Treatment of large infectious extracranial carotid artery pseudoaneurysms in children: a systematic review of the literature.

INTRODUCTION: Extracranial carotid artery pseudoaneurysm is a rare complication of deep neck space infection, and no evidence-based treatment guidelines are available in the literature. METHOD: To clarify the existing experience of the different treatment strategies, the authors performed a systematic literature search using the PubMed, Ovid EMBASE, and Scopus databases in accordance with PRISMA guidelines to review all reported cases of pediatric patients with infectious carotid pseudoaneurysms larger than 1 cm. RESULTS: Twenty-six patients with a median age of 4 years (range 6 months-15 years) were identified. Eighteen patients (69.2%) were treated with endovascular methods, 6 patients (23.1%) with surgical methods, 1 patient (3.8%) with a hybrid endovascular/surgical approach, and 1 patient (3.8%) with conservative management. Recurrence of the pseudoaneurysm occurred in 2 cases (7.7%), both of which were successfully retreated. Of the 6 patients (23.1%) who presented with pre-procedure neurologic deficits, 3 patients had complete or near complete resolution of symptoms after intervention and 3 patients had persistent deficits at last follow-up. Four patients (15.4%) experienced new neurologic deficits post-procedure that resolved at last follow-up. CONCLUSION: The endovascular treatment tends to be the preferred option to treat a large or giant infectious pseudoaneurysm of the carotid artery in the pediatric patient. However, more evidence is necessary to elucidate comparative safety and efficacy profiles of endovascular and surgical management strategies.

Prediction of Outcomes for Ruptured Aneurysm Surgery.

Background and Purpose- Predicting long-term functional outcomes after intracranial aneurysmal rupture can be challenging. We developed and validated a scoring system-the Southwestern Aneurysm Severity Index-that would predict functional outcomes at 1 year after clipping of ruptured aneurysms. Methods- Ruptured aneurysms treated microsurgically between 2000 and 2014 were included. Outcome was defined as Glasgow Outcome Score (ranging from 1, death, to 5, good recovery) at 1 year. The Southwestern Aneurysm Severity Index is composed of multiple prospectively recorded patient demographic, clinical, radiographic, and aneurysm-specific variables. Multivariable analyses were used to construct the best predictive models for patient outcomes in a random 50% of the cohort and validated in the remaining 50%. A scoring system was created using the best model. Results- We identified 527 eligible patients. The Glasgow Outcome Score at 1 year was 4 to 5 in 375 patients (71.2%). In the multivariable logistic regression, the best predictive model for unfavorable outcome included intracerebral hemorrhage (odds ratio [OR], 2.53; 95% CI, 1.55-4.13), aneurysmal size ≥20 mm (OR, 6.07; 95% CI, 1.92-19.2), intraventricular hemorrhage (OR, 2.56; 95% CI, 1.15-5.67), age >64 (OR, 3.53; 95% CI, 1.70-7.35), location (OR, 1.82; 95% CI, 1.10-3.03), and hydrocephalus (OR, 2.39; 95% CI, 1.07-5.35). The Southwestern Aneurysm Severity Index predicts Glasgow Outcome Score at 1 year with good discrimination (area under the receiver operating characteristic curve, derivation: 0.816, 95% CI, 0.759-0.873; validation: 0.803, 95% CI, 0.746-0.861) and accurate calibration ( R2=0.939). Conclusions- The Southwestern Aneurysm Severity Index has been internally validated to predict 1 year Glasgow Outcome Scores at initial presentation, thus optimizing patient or family counseling and possibly guiding therapeutic efforts.

Multimodal analgesia for craniotomy.

PURPOSE OF REVIEW: To explore the data for and against the use of the various components of multimodal analgesia in cranial neurosurgery. RECENT FINDINGS: Postcraniotomy pain is a challenging clinical problem in that analgesia must be accomplished without affecting neurologic function (i.e. 'losing the neurologic exam'). The traditional approach with low-dose opioids is often insufficient and can cause well recognized side effects. Newer multimodal analgesic approaches have proven beneficial in a variety of other surgical patient populations. The combined use of multiple nonopioid analgesics offers the promise of improved pain control and reduced opioid administration, while preserving the clinical neurologic exam. Specifically, acetaminophen and gabapentinoids should be considered for craniotomy patients, both preoperatively and postoperatively. The gabapentinoids have the added benefit of reduced nausea. Scalp blocks have moderate quality evidence supporting their use over incisional infiltration alone, with analgesia that extends into the postoperative period. Intraoperative dexmedetomidine reduces postoperative opioid requirements with the added benefit of reduced postcraniotomy hypertension. Methocarbamol, NSAIDs [both nonspecific cyclooxygenase (COX) 1 and 2 inhibitors and specific COX-2 inhibitors], ketamine, and intravenous lidocaine require further data regarding safety and efficacy in craniotomy patients. SUMMARY: Opioids are the mainstay for treating acute postcraniotomy pain but should be minimized. The evidence to support a multimodal approach is growing; neuroanesthesiologists and neurosurgeons should seek to incorporate multimodal analgesia into the perioperative care of craniotomy patients. Preoperative and postoperative gabapentin and acetaminophen, intraoperative dexmedetomidine, and scalp blocks over incisional infiltration have the most data for benefit, with good safety profiles. Further research is needed to define the safety, efficacy, and dosing parameters for NSAIDs including COX-2 inhibitors, methocarbamol, ketamine, and intravenous lidocaine in cranial neurosurgery.

Risk of Shunting After Aneurysmal Subarachnoid Hemorrhage: A Collaborative Study and Initiation of a Consortium.

BACKGROUND AND PURPOSE: Shunt dependent hydrocephalus after aneurysmal subarachnoid hemorrhage (aSAH) is a common sequela that may lead to poor neurological outcome and predisposes to various interventions, admissions, and complications. We reviewed post-aSAH shunt dependency in a population-based sample and tested the feasibility of a clinical risk score to identify subgroups of aSAH patients with increasing risk of shunting for hydrocephalus. METHODS: A total of 1533 aSAH patients from the population-based Eastern Finland Saccular Intracranial Aneurysm Database (Kuopio, Finland) were used in a recursive partitioning analysis to identify risk factors for shunting after aSAH. The risk model was built and internally validated in random split cohorts. External validation was conducted on 946 aSAH patients from the Southwestern Tertiary Aneurysm Registry (Dallas, TX) and tested using receiver-operating characteristic curves. RESULTS: Of all patients alive ≥14 days, 17.7% required permanent cerebrospinal fluid diversion. The recursive partitioning analysis defined 6 groups with successively increased risk for shunting. These groups also successively risk stratified functional outcome at 12 months, shunt complications, and time-to-shunt rates. The area under the curve-receiver-operating characteristic curve for the exploratory sample and internal validation sample was 0.82 and 0.78, respectively, with an external validation of 0.68. CONCLUSIONS: Shunt dependency after aSAH is associated with higher morbidity and mortality, and prediction modeling of shunt dependency is feasible with clinically useful yields. It is important to identify and understand the factors that increase risk for shunting and to eliminate or mitigate the reversible factors. The aSAH-PARAS Consortium (Aneurysmal Subarachnoid Hemorrhage Patients' Risk Assessment for Shunting) has been initiated to pool the collective insights and resources to address key questions in post-aSAH shunt dependency to inform future aSAH treatment guidelines.

Neurosurgical Emergencies in Sports Neurology.

PURPOSE OF REVIEW: Athletic neurosurgical emergencies are injuries that can lead to mortality or significant morbidity and require immediate recognition and treatment. This review article discusses the epidemiology of sports-related traumatic brain injury (TBI) with an attempt to quantify the incidence of neurosurgical emergencies in sports. Emergencies such as intracranial hemorrhage, second impact syndrome, vascular injuries, and seizures are discussed. RECENT FINDINGS: The incidence of sports-related TBI presenting to level I or II trauma centers in the USA is about 10 in 100,000 population per year. About 14 % of the adult sports-related TBIs and 13 % of the pediatric sports-related TBIs were moderate or severe in nature. Patients presenting with headache and neck pain should prompt further investigation for cervical spine and vascular injuries. CT angiography is becoming the modality of choice to screen for blunt cerebrovascular injuries. The treatment of these injuries remains controversial. High-quality evidence in sports-related TBI is lacking. Further research is required to help guide management of this increasingly prevalent condition. The role of prevention and education should also not be underestimated.

The science and questions surrounding chronic traumatic encephalopathy.

Recently, the pathobiology, causes, associated factors, incidence and prevalence, and natural history of chronic traumatic encephalopathy (CTE) have been debated. Data from retrospective case series and high-profile media reports have fueled public fear and affected the medical community's understanding of the role of sports-related traumatic brain injury (TBI) in the development of CTE. There are a number of limitations posed by the current evidence that can lead to confusion within the public and scientific community. In this paper, the authors address common questions surrounding the science of CTE and propose future research directions.

Alternative cost-effective method to record 3D intra-operative images: a technical note.

The educational value of stereoscopic imaging in neurosurgical training has increasingly been appreciated and its use increased during the last decade. We describe a technique that we developed to acquire and reproduce intra-operative stereoscopic images.

Community consultation in emergency neurosurgical research: lessons from a proposed trial for patients with chronic subdural haematomas.

INTRODUCTION: Chronic subdural haematoma (CSDH) is one of the most common neurosurgical disorders and is especially prevalent in old age. The subdural evacuating port system (SEPS) has emerged in the last few years as a minimally invasive alternative to the standard procedure of burr-hole evacuation. NHS practice is evidence-driven and evidence from high-quality clinical studies is required prior to implementation of any changes. In the UK, the National Research Ethics Service (NRES) advises community consultation prior to starting a clinical trial, where the patient is unlikely to have capacity to consent to enrolment in the trial. To prepare for a trial comparing minimally invasive (SEPS) versus burr-hole evacuation for evacuation of a CSDH, we have designed and undertaken a pre-protocol community consultation survey to examine potential patient participation. MATERIAL(S) AND METHODS: The study population consisted of patients, family members and carers/friends in neurosurgical clinic waiting rooms and wards at Addenbrooke's Hospital, Cambridge, who individually completed a questionnaire (n = 215). RESULTS: Most respondents were willing to participate in the proposed randomised clinical trial (77%; 165/215). Moreover, 80% (171/215) and 74% (159/215) were willing to allow their next of kin and an independent consultant neurosurgeon to give surrogate consent, respectively. CONCLUSION: The results of our pre-protocol community consultation showed that not only would most respondents be willing to participate in the proposed trial, but also would be happy for either next of kin or an independent consultant neurosurgeon to give surrogate consent if they lacked capacity to consent themselves. The advantages of this type of survey are twofold: they increase patient and public involvement in the research process and allow researchers to design study protocols that are acceptable to the community.

Modelling the initial phase of the human rod photoreceptor response to the onset of steady illumination.

The initial time course of the change in photoreceptor outer segment membrane conductance in response to light flashes has been modelled using biochemical analysis of phototransduction, and the model has been successfully applied to a range of in vitro recordings and has also been shown to provide a good fit to the leading edge of the electroretinogram a-wave recorded in vivo. We investigated whether a simple modification of the model's equation would predict responses to the onset of steady illumination and tested this against electroretinogram recordings. Scotopic electroretinograms were recorded from three normal human subjects, using conductive fibre electrodes, in response to light flashes (0.30-740 scotopic cd m(-2) s) and to the onset of steady light (11-1,900 scotopic cd m(-2)). Subjects' pupils were dilated pharmacologically. The standard form of the model was applied to flash responses, as in previous studies, to obtain values for the three parameters: maximal response amplitude r (max), sensitivity S and effective delay time t (eff). A new "step response" equation was derived, and this equation provided a good fit to rod responses to steps of light using the same parameter values as for the flash responses. The results support the applicability of the model to the leading edge of electroretinogram responses: in each subject, the model could be used to fit responses both to flashes of light and to the onset of backgrounds with a single set of parameter values.

The Financial Impact of the COVID-19 Pandemic on Neurosurgery Practice in Spring 2020.

BACKGROUND: The coronavirus disease 2019 (COVID-19) pandemic has changed health care delivery across the United States. Few analyses have specifically looked at quantifying the financial impact of the pandemic on practicing neurosurgeons. A survey analysis was performed to address this need. METHODS: A 19-question survey was distributed to practicing neurosurgeons in the United States and its territories. The questions evaluated respondents' assessments of changes in patient and procedural volume, salary and benefits, practice expenses, staffing, applications for government assistance, and stroke management. Responses were stratified by geographic region. RESULTS: The response rate was 5.1% (267/5224). Most respondents from each region noted a >50% decrease in clinic volume. Respondents from the Northeast observed a 76% decrease in procedure volume, which was significantly greater than that of other regions (P = 0.003). Northeast respondents were also significantly more likely to have been reassigned to nonneurosurgical clinical duties during the pandemic (P < 0.001). Most respondents also noted decreased salary and benefits but experienced no changes in overall practice expenses. Most respondents did not experience significant reductions in nursing or midlevel staffing. These trends were not significantly different between regions. CONCLUSIONS: The COVID-19 pandemic has led to decreases in patient and procedural volume and physician compensation despite stable practice expenses. Significantly more respondents in the Northeast region noted decreases in procedural volume and reassignment to nonneurosurgical COVID-related medical duties. Future analysis is necessary as the pandemic evolves and the long-term clinical and economic implications become clear.

Bertolotti Syndrome With Articulated L5 Transverse Process Causing Intractable Back Pain: Surgical Video Showcasing a Minimally Invasive Approach for Disconnection: 2-Dimensional Operative Video.

Bertolotti syndrome is a commonly missed cause of intractable back pain that affects 4% to 8% of the general population. It involves the congenital malformation of a transitional lumbosacral vertebra, with total or partial and unilateral or bilateral transverse process (TP) fusion or articulation to the sacrum. The pain can be debilitating, and the tethering of the spine to the sacrum can encourage deformity formation in the coronal plane and lead to early degenerative changes, especially if present only unilaterally. We present the case of a 24-yr-old woman with no notable prior medical history who presented with years of lower axial back pain radiating to her thighs, which limited her activities of daily living and was resistant to conservative management. Her imaging showed an abnormally large left L5 TP, which was articulated to the sacrum, and signs of early coronal deformity. She had responded almost completely to repeated steroid injections into the TP-sacral joint, but that effect was very transient. Informed patient consent was obtained prior to her surgery. She underwent a minimally invasive tube disconnection of the abnormal joint with partial distal resection of the TP, and her symptoms completely resolved. This case highlights the importance of correlating clinical symptoms with aberrant anatomy, and the role of selective surgery in providing symptomatic relief. This case report was written in compliance with our institutional ethical review board approval, and patient consent was waived in light of the retrospective and deidentified nature of the data presented in accordance with the University of Texas Southwestern institutional review board.

Automated Pupillometry as a Triage and Assessment Tool in Patients with Traumatic Brain Injury.

OBJECTIVE: Traumatic brain injury (TBI) is a leading cause of morbidity and mortality in young adults. Automated infrared pupillometry (AIP) has shown promising results in predicting neural damage in aneurysmal subarachnoid hemorrhage and ischemic stroke. We aimed to explore potential uses of AIP in triaging patients with TBI. We hypothesized that a brain injury severe enough to require an intervention would show Neurologic Pupil Index (NPI) changes. METHODS: We conducted a prospective pilot study at a level-1 trauma center between November 2019 and February 2020. AIP readings of consecutive patients seen in the emergency department with blunt TBI and abnormal imaging findings on computed tomography were recorded by the assessing neurosurgery resident. The relationship between NPI and surgical intervention was studied. RESULTS: Thirty-six patients were enrolled, 9 of whom received an intervention. NPI was dichotomized into normal (≥3) versus abnormal (<3) and was predictive of intervention (Fisher exact test; P < 0.0001). Six of the 9 patients had a Glasgow Coma Scale (GCS) score ≤8 and imaging signs of increased intracranial pressure (ICP) and underwent craniectomy (n = 4) or ICP monitor placement (n = 2) and had an abnormal NPI. Three patients underwent ICP monitor placement for GCS score ≤8 in accordance with TBI guidelines despite minimal imaging findings and had a normal NPI. The GCS score of these patients improved within 24 hours, requiring ICP monitor removal. NPI was normal in all patients who did not require intervention. CONCLUSIONS: AIP could be useful in triaging comatose patients after blunt TBI. An NPI ≥3 may be reassuring in patients with no signs of mass effect or increased ICP.

Does endovascular therapy change outcomes in nonagenarians with acute ischemic stroke?

BACKGROUND: Ischemic strokes can be devastating for elderly patients, and randomized control trials of mechanical thrombectomy have shown encouraging results. We present the first analysis of clinical outcomes in nonagenarians with acute ischemic stroke treated with best medical therapy compared to endovascular revascularization therapy. METHODS: A retrospective analysis was performed on 42 patients 90 years or older who were treated for acute ischemic stroke. Modified Rankin scores were calculated immediately post-injury, at discharge, and at 30 days and 90 days following discharge. Student's t-test and Wald tests were performed to evaluate whether endovascular treatment was associated with modified Rankin Score improvement at discharge, 30 days, or 90 days after discharge. RESULTS: Follow-up data were available for 32/42 (76%) and 20/42 (48%) patients at 30 and 90 days after discharge, respectively. 8/9 (89%) patients who underwent endovascular treatment reached Thrombolysis in Cerebral Infarction scale 2b or better with no procedural complications. 12/42 (29%) patients, including four who underwent endovascular treatment, were discharged to hospice or deceased. No significant differences in modified Rankin Score improvement were observed between the endovascular and medical management groups at discharge (p = 0.96), at 30 days (p = 0.63), or at 90 days (p = 0.96). CONCLUSIONS: Our analysis shows that revascularization therapy is a safe treatment, but it was not associated with improved functional status in nonagenarians with acute ischemic stroke. Endovascular therapy shows promise, and larger prospective studies are necessary to assess the benefits of revascularization therapy in the elderly population.

Inchoate guidelines of endoscopic resection of colloid cysts.

Colloid cyst are cystic lesions in the third ventricle and could render patients asymptomatic. However, there is an inherent risk of symptomatic progression, acute decompensation, and sudden death. Therefore, there is no clear consensus as how to observe or when to treat a newly diagnosed patient with a colloid cyst. The authors' objective is to identify the risk factors and then develop a risk stratification score to guide neurosurgeons during acute or chronic presentation. Radiological imaging characteristics have been outlined for the risk stratification as well preoperative evaluation. A baseline neuropsychological evaluation is helpful to obtain during an incidental presentation because history and neurological examination could be inconclusive in these cases. Radiological imaging with an MRI brain scan plays a vital role for the initial screening (determination of the cyst size, exact location, and the imaging characteristics) as well as for the preoperative planning. Stereotactic guidance is a high yield, followed by neuroendoscopic resection of the colloid cyst has been an established approach to resect these lesions. Modified colloid cyst risk scoring (mCCRS) system is robust and detailed for the optimal risk stratification of colloid cyst presentation. Stereotactic guided neuroendoscopic resection of the colloid cyst is a safe and efficacious approach to manage these lesions. The intended use, crucial steps involved, and the limitations of the technique have been discussed especially with a focus on the recurrence. Moreover, a comprehensive treatment algorithm has been presented.

Diffuse intrinsic pontine gliomas: Diagnostic approach and treatment strategies.

Diffuse intrinsic pontine gliomas (DIPG) are high grade gliomas of the brainstem with fatal outcomes. Radiation is known to be partially effective to control the immediate flare but relapse is frequent. There has been ongoing research to study the role of molecular subgroups and identification of specific targets but this is not possible with histopathological diagnosis alone. The authors' objective is to highlight the need for and discuss ongoing molecular research. There is an inherent need for the availability of tumor tissue to be able to conduct research studies. The authors advocate the use of neuronavigation assisted stereotactic technique for tumor biopsy. The technique is feasible with a predefined surgical trajectory. After obtaining tissue diagnosis further work can be performed to isolate and identify histone protein genetic mutations and methylation changes responsible for DIPG molecular subgrouping. Moreover, convection enhanced delivery of therapeutic agents is being developed for better instillation of future drug agents. Despite identification of genetic/epigenetic mutations, growth factors, receptors, and tissue biomarkers, the oncogenesis of DIPG remains elusive. The authors' effort to provide a comprehensive review on DIPG to better understand the disease, need for tissue diagnosis, described surgical technique, and need for pre-clinical and clinical future research is novel.

Retrieval of an Intracranially Migrated Dental Injection Needle Through the Foramen Ovale: 2-Dimensional Operative Video.

Dental injection needle migration is a rare complication of orthodontal procedures. When these needles fracture, they typically dislodge into the cervical space or the facial musculature. Migration into the cranial vault is difficult because of the obstacle created by the skull base. We report a rare case of intracranial migration of an anesthetic injection needle through the foramen ovale. A 59-yr-old man underwent the extraction of a right maxillary molar. The distal end of a 25-gauge injection needle broke into his pterygoid musculature, causing him pain while chewing. Vascular imaging obtained after a computed tomography scan of his face showed that the needle had migrated, potentially because of his efforts of mastication, and had traversed the foramen ovale into the middle cranial fossa. The patient started experiencing intermittent right facial numbness, likely due to compression or injury to the right trigeminal nerve. Our oral and maxillofacial colleagues did not believe that the needle could be retrieved from its facial end. The patient elected to undergo the recovery of the needle through a craniotomy given the fact that the object was contaminated and because he was becoming increasingly symptomatic. A right pterional craniotomy was planned. Extradural dissection was performed until the dura going into the foramen ovale was revealed. We could feel the metallic needle under the dural sheath of the trigeminal nerve. The dura was opened sharply directly over the needle. We then proceeded to mobilize the needle into the face, and then pulled it out completely through the craniotomy to avoid injury to the temporal lobe. The patient recovered well and was asymptomatic at the time of discharge. This case report was written in compliance with our institutional ethical review board. Institutional review board (IRB) approval and patient consent were waived in light of the retrospective and deidentified nature of the data presented in accordance with the University of Texas Southwestern (UTSW) IRB.

Occipital neuralgia: A neurosurgical perspective.

Occipital neuralgia typically arises in the setting of nerve compression by fibrosis, surrounding anatomic structures, or osseous pathology, such as bone spurs or hypertrophic atlanto-epistropic ligament. It generally presents as paroxysmal bouts of sharp pain in the sensory distribution of the first three occipital nerves. Due to the long course of the greater occipital nerve (GON), and its peculiar anatomy, and location in a mobile region of the neck, it is unsurprising that the GON is at high risk for compression. Little is known how to diagnose or treat this neuropathic pain syndrome. The objective of this paper is to isolate the etiology involved, and treat this condition promptly. After all nonoperative efforts are exhausted, surgical transection of the nerve is the treatment of choice in these cases. An isolated C2 neurectomy or ganglionectomy is performed for an optimal pain relief. C1-2 instrumented fusion can be considered if, extensive facet arthropathy with instability is identified. Authors review the spectrum of treatment options for this debilitating condition, and discuss the case example of a patient who required conversion to a C1-C2 instrumented fusion following C2 ganglionectomy due to an underlying extensive degenerative disease and intraoperative findings suggestive of atlantoaxial instability.

Systematic Review and Meta-Analysis of Management Strategies and Outcomes in Adult Spinal Neurocysticercosis.

OBJECTIVE: Spinal involvement in neurocysticercosis is rare and can lead to debilitating injury if not diagnosed and treated early. We aim to provide the reader with a thorough analysis of the best available evidence regarding patient characteristics, optimal treatment modality, and outcomes in cases of spinal neurocysticercosis. METHODS: A systematic review of the literature using PubMed, Google Scholar, and Web of Science electronic databases was made according to the PRISMA guidelines. An illustrative case of intramedullary-cervical spinal disease is also presented for illustrative purposes. RESULTS: A total of 46 reports of 103 patients fitting the screening criteria were identified. Isolated spinal involvement was seen in 46.15% of patients. Most infections (76.92%) had an intradural extramedullary localization, with 43.27% of cases involving >1 spinal cord level. The most common presenting symptoms were motor deficits (77.88%), pain syndromes (64.42%), and sensory deficits (53.85%). Combined surgical resection and pharmacologic therapy was the most frequently used treatment modality (49.04%) and had the highest proportion of patients reporting symptomatic improvement at follow-up (78.43%). Combination therapy had a significantly higher rate of neurologic recovery compared with surgery alone (P = 0.004) or medical treatment (P = 0.035). CONCLUSIONS: Spinal involvement in neurocysticercosis should be considered in patients from or who traveled to endemic areas presenting with ring-enhancing lesions. Combined treatment with surgery followed by cysticidal and steroid medication seems to be superior to surgery or medical treatment in isolation and seems to provide the highest chances of recovery.

Matricidal cavernous aneurysms: a multicenter case series.

BACKGROUND: Cavernous carotid artery aneurysms (CCAs) represent a unique subset of intracranial aneurysms due to their distinct natural history and the anatomy of the cavernous sinus. Enlarging CCAs can cause elastic compression of the parent internal carotid artery (ICA). We suggest defining aneurysms that cause luminal stenosis of their parent vessels as 'matricidal aneurysms.'Though many patients are asymptomatic, presenting symptoms of CCAs include ophthalmoplegia with resulting diplopia, vision changes, pain, ptosis, facial numbness, and cavernous-carotid fistula. Less commonly, patients with CCAs can present with epistaxis, subarachnoid hemorrhage, and-in cases of matricidal aneurysms-ischemia due to stenosis. The proper management of stenosis caused by a matricidal CCA is not well established and may not be intuitive. METHODS: We present a multicenter retrospective case series of patients with matricidal CCAs. RESULTS: Forty patients with matricidal aneurysms presented with both asymptomatic and symptomatic stenosis. These patients were either treated with conservative medical management, coiling, flow diversion, or endovascular sacrifice of the parent artery. Planned treatment modalities were not executed in 11 cases (28% treatment failure rate). Presenting symptoms, patient outcomes, and follow-up data are presented for all cases. CONCLUSION: Matricidal aneurysms require careful consideration and planning. The restricted anatomy of the cavernous sinus can make successful execution of endovascular interventions more difficult. Direct elastic compression of the parent artery does not respond to angioplasty and stenting in the same way atherosclerotic stenosis does. Because of this, planning for the possibility of parent vessel sacrifice is important.