Describe a unique pediatric case of a giant peridural (clinoid) ring aneurysm with unusual complications.

This is a case of a 14 y/o male without significant medical history who presented with a giant (i.e. > 5cm) internal carotid (clinoid) artery aneurysm, within the dural ring.

Patient had a poor initial Glasgow Coma Scale (GCS) score, multiple cranial neuropathies, and life-threatening complications. Both supradural (i.e. CN3, seizures, mass effect, hydrocephalus) and infradural (i.e. multiple cranial nerve neuropathies, epistaxis) ring aneurysmal complications were present in this patient. Patient developed a compressive right MCA stroke. Initial treatment included optimizing medical management, and reducing ICP with a unilateral decompressive hemicraniectomy. For the aneurysm, a unilateral parent vessel sacrifice (ICA) via endovascular coil embolization was performed.

This is the first pediatric case of a giant aneurysm provoking supradural and infradural vascular complications. The abnormal clinical symptoms (e.g. increased ICP) and the focal neurological exam (CN palsies, plegia, etc) should guide the management and treatment of dural aneurysms. The early activation of neurovascular team, diagnostic angiogram, and aneurysm repair may influence positively on outcome/prognosis of patients with this rare presentation. Aneurysmal rupture, ICH complications, and risk of irreversible neurological sequela should warrant a multi-disciplinary approach to reduce morbidity and mortality in pediatric patients.