Pediatric traumatic brain injury (TBI) is the leading cause of injury-related death and long-term disability in children worldwide. Current monitoring relies predominantly on invasive techniques that carry procedural risks and are not feasible in all settings or across all severity levels. Noninvasive alternatives, including quantitative automated pupillometry and intracranial pressure (ICP) pulse waveform monitoring, have emerged as promising tools, yet their evidence base in pediatric TBI remains uncharacterized. We conducted a scoping review following the Joanna Briggs Institute methodology, reported per Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews, to characterize existing evidence on these two modalities, examining devices, populations, parameters, and key findings. Five databases (PubMed/MEDLINE, Embase, Cochrane Central, Scopus, CINAHL) were searched through February 2026. Six studies met the inclusion criteria, all addressing quantitative pupillometry. Three evaluated pupillometry in mild TBI in emergency or outpatient settings, one enrolled critically ill children with concurrent invasive ICP monitoring in the pediatric intensive care unit, and two reviewed pupillometry within multimodal neuromonitoring frameworks. All primary studies employed NeurOptics devices. Key findings included time-dependent alterations in pupillary light reflex following concussion and a significant inverse correlation between ICP and pupillometric parameters at thresholds ≥20 mmHg. No primary clinical study evaluated noninvasive ICP pulse waveform morphology devices, specifically P1/P2/P3 analysis characteristic of Brain4care-type technologies in children with TBI. Quantitative pupillometry shows physiologically coherent associations with TBI-related changes, but its utility remains limited by heterogeneous protocols, the absence of age-stratified normative values, and the lack of prospective outcome data. No primary pediatric evidence on noninvasive ICP waveform monitoring was identified, representing the highest-priority evidence gap.

BACKGROUND:Fibrocartilaginous embolism (FCE) is a rare but serious cause of spinal cord infarction. Vertical disc herniation (e.g., Schmorl's nodes) may enable FCE in the thoracolumbar spine but is unlikely in the pediatric cervical spine. We hypothesized that radial disc herniation (annular fissuring), rather than vertical herniation, may contribute to cervical spinal cord infarction in children via an FCE mechanism. METHODS:In this retrospective case-control study, the frequency of annular fissures and nuclear degeneration was assessed in patients with possible FCE from January 2004 to December 2023. The presumed diagnosis of FCE was based on clinical evaluation characteristic imaging findings of cord infarction, and exclusion of other diagnoses in electronic medical records. The two control groups included children without myelopathy (Control 1), selected during a 6-month consecutive sampling period from March to July 2014, and children with non-compressive cervical myelopathy (Control 2), selected through consecutive sampling from April 2004 to February 2014. Data analysis was performed using SPSS (IBM, version 29.0). The significance level was p<0.05. RESULTS:A total of 156 children were included, 18 with possible FCE (Case) and 138 without (Control 1 and Control 2 with 39 and 99 patients, respectively). The median ages (IQR) were 12.6 (9.0-16.5), 9.6 (5.0-15.6), and 10.3 (5.0-14.6) years for Case, Control 1, and Control 2 groups respectively and 48.1% (75/156) were female. Annular fissures were observed in 28.8% (45/156) across ≥1 disc levels, and all patients showed nuclear degeneration at one or more disc levels. Among FCE patients, 88.9% (16/18) had at least one annular fissure. The odds ratio of having an annular fissure in FCE patients compared with the total control group was 30.06 (CI [6.53-138.30]). The odds ratio compared with Control 1 was 31.60 (CI [6.70-148.83]) and compared with Control 2 was 26.66 (CI [5.13-138.56]). CONCLUSION:This study demonstrated a statistically significant association between annular fissures and cervical spinal cord infarction. This finding is consistent with the theory that disc material may embolize through a radial annular tear into the cervical spinal cord microcirculation.

Introduction:Intracranial hypertension is a life-threatening complication of traumatic brain injury (TBI) and a major target in neurocritical care. While ventriculostomy for cerebrospinal fluid diversion and the emerging technique of cisternostomy are used on a regular basis in different areas of the world, their application is heterogeneous on indications, timing, and technical aspects in the surgical procedures. This variability highlights a critical lack of standardized protocols, particularly in resource-constrained environments where optimized recommendations are most needed. Research question:What are the specific, expert-consensus recommendations to standardize the use of ventriculostomy and cisternostomy within a protocol for TBI management? Material and methods:The Neurotrauma Committee of the World Federation of Neurosurgical Societies develop an international consensus, including a methodological group and a panel of 16 expert neurosurgeons following a Delphi process, involving systematic literature review, statement formulation, and iterative blinded voting using a 5-point Likert scale. Consensus was predefined as ≥75% agreement. Results:The panel ratified 69 consensus statements. Core recommendations advocate for ventriculostomy as an early therapeutic intervention for TBI requiring fluid drainage and define cisternostomy as an adjunctive procedure for selected patients with TBI and significant traumatic subarachnoid hemorrhage. Protocols with algorithms were proposed for both procedures. Discussion and conclusion:This consensus provides a practical framework to guide surgical management of TBI using ventriculostomy and or cisternostomy as techniques. It promotes a strategic shift towards prior heterogeneous concepts on ventriculostomy and defines a specific, consensus-guided role for cisternostomy. The statements aim to harmonize global practice and direct future research.

Background and purpose: Spring-assisted cranioplasty has been established as an effective technique for minimally invasive correction of single suture sagittal craniosynostosis. However, the potential for secondary suture synostosis following spring placement remains unclear. This case series represents our institutional experience with spring-assisted cranioplasty and highlights 5 patients with progression to secondary suture craniosynostosis necessitating surgical intervention following initial spring placement.Method and description: IRB-approved data from all patients undergoing spring-assisted cranioplasty for sagittal craniosynostosis (2021-2025) were retrospectively reviewed.Results: Fifty-five patients over the 4-year interval underwent spring-assisted cranioplasty. Fifty-four patients presented with a diagnosis of single suture sagittal craniosynostosis, while one patient had sagittal and unilateral lambdoid craniosynostosis. All patients had 2 springs placed except for the one with concomitant lambdoid synostosis, who received a third. Mean age at spring placement was 3.7 months with a mean interval to removal of 3.8 months. The average operative duration was 80.3 minutes, and the mean length of stay was 1.5 days. Eighteen (32.7%) of patients had an intensive care unit stay and 14 (25.5%) of patients required a blood transfusion. Nine of the 55 patients required an unplanned secondary procedure. Two patients experienced hardware migration with the need for operative adjustment/replacement. Six patients (10.9%) necessitated subsequent CVR: 4 due to the development of secondary unicoronal synostosis and 2 due to inadequate expansions and residual cranial deformities. One patient developed bilateral coronal and right lambdoid synostosis and subsequently underwent suturectomy and helmet therapy.Conclusion: This series highlights the observation of secondary suture craniosynostosis following spring-assisted cranioplasty for sagittal synostosis. Whether the progression is a direct sequelae of underlying spring force mechanics/provider placement or a reflection of natural synostotic evolution remains uncertain. Its clinical significance warrants further investigation and discussion within the broader craniofacial surgical community.

INTRODUCTION:Infectious intracranial aneurysms (IIAs) are rare but serious complications of systemic infections, particularly infective endocarditis. These aneurysms are prone to rupture, leading to significant morbidity and mortality. Management strategies lack consensus due to the rarity of the condition and reliance on small case series. This study examines the clinical management of IIAs using data from a large multicenter cohort. METHODS:A retrospective registry-based cohort study was conducted across 11 tertiary care centers in the USA between 2018 and 2023. Patients with IIAs were identified based on clinical and radiographic criteria. The primary outcome was treatment failure defined as persistence, growth, or rupture of the aneurysm. Secondary outcomes were mortality and the modified Rankin Scale (mRS) score at 90 days and 1 year. Multivariate logistic regressions were used to identify outcome predictors. RESULTS:A total of 104 patients with 166 aneurysms were included, with a median age of 43 years. Medical management was successful in 56% of cases, with failure often within 18 days of initiation. Predictors of failure included younger age, larger aneurysm size, and rupture at presentation. Surgical and endovascular interventions achieved higher success rates with better outcomes. At 90 days, 57% of patients achieved functional independence (mRS 0-2), while the mortality rate was 24%. CONCLUSION:This study highlights the limitations of medical management for IIAs and underscores the need for early surgical or endovascular intervention in high-risk patients. Outcome predictors aid clinical decision-making, optimizing patient management. Further research is needed to standardize management guidelines for IIAs.

While ubiquitin carboxy-terminal hydrolase L1 (UCH-L1) and glial fibrillary acidic protein (GFAP) have demonstrated clinical relevance in evaluating traumatic brain injury (TBI), less is known about how underlying pediatric neurological or psychiatric diagnoses may influence baseline biomarker levels. Plasma samples from a pediatric biobank were analyzed for UCH-L1 and GFAP concentrations. Eligible participants were <19 years of age and had a documented diagnosis of attention-deficit/hyperactivity disorder, anxiety, depression, or seizure disorder but no recent history of trauma, infectious illness, or other chronic medical conditions. Biomarker levels were compared (1) across diagnostic categories, (2) with a separate group of historic controls (n = 216), and (3) with adult thresholds used to guide head CT use in mild TBI (UCH-L1 400 pg/mL; GFAP 35 pg/mL). Among 88 participants (median age 15 years), UCH-L1 and GFAP values remained relatively stable across conditions. There were no significant differences between diagnostic groups or compared with controls. Approximately 6.8% of children had GFAP levels above the adult threshold, whereas <3% exceeded the UCH-L1 threshold. Underlying neuropsychiatric conditions do not appear to meaningfully modify baseline circulating GFAP or UCH-L1 levels in children, suggesting that these conditions may not preclude the use of these biomarkers in the evaluation of pediatric TBI.

Traumatic brain injury (TBI) is increasingly recognized not only as an acute mechanical insult but as a trigger of sustained neuroimmune activation that contributes to chronic neurodegeneration. The complement system has emerged as a central mediator linking acute injury to progressive neuroinflammatory pathology. Following TBI, complement is rapidly activated through classical, lectin, and alternative pathways, converging at C3 and generating downstream effector molecules, including opsonins, anaphylatoxins, and the membrane-attack complex. These mediators amplify inflammation, promote cytotoxic signaling, and exacerbate acute neuronal injury while sustaining chronic microglial and astrocytic activation. In the subacute and chronic phases, complement-dependent opsonization drives maladaptive synaptic pruning, leading to progressive loss of synaptic density and cognitive impairment. Complement activation also contributes to circuit dysfunction and impairs endogenous repair processes by suppressing neurogenesis and neuroblast migration. Preclinical studies consistently identify upstream complement activation, particularly at the level of C3, as a key driver of chronic pathological processes. Consistent with this concept, targeted complement inhibition preserves synaptic integrity and improves functional outcomes. These findings position complement as a promising therapeutic target and support a paradigm shift toward targeting chronic neuroinflammation to prevent long-term neurological sequelae after TBI.

OBJECTIVE:Emerging traumatic brain injury (TBI) guidelines increasingly recognize the role of blood-based biomarkers in improving diagnostic and triage accuracy, yet their integration into pediatric care remains limited and underexplored. This study examined the performance of a blood-based biomarker panel in predicting which pediatric patients with TBI received neurosurgical intervention (NSI). METHODS:This was a prospective cohort study of 425 children (aged 0-17 years) treated at a pediatric tertiary hospital between March 2017 and June 2021 with nonpenetrating TBI (Glasgow Coma Scale [GCS] score 3-15). Standard of care was rendered. NSI included craniotomy, craniectomy, external ventricular drain (EVD) placement, and intracranial pressure (ICP) monitor placement. Blood samples collected within 24 hours of injury were measured for plasma glial fibrillary acidic protein (GFAP), ubiquitin C-terminal hydrolase-L1 (UCH-L1), neurofilament light (NfL), and total tau (t-tau) with the Quanterix Simoa platform, as well as osteopontin (OPN) quantification via ELISA. Logistic regression and area under the curve (AUC) analysis with 95% confidence intervals (CI) were used to measure predictive discrimination. RESULTS:NSI occurred in 14.35% of patients. These children were younger (mean age 6.0 vs 10.1 years) with more severe injury (median GCS score 9.0 vs 15.0) than those who did not require NSI. All median biomarker concentrations were higher in NSI compared with non-NSI patients (p < 0.001). After age and GCS score were controlled for, GFAP significantly predicted NSI (AUC 0.83, 95% CI 0.75-0.90), defining the best predictive model for NSI. CONCLUSIONS:Blood-based biomarkers predicted NSI following pediatric TBI, independent of age and admission GCS score. These findings support further prospective trials to determine whether integrating blood-based biomarkers into clinical triage algorithms and TBI guidelines can improve neurosurgical decision-making and patient outcomes.

OBJECTIVE The aim of this study was to compare the prognostic performance of the Baylor, St. Louis, and Surviving Penetrating Injury to the Brain (SPIN) scoring systems for mortality and neurosurgical intervention in children with gunshot-induced traumatic brain injury (GTBI), clarifying how their differing variable compositions influence accuracy and clinical applicability in pediatric GTBI. METHODS This was a retrospective cohort study of pediatric patients with firearm-related intracranial injuries presenting to a tertiary pediatric trauma center from January 2014 to April 2023. Clinical, laboratory, and neuroimaging variables were abstracted to calculate Baylor, St. Louis, and SPIN scores. Primary outcomes were mortality and neurosurgical intervention (external ventricular drain [EVD] placement, intracranial pressure [ICP] monitor placement, craniotomy, decompressive hemicraniectomy [DHC]). Associations were assessed with univariate and multivariate logistic regressions (α = 0.05). Discrimination was evaluated with receiver operating characteristic (ROC) curves and the area under the ROC curve (AUC). Optimal score cut points were derived for clinical utility, and confusion matrix metrics summarized performance. Clinical utility was assessed quantitatively by statistical performance and qualitatively by considering input availability (e.g., CT dependence), motivating a pragmatic, two-step workflow. RESULTS Eighty-two children (mean age 8.59 ± 4.73 years) met inclusion criteria; mortality occurred in 25.6%, and 54.9% underwent a neurosurgical procedure. All 3 scores were associated with mortality in univariate analyses. In multivariate modeling with age and the scores, the St. Louis score remained the strongest mortality predictor (adjusted OR 1.33, p = 0.013) and showed the highest discrimination (AUC 0.85) with a clinical threshold of 6.5. The SPIN score showed good discrimination (AUC 0.81) with a threshold of 31 and outperformed the Baylor score despite lacking imaging inputs; the Baylor score had lower overall discrimination. For neurosurgical intervention, only EVD placement showed significant univariate associations (St. Louis, SPIN, and age). In multivariate models, St. Louis and SPIN did not retain significance for EVD, but both demonstrated modest discrimination (SPIN AUC 0.671; St. Louis AUC 0.652) and high sensitivity/negative predictive value, supporting use as rule-out tools. No significant associations were observed for ICP monitor placement, craniotomy, or DHC. CONCLUSIONS The authors’ findings support a pragmatic, two-step workflow: use the SPIN scale at first contact, before neuroimaging, to inform triage, then apply the St. Louis scale after imaging to refine prognosis. Predefined cut points for mortality (SPIN score ≤ 31; St. Louis score ≥ 7) and EVD placement (SPIN score ≤ 41; St. Louis score ≥ 2) can standardize bedside decision-making. Their complementary nature suggests their use at different points of patient management to optimize their clinical utility.

INTRODUCTION:Posttraumatic hydrocephalus (PTH) is an uncommon but serious complication of traumatic brain injury (TBI). Although extensively studied in adults, important developmental differences in the pediatric central nervous system contribute to differing PTH pathophysiology, with important differences in diagnosis, clinical course, and treatment. OBJECTIVE:This review synthesizes current evidence regarding pediatric PTH, with specific attention to the influence of pediatric developmental pathophysiology on disease susceptibility, diagnosis, and outcomes. KEY TAKEAWAYS:Pediatric-specific data on PTH remain limited; however, recent studies suggest that younger age - particularly under five years at injury - as well as injury severity are the two strongest predictors of PTH development. Clinically, PTH may present acutely with neurological deterioration or chronically with delayed recovery and neurodevelopmental regression. Early recognition is critical, as untreated PTH can lead to lifelong neurological dysfunction and even death, yet diagnosis is often delayed by symptom overlap with other posttraumatic conditions and difficulties in distinguishing true hydrocephalus from ventriculomegaly. Management is primarily surgical and centers on cerebrospinal fluid (CSF) diversion, most commonly with external ventricular drainage (EVD) in the acute phase and permanent shunting or ventriculostomy in select cases. Despite timely intervention, long-term morbidity remains substantial, underscoring the importance of prevention, early detection, and multidisciplinary follow-up.

Introduction:Mild traumatic brain injury (mTBI) accounts for a significant proportion of emergency department (ED) visits, but current diagnostic protocols often lead to overuse of computed tomography (CT) imaging, despite low diagnostic yield. The BRAIN-CT trial evaluates the impact of rapid access to TBI biomarkers on decision-making for cranial imaging in patients with mTBI. Methods and analysis:This randomized controlled trial will enroll 350 adult patients aged 18-85 years presenting with suspected mild head injury (Glasgow Coma Scale 13-15) within 24 h of trauma. Participants will be randomized into two arms: (1) a biomarker-published group where ED providers receive real-time results of the i-STAT® TBI Cartridge test (detecting GFAP and UCH-L1), and (2) a biomarker-blinded group where results are withheld. The primary outcome is the proportion of patients undergoing CT imaging. Secondary outcomes include hospital length of stay, cost, neurological outcomes, and biomarker correlation with imaging findings. Analysis will involve chi-squared testing, logistic regression, and predictive modeling. Clinical trial registration:clinicaltrials.gov, identifier: NCT06932588.

To evaluate a combined biopsy-ablation procedure as an early intervention in small brain incidentalomas. Patient selection criteria included lesion in deep location, lesion growing over time, and lesion over 1 cm but less than 1.5 cm in diameter. Four patients underwent robotic-assisted stereotaxic biopsy followed by laser interstitial thermal therapy (LITT). Patients were then followed with MRI over time. At time of operation, patients’ age was between 10 and 16 years. Biopsy revealed pilocytic astrocytoma (n = 2) and dysembryonic neuroepithelial tumor (DNET), and one specimen was indeterminate for pathological changes. Imaging follow-up was between 17 and 72 months. None of the lesions showed progression on repeat MRI. Based on published data, it can be expected that roughly 20

OBJECTIVE:To evaluate the role of blood-based biomarkers in pediatric traumatic brain injury (TBI) using a clinical decision analysis (CDA) framework, with the goal of determining whether biomarker integration improves diagnostic accuracy, reduces unnecessary imaging, and supports clinical decision-making. STUDY DESIGN:We developed a CDA model to compare standard clinical assessment strategies/decision rules for children with suspected mild TBI vs strategies incorporating biomarker measurement. Model inputs included published estimates of biomarker test performance (sensitivity, specificity), rates of clinically important TBI, and imaging utilization. Outcomes included diagnostic yield, false-positive and false-negative rates, and projected reductions in neuroimaging. Sensitivity analyses explored the robustness of findings across a range of disease prevalences. RESULTS:Biomarker-enhanced strategies consistently reduced unnecessary head computed tomography utilization compared with clinical assessment alone. Decision-analytic modeling indicated that its integration into assessment strategies could meaningfully decrease radiation exposure at a population level. Sensitivity analyses demonstrated that findings were robust across plausible ranges of injury prevalence. CONCLUSIONS:Application of CDA to pediatric TBI demonstrates the potential value of biomarker integration in improving diagnostic accuracy and optimizing computed tomography utilization. Biomarker-augmented strategies may enhance patient safety by reducing unnecessary radiation exposure, while maintaining sensitivity for clinically important injuries. Prospective validation and real-world implementation studies are needed to confirm clinical effectiveness and cost-effectiveness.

Background Despite the increasing number of decompressive craniectomy (DC) in neurotrauma, the optimal timing for elective cranioplasty (CP) is still debated. Little is known about the CP complications related to surgery, implant material, and post-traumatic hydrocephalus. Objectives To explore the correlation between CP timing, implant material, and the incidence of postoperative complications in patients undergoing CP after DC for severe head injuries. Materials and methods A retrospective multicenter study was conducted from January 2010 to December 2021 across 9 European neurosurgical centers. A cohort of 4007 patients who underwent CP following DC for severe head injury was analyzed. Timing was categorized as: ultra-early (< 30 days), early (31-90 days), late (> 90 days). Complications were defined according to Clavien-Dindo classification, requiring revision surgery and/or hospital readmissions. Results Among the 4007 patients, 352 (8.8%) had ultra-early CP, 1627 (40.5%), and 2028 (51.7%) had early and late CP respectively. Cerebrospinal fluid (CSF) derangement was more frequently associated with large defects and the incidence of Sinking Skin Flap Syndrome (SSFS). SSFS was more frequently diagnosed in patients undergoing late surgery whereas hydrocephalus and epilepsy were less frequently encountered in the ultra-early and early groups (p < 0,05). The overall complication rate was 24.6% (985 patients) including internal hydrocephalus (20%), infection (18%), external hydrocephalus (15%), epilepsy (15%), acute extradural (14%) or subdural hematomas (10%), and subdural hygroma (8%). CP stabilized CSF derangement in 80% of cases, which did not progress into overt hydrocephalus, whereas 17% with definite diagnosis of post-traumatic hydrocephalus required a Ventriculo-Peritoneal shunt (VPS). Simultaneous CP and VPS led to infections in all cases, regardless of implant material. Conclusion Surgery timing has a greater impact on CP complications than implant material. CSF derangement represents the single most relevant factor influencing the clinical course of patients undergoing CP.

Racial disparities in healthcare outcomes have been widely documented in the literature. Black pediatric patients continue to face disproportionate challenges related to traumatic brain injuries (TBI) based on their race, socioeconomic status, access to healthcare, and implicit biases within the healthcare system. Looking specifically at the relationship between neurosurgical intervention, race, and TBI severity together has not yet been studied in the present literature. Prospective cohort of patients 0-20 years-old presenting to a tertiary pediatric hospital emergency department from May 2018 to January 2021 with TBI were analyzed in this study (n=354). Intracranial pressure (ICP) monitors, external ventricular drains (EVD), and/or craniotomies/craniectomies were considered as having neurosurgical interventions (n=55). Variables including race/ethnicity were obtained from parents and electronic medical records. TBI severity was assigned based on lowest Glasgow Coma Scale score. Chi-Square tests were utilized. There was a significant association between race and neurosurgical intervention (χ2 (1) = 10.075, p=0.002), such that Black patients had higher rates of neurosurgical intervention (22.9%) compared to White (10.5%). Severity also correlated with neurosurgical intervention, such that 55.4% of severe TBI patients received neurosurgery compared to 5% of moderate/mild TBI patients (p<0.001). Race and severity were associated (χ2 (1) = 15.715, p<0.001), such that 31.3% of Black patients had severe TBI compared to 13.8% of White patients. Overall Black patients had more severe TBI and thus higher rates of neurosurgical intervention. Future studies should investigate why these rates are seen in Black patients, considering mechanisms of injury and the influence of social determinants of health on outcomes.

Hemispherectomy is an important surgical technique for seizure control. Between 2019 to 2023, 65 sEEGs, 11 functional hemispherectomy surgeries were carried out in the authors’ institution. All patients had at least a one-year follow up. Four patients who fulfilled the standard criteria for hemispherectomy underwent sEEG investigation. All four patients also underwent vEEG, MRI, functional MRI, PET, and neuropsychological studies. One patient underwent a MEG study. Patients’ age ranged from 10 to 16 years and epilepsy etiologies were related to neonatal middle cerebral artery (MCA) stroke secondary to prematurity (n=2), abusive head trauma (n=1), and unknown etiology (n=1). Two cases involved the left hemisphere. All patients presented with various degrees of hemiparesis with corresponding cerebral atrophy. Functional MRI was determined language dominance in one patient; another was indeterminate, and two patients failed. vEEG showed fast, diffuse hemispheric involvement and hinted at seizure onset zone (SOZ) in central and frontal regions, diffuse midline, and posterior quadrant. vEEG findings were the main indications for sEEG investigation. Intracranial sEEG monitoring was used to identify focal seizure onset zones in the retrosplenial cortex, frontal pole, mesial temporal, and perisylvian regions and for functional mapping of eloquent cortex. Based on results, patients underwent posterior quadrant disconnection, All 4 patients were seizure-free at one year with documented functional improvement. All patients were without focal neurological loss. In patients with large MCA stroke, determining the degree of residual function in the affected hemisphere and SOZ can be difficult. sEEG can be used to guide a targeted surgical approach instead of hemispherectomy.

INTRODUCTION: Mycotic or infectious intracranial aneurysms (IIAs) are a rare complication of systemic infections, resulting from microbial infiltration and degradation of the arterial vessel wall. The majority of infective aneurysms are caused by either Staphylococcus or Streptococcus species and involve the aorta, peripheral, cerebral, and visceral arteries. The suggested mechanisms include embolic occlusion, direct infiltration due to sepsis, or injury due to immune complex deposition. Despite their relatively low frequency (0.5%-6.5%), IIAs are associated with high rates of complications and mortality. METHODS: This is a retrospective study of patients treated for infectious intracranial aneurysms to Children’s Healthcare of Atlanta Hospitals between 01/2007 and 01/2023. Patients were identified through the combined screening of procedure codes and survey of the radiology reports. RESULTS: During the study period, a total of 151 patients were treated for infective endocarditis secondary to congenital or acquired heart disease, of which 13 patients (8.6%) presented with intracranial hemorrhage. Infectious intracranial aneurysms occurred in 5 patients (2.6%) with IE. Infectious aneurysms accounted for 15% of intracranial aneurysms treated during the study period. All patients were screened with non-invasive imaging. CONCLUSIONS: Pediatric IIAs are a rare complication of systemic or local CNS infection in children, with IE as the most common predisposing factor. The key to achieving better outcomes entails a multidisciplinary approach from neurosurgery, neuroradiology, cardiac surgery, and neurocritical care in a timely sensible fashion to deliver individualized treatments on a case-by-case basis. Pediatric patients with ruptured IIAs have high rate of re-rupture and early aneurysm securement should be considered via open or endovascular route when safe options are available.