Ruptured AComA aneurysm and asymptomatic bilateral ACA vasospasm in an infant: surgical case report.

Intracranial aneurysms (IAs) are localized dilations of the cerebral vasculature, representing the leading cause for non-traumatic subarachnoid hemorrhage and an important source of morbidity and mortality. Despite it being a frequent pathology and most often diagnosed incidentally, IAs in infants are a very rare occurrence, and the ruptured variant is exceptional. A 4-month-old boy with a negative family history was brought to our department because of several episodes of incoercible vomiting and fever. Upon examination, the child was somnolent, without any noticeable deficit. Transfontanellar ultrasonography and CT angiography revealed a ruptured aneurysm of the anterior communicating artery (AComA), whereas the pre-clipping MRI showed thin, almost angiographically invisible anterior cerebral arteries (ACAs) on both sides due to vasospasm. We intervened surgically by placing an external ventricular shunt in an emergency setting, followed by clipping of the IA in a delayed manner. The child was discharged a month after admission with no deficit, despite the paradoxical aspect of the ACA. Ruptured IAs can be safely treated via microsurgery, even in infants. However, this requires a great amount of experience and surgical expertise. Furthermore, the lack of proper management would most likely result in a severe deficit in the long term. Lastly, the lack of visibility of the ACA on angiographic studies may not have neurological consequences if they occur in this age group.

Ventriculocisternal Shunt Redivivus: Third Ventricle-Cisterna Magna Intradural Shunt: A Technical Note and Case Report.

OBJECTIVE: To present a hitherto unreported modification of the classic Torkildsen procedure: passing a catheter intracranially, between the third ventricle and cisterna magna. METHODS: We applied our technique to a 56-year-old man who presented to our department for treatment of a pineal region mass. RESULTS: The patient was placed in sitting position and the mass was gross totally removed through a supracerebellar infratentorial approach. After the completion of the tumor resection, the patency of the cerebral aqueduct was checked, but the permeability was doubtful. During the same procedure, a shunt was inserted, under direct microsurgical control, into the third ventricle and passed over the cerebellar surface into the cisterna magna. The postoperative course was uneventful, and the patient was discharged from our unit with no neurological deficits and able to carry on with his day-to-day life. CONCLUSIONS: Our case illustrates that ventriculocisternal shunting can successfully be used in selected cases. The variation we describe can be a valuable surgical strategy in patients with pineal region masses, in whom a supracerebellar infratentorial route is used and in whom uncertainty exists regarding the patency of the sylvian aqueduct.