 patient required more than 2 procedures. Aneurysm embolization, parent vessel occlusion, parent vessel reconstruction, and aneurysm trapping were performed in 31.5%, 22.8%, 43.5%, and 2.2% of cases, respectively. The intraoperative complication rate was 3.26%, all were ischemic in nature. Two of these ischemic complications resulted focal neurological deficits from parent vessel occlusion. Aneurysm recurrence was encountered in 7 cases, with 6 of these resulting from coil embolization. In patients treated with parent vessel reconstruction, 1 aneurysm ruptured post‐treatment and 2 patients experienced in‐stent thrombosis. Overall, 83.8% of patients had a good neurological outcome and 77.8% of aneurysms were completed occluded on follow‐up imaging.

Conclusions
The development of pseudoaneurysms in the pediatric population are an important consideration in cases of traumatic head injuries or iatrogenic vessel trauma. These lesions grow rapidly and can carry a high risk of morbidity and mortality if left untreated. Our findings suggest that endovascular treatment of traumatic pseudoaneurysms in the pediatric populations is safe and effective, with high rates of aneurysm occlusion and good neurological outcome. Overall, complications rates are low. Aneurysm embolization can carry an increased risk of aneurysm recurrence.