Introduction: Cerebral vasospasm (CV) due to aneurysmal subarachnoid hemorrhage (aSAH) in the pediatric population is a rare phenomenon.
Methods: An 8-month old female was transferred to our institution with aSAH due to a 4mm paraclinoid aneurysm of the right internal carotid artery (ICA). She was treated successfully with endovascular coiling of the aneurysm. Transcranial doppler ultrasound (TCD) performed 3 days following the rupture demonstrated middle cerebral artery (MCA) velocities greater than 330 cm/sec on the right and greater than 160 cm/sec on the left. The patient showed no focal neurological deficit, though she was sedated. A combination of induced hypertension, hypervolemia, and hemodilution was begun. The following day, mean TCD velocities in all intracranial vessels increased despite medical management. The patient was taken to the angiography suite for cerebral angiogram and possible angioplasty. The angiogram revealed vasospasm of the distal ICA and MCA territory bilaterally, greater than 60%. The vasospasm was refractory to the administration of intra-arterial verapamil. Balloon angioplasty was attempted using a 1.5mm over the wire balloon, but the device could not be advanced safely due to the small size of the patient's vessels and the stiffness of the device. A microcatheter (0.0165'' diameter) was advanced over a J-shaped 0.014'' soft microwire under roadmap guidance to mechanically dilate the supraclinoid ICA and MCA bilaterally.
Results: Dramatic improvement was seen angiographically and TCD velocites decreased to below 200 cm/sec the following day, and continued to trend down afterwards.
Conclusions: This case report highlights a novel modification of an existing technique to safely treat CV in an infant due to aSAH as typical devices used to treat CV could not be used due to the patient's anatomy.
Patient Care: This case report should highlight the use of mechanical vessel dilation in the setting of vasospasm where typical balloon angioplasty devices cannot be used. The knowledge of this technique can improve care of pediatric patients with CV.
Learning Objectives: This case report should remind neurosurgeons that CV, though rare, can occur in infants with aSAH. Diagnosis of symptomatic CV is difficult to make in infants, and TCD should be performed routinely. The endovascular treatment of CV in infants often precludes the use of devices designed for adult patients. The use of mechanical dilation - modified Dotter technique - with modern microcatheters and microwires can provide good angiographic and clinical outcomes.