Initial Management at Presentation
- Emergency surgery in case of impending herniation: In this setting the author prefers surgical treatment of the aneurysm, which allows evacuation of hematoma to relieve mass effect or decompressive craniectomy to treat intracranial hypertension. An EVD may be required.
- Urgent surgery in other cases: Surgery or endovascular treatment within 24–72 hours is preferred in ruptured or otherwise acutely symptomatic aneurysms and stable initial clinical status.
Unruptured oligosymptomatic or incidental aneurysms
- Analyze risk/benefit: Decision based on risk/benefit analysis and discussion about treatment modalities with parents.
Vigilant follow-up is recommended in children after treatment of an intracranial aneurysm, since both the annual risk of recurrence as well as the annual risk of de novo aneurysm formation are determined to be around 3% in pediatric series, which is higher than for adults (30, 58). In the absence of guidelines, the following recommendations are based on the available literature:
- Initial visit 4–6 weeks postoperatively: The first postoperative office visit should be scheduled 4–6 weeks after treatment.
- Annual visits: Thereafter, annual office visits should be scheduled with MRI scans including MR angiography, especially in coiled aneurysms.
- Angiography at 1 and 5 years: DSA should be discussed 1 and 5 years after treatment.