Pediatric cranial hydatid disease: lessons learned from three successive surgical interventions in a single patient with long-term follow-up.

Brain involvement in hydatid disease accounts for 1-2% of all Echinococcus granulosus infections. Extradural localization remains exceptional, particularly when associated with intra-axial dissemination or infection. Here, we report the complete clinical course over 4 years of a pediatric patient who presented sequentially with a primary osteolytic extradural complicated hydatid cyst, likely via microscopic dural disruption or hematogenous seeding, and subsequently underwent customized low-cost acrylic cranioplasty using a 3D-printed mold. At final follow-up (4 years post-initial presentation, 3 years post-final surgery), the patient remains disease free with favorable cosmetic outcome. Neurological examination is normal, and cognitive assessment demonstrates age-appropriate development. He shows normal academic performance and social integration. The cost-effective cranioplasty technique (< 2000 Tunisian dinars ≈ €600) provided perfect cranial contour restoration with no implant-related complications. To our knowledge, this is the first reported pediatric case of sequential extradural, disseminated intra-axial, and multiply recurrent cranial hydatidosis which demonstrates that a multidimensional strategy combining radical surgery, antiparasitic therapy, and delayed custom cranioplasty can achieve favorable long-term functional and cosmetic outcomes even in resource-limited settings. The favorable long-term recovery in neurological function, cognitive abilities, and quality of life underscores the importance of aggressive recurrence management and multidisciplinary follow-up in pediatric neuroparasitology.