Long-term Outcomes of Cerebral Aneurysms in Children
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Long-term Outcomes of Cerebral
Aneurysms in Children
Aymeric Amelot, MD, PhD,a,b Guillaume Saliou, MD, PhD,c,d Sandro Benichi, MD,b Quentin Alias, MD,c Grégoire Boulouis, MD,e,f
Michel Zerah, MD, PhD,b Nozar Aghakhani, MD, PhD,g Augustin Ozanne, MD, PhD,c Thomas Blauwblomme, MD, PhD,b
Olivier Naggara, MD, PhDe,f
BACKGROUND: Our aim was to report the long-term clinical and imaging outcomes of #15-year- abstract
old children treated for ruptured or symptomatic cerebral aneurysms and to identify
prognostic factors for clinical outcome, recurrence, and rebleeding.
METHODS: We retrospectively identified all pediatric cases of cerebral aneurysm from 2000 to
2015 and then prospectively evaluated long-term occlusion using brain MRI and clinical
outcome measures: outcome was considered favorable if King’s Outcome Scale for Childhood
Head Injury score was $5. We performed univariate analysis and logistic binary regression to
identify variables associated with clinical and imaging outcomes.
RESULTS:Fifty-one children (aged 8.5 6 1.1 years [mean 6 SD], with 37 ruptured and 14
symptomatic aneurysms) were included, and endovascular treatments (84%) or microsurgical
procedures (16%) were performed. Despite a 19.6% death rate, at a mean follow-up of 8.3
years, 35 children (68.6%) had a favorable outcome. Annual bleeding and aneurysm
recurrence rates were 1.4% 6 1.1% and 2.6% 6 1.8%, respectively. Cerebral ischemia,
whether initial or delayed within the first month, was predictive of poor clinical outcome in
multivariate analysis (odds ratio: 25; 95% confidence interval: 0.43–143; P , .0001), whereas
aneurysm size .5 mm was the only factor associated with recurrence (odds ratio: 14.6; 95%
confidence interval: 2.4–86.1; P = .003).
Two-thirds of studied #15-year-old children suffering from ruptured or
CONCLUSIONS:
symptomatic cerebral aneurysms had long-term favorable outcome. Annual bleeding and
aneurysm recurrence rates have shown to be low after endovascular or surgical treatment.
Long-term imaging follow-up helps to depict aneurysm recurrence or de novo aneurysm
formation and to prevent rebleeding.
a
Department of Neurosurgery, La Pitié-Salpétrière Hospital, Université Paris Sorbonne, Paris, France; WHAT’S KNOWN ON THIS SUBJECT: Cerebral arterial
b
Departments of Pediatric Neurosurgery and ePediatric Radiology, Necker Hospital for Sick Children, Université aneurysms are extremely rare in children in comparison with
Paris Descartes, Paris, France; Departments of cNeuroradiology and gNeurosurgery, Kremlin-Bicêtre Hospital, Le adults. Long-term clinical and imaging follow-up studies on
Kremlin-Bicêtre, France; dDepartment of Neuroradiology, Centre Hospitalier Universitaire Vaudois, Lausanne, pediatric cerebral aneurysms are scarce, especially in young
Switzerland; and fDepartment of Neuroradiology, Sainte-Anne Hospital and Université Paris Descartes, INSERM patients under 15 years old that are managed endovascularly.
UMR S894, Paris, France
WHAT THIS STUDY ADDS: We demonstrated that two-thirds of
Drs Amelot, Blauwblomme, Naggara, and Saliou conceptualized and designed the study, conducted children suffering from a ruptured or symptomatic cerebral
the initial analyses, and drafted the initial manuscript; Drs Alias, Boulouis, Ozanne, Benichi, Zerah, aneurysm had a long-term favorable outcome. Annual
and Aghakhani drafted and reviewed the manuscript; and all authors approved the final manuscript bleeding and aneurysm recurrence rates are low after
as submitted and agree to be accountable for all aspects of the work. treatment. Long-term imaging follow-up is mandatory to
DOI: https://doi.org/10.1542/peds.2018-3036 detect aneurysm recurrence and de novo aneurysm.
Accepted for publication Feb 26, 2019
To cite: Amelot A, Saliou G, Benichi S, et al. Long-term
Address correspondence to Aymeric Amelot, MD, PhD, Department of Neurosurgery, Groupe Outcomes of Cerebral Aneurysms in Children. Pediatrics.
Hospitalier Universitaire de la Pitié-Salpêtrière, 47-83, Boulevard de l’Hôpital, 75013 Paris, France. 2019;143(6):e20183036
E-mail: aymmed@hotmail.fr
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PEDIATRICS Volume 143, number 6, June 2019:e20183036 ARTICLECerebral arterial aneurysms are Clinical and Imaging Parameters classifying long-term aneurysm
extremely rare in children compared We extracted clinical and occlusion using magnetic resonance
with adults, accounting for ,4% of all demographic data from patient angiography or DSA, according to
intracranial aneurysms.1–3 charts. We registered the World the 3-grade Raymond classification:
Endovascular treatment (EVT) and Federation of Neurological Surgeons grade 1, no contrast filling; grade 2,
surgical clipping are treatment (WFNS) grade for aneurysmal neck remnant; and grade 3,
options; the transarterial subarachnoid hemorrhage (SAH) and opacification of the aneurysmal
embolization with coiling procedure the Fisher’s score at onset.7,8 We sac.11
has increased in recent years. Long- defined aneurysm size and location at
term clinical and imaging follow-up onset on magnetic resonance Treatment Strategy
studies on pediatric cerebral angiography, computed Except in cases requiring emergency
aneurysms are scarce, especially in tomography–angiography, or digital intracranial hemorrhage evacuation
young patients under 15 years old or subtraction angiography (DSA) (Glasgow Coma Scale score ,8,
in current endovascular cohorts.4,5 obtained at admission. They were posterior fossa intracranial
Our aim here was to report the long- then classified as saccular or acute hemorrhage [ICH], or with mass
term clinical and imaging outcomes of dissecting and/or fusiform effect), the treatment modality was
#15-year-old children taken in aneurysms.9,10 Two neuroradiologists decided at a multidisciplinary
charge from the year 2000 to 2015 came to a common agreement consensus meeting including
and treated for ruptured or concerning posttreatment as well as pediatric neurosurgeons and
symptomatic cerebral aneurysms as
well as to identify prognostic factors TABLE 1 Baseline Patient and Aneurysm Characteristics
for clinical outcome, recurrence, and Symptomatic Patient Characteristics n (%) or Mean 6 SD
rebleeding.
Patients 51
Male sex 35 (68.6)
Age, y 8.5 6 1.1
METHODS
Vascular disease 5 (9.8)
Study Design and Participants Sickle cell disease 4 (7.3)
Genetic dysmorphic syndrome 3 (5.8)
We performed this study according to Familial history of aneurysm 2 (4)
the strengthening the reporting of Clinical presentation
observational studies in epidemiology SAH 37 (72.5)
Initial coma (GCS score ,8) 7 (13.7)
(STROBE) statement6 and French WFNS score 3–5 18 (35.3)
legislation, and because the study Fisher’s score 4–5 26 (50.9)
implied retrospective analysis of Headaches 9 (17.6)
anonymized data collected as part of Epilepsy 1 (1.9)
routine clinical care, it did not require Cranial nerve palsy 2 (3.9)
Ischemic stroke 2 (3.9)
formal approval by an ethics Baseline treated aneurysm characteristics 51
committee nor patient written Aneurysm type
informed consent. We informed each Saccular 31 (60.7)
patient of his or her participation in Fusiform or dissecting 20 (29.3)
the study. The study was Ruptured 37 (72.5)
Patients with multiple aneurysms 8 (15.6)
a multicenter retrospective pediatric Fundus size, mm 9.9 (7.5)
study (Bicêtre Hospital, Necker ,10 30 (58.8)
Hospital, Saint-Anne Hospital, Paris, 10–25 18 (34.6)
France) that included all consecutive .25 3 (5.8)
children treated between 2000 and Anterior circulation location 36 (70.5)
Middle cerebral artery 11 (21.5)
2015. Inclusion criteria were (1) Anterior complexa 4 (7.3)
intracranial arterial aneurysm (IAA) Internal carotid arteryb 21 (41.2)
and (2) age ,18 years. We excluded Posterior circulation location 15 (29.5)
patients with (1) arteriovenous Posterior communicating artery 3 (5.4)
malformation–related aneurysms, (2) Posterior cerebral artery 6 (10.9)
Vertebral-basilar artery 4 (7.3)
vein of Galen aneurysmal Superior cerebellar artery 2 (3.6)
malformation, and (3) mycotic
GCS, Glasgow Coma Scale.
pseudoaneurysm, because they a Included anterior communicating artery and A1-A2 junction aneurysms.
correspond to different diseases. b Included ophthalmic artery region, supraclinoid, superior hypophyseal artery, and internal carotid artery bifurcation.
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2 AMELOT et alpediatric interventional level was set at P = .003. All variables (9 thunderclap headaches without
neuroradiologists. For children in with a significant association in the SAH, 1 epilepsy or seizure, 2 partial
good clinical condition in which univariate analyses after adjustment third nerve deficits, and 2 related to
surgical ICH evacuation was not were entered into a multiple logistic ischemic stroke).
indicated, EVT was considered as regression model by using backward
Five children (9.8%) had a vascular
first-line therapy. In cases of EVT elimination procedures to analyze
disease, 3 (5.8%) had a genetic
failure, surgical clipping was potential predictors of unfavorable
dysmorphic syndrome (dwarfism or
performed. outcome. Statistical analyses were
unlabeled), and 4 (7.8%) had a sickle
performed using Stata version 11
Follow-up cell disease. Two children (4%) had at
(Stata Corp, College Station, TX).
least 1 first-degree family relative
We collected clinical and imaging
with IAA.
follow-up data during hospitalization
and follow-up DSA during an external RESULTS
Initial Treatment
consultation or by telephone
Clinical Presentation Aneurysm characteristics are
interviews. We contacted all patients
to undergo a physical examination We present child and aneurysm presented in Table 1. All symptomatic
and brain magnetic resonance baseline characteristics in the children (n = 51) were treated (Fig 1)
angiography. We made repeated supplemental Table 1. Over the study with EVT (n = 43) or clipping (n = 8).
telephone calls to contact missing period, 51 children (73 aneurysms; We encountered failure in 2 EVTs
patients and their families (family, mean age 6 SD: 8.5 6 1.1 years; (3.9%) and 1 surgical clipping
relatives, and general physician). interquartile range: 5.1–11.1 years) (12.5%), but they were all then
When appropriate, we collected met our inclusion criteria. successfully treated using the
causes of death. The total number of alternative technique.
Thirty-seven children (72.5%)
months of clinical and imaging follow-
presented with SAH from a ruptured Clinical Outcome
up for each patient was recorded.
aneurysm. We show WFNS grade and
Clinical outcome was defined Mean clinical follow-up was 8.3 years
Fisher’s scores in Table 1.
according to the King’s Outcome Scale (range: 12 months–19.5 years, 423.3
for Childhood Head Injury Fourteen patients (27.5%) had patient years), with favorable
(KOSCHI).12 Favorable clinical a symptomatic unruptured aneurysm outcome encountered in 35 out of 51
outcome was defined as a KOSCHI
score $5.
Statistics
Associations between variables were
analyzed by Fisher’s exact test or x2
test. The distribution of categorical
variables was described by
frequencies and percentages,
continuous and normally distributed
variables by means and SDs, and
continuous and non-normally
distributed variables by medians and
interquartile range. Predictive factors
for unfavorable outcome, aneurysm
recurrence, or rebleeding were tested
by univariate statistics by using
analysis of variance and x2 or Fisher’s
exact tests, as appropriate. According
to the number of pairwise
comparisons of interest, type 1 error
was adjusted by using the Bonferroni
multiple comparison adjustment. For
example, a level of .05 divided by 17
comparisons yielded an adjusted a of FIGURE 1
.003; thus, the statistical significance Flowchart diagram.
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PEDIATRICS Volume 143, number 6, June 2019 3TABLE 2 Clinical and Aneurysmal Predictive Factors for Death, Unfavorable Outcome, Rebleeding, and Recurrent Aneurysm (P Values Were Calculated by
the Log-Rank Test)
Baseline Clinical and Univariate Analysis, P Multivariate Analysis, OR (95% CI) P
Aneurysm Characteristics Death Unfavorable Aneurysm Aneurysm Death Unfavorable Aneurysm Aneurysm
Outcome Rebleeding Recurrence Outcome Rebleeding Recurrence
Sex .58 .99 .60 .23 — — — —
Age, y
,2 .353 .118 .202 .328 — — — —
,5 .113 .099 .908 .169 — — — —
,8 .486 .126 .640 .236 — — — —
,12 .714 .527 .706 .925 — — — —
SAH .08 .13 .40 .18 — — — —
Coma .004a .005a .738 .670 16.7 (2.3–115.1) 4.4 (0.6–27.0) .137 — —
.004a
Multiple aneurysms .11 .70 .30 .13 — — — —
Posterior circulation .11 .39 .15 .34 — — — —
aneurysm
Aneurysm size .5 mm .03a .04a .30 .002a 1.0 (0.1–2.7) .99 0.17 (0.1–2.21) — 14.6 (2.4–86.0)
.179 .003a
Aneurysm form
Saccular .46 .15 .41 .23 — — — —
Fusiform or dissecting .63 .66 .57 .73 — — — —
Complications
Hydrocephalus .67 .68 .86 .73 — — — —
Stroke .018a .0001a .70 .29 8.6 (1.4–53.1) 24.7 (4.3–142.1) — —
.003a ,.0001a
Vasospasm .46 .99 .79 .05 — — — —
Rebleeding .016a .06 — .52 9.2 (3.7–38.1) — — —
.02a
—, not applicable.
a Statistically significant.
(68.6%) children (31 and 4 had factors for rebleeding in the Imaging Outcome
KOSCHI 5B and KOSCHI 5A, univariate survival analysis (data not Forty children were prospectively
respectively). Unfavorable outcome shown). managed on imaging (DSA, n = 9; 1.5
included 1 child with moderate Tesla, n = 17; 3.0 Tesla, n = 14) for
disability (KOSCHI 4), 1 with severe In univariate analysis (Table 2),
unfavorable outcome was associated a mean follow-up period of 7.1 years
disability (KOSCHI 3), 4 who (range: 6 months–19.5 years; 312.4
presented a vegetative state with aneurysm size of .5 mm
(P = .04), ischemic stroke (P = .0001), patient years).
(KOSCHI 2), and 10 who died
(KOSCHI 1). and initial coma (P = .005). Ischemic Eight aneurysm recurrences
stroke was the only factor occurred in 8 patients (EVT, n = 7
Among 37 SAH patients, 23 children independently associated with [19%]; surgery, n = 1 [14%]; mean
had a favorable outcome. Among the unfavorable outcome (odds ratio delay: 1.7 6 1.4 years; annual
14 unfavorable outcomes, 10 children [OR]: 24.7; 95% confidence interval aneurysmal recurrence rate:
died within the first month of SAH [CI]: 4.3–142.1; P , .0001). Acute 2.6% 6 1.8%). No significant
onset (n = 9; mean onset-to-death ischemic strokes recorded in our association was found between
delay: 12 days) or from the bleeding series were due to dissecting recurrence and aneurysm type
of an untreated additional aneurysm aneurysms and occurred via (Table 2). The annual re-treatment
(n = 1; annual case fatality rate from perforating branches from the rate was 1.2% 6 1.00% (5 re-
rebleeding: 0.2% 6 0.1%). dissection or in the vascular territory treatments; EVT, n = 3; surgery,
Rebleeding occurred in 6 patients downstream. Ischemic stroke (OR: n = 2), and the annual de novo
(annual bleeding rate: 1.4% 6 1.1%; 8.6; 95% CI: 1.4–53.1; P = .003), coma aneurysm rate was 0.7% 6 0.4%
median delay: 26 months; range: at onset (OR: 16.7; 95% CI: (2 IAAs in 2 patients). Aneurysm
1.2–36 months), 4 from aneurysm 2.3–115.1; P = .004), and rebleeding size .5 mm was independently
recurrence, 1 from a de novo (OR: 9.2; 95% CI: 3.7–38.1; P = .02) associated with aneurysm
aneurysm, and 1 from an additional were independent risk factors recurrence (OR: 14.6; 95% CI:
aneurysm. We did not identify risk of death. 2.4–86.0; P = .003).
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4 AMELOT et alDISCUSSION
Annual De Novo or
Enlarging Rate of
Aneurysm, % In this study of #15-year-old children
Untreated
Unknown
2.4c treated for ruptured or symptomatic
3.7c
7.8
1.3
0.7
IAA, a favorable outcome occurred in
two-thirds of cases. The annual
bleeding rate after treatment, re-
Recurrence
Unknown
treatment rate, and aneurysmal
Rate, %
Annual
1.8c
2.6
0.6
1.4
2.6
recurrence rate were, respectively,
1.4%, 1.2%, and 2.6%. Annual de
novo aneurysm rate, mainly based on
Imaging
Mean
34.0d
3 Tesla MRI examinations, was 0.7%.
3.0c
5.7
4.5
3.0
7.1
FU
The current study focused on patients
Unknown
Unknown
Clinical
treated after the year 2000 and
Mean
FU, y
5.7
4.9
3.0
8.3
therefore concerned recent
management strategy. Indeed,
31, 47, 12, 15
a majority of pediatric IAA studies in
28, 32, 5, 7
31, 20, 0, 0
unknown,
Fusiform,
Unknown
unknown
unknown
Saccular
17, 6, 5,
21, 22,
the literature include few patients,
treated often over several decades.
The current study significantly differs
Clipping,
Surgery:
from the previous studies, and we
Type of
Otherb
19, 10
48, 24
60, 20
8, 9
0
8
provide additional information on
outcomes after symptomatic cerebral
aneurysms in children (summarized
Nonelectivea
Type of EVT:
Elective,
12, 14
20, 11
10, 10
in Table 3). First, we focused on
3, 0
43
0
a young population, for .25% of our
population was ,5 years old. Our
study showed favorable outcome for
Symptomatic,
14, unknown,
Incidental
Ruptured,
over two-thirds of cases. Concerning
11, 35, 26
unknown
7, 13, 12
25, 29, 6
89, 18, 7
37, 14, 0
the risk of annual recurrence, in our
series it was 2.6%, a rate similar to
one observed in the adult series of
aneurysms.2,3 In contrast, the Finnish
Age, y
Mean
11.7
12.0
12.3
14.5
13.0
8.5
cohort reported a lower annual rate
TABLE 3 Detailed Characteristics of Previous Studies With Follow-up $3 Years
of aneurysm recurrence of 0.6% in
aneurysms
patients,
114, 130
77, 103
the pediatric patients.4 In this largest
32, 43
48, 72
23, 28
51, 73
No.
No.
long-term cohort study (1939–2010),
Koroknay-Pál et al4 described 114
of Treatment
older children (mean age .14 years)
Median Year
1997–2003
1981–2010
1989–2005
1937–2009
1998–2010
2000–2015
a Includes parent vessel occlusion with coils or glue and flow reversal.
that could, in part, explain the
b Includes trapping, wrapping, ligation, bypass, or high-flow bypass.
difference in results (Table 3).
Secondly, as our study concerns
retrospective
retrospective
retrospective
retrospective
retrospective
prospective
Single center,
Single center,
Single center,
Single center,
Single center,
Enrollment
d Follow-up of the subgroup of 1-y survivors (n = 88).
children treated recently, 84% of
Setting,
Multicenter,
treatments were endovascular, a rate
similar to the ones seen in the recent
adult cohorts.2,4,14,16 Conversely, in
the study performed by Koroknay-Pál
c Recalculated from published data.
United States
United States
United States
Observational,
Observational,
Observational,
Observational,
Observational,
Observational,
et al4 on older children, 98%
Study
Finland
Finland
France
underwent surgical clipping, which
may also explain our different results
(Table 3).
et al2,14
Koroknay-
FU, follow-up
et al4,5
et al13
et al15
With aneurysm formation being
et al3
study
Authors
Present
Kakarla
Pál
Sanai
Saraf
Hetts
extremely rare in children, an
underlying vascular disease is often
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PEDIATRICS Volume 143, number 6, June 2019 5suspected or identified, for instance, in adults,20 not previously described registered in dedicated neurovascular
sickle cell disease in the present in children. Interestingly, the 40% databases. IAA remains rare, and
series or in the literature.17 However, rate of fusiform or dissecting randomized pediatric studies are
in our series and as previously aneurysms did not influence this probably unrealistic. We were unable
reported, no connective tissue higher recurrence rate. We found to perform analysis on the basis of the
disorders were diagnosed.4 a low de novo aneurysm rate, treatment modality because only 8
The annual de novo aneurysm rate, a finding that may be due to the short children were in the surgical group. In
mainly based on 3 Tesla MRI follow-up compared with the Finnish addition, surgery was mainly
examinations, was low, estimated at cohort.5 performed in cases requiring
0.7%, whereas the annual rebleeding emergency intracranial hemorrhage
Even if safe and efficacious, the long-
rate was 1.4%. In addition, these evacuation, precluding any outcome
term durability of endovascular
rates seem to compare favorably with comparison with EVT. Researchers
embolization remains a concern,
adult cohorts.18,19 conducting further studies should
especially in ruptured aneurysms,
help to provide more reliable data as
Furthermore, the good neurologic where stent-assisted coiling or a flow
well as a better understanding of this
outcome rate reported here is higher diverter is rarely used. Indeed, in
rare but sometimes devastating
than previously described.2,4,16 This unruptured aneurysms, this
disease.
may be explained by a higher rate of recurrence rate ranges from 7% to
treatment of ruptured aneurysms 27% and increases to 17% to 52% in
than before and by the major ruptured aneurysms.11,21–26 However, CONCLUSIONS
advances in neurointensive care among our 7 patients treated In this series, ruptured intracranial
because outcome was not surgically, 1 had a recurrence and aneurysms are still associated with
significantly worsened by initial subsequently bled and died. It was an a high mortality rate in the acute
coma.16 However, the long-term rate acute dissecting aneurysm, initially phase in pediatric patients; however,
of aneurysm-related death was not as misdiagnosed as a saccular carotid a favorable long-term outcome is
high as reported in the Koroknay-Pál aneurysm: no mural hematoma, seen in two-thirds of cases. Despite
et al5 series, who described 26% double lumen, or intimal flap were a low annual rebleeding or
aneurysm-related death. identified on angio-imaging aneurysm recurrence rate, lifelong
(computed tomography–angiography clinical and imaging follow-up is
A 10% to 19% excess of mortality
and DSA) performed before surgery. mandatory to detect aneurysm
20 years after diagnosis in 1-year
The diagnosis was made during recurrence and de novo aneurysm
survivors of pediatric SAH was
surgery, and although wrapping was formation.
described.4 Because this mortality is
successful to reconstruct the artery, it
mainly aneurysm related (76%) after
failed to prevent an early recurrence
rebleeding from a recurrent or
and fatal rebleeding. Because no ABBREVIATIONS
bleeding from a de novo aneurysm,
guidelines for the treatment of
long-term imaging follow-up is DSA: digital subtraction
ruptured dissecting aneurysms are
mandatory in children. We showed angiography
available, at least early posttreatment
effectiveness of EVT with annual EVT: endovascular treatment
follow-up imaging is mandatory to
bleeding and aneurysm recurrence IAA: intracranial arterial aneurysm
rule out fresh recurrence, which
rates similar to those previously KOSCHI: King’s Outcome Scale for
would indicate re-treatment to
described for pediatric microsurgery Childhood Head Injury
prevent new bleeding.
or in adult endovascular series.3,4,14 SAH: subarachnoid hemorrhage
We identified a significantly higher One limitation of this study is its WFNS: World Federation of
recurrence rate in cases of larger retrospective design, although all our Neurological Surgeons
aneurysms, a well-known association patients were prospectively
PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online, 1098-4275).
Copyright © 2019 by the American Academy of Pediatrics
FINANCIAL DISCLOSURE: The authors have indicated they have no financial relationships relevant to this article to disclose.
FUNDING: No external funding.
POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose.
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PEDIATRICS Volume 143, number 6, June 2019 7Long-term Outcomes of Cerebral Aneurysms in Children
Aymeric Amelot, Guillaume Saliou, Sandro Benichi, Quentin Alias, Grégoire
Boulouis, Michel Zerah, Nozar Aghakhani, Augustin Ozanne, Thomas Blauwblomme
and Olivier Naggara
Pediatrics originally published online May 8, 2019;
Updated Information & including high resolution figures, can be found at:
Services http://pediatrics.aappublications.org/content/early/2019/05/06/peds.2
018-3036
References This article cites 26 articles, 6 of which you can access for free at:
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018-3036#BIBL
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Downloaded from www.aappublications.org/news by guest on January 14, 2021Long-term Outcomes of Cerebral Aneurysms in Children
Aymeric Amelot, Guillaume Saliou, Sandro Benichi, Quentin Alias, Grégoire
Boulouis, Michel Zerah, Nozar Aghakhani, Augustin Ozanne, Thomas Blauwblomme
and Olivier Naggara
Pediatrics originally published online May 8, 2019;
The online version of this article, along with updated information and services, is
located on the World Wide Web at:
http://pediatrics.aappublications.org/content/early/2019/05/06/peds.2018-3036
Pediatrics is the official journal of the American Academy of Pediatrics. A monthly publication, it
has been published continuously since 1948. Pediatrics is owned, published, and trademarked by
the American Academy of Pediatrics, 345 Park Avenue, Itasca, Illinois, 60143. Copyright © 2019
by the American Academy of Pediatrics. All rights reserved. Print ISSN: 1073-0397.
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