A spontaneous dissecting posterior cerebral artery aneurysm in a one-year-old

A spontaneous dissecting posterior cerebral artery aneurysm in a one-year-old | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Case Report A spontaneous dissecting posterior cerebral artery aneurysm in a one-year-old ibtissam EL OUALI, Meriem FIKRI, Lina BELKOUCHI, Latifa OUSKOU, and 2 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7221427/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract We report a rare and complex condition in a one-year-old boy, where both an intracranial dissecting aneurysm and Factor XIII deficiency were present. The child was brought to the hospital due to spontaneous subarachnoid hemorrhage and an intracerebral hematoma in the occipital lobe. Magnetic resonance angiography revealed a ruptured dissecting aneurysm in the distal segment of the right posterior cerebral artery with PCA infarcts. The patient's neurological condition rapidly deteriorated due to a Factor XIII deficiency, which heightened the risk of bleeding. This was promptly managed with Factor XIII administration, stabilizing the patient sufficiently for arteriography, followed by successful coil embolization. For initial screening, CT angiography (CTA) or MR angiography (MRA) are effective, accessible options; however, cerebral angiography remains the gold standard for precise localization of cerebral aneurysms. This case highlights the critical role of timely diagnostic imaging and surgical intervention in managing pediatric intracranial aneurysms. Pediatric cerebral aneurysms Thrombophilia MRA Embolization Figures Figure 1 Figure 2 Figure 3 Figure 4 Introduction Pediatric intracranial aneurysms (PIAs) are relatively rare, accounting for less than 5% of all cerebral aneurysms 1 and posterior circulation aneurysms have a higher incidence in children (approximately 25%) compared to adults (about 8%) 2 , more frequently found in the distal segments of cerebral arteries 3 . Endovascular treatment of cerebral aneurysms is especially favored for posterior circulation aneurysms due to their deep-seated locations, which present significant challenges for open surgical access 4 . Case presentation A one-year-old boy with previously undiagnosed severe Factor XIII deficiency (< 1%) was admitted to our hospital in a semicomatose state following an 8-hour history of nausea, vomiting, headache, left-sided tonic-clonic seizures, and left hemiplegia. The family reported no prior episodes of bleeding into soft tissues, joints, or other areas, but mentioned a family history of bleeding disorders among the patient’s cousins. There was no history of trauma or recent infectious exposure. Brain computerized tomography scan (Fig. 1 ) and magnetic resonance imaging (Fig. 2 ) showed right occipital subarachnoidal and intraventricular hemorrhage, right periventricular hemorrhage, and PCA infarct. The patient was treated with external ventricular drainage (DVE) (Fig. 1 , a), and an MR angiography was performed for further assessment. It confirmed the findings and additionally identified an aneurysm in the distal segment of the right posterior cerebral artery (Fig. 2 ). Hemostatic testing, revealed a normal level of Prothrombin Time (PT) (12 seconds), Activated Partial Thromboplastin Time (aPTT) (30 seconds) and International Normalized Ratio (INR) (1.1). However, factor XIII Activity Assay was Low (3% of normal activity) and clot solubility test was positive indicating FXIII deficiency. In this urgent case the genetic analysis was not performed and the diagnosis was primarily established based on hemostatic tests. Inflammatory markers, CRP, ESR, and complete blood count (CBC) were normal. Blood cultures were negative an lumbar puncture was suggestive of subarachnoid hemorrhage. Echocardiography screening did not show any sign for infectious endocarditis and viral serology was also negative. After the administration of Factor XIII, the patient's neurological status improved, making arteriography feasible. This confirmed the presence of an aneurysm and endovascular parent artery occlusion was performed. It shows an irregular saccular aneurysm of the distal bifurcation of the right PCA at the P3-P4 junction measuring 3.4 x 2.3 mm with a 4 mm wide neck, heading outwards, upwards and forwards. This is associated with severe vasospasm of P3 and its dividing branches (Fig. 3 ). Through a 4 Fr introducer placed in the right femoral artery, a guiding catheter was placed in the left vertebral artery. Coaxial installation of a micro catheter equipped with a micro wire and catheterization of the aneurysm. Then embolization of the sac and the distal portion of P3 using 3 coils: optima complex supersoft 3 mm x 6 cm and 2 mm x 6 cm, and helical supersoft 2.5 mm x 4 cm. Then injection of mg of nimodipine in situ. The final check shows the exclusion of the aneurysm and its supporting branch. The post-operative CT-scan demonstrated no cerebral infarcts and almost complete resolution of bleeding (Fig. 4 ). The patient showed signs of awakening from the coma with a high possibility of persisting reduced visual acuity. Discussion Retrospective studies estimate an incidence of 3–4% for pediatric intracranial aneurysms. We propose an approximate occurrence rate of 1 to 3 cases per 1 million population in the pediatric age group 5 . PIC are often associated with underlying genetic disorders, such as Marfan syndrome, Ehlers-Danlos syndrome, polycystic kidney disease, hereditary hemorrhagic telangiectasia, cavernous angiomas, Von-Hippel-Lindau disease, arteriovenous malformations, Sturge-Weber syndrome and moyamoya disease. Also, it is not uncommon to find asymptomatic familial cases. Predisposing conditions, like infection tumor, trauma or dissection has also been reported. But in most reported cases, spontaneous dissecting aneurysms were unexplained with possible contribution of high flow states that in some instances is related to associated AVM’s6 There was no significant history of recent or prior trauma in our patient. In literature, the majority of aneurysms were localized to the P2/P3 segments of the PCA, which runs along the tentorium cerebelli and courses supratentorially. One hypothesis for the development of the dissecting PCA aneurysm is the mechanical stress placed on the vessel wall at the tentorial edges. While Factor XIII (FXIII) deficiency is a rare bleeding disorder known for causing spontaneous intracranial hemorrhages (ICH) 7 , there is no documented evidence directly linking FXIII deficiency to the formation of cerebral aneurysms in pediatric patients. while FXIII deficiency increases the risk of bleeding complications, including ICH, especially in patients with weakened blood vessels walls in case of structural development anomalies such as cerebral aneurysms 8 , it does not appear to contribute directly to the pathogenesis of cerebral aneurysms in children. However, studies by Kamal Kumar Sawlani et al., Shiho Amano et al., and Sneha Singh et al. 9 , 10 , 11 provide valuable insights into the presentation, diagnosis, and management of intracranial aneurysms in the pediatric population, including considerations for underlying conditions such as factor XIII deficiency. Although they do not link the disease to Factor XIII deficiency, it is crucial to acknowledge that any coagulopathy, such as Factor XIII deficiency, may increase the risk of aneurysm formation. The bleeding tendency associated with such conditions could play a role in the development or rupture of aneurysms. For a deeper understanding of the connection between Factor XIII deficiency and intracranial aneurysms, further research is required. The most frequent clinical presentation is subarachnoid hemorrhage (SAH), focal or generalized seizures 12 . Ischemic stroke presentation of the dissecting PCA was also reported in literature 13 . For children at elevated risk of intracranial aneurysms but without symptoms, a CT angiogram or MR angiogram serves as an effective and appropriate initial screening method. As previously noted, however, cerebral angiography remains the diagnostic gold standard for precise localization of cerebral aneurysms 14 . Magnetic Resonance Angiography (MRA) is considered the primary imaging choice for long-term follow-up of untreated, endovascularly managed, and nonclipped microsurgically treated intracranial aneurysms (IAs). It is particularly valuable in detecting vascular injuries, including intramural hematomas, as well as brain tissue changes associated with dissections, such as ischemia and hemorrhage in overlapping vascular regions. MRA allows simultaneous imaging of all arterial feeders, contributions, and collateral vessels. Identifying luminal stenosis near an aneurysm can also help distinguish between fusiform aneurysms and dissecting pseudoaneurysms. Advanced MRI sequences like steady-state free precession enable clear imaging of arterial walls, identifying both mural and luminal thrombosis. Time-of-flight (TOF) MRA relies on blood flow properties and may produce false negatives when aneurysms exhibit low or turbulent flow. Phase-contrast MRA, which is less affected by T1 hyperintensity from subacute bleeding, may be preferable for acute or subacute cases if needed 12 , 13 . Following confirmation of subarachnoid hemorrhage (SAH) in pediatric patients, a four-vessel cerebral angiogram is advised. Cerebral angiography can detect a structural source of SAH in about 50–70% of cases. For cases initially yielding negative results, around 10–20% may reveal an aneurysm on repeat angiography two weeks later. Certain factors, such as localized arterial spasm or thrombosis within the aneurysmal neck, may impede lesion filling during the angiogram, leading to initial negative findings.¹ The precise definition of dissecting aneurysms is not clearly established in the literature. Typically, these aneurysms are characterized by descriptions based on expert consensus regarding their angiographic appearance, often referred to as having a “pearl and string” or “blowout” appearance.¹³,¹⁴ The management relies on two aspects: the first is medical, and the second is surgical. In cases of hydrocephalus, definitive CSF diversion is frequently required, along with vigilant monitoring of fluid status, contrast administration, blood pressure, and neuroprotective measures. Antiepileptic medications are necessary to prevent seizures following SAH.¹⁵,¹⁶ Also, medication to counteract the adverse effects of secondary hypertension and hypoxia are of use.¹⁷ To prevent vasospasm, nimodipine should be administered.¹⁸ On the other hand, the primary objective of neurovascular intervention is to minimize the risk of aneurysmal rupture, alleviate mass effect, and maintain the integrity of the cerebral vasculature.¹⁹ Treatment options for cerebral aneurysms include endovascular coiling and surgical clipping. The choice between these approaches depends on factors such as the patient's symptoms and age, with a growing preference for endovascular coiling due to its lower mortality rates and shorter hospital stays compared to surgical clipping. However, there is limited comprehensive outcome data available for these treatments in pediatric patients.²⁰ Pediatric endovascular procedures face challenges due to the limited availability of appropriately sized devices for smaller vessels in children. This includes difficulties in selecting the right-sized catheters, balloons, and stents, and navigating the vascular system without causing injury. Imaging adjustments are also required. The use of fluoroscopy, intravascular ultrasound (IVUS), or magnetic resonance imaging (MRI) must be adjusted to accommodate the child’s size, which may necessitate adjustments in radiation dose or imaging settings to avoid exposure to excessive radiation, while the risk of complications like vessel dissection or thrombosis is higher. In some cases, customized devices may be necessary. Managing anticoagulation is more complex in children, and a multi-disciplinary approach is essential for successful outcomes. Overall, specialized techniques and smaller, tailored devices are crucial for improving pediatric endovascular procedures.²¹ For microsurgical interventions, options include clip reconstruction, trapping, and bypass with proximal occlusion. Surgical obliteration of the aneurysmal sac has been linked to lower recurrence rates and a reduced likelihood of developing new aneurysms.²² Preserving the posterior cerebral artery (PCA) with stent-assisted coiling may be a viable option, particularly in cases where sacrificing the artery could lead to significant deficits, such as in a young patient who might be impacted by loss of driving ability. However, the long-term effectiveness and safety of this artery-preserving technique cannot be fully determined based on the limited data available from small case series.¹⁴,²⁴ In literature, the Pipeline Embolization Device (PED) is promoted as a safe flow-diverting technique which works by diverting blood flow away from the aneurysm, while preserving the parent artery.²⁵ Despite the International Subarachnoid Aneurysm Trial (ISAT) demonstration of the superiority of coil embolization over clipping for ruptured aneurysms in terms of prognosis, it is important to note that clipping may offer better long-term durability, which is a crucial consideration for children due to their longer life expectancy.²⁶,²⁷,²⁸ Conclusion In summary, cerebral aneurysms are rare in the first year of life, especially those caused by dissection. Early detection, swift diagnosis, and a comprehensive approach involving neurosurgery, neurology, and rehabilitation are crucial for achieving positive outcomes. Currently, the management of PIAs remains under-defined due to their rarity, and, to the best of our knowledge, only a limited number of cases have been documented in the literature. Declarations Acknowledgments: I would like to express my gratitude to my professors and all the colleagues who participated in the completion of this work. Not applicable. Ethical considerations: Our institution does not require ethical approval for reporting individual cases or case series. Consent to participate: Not applicable. Consent for publication: A statement confirming that informed consent for publication was provided by a legally authorized representative. Declaration of conflicting interest: The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article. Funding statement: The author(s) received no financial support for the research, authorship, and/or publication of this article. Data availability: Data sharing is not applicable to this article as no new data were created or analyzed in this study. Author Contribution Ibtissam EL OUALI: Conception, writing and collection of Data.Meriem FIKRI: Performed the neuro vascular management of the patient and supervised the work and validation of the final manuscript.Lina BELKOUCHI: Supervision and collection of Data.Latifa OUSKOU: Collection of Data.Siham EL HADDAD: Verification of the analytical methods, supervised the findings of this work and validation of the work.Latifa CHAT: Supervision and validation of the final workAll authors discussed the results and contributed to the final manuscript. References Lasjaunias P, Wuppalapati S, Alvarez H, Rodesch G, Ozanne A. Intracranial aneurysms in children aged under 15 years: review of 59 consecutive children with 75 aneurysms. Childs Nerv Syst . 2005 Jun;21(6):437-50. doi:10.1007/s00381-004-1125-x. Garg M, Shambanduram S, Singh PK, Sebastian LJD, Sawarkar DP, Kumar A, Gaikwad S, Chandra PS, Kale SS. Management of pediatric posterior circulation aneurysms-12-year single-institution experience. World Neurosurg . 2018;116:e624-e633. Koroknay-Pal P, Lehto H, Niemela M, Kivisaari R, Hernesniemi J. Long-term outcome of 114 children with cerebral aneurysms. J Neurosurg Pediatr . 2012;9(6):636-645. Heredia-Gutiérrez A, Carbarín-Carbarín ME. Cerebral aneurysms in pediatrics: a case report and review of the literature. Bol Med Hosp Infant Mex . 2021;78(6):636-641. doi:10.24875/BMHIM.20000406. Deora H, Rao KVLN, Somanna S, Srinivas D, Shukla DP, Bhat DI. Surgically Managed Pediatric Intracranial Aneurysms: How Different Are They from Adult Intracranial Aneurysms? Pediatr Neurosurg . 2017;52(5):313-317. Fox CK, Singh S, Kumar A, Sawlani KK, Gupta V, Suri V, Sarkar C. Intracranial aneurysms in children. J Neurosurg Pediatr . 2012;10(3):199-207. doi:10.3171/2012.5.PEDS11452. Naderi M, Zarei T, Haghpanah S, et al. Intracranial hemorrhage pattern in the patients with factor XIII deficiency. Ann Hematol . 2014;93:693-697. doi:10.1007/s00277-013-1918-7. Xu Z, Rui YN, Hagan JP, et al. Intracranial Aneurysms: Pathology, Genetics, and Molecular Mechanisms. Neuromol Med . 2019;21:325-343. doi:10.1007/s12017-019-08537-7. Sawlani KK, Gupta V, Singh S, Sharma MC, Suri V, Sarkar C, et al. Intracranial aneurysms in children: a study of 23 patients. Childs Nerv Syst . 2004;20(7):432-436. Amano S, Takahashi T, Saito N, Yamada M, Kuroda S, Ishikawa T, et al. Pediatric intracranial aneurysms: surgical experience with 57 patients. Neurosurgery . 2008;62(4):832-838. Singh S, Kumar A, Sawlani KK, Gupta V, Suri V, Sarkar C, et al. Intracranial aneurysms in children: an Indian perspective. Neurol India . 2005;53(3):310-314. Levy ML, Levy DM, Manna B. Pediatric Cerebral Aneurysm. [Updated 2023 Aug 8]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK537085/ Bhogal P, Makalanda HL, Brouwer PA, et al. Pediatric intracranial arterial dissection: multicenter treatment outcomes. Stroke . 2022;53(2):e50-e53. doi:10.1161/STROKEAHA.121.036789. Ghali MGZ, Srinivasan VM, Cherian J, Kim L, Siddiqui A, Aziz-Sultan MA, et al. Pediatric Intracranial Aneurysms: Considerations and Recommendations for Follow-Up Imaging. World Neurosurg . 2018;109:418-431. doi:10.1016/j.wneu.2017.09.150. Ferriero DM, et al. Management of Stroke in Neonates and Children. Stroke . 2024;55(1):e1-e20. doi:10.1161/STR.0000000000000434. Fox CK, et al. Antiepileptic Drug Use in Neonates and Children With Aneurysmal Subarachnoid Hemorrhage. J Child Neurol . 2017;32(1):79-83. doi:10.1177/0883073816670826. Kochar A, Hildebrandt K, Silverstein R, Appavu B. Approaches to neuroprotection in pediatric neurocritical care. World J Crit Care Med . 2023;12(3):116-129. doi:10.5492/wjccm.v12.i3.116. Lauzier DC, Huguenard AL, Srienc AI, et al. A review of technological innovations leading to modern endovascular brain aneurysm treatment. Front Neurol . 2023;14:1156887. doi:10.3389/fneur.2023.1156887. Donnelly BM, Monteiro A, Recker MJ, Lim J, Lai PMR, Jacoby WT, et al. Endovascular Treatment for Complex Vascular Pathologies in the Pediatric Population: Experience from a Center with Dual-Trained Neurosurgeons. World Neurosurg . 2024;189:e696-e708. doi:10.1016/j.wneu.2024.06.151. Aghamiri SH, Salimi S, Sepehri Rad A, Sistanizad M, Pourheidar E. A spontaneous dissecting posterior cerebral artery aneurysm in a 10-month-old female infant: a case report. Iran J Child Neurol . 2022;16(3):199-203. doi:10.22037/ijcn.v16i3.34090. de Barros Faria M, Castro RN, Lundquist J, et al. The role of the pipeline embolization device for the treatment of dissecting intracranial aneurysms. AJNR Am J Neuroradiol . 2011;32(11):2192-2195. doi:10.3174/ajnr.A2671. Ravindra VM, Karsy M, Lanpher A, et al. Intracranial arterial dissection in children: a systematic review. J Neurosurg Pediatr . 2021;27(3):247-256. Pinto Silva R, Teles Silva C, Silva MJ, Alberto Silva P, Ribeiro A. Ruptured Intracranial Aneurysm in a 60-Day-Old Infant: An Extreme Case. Cureus . 2024;16(2):e53442. doi:10.7759/cureus.53442. Mohotti JE, Carter NS, Zhang VJW, Lai LT, Xenos C, Asadi H, Chandra RV. Neonatal intracranial aneurysms: case report and review of the literature. J Neurosurg Pediatr . 2018;21(5):471-477. doi:10.3171/2017.10.PEDS17226. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-7221427","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Case Report","associatedPublications":[],"authors":[{"id":495831059,"identity":"b3bb25f0-0447-4ca1-a106-50f164038f75","order_by":0,"name":"ibtissam EL OUALI","email":"data:image/png;base64,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","orcid":"","institution":"Centre Hospitalier Ibn Sina","correspondingAuthor":true,"prefix":"","firstName":"ibtissam","middleName":"EL","lastName":"OUALI","suffix":""},{"id":495831061,"identity":"cbda6b83-79d0-4ce9-a663-8561f38c5381","order_by":1,"name":"Meriem FIKRI","email":"","orcid":"","institution":"Centre Hospitalier Ibn Sina","correspondingAuthor":false,"prefix":"","firstName":"Meriem","middleName":"","lastName":"FIKRI","suffix":""},{"id":495831062,"identity":"c8099cfa-b13a-4821-b2a9-f0f51a6eac62","order_by":2,"name":"Lina BELKOUCHI","email":"","orcid":"","institution":"Centre Hospitalier Ibn Sina","correspondingAuthor":false,"prefix":"","firstName":"Lina","middleName":"","lastName":"BELKOUCHI","suffix":""},{"id":495831063,"identity":"c21dd10c-b0d7-4b9b-94b4-8280adb5f344","order_by":3,"name":"Latifa OUSKOU","email":"","orcid":"","institution":"Centre Hospitalier Ibn Sina","correspondingAuthor":false,"prefix":"","firstName":"Latifa","middleName":"","lastName":"OUSKOU","suffix":""},{"id":495831066,"identity":"972ae17f-b868-4573-b3b3-e5fbde917679","order_by":4,"name":"Siham ELHADDAD","email":"","orcid":"","institution":"Centre Hospitalier Ibn Sina","correspondingAuthor":false,"prefix":"","firstName":"Siham","middleName":"","lastName":"ELHADDAD","suffix":""},{"id":495831068,"identity":"3eae4a1d-fa5d-4b34-aa96-2cd1ce10cd67","order_by":5,"name":"Latifa CHAT","email":"","orcid":"","institution":"Centre Hospitalier Ibn Sina","correspondingAuthor":false,"prefix":"","firstName":"Latifa","middleName":"","lastName":"CHAT","suffix":""}],"badges":[],"createdAt":"2025-07-26 13:23:10","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-7221427/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-7221427/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":88755621,"identity":"55bb7116-7cbf-48aa-85ba-e9f277748198","added_by":"auto","created_at":"2025-08-11 07:12:52","extension":"jpg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":47829,"visible":true,"origin":"","legend":"\u003cp\u003eUnenhanced brain CT scan in a one-year-old semi-comatose infant presenting with left-sided tonic-clonic seizures and left hemiplegia shows right occipital subarachnoid (a, arrow) and intraventricular hemorrhage, right periventricular intracranial hemorrhage, surrounded by edema (a, thick arrow). The patient was treated with external ventricular drainage (DVE) (b, arrowhead).\u003c/p\u003e","description":"","filename":"figure1.jpg","url":"https://assets-eu.researchsquare.com/files/rs-7221427/v1/60466d35ca9b653cc4619b67.jpg"},{"id":88756545,"identity":"8604a4ab-bc37-4b41-9657-136f5fac603c","added_by":"auto","created_at":"2025-08-11 07:20:51","extension":"jpg","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":64532,"visible":true,"origin":"","legend":"\u003cp\u003eMR angiography confirmed the CT scan findings, showing the intracranial hemorrhage (a, b, arrowhead), and additionally identified infarcts in both deep MCA territories and bilateral PCA on DWI sequence and ADC map (c, d, arrows), with total flow absence in P2 and P3 segments of the right PCA on time-of-flight (TOF) imaging (e, thick arrow), and an aneurysm in the distal segment of the right posterior cerebral artery on coronal and axial dynamic angiography (f, g, circle).\u003c/p\u003e","description":"","filename":"figure2.jpg","url":"https://assets-eu.researchsquare.com/files/rs-7221427/v1/6f50b0e29084e1656a46a67d.jpg"},{"id":88756546,"identity":"a6487dea-103f-442c-8b96-2ae0da2d0c71","added_by":"auto","created_at":"2025-08-11 07:20:52","extension":"jpg","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":31630,"visible":true,"origin":"","legend":"\u003cp\u003eCerebral angiography confirmed a 34×23 mm wide-necked aneurysm (39 mm neck length) (a), at the P3 section of the right PCA (b, c, arrow). Post-embolization right vertebral artery arteriography confirmed nearly complete embolization of the aneurysm (c, d).\u003c/p\u003e","description":"","filename":"figure3.jpg","url":"https://assets-eu.researchsquare.com/files/rs-7221427/v1/dd8a8cdf5773a436c84db765.jpg"},{"id":88755622,"identity":"a6b130b1-3962-4ab1-b59a-e1a7dd8fb1dd","added_by":"auto","created_at":"2025-08-11 07:12:52","extension":"jpg","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":17585,"visible":true,"origin":"","legend":"\u003cp\u003ePost-operative brain CT scan demonstrated almost complete resolution of the bleeding.\u003c/p\u003e","description":"","filename":"Figure4.jpg","url":"https://assets-eu.researchsquare.com/files/rs-7221427/v1/c87c61cc697977a6d6fa1357.jpg"},{"id":103208346,"identity":"544ce10e-6f79-49e0-8dbd-76fd899d08d1","added_by":"auto","created_at":"2026-02-23 07:57:27","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":541749,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7221427/v1/b59c6b95-dadc-4890-b5d9-f8264933ee5d.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"A spontaneous dissecting posterior cerebral artery aneurysm in a one-year-old","fulltext":[{"header":"Introduction","content":"\u003cp\u003ePediatric intracranial aneurysms (PIAs) are relatively rare, accounting for less than 5% of all cerebral aneurysms\u003csup\u003e\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u003c/sup\u003e and posterior circulation aneurysms have a higher incidence in children (approximately 25%) compared to adults (about 8%)\u003csup\u003e2\u003c/sup\u003e, more frequently found in the distal segments of cerebral arteries\u003csup\u003e\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e\u003cp\u003eEndovascular treatment of cerebral aneurysms is especially favored for posterior circulation aneurysms due to their deep-seated locations, which present significant challenges for open surgical access\u003csup\u003e\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e"},{"header":"Case presentation","content":"\u003cp\u003eA one-year-old boy with previously undiagnosed severe Factor XIII deficiency (\u0026lt; 1%) was admitted to our hospital in a semicomatose state following an 8-hour history of nausea, vomiting, headache, left-sided tonic-clonic seizures, and left hemiplegia. The family reported no prior episodes of bleeding into soft tissues, joints, or other areas, but mentioned a family history of bleeding disorders among the patient’s cousins. There was no history of trauma or recent infectious exposure.\u003c/p\u003e\u003cp\u003eBrain computerized tomography scan (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e) and magnetic resonance imaging (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e) showed right occipital subarachnoidal and intraventricular hemorrhage, right periventricular hemorrhage, and PCA infarct. The patient was treated with external ventricular drainage (DVE) (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e, a), and an MR angiography was performed for further assessment. It confirmed the findings and additionally identified an aneurysm in the distal segment of the right posterior cerebral artery (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eHemostatic testing, revealed a normal level of Prothrombin Time (PT) (12 seconds), Activated Partial Thromboplastin Time (aPTT) (30 seconds) and International Normalized Ratio (INR) (1.1). However, factor XIII Activity Assay was Low (3% of normal activity) and clot solubility test was positive indicating FXIII deficiency. In this urgent case the genetic analysis was not performed and the diagnosis was primarily established based on hemostatic tests.\u003c/p\u003e\u003cp\u003eInflammatory markers, CRP, ESR, and complete blood count (CBC) were normal. Blood cultures were negative an lumbar puncture was suggestive of subarachnoid hemorrhage.\u003c/p\u003e\u003cp\u003eEchocardiography screening did not show any sign for infectious endocarditis and viral serology was also negative.\u003c/p\u003e\u003cp\u003eAfter the administration of Factor XIII, the patient's neurological status improved, making\u003c/p\u003e\u003cp\u003earteriography feasible. This confirmed the presence of an aneurysm and endovascular parent artery occlusion was performed.\u003c/p\u003e\u003cp\u003eIt shows an irregular saccular aneurysm of the distal bifurcation of the right PCA at the P3-P4 junction measuring 3.4 x 2.3 mm with a 4 mm wide neck, heading outwards, upwards and forwards. This is associated with severe vasospasm of P3 and its dividing branches (Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eThrough a 4 Fr introducer placed in the right femoral artery, a guiding catheter was placed in the left vertebral artery.\u003c/p\u003e\u003cp\u003eCoaxial installation of a micro catheter equipped with a micro wire and catheterization of the aneurysm. Then embolization of the sac and the distal portion of P3 using 3 coils: optima complex supersoft 3 mm x 6 cm and 2 mm x 6 cm, and helical supersoft 2.5 mm x 4 cm. Then injection of mg of nimodipine in situ.\u003c/p\u003e\u003cp\u003eThe final check shows the exclusion of the aneurysm and its supporting branch.\u003c/p\u003e\u003cp\u003eThe post-operative CT-scan demonstrated no cerebral infarcts and almost complete resolution of bleeding (Fig.\u0026nbsp;\u003cspan refid=\"Fig4\" class=\"InternalRef\"\u003e4\u003c/span\u003e). The patient showed signs of awakening from the coma with a high possibility of persisting reduced visual acuity.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eRetrospective studies estimate an incidence of 3\u0026ndash;4% for pediatric intracranial aneurysms. We propose an approximate occurrence rate of 1 to 3 cases per 1\u0026nbsp;million population in the pediatric age group\u003csup\u003e\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e\u003cp\u003ePIC are often associated with underlying genetic disorders, such as Marfan syndrome, Ehlers-Danlos syndrome, polycystic kidney disease, hereditary hemorrhagic telangiectasia, cavernous angiomas, Von-Hippel-Lindau disease, arteriovenous malformations, Sturge-Weber syndrome and moyamoya disease. Also, it is not uncommon to find asymptomatic familial cases. Predisposing conditions, like infection tumor, trauma or dissection has also been reported. But in most reported cases, spontaneous dissecting aneurysms were unexplained with possible contribution of high flow states that in some instances is related to associated AVM\u0026rsquo;s6\u003c/p\u003e\u003cp\u003eThere was no significant history of recent or prior trauma in our patient.\u003c/p\u003e\u003cp\u003eIn literature, the majority of aneurysms were localized to the P2/P3 segments of the PCA, which runs along the tentorium cerebelli and courses supratentorially. One hypothesis for the development of the dissecting PCA aneurysm is the mechanical stress placed on the vessel wall at the tentorial edges.\u003c/p\u003e\u003cp\u003eWhile Factor XIII (FXIII) deficiency is a rare bleeding disorder known for causing spontaneous intracranial hemorrhages (ICH)\u003csup\u003e\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e\u003c/sup\u003e, there is no documented evidence directly linking FXIII deficiency to the formation of cerebral aneurysms in pediatric patients.\u003c/p\u003e\u003cp\u003ewhile FXIII deficiency increases the risk of bleeding complications, including ICH, especially in patients with weakened blood vessels walls in case of structural development anomalies such as cerebral aneurysms\u003csup\u003e\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e\u003c/sup\u003e, it does not appear to contribute directly to the pathogenesis of cerebral aneurysms in children.\u003c/p\u003e\u003cp\u003eHowever, studies by Kamal Kumar Sawlani et al., Shiho Amano et al., and Sneha Singh et al.\u003csup\u003e\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e,\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e,\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e\u003c/sup\u003e provide valuable insights into the presentation, diagnosis, and management of intracranial aneurysms in the pediatric population, including considerations for underlying conditions such as factor XIII deficiency. Although they do not link the disease to Factor XIII deficiency, it is crucial to acknowledge that any coagulopathy, such as Factor XIII deficiency, may increase the risk of aneurysm formation. The bleeding tendency associated with such conditions could play a role in the development or rupture of aneurysms.\u003c/p\u003e\u003cp\u003eFor a deeper understanding of the connection between Factor XIII deficiency and intracranial aneurysms, further research is required.\u003c/p\u003e\u003cp\u003eThe most frequent clinical presentation is subarachnoid hemorrhage (SAH), focal or generalized seizures\u003csup\u003e\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e\u003cp\u003eIschemic stroke presentation of the dissecting PCA was also reported in literature\u003csup\u003e\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e\u003cp\u003eFor children at elevated risk of intracranial aneurysms but without symptoms, a CT angiogram or MR angiogram serves as an effective and appropriate initial screening method. As previously noted, however, cerebral angiography remains the diagnostic gold standard for precise localization of cerebral aneurysms\u003csup\u003e\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003eMagnetic Resonance Angiography (MRA) is considered the primary imaging choice for long-term follow-up of untreated, endovascularly managed, and nonclipped microsurgically treated intracranial aneurysms (IAs). It is particularly valuable in detecting vascular injuries, including intramural hematomas, as well as brain tissue changes associated with dissections, such as ischemia and hemorrhage in overlapping vascular regions. MRA allows simultaneous imaging of all arterial feeders, contributions, and collateral vessels. Identifying luminal stenosis near an aneurysm can also help distinguish between fusiform aneurysms and dissecting pseudoaneurysms. Advanced MRI sequences like steady-state free precession enable clear imaging of arterial walls, identifying both mural and luminal thrombosis. Time-of-flight (TOF) MRA relies on blood flow properties and may produce false negatives when aneurysms exhibit low or turbulent flow. Phase-contrast MRA, which is less affected by T1 hyperintensity from subacute bleeding, may be preferable for acute or subacute cases if needed\u003csup\u003e\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e,\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e\u003cp\u003eFollowing confirmation of subarachnoid hemorrhage (SAH) in pediatric patients, a four-vessel cerebral angiogram is advised. Cerebral angiography can detect a structural source of SAH in about 50\u0026ndash;70% of cases. For cases initially yielding negative results, around 10\u0026ndash;20% may reveal an aneurysm on repeat angiography two weeks later. Certain factors, such as localized arterial spasm or thrombosis within the aneurysmal neck, may impede lesion filling during the angiogram, leading to initial negative findings.\u0026sup1;\u003c/p\u003e\u003cp\u003eThe precise definition of dissecting aneurysms is not clearly established in the literature. Typically, these aneurysms are characterized by descriptions based on expert consensus regarding their angiographic appearance, often referred to as having a \u0026ldquo;pearl and string\u0026rdquo; or \u0026ldquo;blowout\u0026rdquo; appearance.\u0026sup1;\u0026sup3;,\u0026sup1;⁴\u003c/p\u003e\u003cp\u003eThe management relies on two aspects: the first is medical, and the second is surgical. In cases of hydrocephalus, definitive CSF diversion is frequently required, along with vigilant monitoring of fluid status, contrast administration, blood pressure, and neuroprotective measures. Antiepileptic medications are necessary to prevent seizures following SAH.\u0026sup1;⁵,\u0026sup1;⁶ Also, medication to counteract the adverse effects of secondary hypertension and hypoxia are of use.\u0026sup1;⁷ To prevent vasospasm, nimodipine should be administered.\u0026sup1;⁸\u003c/p\u003e\u003cp\u003eOn the other hand, the primary objective of neurovascular intervention is to minimize the risk of aneurysmal rupture, alleviate mass effect, and maintain the integrity of the cerebral vasculature.\u0026sup1;⁹ Treatment options for cerebral aneurysms include endovascular coiling and surgical clipping. The choice between these approaches depends on factors such as the patient's symptoms and age, with a growing preference for endovascular coiling due to its lower mortality rates and shorter hospital stays compared to surgical clipping. However, there is limited comprehensive outcome data available for these treatments in pediatric patients.\u0026sup2;⁰\u003c/p\u003e\u003cp\u003ePediatric endovascular procedures face challenges due to the limited availability of appropriately sized devices for smaller vessels in children. This includes difficulties in selecting the right-sized catheters, balloons, and stents, and navigating the vascular system without causing injury. Imaging adjustments are also required. The use of fluoroscopy, intravascular ultrasound (IVUS), or magnetic resonance imaging (MRI) must be adjusted to accommodate the child\u0026rsquo;s size, which may necessitate adjustments in radiation dose or imaging settings to avoid exposure to excessive radiation, while the risk of complications like vessel dissection or thrombosis is higher. In some cases, customized devices may be necessary. Managing anticoagulation is more complex in children, and a multi-disciplinary approach is essential for successful outcomes. Overall, specialized techniques and smaller, tailored devices are crucial for improving pediatric endovascular procedures.\u0026sup2;\u0026sup1;\u003c/p\u003e\u003cp\u003eFor microsurgical interventions, options include clip reconstruction, trapping, and bypass with proximal occlusion. Surgical obliteration of the aneurysmal sac has been linked to lower recurrence rates and a reduced likelihood of developing new aneurysms.\u0026sup2;\u0026sup2;\u003c/p\u003e\u003cp\u003ePreserving the posterior cerebral artery (PCA) with stent-assisted coiling may be a viable option, particularly in cases where sacrificing the artery could lead to significant deficits, such as in a young patient who might be impacted by loss of driving ability. However, the long-term effectiveness and safety of this artery-preserving technique cannot be fully determined based on the limited data available from small case series.\u0026sup1;⁴,\u0026sup2;⁴ In literature, the Pipeline Embolization Device (PED) is promoted as a safe flow-diverting technique which works by diverting blood flow away from the aneurysm, while preserving the parent artery.\u0026sup2;⁵\u003c/p\u003e\u003cp\u003eDespite the International Subarachnoid Aneurysm Trial (ISAT) demonstration of the superiority of coil embolization over clipping for ruptured aneurysms in terms of prognosis, it is important to note that clipping may offer better long-term durability, which is a crucial consideration for children due to their longer life expectancy.\u0026sup2;⁶,\u0026sup2;⁷,\u0026sup2;⁸\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eIn summary, cerebral aneurysms are rare in the first year of life, especially those caused by dissection. Early detection, swift diagnosis, and a comprehensive approach involving neurosurgery, neurology, and rehabilitation are crucial for achieving positive outcomes. Currently, the management of PIAs remains under-defined due to their rarity, and, to the best of our knowledge, only a limited number of cases have been documented in the literature.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eAcknowledgments:\u003c/strong\u003e\u003cbr\u003e\u0026nbsp;I would like to express my gratitude to my professors and all the colleagues who participated in the completion of this work.\u003cbr\u003e\u0026nbsp;Not applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthical considerations:\u003c/strong\u003e\u003cbr\u003e\u0026nbsp;Our institution does not require ethical approval for reporting individual cases or case series.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent to participate:\u003c/strong\u003e\u003cbr\u003e\u0026nbsp;Not applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication:\u003c/strong\u003e\u003cbr\u003e\u0026nbsp;A statement confirming that informed consent for publication was provided by a legally authorized representative.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eDeclaration of conflicting interest:\u003c/strong\u003e\u003cbr\u003e\u0026nbsp;The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding statement:\u003c/strong\u003e\u003cbr\u003e\u0026nbsp;The author(s) received no financial support for the research, authorship, and/or publication of this article.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData availability:\u003c/strong\u003e\u003cbr\u003e\u0026nbsp;Data sharing is not applicable to this article as no new data were created or analyzed in this study.\u003c/p\u003e\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eIbtissam EL OUALI: Conception, writing and collection of Data.Meriem FIKRI: Performed the neuro vascular management of the patient and supervised the work and validation of the final manuscript.Lina BELKOUCHI: Supervision and collection of Data.Latifa OUSKOU: Collection of Data.Siham EL HADDAD: Verification of the analytical methods, supervised the findings of this work and validation of the work.Latifa CHAT: Supervision and validation of the final workAll authors discussed the results and contributed to the final manuscript.\u003c/p\u003e"},{"header":"References","content":"\u003col start=\"1\" type=\"1\"\u003e\n\u003cli\u003eLasjaunias P, Wuppalapati S, Alvarez H, Rodesch G, Ozanne A. 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Endovascular Treatment for Complex Vascular Pathologies in the Pediatric Population: Experience from a Center with Dual-Trained Neurosurgeons. \u003cem\u003eWorld Neurosurg\u003c/em\u003e. 2024;189:e696-e708. doi:10.1016/j.wneu.2024.06.151.\u003c/li\u003e\n\u003cli\u003eAghamiri SH, Salimi S, Sepehri Rad A, Sistanizad M, Pourheidar E. A spontaneous dissecting posterior cerebral artery aneurysm in a 10-month-old female infant: a case report. \u003cem\u003eIran J Child Neurol\u003c/em\u003e. 2022;16(3):199-203. doi:10.22037/ijcn.v16i3.34090.\u003c/li\u003e\n\u003cli\u003ede Barros Faria M, Castro RN, Lundquist J, et al. The role of the pipeline embolization device for the treatment of dissecting intracranial aneurysms. \u003cem\u003eAJNR Am J Neuroradiol\u003c/em\u003e. 2011;32(11):2192-2195. doi:10.3174/ajnr.A2671.\u003c/li\u003e\n\u003cli\u003eRavindra VM, Karsy M, Lanpher A, et al. Intracranial arterial dissection in children: a systematic review. \u003cem\u003eJ Neurosurg Pediatr\u003c/em\u003e. 2021;27(3):247-256.\u003c/li\u003e\n\u003cli\u003ePinto Silva R, Teles Silva C, Silva MJ, Alberto Silva P, Ribeiro A. Ruptured Intracranial Aneurysm in a 60-Day-Old Infant: An Extreme Case. \u003cem\u003eCureus\u003c/em\u003e. 2024;16(2):e53442. doi:10.7759/cureus.53442.\u003c/li\u003e\n\u003cli\u003eMohotti JE, Carter NS, Zhang VJW, Lai LT, Xenos C, Asadi H, Chandra RV. Neonatal intracranial aneurysms: case report and review of the literature. \u003cem\u003eJ Neurosurg Pediatr\u003c/em\u003e. 2018;21(5):471-477. doi:10.3171/2017.10.PEDS17226.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Pediatric cerebral aneurysms, Thrombophilia, MRA, Embolization","lastPublishedDoi":"10.21203/rs.3.rs-7221427/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7221427/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003eWe report a rare and complex condition in a one-year-old boy, where both an intracranial dissecting aneurysm and Factor XIII deficiency were present. The child was brought to the hospital due to spontaneous subarachnoid hemorrhage and an intracerebral hematoma in the occipital lobe.\u003c/p\u003e\n\u003cp\u003eMagnetic resonance angiography revealed a ruptured dissecting aneurysm in the distal segment of the right posterior cerebral artery with PCA infarcts. The patient's neurological condition rapidly deteriorated due to a Factor XIII deficiency, which heightened the risk of bleeding. This was promptly managed with Factor XIII administration, stabilizing the patient sufficiently for arteriography, followed by successful coil embolization.\u003c/p\u003e\n\u003cp\u003eFor initial screening, CT angiography (CTA) or MR angiography (MRA) are effective, accessible options; however, cerebral angiography remains the gold standard for precise localization of cerebral aneurysms. This case highlights the critical role of timely diagnostic imaging and surgical intervention in managing pediatric intracranial aneurysms.\u003c/p\u003e","manuscriptTitle":"A spontaneous dissecting posterior cerebral artery aneurysm in a one-year-old","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-08-11 07:12:47","doi":"10.21203/rs.3.rs-7221427/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"4d5046e7-ed1e-44f5-802e-cdfa9ce2eefa","owner":[],"postedDate":"August 11th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2026-02-23T07:57:08+00:00","versionOfRecord":[],"versionCreatedAt":"2025-08-11 07:12:47","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-7221427","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7221427","identity":"rs-7221427","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}