Introduction: Pediatric cerebrovascular lesions include aneurysms, arteriovenous malformations (AVM), and vein of Galen malformations (VOGM). These entities are exceedingly rare, and among the most challenging cranial lesions to treat. Although this is due in part to their relative complexity, a major hurdle is their very low incidence; with most tertiary referral centers treating <1 pediatric aneurysm annually, the nearly all residents graduate with little or no exposure to this niche. Correspondingly, our study goal was to identify a representative case for each major lesional pediatric cerebrovascular disease, 3D print serially deconstructed models to demonstrate the anatomic relationships between the lesion and the surrounding vascular and bony structures, and design a resident-oriented pediatric cerebrovascular curriculum.
Methods: Retrospective series of pediatric cerebrovascular cases identified for 3D printing as illustrative examples of major pathologies. Segmentation was carried out using Mimic software; models were printed on a multilateral multicolor Objet 500 and a multicolor single material Projet 660. Trainees were serially presented cases with traditional imaging followed by 3D-printed models, and surveyed regarding key anatomic relationships and management principles.
Results: Three lesional pediatric cerebrovascular cases were 3D printed and included in the study. A 7-month-old female presented with new-onset seizures; head CT/CTA identified subarachnoid hemorrhage and a partially thrombosed giant left MCA aneurysm, which subsequently rebled. An emergent hemicraniectomy and aneurysm clipping was performed, and the patient recovered uneventfully, with moderate persistent deficits attributable to left MCA ischemia. A 3-day-old neurologically intact male neonate developed signs of right heart strain without frank cardiac failure. Head ultrasound identified a large, complex, high-flow, choroidal type VOGM, supplied from numerous bilateral enlarged numerous thalamic, choroidal, and pericallosal perforators, and drainage into a large prosencephalic vein. Several months of observation were elected prior to endovascular obliteration, which was pursued elsewhere. A 10-year-old female presented with severe, acute-onset headache and decreased level-of-consciousness; head CT/CTA demonstrated expansive posterior fossa hemorrhage from a left superior cerebellar artery AVM with deep drainage. Emergent EVD placement and posterior fossa decompression was completed, during which the AVM was encountered and resected. She recovered well with moderate bilateral lower extremity incoordination and stuttering speech, which have progressively improved in follow-up. Survey feedback following curriculum administration confirmed significant improvement in resident understanding of pediatric cerebrovascular disease, with all participants indicating a favorable response to 3D printed models.
Conclusion: Pediatric cerebrovascular lesions present a wide swath of management and training challenges, attributable at once to anatomic complexity, clinical unpredictability, and relative rarity. Our preliminary results suggest that 3D printing may provide an important opportunity to incorporate a larger volume of rare cases into resident training curricula, and provide a new, effective technique for studying case-specific lesional vascular anatomy.
