Introduction: Cerebral aneurysms are rare in the pediatric population, making a definitive treatment algorithm difficult. Microsurgical clipping is the first choice for treatment, though it has its disadvantages. Extracranial-intracranial (EC-IC) bypass, though not commonly performed in the pediatric aneurysm population, has been reported in a small number of studies to be both safe and effective for the management of cerebral aneurysms.

Methods: The authors present an illustrative case of a child with a distal middle cerebral artery (MCA) aneurysm in eloquent territory successfully treated with a superficial temporal artery (STA) to MCA bypass and trapping and review all literature on pediatric EC-IC bypass in the treatment of intracranial aneurysms.

Results: The pediatric population poses unique challenges, including small vessel diameter, graft considerations such as size and long-term impact of graft harvest, future growth of the patient, and longer expected lifetimes. Seven reports totaling 43 EC-IC bypass cases have been reported, in addition to our patient with a successful EC-IC bypass for a giant aneurysm. A conservative assessment of the best available literature dictates that EC-IC bypass for aneurysms in the pediatric population can achieve aneurysm obliteration in 90% or greater of the cases with a long-term complication rate of less than 10%. When considering that a greater proportion of these aneurysms are giant or fusiform these outcomes are equal to or superior to those achieved in the adult population.

Conclusions: Though the majority of reported EC-IC bypasses for aneurysms in the pediatric population have demonstrated to be safe and effective, there still remains a relatively small number of cases performed overall, and most of these cases have relatively short-term follow up data. Further analysis with longer follow up periods is warranted. However, the outcomes reported in the above review suggest that EC-IC bypass can provide a therapeutic benefit for a select pediatric aneurysm population.

Patient Care: By demonstrating that, though rarely performed in the pediatric aneurysm population, EC-IC bypass can be done both safely and effectively.

Learning Objectives: By conclusion of this session, participants should be able to: 1) Understand Extracranial-Intracranial bypass can be performed safely and effectively in a select pediatric aneurysm population

References: 1. Kalani MY, Elhadi AM, Ramey W, et al. Revascularization and pediatric aneurysm surgery. Journal of neurosurgery. Pediatrics. 2014;13(6):641-646. 2. Hetts SW, Narvid J, Sanai N, et al. Intracranial aneurysms in childhood: 27-year single-institution experience. AJNR. American journal of neuroradiology. 2009;30(7):1315-1324. 3. Peron S, Jimenez-Roldan L, Cicuendez M, et al. Ruptured dissecting cerebral aneurysms in young people: report of three cases. Acta neurochirurgica. 2010;152(9):1511-1517. 4. Fulkerson DH, Voorhies JM, Payner TD, et al. Middle cerebral artery aneurysms in children: case series and review. Journal of neurosurgery. Pediatrics. 2011;8(1):79-89. 5. Aryan HE, Giannotta SL, Fukushima T, Park MS, Ozgur BM, Levy ML. Aneurysms in children: review of 15 years experience. Journal of clinical neuroscience : official journal of the Neurosurgical Society of Australasia. 2006;13(2):188-192. 6. Krishna H, Wani AA, Behari S, Banerji D, Chhabra DK, Jain VK. Intracranial aneurysms in patients 18 years of age or under, are they different from aneurysms in adult population? Acta neurochirurgica. 2005;147(5):469-476; discussion 476. 7. Meyer FB, Sundt TM, Jr., Fode NC, Morgan MK, Forbes GS, Mellinger JF. Cerebral aneurysms in childhood and adolescence. Journal of neurosurgery. 1989;70(3):420-425. 8. Huang J, McGirt MJ, Gailloud P, Tamargo RJ. Intracranial aneurysms in the pediatric population: case series and literature review. Surgical neurology. 2005;63(5):424-432; discussion 432-423. 9. Ikeda DS, Marlin ES, Shaw A, Powers CJ. Successful endovascular reconstruction of a recurrent giant middle cerebral artery aneurysm with multiple telescoping flow diverters in a pediatric patient. Pediatric neurosurgery. 2015;50(2):88-93. 10. Jahromi BS, Mocco J, Bang JA, et al. Clinical and angiographic outcome after endovascular management of giant intracranial aneurysms. Neurosurgery. 2008;63(4):662-674; discussion 674-665. 11. Kim LJ, Tariq F, Sekhar LN. Pediatric bypasses for aneurysms and skull base tumors: short- and long-term outcomes. Journal of neurosurgery. Pediatrics. 2013;11(5):533-542. 12. Alamanda VK, Tomycz L, Velez D, Singer RJ. Direct, High-flow Bypass for a Pediatric Giant, Fusiform Aneurysm of the Inferior Division of M2: Case Report and Review of Literature. Journal of surgical technique and case report. 2012;4(1):53-57. 13. Zhang YJ, Barrow DL, Day AL. Extracranial-intracranial vein graft bypass for giant intracranial aneurysm surgery for pediatric patients: two technical case reports. Neurosurgery. 2002;50(3):663-668. 14. Abla AA, Zaidi HA, Crowley RW, et al. Optic chiasm compression from mass effect and thrombus formation following unsuccessful treatment of a giant supraclinoid ICA aneurysm with the Pipeline device: open surgical bailout with STA-MCA bypass and parent vessel occlusion. Journal of neurosurgery. Pediatrics. 2014;14(1):31-37. 15. Lansen TA, Kasoff SS, Arguelles JH. Giant pediatric aneurysm treated with ligation of the middle cerebral artery with the Drake tourniquet and extracranial-intracranial bypass. Neurosurgery. 1989;25(1):81-85. 16. Goedee HS, Depauw PR, vd Zwam B, Temmink AH. Superficial temporal artery-middle cerebral artery bypass surgery in a pediatric giant intracranial aneurysm presenting as migraine-like episodes. Child's nervous system : ChNS : official journal of the International Society for Pediatric Neurosurgery. 2009;25(2):257-261. 17. Kalani MY, Zabramski JM, Hu YC, Spetzler RF. Extracranial-intracranial bypass and vessel occlusion for the treatment of unclippable giant middle cerebral artery aneurysms. Neurosurgery. 2013;72(3):428-435; discussion 435-426.