Individualized treatment for pediatric intracranial aneurysms in China: case series and literature review

Objective Pediatric intracranial aneurysms are rare, accounting for a small proportion of all aneurysms, yet they often present with acute onset, rapid deterioration, and a high risk of rupture. Diagnostic and therapeutic standards remain inconsistent due to limited evidence. Methods We retrospectively reviewed four pediatric patients (≤14 years) with ruptured intracranial aneurysms treated at our center from January 1, 2021 to December 31, 2025. Clinical presentation, imaging findings, treatment selection, and postoperative outcomes were analyzed. Functional outcomes were assessed using the modified Rankin Scale (mRS) over a 2-year follow-up period. And conduct a retrospective analysis based on literature to summarize the clinical presentation, treatment selection, prognosis, and other characteristics of pediatric intracranial aneurysms. Results All four pediatric patients successfully underwent either endovascular embolization or microsurgical clipping. Three patients achieved neurological improvement to varying degrees, while one patient with severe preoperative brain herniation died postoperatively. A total of 23 cases of pediatric intracranial aneurysms were retrieved from 21 English-language reports. Including the 4 cases in this study, the total number was 27. The male-to-female ratio was 16:11 (16 males and 11 females), and the age at onset ranged from 0.03 to 15 years (mean ± standard deviation: 6.5 ± 4.8 years). Clinical manifestations included sudden severe headache, nausea, vomiting, impaired consciousness, and so on. Initial imaging examinations showed intracranial hematoma on cranial CT (indicating ruptured intracranial aneurysms) or incidental findings on CTA/MRI (for unruptured intracranial aneurysms). The diagnosis of intracranial aneurysm was subsequently confirmed by cerebral angiography (DSA) or direct intraoperative exploration (because some patients were critically ill and could not undergo DSA). Among these, 17 were ruptured intracranial aneurysms and 6 were unruptured. Endovascular embolization was performed in 11 cases, microsurgical clipping in 10 cases, combined surgery in 1 case, and conservative treatment in 1 case. All cases in our center were ruptured intracranial aneurysms: 2 underwent endovascular treatment and 2 underwent microsurgical clipping. Conclusion Symptoms of ruptured intracranial aneurysms in children are easily misinterpreted, necessitating precise diagnosis through multimodal imaging. Treatment strategies require individualization: endovascular therapy may be prioritized for posterior circulation or hemodynamically complex aneurysms, while surgical one-stop procedures are indicated for cases with massive hematoma or brain herniation. Long-term standardized follow-up is critical for monitoring aneurysm recurrence in pediatric patients.