Ruptured mycotic cerebral aneurysm development from pseudoocclusion due to septic embolism

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.

Acute enlargement, morphological changes, and rupture of intracranial infectious aneurysm in infective endocarditis. Serial imaging

A 72-year-old man received a transcatheter aortic valve implantation (TAVI) 2 years ago for leakage of the degenerative bioprosthesis with Corevalve n°31 implantation, presented infective endocarditis (IE) (streptococcus sanguinis) of the bioprosthetic aortic valve. One month after antibiotic treatment was initiated, he presented a left-sided hemiplegia, a right frontal hematoma. MRI/contrast-enhanced magnetic resonance angiography (CE-MRA) revealed 2 infectious intracranial aneurysms (IIAs) of the right (10 mm) and left middle cerebral artery (MCA) (M2 segment, 5 mm). The right MCA IIA was treated within 1 day by glue-embolization. Seven days later, the patient acutely developed motor aphasia. CE-MRA showed significant enlargement (15 mm) and morphologic change of the ruptured left MCA IIA. This IIA was treated with Onyx-embolization. This case adds additional evidence that IIAs, during IE, can show rapid growth and morphological change over a 7 day course and emphasizes the imperative need of close imaging follow-up when IIAs are managed by antibiotic therapy.

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.

Republished: Intracranial vessel occlusion preceding the development of mycotic aneurysms in patients with endocarditis

Mycotic aneurysms (MA) are an uncommon complication of infectious endocarditis. Septic emboli are thought to be the precipitating event in their development, but the evidence for this is sparse. We present three cases in which septic embolic occlusion preceded MA development at the occlusion site, suggesting that documented angiographic emboli in patients with infectious endocarditis and bacteremia constitute a risk factor for MA formation. Two adult patients with a history of intravenous drug use and one child with congenital heart disease are described. They were all diagnosed with infectious endocarditis and developed neurological symptoms during their hospital course. Initial catheter-based cerebral angiograms demonstrated vascular occlusions, which were followed by the development of MA at the same sites within 1 month. Septic emboli, documented on cerebral angiogram, in patients with infectious endocarditis may precede the appearance of MA. Patients with angiographic occlusions in the setting of endocarditis warrant close follow-up.

Intracranial vessel occlusion preceding the development of mycotic aneurysms in patients with endocarditis

Mycotic aneurysms (MA) are an uncommon complication of infectious endocarditis. Septic emboli are thought to be the precipitating event in their development, but the evidence for this is sparse. We present three cases in which septic embolic occlusion preceded MA development at the occlusion site, suggesting that documented angiographic emboli in patients with infectious endocarditis and bacteremia constitute a risk factor for MA formation. Two adult patients with a history of intravenous drug use and one child with congenital heart disease are described. They were all diagnosed with infectious endocarditis and developed neurological symptoms during their hospital course. Initial catheter-based cerebral angiograms demonstrated vascular occlusions, which were followed by the development of MA at the same sites within 1 month. Septic emboli, documented on cerebral angiogram, in patients with infectious endocarditis may precede the appearance of MA. Patients with angiographic occlusions in the setting of endocarditis warrant close follow-up.