Endovascular treatment of bacterial intracranial aneurysms

Flow Diversion as Destination Treatment of Intracranial Mycotic Aneurysms: A Retrospective Case Series

BACKGROUND

Mycotic aneurysms represent a rare type of intracranial aneurysm. Treatment options usually consist of coiling, clipping, or liquid embolization. Data regarding outcomes after flow diversion of mycotic aneurysms are sparse.

OBJECTIVE

To present a single-center case series regarding our experience with FD as definitive treatment for ruptured mycotic aneurysms initially treated with coil embolization.

METHODS

We retrospectively reviewed a prospectively maintained database of all cerebrovascular procedures performed at a single institution between 2017 and 2021 for cases that used FD for the management of intracranial mycotic aneurysms. Prospectively collected data included patient demographics, medical history, rupture status, aneurysm morphology, aneurysm location, and periprocedural complications. The main outcomes included neurological examination and radiographic occlusion rate on cerebral digital subtraction angiography.

RESULTS

Three patients with 4 ruptured mycotic aneurysms that were initially treated with coil embolization were identified that required retreatment. The aneurysms were located along the middle cerebral artery bifurcation (n = 2), posterior cerebral artery P1/2 junction (n = 1), and basilar artery apex (n = 1), which all demonstrated recurrence after initial coil embolization. Successful retreatment using flow diverting stents was performed in all 3 patients. At the last angiographic follow-up, all aneurysms demonstrated complete occlusion. No patients suffered new periprocedural complications or neurological deficits after FD.

CONCLUSION

Flow-diverting stents may be an effective treatment option for intracranial mycotic aneurysms that are refractory to previous endovascular coiling. Future studies are warranted to establish the associated long-term safety and clinical efficacy.

Simultaneous intracerebral and subarachnoid hemorrhages caused by multiple infectious intracranial aneurysms treated endovascularly and by microsurgical clipping: illustrative case

BACKGROUND

Infected intracranial aneurysms are relatively rare but tend to occur in multiple locations. Establishing an optimal treatment strategy for multiple ruptured aneurysms is often challenging, especially when simultaneous ruptures occur in different locations. We report a case of simultaneous intracerebral and subarachnoid hemorrhages caused by the rupture of multiple infected intracranial aneurysms.

OBSERVATIONS

A 23-year-old male with a 2-week history of chronic fever presented with sudden onset of severe headache and visual disturbance. Computed tomography showed intracerebral hemorrhage in the right occipital lobe and subarachnoid hemorrhage in the area of the left Sylvian fissure. Further investigation documented Staphylococcus bacteremia, verrucae on the mitral valve, and aneurysms arising from the right posterior cerebral artery (PCA) and the left middle cerebral artery (MCA). A larger aneurysm arising from the PCA was successfully occluded endovascularly, but subsequent endovascular occlusion of the MCA aneurysm was unsuccessful because some important branches were observed extending from the aneurysm. The left MCA aneurysm was then obliterated by angioplastic clipping via left pterional craniotomy. The patient showed a favorable neurological recovery after treatment.

LESSONS

In such complex cases of infectious aneurysms, the method and timing of treatment need to be carefully determined based on the medical condition.

Erratum to Evaluating the safety and efficacy of various endovascular approaches for the treatment of infectious intracranial aneurysms: a systematic review. World Neurosurgery. Volume 144, December 2020, Pages 293-298.e15

OBJECTIVE

A review of endovascular cerebral mycotic aneurysm treatment with Onyx liquid embolic, N-butyl-2-cyanoacrylate (NBCA), or coil embolization has not been reported. The authors conduct a systematic review on endovascular treatment methods of mycotic aneurysms.

METHODS

A systematic literature review was performed using the PubMed and MEDLINE databases for studies published between 1986 and 2020. All studies assessing outcomes related to endovascular Onyx embolization, NBCA embolization, or coiling were included.

RESULTS

A total of 74 studies were ultimately selected, including 180 (67% male) patients comprising 243 aneurysms treated endovascularly. The mean age was 38.2 ± 17.6 years, and the most common symptom on presentation was headache (31%). Most aneurysms were located on the middle cerebral artery (52.5%), and over half presented with rupture (53.8%). Coiling was the most commonly employed technique (50.4%), and obliteration rates were comparable across coiling, NBCA, and Onyx (99.1%, 100%, 100%, respectively). Complication rates were also comparable (4.3% vs. 15.2% vs. 8.1%).

CONCLUSION

Embolization for infectious intracranial aneurysm appears to be an effective treatment option for mycotic aneurysms. Embolization rates were comparable between coiling, NBCA, and Onyx embolization. Noninferiority among these modalities cannot be demonstrated given the retrospective nature of this review, evolution of endovascular techniques over the years, and changes in treatment paradigms in the last 2 decades. Ideally, further prospective research will be needed to find which treatment method offers the lowest complication rates and the best outcomes for patients with mycotic aneurysms.

Evaluating the Safety and Efficacy of Various Endovascular Approaches for Treatment of Infectious Intracranial Aneurysms: A Systematic Review

OBJECTIVE

A review of endovascular cerebral mycotic aneurysm treatment with Onyx liquid embolic, N-butyl-2-cyanoacrylate (NBCA), or coil embolization has not been reported. The authors conduct a systematic review on endovascular treatment methods of mycotic aneurysms.

METHODS

A systematic literature review was performed using the PubMed and MEDLINE databases for studies published between 1986 and 2020. All studies assessing outcomes related to endovascular Onyx embolization, NBCA embolization, or coiling were included.

RESULTS

A total of 73 studies were ultimately selected including 180 (67% male) patients comprising 243 aneurysms treated endovascularly. The mean age was 38.2 ± 17.6 years, and the most common symptom on presentation was headache (31%). Most aneurysms were located on the middle cerebral artery (52.5%), and over half presented with rupture (53.8%). Coiling was the most commonly employed technique (50.4%), and obliteration rates were comparable across coiling, NBCA, and Onyx (99.1%, 100%, 100%, respectively). Complication rates were also comparable (4.3% vs. 15.2% vs. 8.1%).

CONCLUSIONS

Embolization for infectious intracranial aneurysm appears to be an effective treatment option for mycotic aneurysms. Embolization rates were comparable among coiling, NBCA, and Onyx embolization. Noninferiority among these modalities cannot be demonstrated given the retrospective nature of this review, evolution of endovascular techniques over the years, and changes in treatment paradigms in the past 2 decades. Ideally, further prospective research will be necessary to find which treatment method offers the lowest complication rates and the best outcomes for patients with mycotic aneurysms.

Large intracranial aneurysm after transsphenoidal surgery for pituitary macroadenoma

Uncontrolled cerebrospinal fluid (CSF) leakage after transsphenoidal surgery (TSS) for pituitary adenoma can lead to meningitis. Intracranial mycotic pseudoaneurysm is a rare complication in central nervous system infection. Large single pseudoaneurysm is more uncommon. Most mycotic aneurysms occur due to endocarditis. The present patient had no heart problem and was infected by CSF leakage after transsphenoidal surgery. We present a case of large ruptured mycotic pseudoaneurysm as a complication of cerebral infection after TSS for pituitary macroadenoma.

Subarachnoid and intra-cerebral hemorrhage in young adults: rare and underdiagnosed

OBJECTIVES

Convexity subarachnoid and intra-cerebral hemorrhages, in patients aged<50 years, are always a diagnostic challenge. This condition is characterized by acute headaches with or without neurological symptoms and/or seizures, and by the radiological demonstration of subarachnoid and/or intra-cerebral hemorrhages and, more rarely, by the association of ischemic events.

PATIENTS AND METHODS

In a prospective series of 30 consecutive patients (median age 31 years; 22 women) with a subarachnoid and intra-cerebral hemorrhages, 19 were diagnosed with reversible cerebral vasoconstriction syndrome (RCVS), 7 with cerebral venous sinus thrombosis (CVST), and 4 with a bleeding mycotic aneurysm (MA).

RESULTS

RCVS appeared spontaneously in 16 patients and was related to the postpartum period in three cases. Subarachnoid hemorrhage (SAH) was demonstrated in 24 patients as follows: 18 cases were in cortical areas, 4 were in the polygon of Willis, one was inter-hemispheric, and one was inter-hemispheric/intra-cerebral. A convexity pure intra-cerebral hemorrhage (ICH) was recorded in 6 cases. Among the 7 patients suffering from CVST, the superior sagittal sinus was involved in 4 cases, the transverse sinuses (TS) in 2, and the TS plus sigmoid sinus (SS) in one.

CONCLUSION

The three most common causes in this series were RCVS, followed by CVST and bleeding from MA. Because of atypical clinical or radiological presentations, this large spectrum of etiologies can cause diagnostic difficulties. Therefore, careful analysis is needed to ensure correct and prompt diagnosis and to avoid any dangerous delays in management.

A short segment intracranial-intracranial jump graft bypass followed by proximal arterial occlusion for a distal MCA aneurysm

Background:

To describe the use of a short segment cortical intracranial–intracranial (IC–IC) bypass for the treatment of a distal middle cerebral artery (MCA) aneurysm.

Case Description:

A 54-year-old woman presented with a loss of consciousness followed by multiple seizures and was found to have a partially thrombosed distal MCA aneurysm. This possibly mycotic aneurysm was treated by creating a short segment jump graft between a normal cortical artery and a nearby cortical branch arising from the aneurysmal M3 arterial segment. The bypass allowed for subsequent occlusion of the aneurysmal vessel without ischemic consequence. At surgery, the anterior division of the superficial temporal artery (STA) was exposed and dissected. Intraoperative angiography was utilized to localize a cortical artery arising from the involved segment as well as a nearby cortical artery arising from a distinct, uninvolved MCA branch. A segment of the STA was harvested, and then 10-0 suture was utilized to anastomose this short segment, to both the involved and normal cortical arteries. This created a short jump graft allowing for subsequent sacrifice of the diseased artery. Following surgery, the patient immediately underwent coil embolization of the aneurysm back into the parent artery resulting in local vascular sacrifice. The remainder of the patient's hospital course was uneventful. She was discharged home in good condition.

Conclusions:

We suggest that cortical IC–IC bypass followed by endovascular arterial sacrifice as performed in our case represents a simple and safe option for treating unclippable distal MCA aneurysms including mycotic lesions.

Early Endovascular Coiling of Posterior Communicating Artery Saccular Aneurysm in the Setting of Staphylococcus Bacteremia

OBJECTIVE

Although infectious complications of endovascular aneurysm treatment are in general rare, platinum coil therapy for patients with ruptured cerebral aneurysms and active bacteremia could be expected to carry increased risk. The literature on the timing and safety of endovascular treatment in this setting, however, is limited. In this report, the authors present a case of aneurysmal subarachnoid hemorrhage and active bacteremia in which intravenous antibiotics and early endovascular therapy were successfully used. A review of the literature is also provided.

CLINICAL PRESENTATION

A 79-year-old woman presented with Hunt-Hess grade 4, Fisher grade 3 + 4 subarachnoid hemorrhage. Blood cultures obtained on admission revealed gram-positive cocci, which later proved to be coagulase-negative Staphylococcus.

INTERVENTION

Intravenous cefepime and vancomycin were begun soon after admission. A right posterior communicating artery saccular aneurysm was identified on diagnostic cerebral angiography and was treated with bare platinum coils 28 hours after antibiotic therapy was initiated. An extended course of vancomycin was completed. No intracranial infectious complications were noted at 34-month clinical and radiographic follow-up.

CONCLUSION

This is the first case report to document the efficacy and safety of early endovascular coil embolization of a ruptured saccular cerebral aneurysm presenting in the context of active bacteremia. Review of the available literature suggests that a similar strategy for ruptured infectious aneurysms may also be safe. Further validation of this approach for both saccular and infectious aneurysms, however, is required.

Endovascular management of infective intracranial aneurysms with acrylic glue. A report of two cases

SUMMARY

Cerebral mycotic aneurysms (MAs) also called infective aneurysms, are uncommon and are usually encountered in patients with infective endocarditis. These aneurysms often present with intracranial hemorrhage. MAs may resolve on treatment with antibiotics alone. However prognosis with medical management alone is unpredictable. Good prognosis with surgery has been reported for single accessible ruptured MAs. However surgery is associated with significant morbidity. Endovascular treatment of MAs along with appropriate antibiotics is emerging as an acceptable option for these patients. We describe two cases of infective endocarditis complicated by ruptured MA treated successfully by liquid embolic glue material.

Intracranial infectious aneurysms: a comprehensive review

Intracranial infectious aneurysms, or mycotic aneurysms, are rare infectious cerebrovascular lesions which arise through microbial infection of the cerebral arterial wall. Due to the rarity of these lesions, the variability in their clinical presentations, and the lack of population-based epidemiological data, there is no widely accepted management methodology. We undertook a comprehensive literature search using the OVID gateway of the MEDLINE database (1950-2009) using the following keywords (singly and in combination): "infectious," "mycotic," "cerebral aneurysm," and "intracranial aneurysm." We identified 27 published clinical series describing a total of 287 patients in the English literature that presented demographic and clinical data regarding presentation, treatment, and outcome of patients with mycotic aneurysms. We then synthesized the available data into a combined cohort to more closely estimate the true demographic and clinical characteristics of this disease. We follow by presenting a comprehensive review of mycotic aneurysms, highlighting current treatment paradigms. The literature supports the administration of antibiotics in conjunction with surgical or endovascular intervention depending on the character and location of the aneurysm, as well as the clinical status of the patient. Mycotic aneurysms comprise an important subtype of potentially life-threatening cerebrovascular lesions, and further prospective studies are warranted to define outcome following both conservative and surgical or endovascular treatment.

Intracranial microbial aneurysm (infectious aneurysm): current options for diagnosis and management

The histopathological characteristic of intracranial microbial aneurysm (MA)-infectious aneurysm is the presence of infection and destruction of the walls of the vessels. It can occur in the setting of predisposing infections that spread by endovascular mechanism (e.g., infective endocarditis) or extravascular mechanism (e.g., meningitis). MA is probably a better term than mycotic, infectious, or infective aneurysm as a wide variety of bacteria, fungi, mycobacteria, and virus can cause MA. Typically MAs are multiple, distal, and fusiform aneurysms, but the angiographic and clinical presentations can vary widely. The most common presentation of MA is intracranial bleed. CT angiography, MR angiography, or Digital subtraction angiography can be deployed to detect MA. By combining the clinical findings, imaging, and angiographic findings, it is possible to arrive at a correct diagnosis in most instances. MAs carry higher risk of rupture and fatal bleed when compared to other aneurysms. The treatment options include antimicrobial therapy, surgery, and endovascular therapy. The management strategy is based on large case series rather than controlled trials. All MA should receive appropriate antibiotic therapy. Ruptured MA with mass effect would require surgery in most situations, while those without mass effect and in non-eloquent locations could also be managed by endovascular therapy. Unruptured MA could be managed according to the size, location, and risk of bleeding-by antibiotic therapy, surgery, or endovascular therapy. Monitoring the resolution of the MA under antibiotic therapy by serial CT angiography is another option, but it carries higher risk of bleeding. Treatment of the underlying predisposing infection is an important component of therapy.

Infectious intracranial aneurysms in the pediatric population: endovascular treatment with Onyx

OBJECTS

Infectious intracranial aneurysms present a treatment challenge in the pediatric population. Current endovascular strategies and tools have been developed, which make treatment of infectious intracranial aneurysms with liquid embolics safe and effective. This study reviews the use of the liquid embolic Onyx in the treatment of infectious intracranial aneurysms in the pediatric population.

MATERIALS AND METHODS

We used an endovascular approach to treat ruptured infectious intracranial aneurysms. We embolized the aneurysms with either Onyx alone or in combination with platinum coils.

CONCLUSION

Endovascular therapy with liquid embolics (Onyx) has been shown to be a safe and effectual treatment option in the case of pediatric infectious intracranial aneurysms. The combination of endovascular modalities can also be used to tailor the therapeutic goal of exclusion of infectious aneurysms with good results. Further studies are needed to assess the long-term effectiveness of this approach to pediatric infectious intracranial aneurysms.

Staphylococcus endocarditis associated with infectious vasculitis and recurrent cerebral hemorrhages

BACKGROUND

Patients with infectious endocarditis, who do not respond to conservative medical therapy usually need rapid valve surgery. This poses a difficult dilemma in patients with intracranial aneurysms and hemorrhage, although endovascular treatment of infectious aneurysms might be an advantage in therapy in these patients.

METHODS

We present a patient with ruptured infectious intracranial aneurysm complicating endocarditis with hemorrhage after successful coil occlusion of the aneurysm and review the literature on studies reporting endovascular treatment in adults with infectious aneurysms.

RESULTS

In total 34 adults have been reported with endovascular treatment of infectious aneurysms. All patients were initially presented with hemorrhage. Reported mortality rate was low (6%), and neurologic disability was reported in 37% of other patients. Rehemorrhage has been described in one other patient after endovascular treatment of an infectious aneurysm after rupture of a new aneurysm. In our patient, CT suggested a generalized cerebral infectious vasculitis.

CONCLUSIONS

Endovascular treatment of infectious aneurysms seems to be a great advantage, but endovascular coiling may not prevent hemorrhage associated with panvasculitis rupture of a new aneurysm.

Different modalities of treatment of intracranial mycotic aneurysms: report of 4 cases

BACKGROUND

Intracranial mycotic aneurysms, although rare neurovascular pathology, represented a neurosurgical challenge that required careful stepwise decision making. Different approaches for their management were used. We present our experience with 4 patients treated in terms of indications and efficacy of different treatment modalities.

METHODS

Four patients with infective endocarditis and 5 intracranial mycotic aneurysms were treated during the last 5 years. All of the patients were men; their ages ranged between 29 and 62 years (mean, 47.3 years). Distal MCA was the commonest site (3 patients) of aneurysm, 1 was located at the distal PCA, whereas the remaining aneurysm was at the distal ACA. Angiographic studies were done in 2 patients because of neurologic signs and for screening in 2 patients with documented endocarditis.

RESULTS

One patient was treated conservatively because of his moribund general condition; 1 patient was treated with direct surgical clipping; 1 patient was treated with surgical trapping and resection of the aneurysm without revascularization; and the remaining patient, harboring 2 distal mycotic aneurysms, was treated with selective embolization for his PCA aneurysm and endovascular trapping for the distal ACA aneurysm. Follow-up angiographic results showed stable occlusion of the aneurysms. No periprocedural technical complications were reported, and none of the patients, including the patient with medical treatment only, has ever experienced new neurologic events after definitive treatment.

CONCLUSIONS

Prolonged courses of antibiotics are recommended for all patients with mycotic aneurysms. Selective endovascular embolization or trapping with soft and ultrasoft electrolytically detachable coils seems to be an effective technique that should be considered for treatment of dynamic unruptured mycotic aneurysms, with conventional surgical repair restricted for ruptured aneurysms with associated hematoma and high intracranial pressure.

An unusual case of ruptured distal anterior cerebral artery aneurysm associated with brucellosis

Reports have noted aneurysmal dilatation of arteries in association with brucellosis, but involvement of intracranial vessels has not been documented to date. Sixty-one year old female patient who had been diagnosed with brucellosis 14 months earlier presented with symptoms of subarachnoid hemorrhage (SAH). Due to deterioration of the patient's clinical condition in spite of a two-drug antibiotic regimen, she was treated surgically and made a full recovery. It is important to identify this association promptly, as there are clinical implications for optimal management. The article also discusses the timing and duration of antibiotic therapy, indications for and considerations regarding surgery, and the use of other treatment modalities.

Endovascular Treatment for a Unusually Large Mycotic Aneurysm Manifesting as Intracerebral Hemorrhage-Case Report-

A 62-year-old male presented with an unusually large mycotic aneurysm mimicking a saccular aneurysm manifesting as coma and hypotension. Computed tomography showed intracerebral and intraventricular hemorrhage. He was in septic shock due to acute infectious endocarditis. Cerebral angiography disclosed a large distal anterior cerebral artery aneurysm. The diagnosis was mycotic aneurysm based on the morphological features and associated endocarditis. The aneurysm and the parent artery were successfully occluded by endovascular embolization. High-dose antibiotic therapy in the following 6 weeks resulted in resolution of the infectious endocarditis. Early exclusion of ruptured mycotic aneurysm is mandatory because of the high risk of rerupture. Endovascular treatment is an effective alternative for mycotic aneurysms, especially if the patient's general condition is poor. Parent artery occlusion can be safely tolerated if the aneurysm is located distally.

A case of multiple cranial nerve palsy due to sphenoid sinusitis complicated by cerebral aneurysm

A case of sphenoid sinusitis and internal carotid aneurysm presenting with multiple cranial nerve palsy is reported. A 46-year-old man with high fever and neck rigidity developed progressive visual loss and ophthalmoplegia on both sides, and ptosis, mydriasis and facial numbness on the right side. CT scan and MRI revealed abnormal shadow of the sphenoid sinus and the cavernous sinus. Sphenoidectomy and antibiotic therapy improved left visual acuity, but the right visual disturbance remained. Cerebral angiography performed 20 days after the operation, showed an aneurysm of the cavernous portion of the right internal carotid artery. This aneurysm could be called "bacterial aneurysm" due to sphenoid sinusitis and cavernous sinusitis. However, there is another possibility that the enlargement of an idiopathic and asymptomatic intracavernous aneurysm due to rapid and severe parasinusitis induced bilateral cavernous sinus syndrome with the right side dominance. After endovascular coil placement, his right visual disturbance partially recovered.

Current best practices and guidelines. Assessment and management of complications in infective endocarditis

The most important complications of endocarditis are congestive heart failure, paravalvular abscess formation, and embolism, especially stroke. In addition, endocarditis may be complicated by septic arthritis, vertebral osteomyelitis, pericarditis, metastatic abscesses and an array of renal problems ranging from immune-complex glomerulonephritis to renal abscesses. Adverse reactions associated with medical treatment of endocarditis can also result in significant complications such as ototoxicity and nephrotoxicity, skin rashes, and serum sickness. This review focuses on the cardiac, embolic, neurologic and renal complications of endocarditis and discusses how these complications influence the clinical management of individual cases in daily practice.

Management of intracranial infectious aneurysms: a series of 16 cases

OBJECTIVE

The purpose of this study was to better define the management of intracranial infectious aneurysms.

METHODS

We present a retrospective review of the management of 16 patients with intracranial infectious aneurysms. The mean follow-up period was 86 months.

RESULTS

None of the patients had a rehemorrhage during antibiotic treatment. The mortality and long-term outcome from ruptured intracranial infectious aneurysms may be better than previously thought. There was no significant difference in long-term outcome between patients with single or multiple infectious aneurysms or between patients who underwent surgical resection and those who were treated only with antibiotics.

CONCLUSION

Operative treatment should be pursued for patients with ruptured infectious aneurysms. Patients with unruptured intracranial infectious aneurysms should be observed during antibiotic therapy and followed up with cerebral angiography. Surgical resection should be considered if the aneurysm enlarges and the patient's general medical condition allows general anesthesia to be tolerated.

Mycotic aneurysm: an uncommon cause for intra-cranial hemorrhage

Intra-cranial mycotic aneurysms due to an infective process elsewhere in the body constitute an uncommon cause of intra-cranial hemorrhage. The condition carries a grave prognosis. Mycotic aneurysms secondary to infective endocarditis (IE) rarely occur in children. This communication describes a seven-year-old girl who presented with fever and neurological abnormalities. She was diagnosed to have a mycotic aneurysm secondary to IE. Digital subtraction angiography (DSA) confirmed the diagnosis, delineated anatomical details and later detected the complete resolution of the aneurysm following conservative management with intravenous antimicrobial agents.

Current best practices and guidelines. Assessment and management of complications in infective endocarditis

The most important complications of endocarditis are congestive heart failure, paravalvular abscess formation, and embolism, especially stroke. In addition, endocarditis may be complicated by septic arthritis, vertebral osteomyelitis, pericarditis, metastatic abscesses and an array of renal problems ranging from immune-complex glomerulonephritis to renal abscesses. Adverse reactions associated with medical treatment of endocarditis can also result in significant complications such as ototoxicity and nephrotoxicity, skin rashes, and serum sickness. This review focuses on the cardiac, embolic, neurologic and renal complications of endocarditis and discusses how these complications influence the clinical management of individual cases in daily practice.

Endovascular treatment of cerebral mycotic aneurysms

PURPOSE

To evaluate the endovascular treatment (EVT) of mycotic aneurysms (MAs).

MATERIALS AND METHODS

Clinical and radiologic data of 18 MAs treated with EVT were retrospectively reviewed. There were 14 patients (11 men, three women), ranging in age from 28 to 64 (mean age, 44 years). All patients had endocarditis and positive blood culture. The aneurysms were located within the distal cerebral circulation (n = 13) or in the circle of Willis (n = 5). There were 12 ruptured aneurysms and six unruptured aneurysms. Distal or fusiform aneurysms were treated by means of parent vessel occlusion. Proximal saccular aneurysms were selectively treated.

RESULTS

Endovascular treatment was successful for all aneurysms. No aneurysm bled after embolization during clinical follow-up. Follow-up angiograms obtained in 11 of 14 patients 6 months to 2 years after the procedures showed stable occlusions. Transient complications occurred in two cases, with worsening of hemiparesis and quadrantanopia. Five patients underwent surgical cardiac valve replacement within 1 week of EVT without neurologic complications. The late clinical outcome was normal neurologic status (n = 9) or permanent disability that was related to the initial stroke (n = 5).

CONCLUSION

EVT is a reliable and safe technique that should be considered at the time of diagnosis of cerebral mycotic aneurysms.

Current multimodality management of infectious intracranial aneurysms

OBJECTIVE

To implement an algorithm for and assess multimodality (medical, endovascular, and microsurgical) treatment of patients with infectious intracranial aneurysms.

METHODS

Twenty patients with 27 infectious aneurysms were treated during a 10-year period. Bacterial endocarditis was the most common cause (65%). Most aneurysms presented with rupture (75%), and the middle cerebral artery was the most common location (70%).

RESULTS

Five patients were treated endovascularly, with direct coiling for three patients and parent artery occlusion for two patients. Ten patients (15 aneurysms) were treated surgically, with 6 aneurysms being trapped/resected, 2 trapped/bypassed, 4 clipped, and 3 wrapped. Five patients were treated medically. Treatment-associated neurological morbidity was observed for two patients (10%), and two patients died (10%). Good outcomes were observed for 16 patients (80%).

CONCLUSION

Factors that guide management decisions for these patients include aneurysm rupture, hematomas with increased intracranial pressure, and the eloquence of brain tissue supplied by the parent artery. Patients with unruptured infectious aneurysms are initially treated medically, with antibiotics and serial angiography. Patients with ruptured aneurysms that are not associated with hematomas and that do not involve eloquent vascular territory are treated endovascularly. Patients with ruptured aneurysms are treated surgically when there is a hematoma or the risk of ischemic complications in eloquent territory. Therefore, endovascular therapy is the first option for patients in stable condition with ruptured aneurysms; surgical therapy is the first option for patients in unstable condition with ruptured aneurysms and the second option for patients in stable condition who experience failure of endovascular therapy. Medically treated patients with enlarging or dynamic unruptured aneurysms also require direct surgical or endovascular intervention. Favorable patient outcomes can be achieved with this multimodality management.

Intracranial infective aneurysms presenting with haemorrhage: an analysis of angiographic findings, management and outcome

AIM

This study is an analysis of angiographic findings in 17 patients with infective aneurysms who presented with intracranial haemorrhage and reviews the management and outcome in the context of the existing literature.

MATERIALS AND METHODS

A retrospective study of infective aneurysms in 17 patients was carried out. Cranial angiography was performed in all patients. The location, size and outline of aneurysms were analysed. Ten patients were managed conservatively and six patients underwent surgery for the ruptured infective aneurysms and were followed up for a period of 35.8 months and 23 months, respectively.

RESULTS

Twenty-two aneurysms were identified (five unruptured) in 17 patients. Twenty aneurysms (90. 9%) were distal in location and two (9.1%) proximal. Sixty percent were in the posterior circulation with 55% in the posterior cerebral artery (PCA) territory, 27.3% in the middle cerebral artery (MCA) territory and 9.1% in the anterior cerebral artery (ACA) territory. Fourteen aneurysms were small (3-5 mm) and eight were medium sized (6-9 mm). 72.7% of aneurysms had irregular outline and 27.3% regular outline. Out of the 10 ruptured aneurysms managed conservatively, eight resolved. One patient died, presumably due to rebleed, and one had infarction due to parent vessel thrombosis. Six aneurysms were surgically managed with good results. Of the five unruptured aneurysms one was surgically managed and the remaining four conservatively managed patients did not bleed during follow-up.

CONCLUSION

Patients with ruptured infective aneurysms fared well with medical management and the outcome in this series is better than that reported in literature. Patients on conservative management, however, need closer monitoring with angiographic follow-up. Active management is required with enlarging or persisting aneurysms.

Endovascular coil embolisation of metachronous mycotic aneurysms. Case presentation and review of technical and management issues

SUMMARY

While receiving optimal antibiotic therapy for subacute bacterial endocarditis (SBE), a teenage girl with mild congenital mitral insufficiency presented with two separate episodes of subarachnoid haemorrhage from two rapidly evolving metachronous mycotic aneurysms within the vertebrobasilar circulation. Both aneurysms were successfully treated by endovascular coil embolisation with the GDC system. This permitted at the minimum, successful amelioration of the short term risk of rerupture of the aneurysms, and facilitated operative management of the patient's infected mitral valve. The case further illustrates the utility and effectiveness of endovascular therapy for managing not only the neurovascular sequelae of SBE, but also perhaps the enhanced ability to optimally manage the source of mycotic aneurysms. In addition, the potential limitations and risks of this therapeutic strategy are assessed.