Neurosurgeons from the Universita degli Studi di Roma “La Saspeinza,” Rome, Italy, report a 4-year-old girl with a cerebral saccular aneurysm and analyze 71 cases under 5 years of age in the literature. The patient presented with headache, vomiting and immediate coma with opisthotonus and trismus. A CT scan revealed a round, hyperdense area near the midbrain, and an angiogram demonstrated an aneurysm on the left posterior cerebral artery. Recovery of consciousness and regression of nuchal rigidity took 3-4 days. At operation 12 days after the bleed, the artery was clipped above and below the aneurysm. A post-operative right facial-brachial paresis had resolved after 1 year but the hemianopia persisted.
Saccular aneurysms are rare in childhood, accounting for only 1-2% of cases. Most occur in the first year of life and affect the middle and anterior cerebral arteries in 40% and 12% of cases, respectively. Surgery appears to be tolerated better in early childhood than in adults, with operative mortalities after 1970 of 2.3% and 7.8% respectively. 
COMMENT. Early versus delayed operation for ruptured intracranial aneurysm is controversial. An International Comparative Study on Timing of Aneurysm Surgery in 3000 cases is expected to answer this question . The favorable outcome in this 4-year-old child would support a delay in operation until after recovery from the acute hemorrhage. The early age of presentation of the saccular aneurysm in children contrasts with an average age of 10 years for children with arteriovenous malformations  — (see Ped Neuro Briefs 1987; 1: 8).