Although ruptured aneurysms are very rare in children, there are some “red flags” that significantly influence diagnostic approach and urgency of treatment:
- Sudden, severe headache (thunderclap headache)
- Signs of elevated ICP: These signs are age dependent and include impaired consciousness, lethargy, irritability, nausea and vomiting, tense or bulging fontanel, and gaze abnormality (e.g., Parinaud syndrome). Urgent treatment is required.
- Signs of herniation in comatose patients: These include uni- or bilateral mydriasis and a Cushing response, i.e., bradycardia and hypertension. Urgent treatment is required.
- Standard preoperative blood tests: These should comprise all basic tests, including a coagulation screen, as well as blood typing and crossmatching.
- Typically initial imaging: CT is the initial radiologic modality, especially in emergency situations. It is equally as capable of detecting acute intracranial hemorrhage as MRI (33). Characteristic distribution of subarachnoid, intracerebral, or subdural hemorrhage should raise suspicion of a ruptured aneurysm in patients of all ages.
- CT angiography sensitive and specific: Multidetector row CT angiography has a high sensitivity and specificity for the detection of intracranial aneurysms (29).
- Consider radiation exposure risk: The risk of radiation exposure in children has to be kept in mind. The risk of leukemia was estimated to be 1.9 cases per 10, 000 head CT scans performed in children younger than 5 years of age (48). However, no head CT rules have been validated for vascular conditions in children, unlike in pediatric head trauma.
- Preferred: MRI should be preferred in nonemergent cases, especially with regard to avoiding radiation exposure.
- FLAIR and T2-weighted sequences: FLAIR and T2-weighted sequences were shown to be capable of detecting subarachnoid hemorrhage (66). Moreover, 3D time-of-flight MR angiography, especially at 3 Tesla, can be used to depict intracranial aneurysms (24).
- Gold standard: DSA is considered the gold standard in the diagnostic approach to intracranial aneurysms. In a large series of DSA performed on children with a mean age of 12 years, all angiograms were technically successful, and there was no iatrogenic dissection and no neurological deficit secondary to a thromboembolic event, accounting for intraprocedural and postprocedural complication rates of 0.0% and 0.4%, respectively (12).
- EEG: EEG may be indicated in patients presenting with seizures or symptoms suspicious of seizures.
- Neuropsychological assessment: This is not performed on a routine basis, although it might be useful in selected cases or as part of a clinical trial.