Aneurysmal subarachnoid hemorrhage in infants: a case report and systematic review with pooled individual patient-level analysis.

BACKGROUND

Aneurysmal subarachnoid hemorrhage (aSAH) in infants is exceptionally rare, posing unique diagnostic and therapeutic challenges due to nonspecific clinical features and lack of standardized management protocols.

CASE PRESENTATION: We report a 6-month-old male presenting with vomiting, decreased consciousness, and seizures. Neuroimaging revealed diffuse subarachnoid hemorrhage from a ruptured left middle cerebral artery (MCA) aneurysm. Despite aggressive stabilization, the patient suffered rebleeding and succumbed to catastrophic complications.

METHODS

A systematic review following PRISMA guidelines was conducted (CRD420251145008). PubMed, Embase, and Cochrane CENTRAL were searched (2005-2025) for aSAH cases in infants ≤ 12 months. Extracted individual patient data were combined into a pooled individual-level analysis comparing survival and functional outcomes between intervention (endovascular/microsurgical) and conservative management using Fisher's exact test.

RESULTS

Sixty cases were identified (median age 6 months; 56% male). The MCA was the most frequently affected site (38%). Seizures (42%) and altered consciousness (38%) were common presentations. In the pooled analysis, 43 infants underwent intervention (37% endovascular, 33% microsurgical) while 8 received conservative management. Intervention was associated with a trend toward improved survival (88% vs. 63%; OR 4.50, 95% CI 0.73-28.9, p = 0.11). No significant difference in survival (OR 0.71, p > 0.99) or favorable functional outcome (OR 0.89, p > 0.99) was found between endovascular and microsurgical cohorts.

CONCLUSIONS

Infantile aSAH is a devastating condition requiring early neuroimaging. Quantitative synthesis suggests active intervention may offer a survival advantage over conservative management, with both endovascular and microsurgical approaches demonstrating comparable efficacy in specialized centers.