Pediatric Intracranial Aneurysms: Experience from a Singapore Children’s Hospital
Abstract
:1. Introduction
2. Materials and Methods
2.1. Study Design, Patient Demographics, and Variables of Interest
2.2. Outline of Treatment Workflow
2.3. Literature Review
3. Results
3.1. Baseline Patient Characteristics
3.2. Aneurysm Features: Morphology, Location, and Aetiology
3.3. Treatment Modalities and Outcomes
3.4. Illustrative Case Example: Challenging Diagnosis
3.5. Literature Review Findings
4. Discussion
4.1. Pediatric Intracranial Aneurysms: An Overview
4.2. Aneurysm Morphology and Management Outcomes: Our Institutional Experience
4.3. Risk Factors Unique to the Pediatric Population
4.4. Clinical Outcomes
4.5. Aneurysmal Cerebral Vasospasm: Is This Phenomenon Less Prevalent in Children?
4.6. Study Critique and Future Directions
5. Conclusions
Author Contributions
Funding
Institutional Review Board Statement
Informed Consent Statement
Data Availability Statement
Conflicts of Interest
References
- Herman, J.M.; Rekate, H.L.; Spetzler, R.F. Pediatric intracranial aneurysms: Simple and complex cases. Pediatr. Neurosurg. 1991, 17, 66–72; discussion 73. [Google Scholar] [CrossRef] [PubMed]
- Ventureyra, E.C.; Higgins, M.J. Traumatic intracranial aneurysms in childhood and adolescence. Case reports and review of the literature. Childs Nerv. Syst. 1994, 10, 361–379. [Google Scholar] [CrossRef] [PubMed]
- Huang, J.; McGirt, M.J.; Gailloud, P.; Tamargo, R.J. Intracranial aneurysms in the pediatric population: Case series and literature review. Surg. Neurol. 2005, 63, 424–432; discussion 432–433. [Google Scholar] [CrossRef] [PubMed]
- Sharma, B.S.; Sinha, S.; Mehta, V.S.; Suri, A.; Gupta, A.; Mahapatra, A.K. Pediatric intracranial aneurysms—Clinical characteristics and outcome of surgical treatment. Childs Nerv. Syst. 2007, 23, 327–333. [Google Scholar] [CrossRef] [PubMed]
- Krings, T.; Geibprasert, S.; terBrugge, K.G. Pathomechanisms and treatment of pediatric aneurysms. Childs Nerv. Syst. 2010, 26, 1309–1318. [Google Scholar] [CrossRef] [PubMed]
- Kanaan, I.; Lasjaunias, P.; Coates, R. The spectrum of intracranial aneurysms in pediatrics. Minim. Invasive Neurosurg. 1995, 38, 1–9. [Google Scholar] [CrossRef] [PubMed]
- Sanai, N.; Auguste, K.I.; Lawton, M.T. Microsurgical management of pediatric intracranial aneurysms. Childs Nerv. Syst. 2010, 26, 1319–1327. [Google Scholar] [CrossRef] [PubMed]
- Garg, K.; Singh, P.K.; Sharma, B.S.; Chandra, P.S.; Suri, A.; Singh, M.; Kumar, R.; Kale, S.S.; Mishra, N.K.; Gaikwad, S.K.; et al. Pediatric intracranial aneurysms—Our experience and review of literature. Childs Nerv. Syst. 2014, 30, 873–883. [Google Scholar] [CrossRef] [PubMed]
- Chen, R.; Zhang, S.; ** versus endovascular coiling in 2143 patients with ruptured intracranial aneurysms: A randomised comparison of effects on survival, dependency, seizures, rebleeding, subgroups, and aneurysm occlusion. Lancet 2005, 366, 809–817. [Google Scholar] [CrossRef]
- McDougall, C.G.; Spetzler, R.F.; Zabramski, J.M.; Partovi, S.; Hills, N.K.; Nakaji, P.; Albuquerque, F.C. The Barrow Ruptured Aneurysm Trial. J. Neurosurg. 2012, 116, 135–144. [Google Scholar] [CrossRef] [PubMed]
- Spetzler, R.F.; McDougall, C.G.; Zabramski, J.M.; Albuquerque, F.C.; Hills, N.K.; Russin, J.J.; Partovi, S.; Nakaji, P.; Wallace, R.C. The Barrow Ruptured Aneurysm Trial: 6-year results. J. Neurosurg. 2015, 123, 609–617. [Google Scholar] [CrossRef] [PubMed]
- Sorteberg, A.; Dahlberg, D. Intracranial Non-traumatic Aneurysms in Children and Adolescents. Curr. Pediatr. Rev. 2013, 9, 343–352. [Google Scholar] [CrossRef] [PubMed]
- O’Neal, C.M.; Ernst, G.L.; Hughes, K.L.; Stephens, T.M.; Hendrix, M.C.; Gross, N.L.; Bohnstedt, B.N.; Cheema, A.A. Reported incidence and treatment modalities of giant cerebral aneurysms in the pediatric population: A systematic review and illustrative case report. J. Clin. Neurosci. 2021, 90, 14–20. [Google Scholar] [CrossRef]
- Navarro, R.; Brown, B.L.; Beier, A.; Ranalli, N.; Aldana, P.; Hanel, R.A. Flow diversion for complex intracranial aneurysms in young children. J. Neurosurg. Pediatr. 2015, 15, 276–281. [Google Scholar] [CrossRef] [PubMed]
- Ikeda, D.S.; Marlin, E.S.; Shaw, A.; Powers, C.J. Successful endovascular reconstruction of a recurrent giant middle cerebral artery aneurysm with multiple telesco** flow diverters in a pediatric patient. Pediatr. Neurosurg. 2015, 50, 88–93. [Google Scholar] [CrossRef] [PubMed]
- Wehman, J.C.; Hanel, R.A.; Levy, E.I.; Hopkins, L.N. Giant cerebral aneurysms: Endovascular challenges. Neurosurgery 2006, 59, S3-125–S3-138. [Google Scholar] [CrossRef] [PubMed]
- Tominaga, T. Giant Cerebral Aneurysm: Still Formidable Challenges in Modern Neurosurgery. Jma J. 2022, 5, 377–378. [Google Scholar] [CrossRef] [PubMed]
- Schievink, W.I.; Mokri, B.; Piepgras, D.G.; Gittenberger-de Groot, A.C. Intracranial Aneurysms and Cervicocephalic Arterial Dissections Associated with Congenital Heart Disease. Neurosurgery 1996, 39, 685–690. [Google Scholar] [CrossRef]
- Curtis, S.L.; Bradley, M.; Wilde, P.; Aw, J.; Chakrabarti, S.; Hamilton, M.; Martin, R.; Turner, M.; Stuart, A.G. Results of screening for intracranial aneurysms in patients with coarctation of the aorta. Am. J. Neuroradiol. 2012, 33, 1182–1186. [Google Scholar] [CrossRef]
- Donti, A.; Spinardi, L.; Brighenti, M.; Faccioli, L.; Leoni, C.; Fabi, M.; Trossello, M.P.; Gargiulo, G.D.; Bonvicini, M. Frequency of intracranial aneurysms determined by magnetic resonance angiography in children (mean age 16) having operative or endovascular treatment of coarctation of the aorta (mean age 3). Am. J. Cardiol. 2015, 116, 630–634. [Google Scholar] [CrossRef] [PubMed]
- Flores, B.C.; Patel, A.R.; Braga, B.P.; Weprin, B.E.; Batjer, H.H. Management of infectious intracranial aneurysms in the pediatric population. Childs Nerv. Syst. 2016, 32, 1205–1217. [Google Scholar] [CrossRef] [PubMed]
- Eddleman, C.S.; Surdell, D.; DiPatri, A., Jr.; Tomita, T.; Shaibani, A. Infectious intracranial aneurysms in the pediatric population: Endovascular treatment with Onyx. Childs Nerv. Syst. 2008, 24, 909–915. [Google Scholar] [CrossRef] [PubMed]
- Pietro Mazzoni, M.; Chiriboga, C.A.; Millar, W.S.; Rogers, A. Intracerebral aneurysms in human immunodeficiency virus infection: Case report and literature review. Pediatr. Neurol. 2000, 23, 252–255. [Google Scholar] [CrossRef]
- Junichi Masuda, C.Y.; Waki, R.; Ogata, J.; Kuriyama, Y.; Yamaguchi, T. Histopathological analysis of the mechanisms of intracranial hemorrhage complicating infective endocarditis. Stroke 1992, 23, 843–850. [Google Scholar] [CrossRef] [PubMed]
- Bakhaidar, M.G.; Ahamed, N.A.; Almekhlafi, M.A.; Baeesa, S.S. Novo intracerebral aneurysm in a child with acquired immunodeficiency syndrome. Neurosciences 2015, 20, 285–291. [Google Scholar] [CrossRef] [PubMed]
- Somboonnithiphol, K.; Chanthanaphak, E.; Singhara Na Ayudhaya, S.P.; Khongkhatithum, C.; Sirilert, B. Successful endovascular treatment of pediatric basilar infectious (mycotic) aneurysm: A case report and review of the literature. Childs Nerv. Syst. 2021, 37, 2687–2693. [Google Scholar] [CrossRef] [PubMed]
- Yazbak, P.A.; McComb, J.G.; Raffel, C. Pediatric traumatic intracranial aneurysms. Pediatr. Neurosurg. 1995, 22, 15–19. [Google Scholar] [CrossRef] [PubMed]
- de Gast, A.N.; Sprengers, M.E.; van Rooij, W.J.; Lavini, C.; Sluzewski, M.; Majoie, C.B. Long-term 3T MR angiography follow-up after therapeutic occlusion of the internal carotid artery to detect possible de novo aneurysm formation. AJNR Am. J. Neuroradiol. 2007, 28, 508–510. [Google Scholar]
- Sprengers, M.E.; van Rooij, W.J.; Sluzewski, M.; Rinkel, G.J.; Velthuis, B.K.; de Kort, G.A.; Majoie, C.B. MR angiography follow-up 5 years after coiling: Frequency of new aneurysms and enlargement of untreated aneurysms. AJNR Am. J. Neuroradiol. 2009, 30, 303–307. [Google Scholar] [CrossRef]
- Hetts, S.W.; English, J.D.; Dowd, C.F.; Higashida, R.T.; Scanlon, J.T.; Halbach, V.V. Pediatric intracranial aneurysms: New and enlarging aneurysms after index aneurysm treatment or observation. AJNR Am. J. Neuroradiol. 2011, 32, 2017–2022. [Google Scholar] [CrossRef] [PubMed]
- Ravindra, V.M.; Karsy, M.; Schmidt, R.H.; Taussky, P.; Park, M.S.; Bollo, R.J. Rapid de novo aneurysm formation after clip** of a ruptured middle cerebral artery aneurysm in an infant with an MYH11 mutation. J. Neurosurg. Pediatr. 2016, 18, 463–470. [Google Scholar] [CrossRef] [PubMed]
- Kadian-Dodov, D.; Gornik, H.L.; Gu, X.; Froehlich, J.; Bacharach, J.M.; Chi, Y.W.; Gray, B.H.; Jaff, M.R.; Kim, E.S.; Mace, P.; et al. Dissection and Aneurysm in Patients With Fibromuscular Dysplasia: Findings From the U.S. Registry for FMD. J. Am. Coll. Cardiol. 2016, 68, 176–185. [Google Scholar] [CrossRef] [PubMed]
- Touze, E.; Southerland, A.M.; Boulanger, M.; Labeyrie, P.E.; Azizi, M.; Bouatia-Naji, N.; Debette, S.; Gornik, H.L.; Hussain, S.M.; Jeunemaitre, X.; et al. Fibromuscular Dysplasia and Its Neurologic Manifestations: A Systematic Review. JAMA Neurol. 2019, 76, 217–226. [Google Scholar] [CrossRef] [PubMed]
- Nakamura, M.; Rosahl, S.K.; Vorkapic, P.; Forster, C.; Samii, M. De novo formation of an aneurysm in a case of unusual intracranial fibromuscular dysplasia. Clin. Neurol. Neurosurg. 2000, 102, 259–264. [Google Scholar] [CrossRef] [PubMed]
- Wostrack, M.; Sandow, N.; Vajkoczy, P.; Schatlo, B.; Bijlenga, P.; Schaller, K.; Kehl, V.; Harmening, K.; Ringel, F.; Ryang, Y.M.; et al. Subarachnoid haemorrhage WFNS grade V: Is maximal treatment worthwhile? Acta Neurochir. 2013, 155, 579–586. [Google Scholar] [CrossRef] [PubMed]
- Taylor, C.J.; Robertson, F.; Brealey, D.; O’Shea, F.; Stephen, T.; Brew, S.; Grieve, J.P.; Smith, M.; Appleby, I. Outcome in poor grade subarachnoid hemorrhage patients treated with acute endovascular coiling of aneurysms and aggressive intensive care. Neurocrit. Care 2011, 14, 341–347. [Google Scholar] [CrossRef] [PubMed]
- Mundkur, N. Neuroplasticity in children. Indian J. Pediatr. 2005, 72, 855–857. [Google Scholar] [CrossRef] [PubMed]
- Cobb, M.I.-P.H.; Zomorodi, A.R.; Hauck, E.F.; Smith, T.P.; Fernando Gonzalez, L. Optimal pediatric dosing of anti-platelet agents for pipeline stent embolization—A case report and review of the literature. Child’s Nerv. Syst. 2017, 33, 685–690. [Google Scholar] [CrossRef]
- Barburoglu, M.; Arat, A. Flow Diverters in the Treatment of Pediatric Cerebrovascular Diseases. AJNR Am. J. Neuroradiol. 2017, 38, 113–118. [Google Scholar] [CrossRef]
- Zacharia, B.E.; Hickman, Z.L.; Grobelny, B.T.; DeRosa, P.; Kotchetkov, I.; Ducruet, A.F.; Connolly, E.S., Jr. Epidemiology of aneurysmal subarachnoid hemorrhage. Neurosurg. Clin. N. Am. 2010, 21, 221–233. [Google Scholar] [CrossRef] [PubMed]
- Macdonald, R.L. Delayed neurological deterioration after subarachnoid haemorrhage. Nat. Rev. Neurol. 2014, 10, 44–58. [Google Scholar] [CrossRef] [PubMed]
- Pickard, J.D.; Murray, G.D.; Illingworth, R.; Shaw, M.D.; Teasdale, G.M.; Foy, P.M.; Humphrey, P.R.; Lang, D.A.; Nelson, R.; Richards, P.; et al. Effect of oral nimodipine on cerebral infarction and outcome after subarachnoid haemorrhage: British aneurysm nimodipine trial. BMJ 1989, 298, 636–642. [Google Scholar] [CrossRef] [PubMed]
- Rumalla, K.; Smith, K.A.; Arnold, P.M.; Mittal, M.K. Subarachnoid Hemorrhage and Readmissions: National Rates, Causes, Risk Factors, and Outcomes in 16,001 Hospitalized Patients. World Neurosurg. 2018, 110, e100–e111. [Google Scholar] [CrossRef] [PubMed]
- Ciurea, A.V.; Palade, C.; Voinescu, D.; Nica, D.A. Subarachnoid hemorrhage and cerebral vasospasm—Literature review. J. Med. Life 2013, 6, 120–125. [Google Scholar] [PubMed]
- Lee, D.; Lee, J.; Kim, K.H.; Kim, J.H.; Lee, J. Diffuse Cerebral Vasospasm After Aneurysmal Subarachnoid Hemorrhage in a 15-Year-Old Girl: A Case Report. Front. Radiol. 2021, 1, 774739. [Google Scholar] [CrossRef]
- Heffren, J.; McIntosh, A.M.; Reiter, P.D. Nimodipine for the Prevention of Cerebral Vasospasm After Subarachnoid Hemorrhage in 12 Children. Pediatr. Neurol. 2015, 52, 356–360. [Google Scholar] [CrossRef] [PubMed]
- Gillis, H.; Lovett, M.; O’Brien, N. 782: Novel Treatment of Cerebral Vasospasm following Aneurysm Rupture in a Pediatric Patient. Crit. Care Med. 2019, 47, 370. [Google Scholar] [CrossRef]
- Zhou, S.; Dion, P.A.; Rouleau, G.A. Genetics of Intracranial Aneurysms. Stroke J. Cereb. Circ. 2018, 49, 780–787. [Google Scholar] [CrossRef]
Variable | n (%, Unless Stated Otherwise) |
---|---|
Age range in years (mean) | 0.17 to 14 (5.8 ± 4.7) |
Length of follow-up range in months (mean) | 3 to 185 (70) |
Number of patients | 11 (100) |
Gender | |
Male | 10 (90.1) |
Female | 1 (0.09) |
Clinical Presentation | |
Decreased consciousness | 7 (63.6) |
Headache | 1 (0.09) |
Cranial nerve palsy | 1 (0.09) |
Seizure | 1 (0.09) |
Incidental 1 | 3 (27.3) |
WFNS Grade (at first diagnosis) | |
I to II | 2 (18.2) |
III to IV | 4 (36.4) |
Not applicable (as unruptured) | 5 (45.5) |
Glasgow Outcome Scale (GOS) | |
1 | 0 (0) |
2 | 0 (0) |
3 | 1 (0.09) |
4 | 3 (27.3) |
5 | 7 (63.6) |
Total number of PIA per patient 1 | |
Single | 8 (72.7) |
Multiple | 3 (27.3) |
Total number of PIA in this study | 14 (100) |
Location | |
Anterior circulation | 11 (78.6) |
Posterior circulation | 3 (21.4) |
Type of aneurysm | |
Dissecting | 6 (42.9) |
Mycotic | 5 (35.7) |
Saccular | 3 (21.4) |
Size of aneurysm | |
<1 cm | 7 (50) |
1 to 2 cm | 5 (35.7) |
≥2.5 cm | 2 (14.3) |
Treatment modality | |
Conservative | 1 (7.1) |
Endovascular procedure(s) | 5 (35.7) |
Microsurgical clip** or excision | 8 (57.1) |
Year/Authors | Patient Number (%) | Males (%) | Good Outcomes 1 (%) | Mortality (%) | Total Number of PIA (%) | Giant PIA (%) | Mycotic PIA (%) | Treatment Modality (%) |
---|---|---|---|---|---|---|---|---|
2001/Proust et al. [29] | 22 (100) | 16 (72) | 14 (63.6) | 5 (22.7) | 25 (100) | 3 (12) | 2 (8) | Surgery 18 (81.8); endovascular 4 (18.2) |
2005/Huang et al. [3] | 19 (100) | 13 (68.4) | 18 (94.7) | 1 (5.3) | 19 (100) | 7 (36.8) | 0 (0) | Surgery 13 (68.4); endovascular 3 (15.8); conservative 3 (15.8) |
2005/Lasjaunia et al. [16] | 59 (100) | 35 (59) | N.A. | 5 (8) | 75 (100) | 1 (1.7) | 15 (20) | Surgery 28 (37.3); endovascular 13; conservative 16 (27.1) |
2005/Agid et al. [30] | 33 (100) | 16 | 21 (64) | 5 (15) | 37 (100) | 11 (29.7) | 5 (13.5) | Surgery 10 (27); endovascular 13 (35.1); conservative 14 (37.8) |
2007/Sharma et al. [4] | 55 (100) | 38 (69) | 36 (90) | 2 (5) | 67 (100) | 13 (19.4) | 2 (3) | 2 Surgery 40 (72.7); conservative 15 (27.3) |
2008/Stiefel et al. [31] | 12 (100) | 4 (33) | 9 (75) | 1 (8) | 13 (100) | 1 (7.7) | 0 (0) | Surgery 8 (61.5); endovascular 5 (38.5) |
2009/Liang et al. [32] | 24 (100) | 14 (58) | 22 (92) | 1 (4) | 24 (100) | 8 (33.3) | 1 (4) | Surgery 4; endovascular 14; conservative 5 |
2009/Lv et al. [33] | 25 (100) | 20 (80) | N.A. | 1 (1.3) | 25 (100) | 17 (68) | 0 (0) | Endovascular 24 (96); conservative 1 (4) |
2009/Hetts et al. [15] | 77 (100) | 37 (48.1) | N.A. | 1 (1)1.3 | 103 (100) | 8 (11%) | 12 (15.6) | 2 Surgery 29 (37.7); endovascular 30 (39); conservative 18 (23.4) |
2009/Kakarla et al. [34] | 48 (100) | 28 (58.3) | 44 (91.7) | 1 (2.1) | 72 (100) | 16 (22.2) | 5 (6.9) | 2 Surgery 48 (100); endovascular—done post-surgery 3 (6.3) |
2013/Garg et al. [8] | 62 (100) | 45 (72.6) | 45 (72.6) | 1 (1.4) | 74 (100) | 11 (14.9) | 2 (2.7) | 2 Surgery 43 (69.4); endovascular 19 (30.6), conservative 6 (9.7) |
2015/Gross et al. [35] | 33 (100) | 16 (48.5) | N.A. | N.A. | 33 (100) | N.A. | N.A. | Surgery 8 (24.2); endovascular 15 (45.5); conservative 10 (30.3) |
2015/Vargas et al. [36] | 5 (100) | 5 (100) | 4 (83.3) | 1 (16.7) | 6 (100) | 4 (66.7) | 0 (0) | Endovascular 6 (100) |
2018/Chen et al. [37] | 35 (100) | 25 (71.4) | 30 (85.7) | 1 (2.9) | 35 (100) | 16 (45.7) | 0 (0) | Surgery 20 (57.1); endovascular 15 (42.9) |
2019/Amelot et al. [38] | 51 (100) | 35 (68.6) | 35 (68.6) | 10 (29.6) | 51 (100) | 3 (5.9) | N.A. | Surgery 8 (15.7), endovascular 43 (84.3) |
2019/Kim et al. [13] | 26 (100) | 17 (65.4) | 20 (76.9) | 1 (3.9) | 33 (100) | 2 (7.7) | 2 (7.7) | Surgery 10 (38.5); endovascular 10 (38.5); conservative 5 (19.2) |
2019/Nam et al. [39] | 23 (100) | 15 (65.2) | 19 (61.3) | 1 (4.3) | 31(100) | 3 (13) | N.A. | Surgery 3 (9.7); endovascular 21 (67.7); combined surgery & endovascular 1 (3.2); conservative 1 (3.2) |
2019/Thioub et al. [40] | 10 (100) | 4 (40) | 8 (80) | 1 (10) | 10 (100) | 1 (10) | 4 (40) | Surgery 7 (70); endovascular 3 (30) |
2019/Yasin et al. [27] | 41 (100) | 25 (61) | 37 (90.2) | 2 (4.9) | 57 (100) | 1 (1.8) | 2 (3.5) | Surgery 13 (22.8); endovascular 25 (43.9); conservative 19 (33.3) |
2021/Ciurea et al. [28] | 47 (100) | 28 (59.6) | 37 (78.5) | 1 (2.1) | 47 (100) | 14 (29.8) | N.A. | Surgery 46 (97.9); endovascular 1 (2.1) |
2021/Garrido et al. [41] | 18 (100) | 14 (77.8) | 15 (83.3) | 1 (5.6) | 21 (100) | 4 (19) | 2 (9.5) | Surgery 9 (42.9); endovascular 12 (57.1) |
2021/Xu et al. [42] | 47 (100) | 29 (61.7) | 40 (90.9) | 5 (10.6) | 53 (100) | 10 (18.9) | 1 (1.9) | Surgery 31 (58.5); endovascular 16 (30.2); medical 3 1 (1.9) |
2022/de Aguiar et al. [17] | 12 (100) | 5 (41.7) | 10 (83.3) | 2 (16.7) | 17 (100) | 6 (35.3) | 2 (11.8) | Surgery 0 (0); endovascular 12 (70.6); conservative 5 (29.4) |
2023/Brandel et al. [26] | 33 (100) | 21 (63.6) | 21 (63.6) | 6 (18.2) | 37 (100) | 12 (32.4) | 1 (2.7) | Surgery 25 (67.6); endovascular 8 (21.6) |
2024/Current study | 11 (100) | 10 (90.1) | 10 (90.1) | 0 (0) | 14 (100) | 2 (14.3) | 5 (35.7) | Surgery 8 (57.1); endovascular 5 (35.7); conservative 1 (7.1) |
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Chua, F.H.Z.; Cheong, T.M.; Kirollos, R.W.; Ng, L.P.; Seow, W.T.; Low, S.Y.Y. Pediatric Intracranial Aneurysms: Experience from a Singapore Children’s Hospital. Surgeries 2024, 5, 434-448. https://doi.org/10.3390/surgeries5020036
Chua FHZ, Cheong TM, Kirollos RW, Ng LP, Seow WT, Low SYY. Pediatric Intracranial Aneurysms: Experience from a Singapore Children’s Hospital. Surgeries. 2024; 5(2):434-448. https://doi.org/10.3390/surgeries5020036
Chicago/Turabian StyleChua, Felicia H. Z., Tien Meng Cheong, Ramez W. Kirollos, Lee ** Ng, Wan Tew Seow, and Sharon Y. Y. Low. 2024. "Pediatric Intracranial Aneurysms: Experience from a Singapore Children’s Hospital" Surgeries 5, no. 2: 434-448. https://doi.org/10.3390/surgeries5020036