National treatment practices in the management of infectious intracranial aneurysms and infective endocarditis

Singla, Amit; Fargen, Kyle M; Blackburn, Spiros; Neal, Dan; Martin, Tomas D.; Heß, Peter; Beaver, Thomas M.; Klodell, Charles T.; Hoh, Brian L.

doi:10.1136/neurintsurg-2015-011834

Cited by 50 publications

(51 citation statements)

References 29 publications

Supporting

Mentioning

Contrasting

Order By: Relevance

“…It is difficult to draw valid conclusions concerning the outcome of patients with ICMA, 184 for many reasons: (1) ICMA is a relatively rare condition, and there are no controlled studies. (2) Reviews of reported series often span decades during which radiologic modalities, interventional techniques, microvascular surgery, and management of underlying conditions evolved and improved over time.…”

Section: Prognosismentioning

confidence: 99%

See 1 more Smart Citation

Vascular Graft Infections, Mycotic Aneurysms, and Endovascular Infections: A Scientific Statement From the American Heart Association

Wilson¹,

Bower²,

Creager³

et al. 2016

Circulation

357

307

View full text Add to dashboard Cite

The use of synthetic material for reconstructive vascular surgery was first reported during the early 1950s. Infection involving vascular graft prostheses is an infrequent but devastating complication of reconstructive vascular graft surgery and is associated with a high morbidity and, in some situations, mortality. Improvements in surgical techniques and graft design, including the use of native venous or arterial tissue, have reduced the frequency of infection and severity of complications from vascular graft infection (VGI). However, these advances have also led to more frequent vascular graft procedures occurring in a patient population with multiple underlying comorbidities that would have previously disqualified them as candidates for vascular reconstructive surgery. Underlying comorbidities, such as diabetes mellitus or immune compromise, increase the risk of infection and serious infection-related complications. The major complications of VGI include sepsis, amputation, disruption of infected anastomotic suture line with rupture or pseudoaneurysm formation, embolization of infected thrombi, reinfection of reconstructed vascular grafts, enteric fistulae to the small or large bowel, bacteremic spread of infection to other sites, and death. VGIs can be categorized broadly into those that occur in an extracavitary location, primarily in the groin or lower extremities, or in an intracavitary location, primarily within the abdomen or less commonly within the thorax. frequencyThe frequency of VGI depends on the anatomic location of the graft. The infection rate is 1.5% to 2% for most extracavitary grafts and as high as 6% with vascular grafts in the groin. [1][2][3][4][5][6][7][8][9] For intracavitary grafts, the infection rate is ≈1% to 5%. 1-6 Graft infection is most common after emergency procedures and after reoperation. [1][2][3][4]10 Aortic graft erosion or fistulous communication into the duodenum or other areas of the bowel reportedly occurs in 1% to 2% of patients after aortic reconstruction. 11,12 MicrobiologyThe microbiological cause of VGI has evolved over the years. 1 In early published studies, Staphylococcus aureus was the predominant microorganism recovered. 1,13 Improvements in surgical technique, administration of prophylactic antistaphylococcal antimicrobial therapy, and other factors have resulted in a changing microbiological epidemiology. Vascular graft surgery performed on patients with multiple underlying comorbidities and the increased frequency of emergency procedures have contributed to the changing spectrum of infection. Other factors such as changes in hospital flora, surgery in patients with complicated vascular anatomy, and multiple revisions of previous vascular surgery have resulted in a more diverse microbio- clInIcal stateMents anD GuIDelInes logical spectrum of infection, which includes multidrugresistant strains, polymicrobial infection, and Candida species. Gram-positive cocci accounts for at least two thirds of VGIs. 1,13 Infections caused by coagulase-negative staphylococ...

show abstract

Section: Prognosismentioning

confidence: 99%

“…Patients who have rupture of an ICMA have worse outcomes than those who do not. 112,117,125,135,162,184 Patients with multiple ICMAs have worse outcomes than those with a single ICMA. 135,174 Mortality was significantly higher for older people and for those with meningitis and ICMA located in the vertebrobasilar territory.…”

Section: Prognosismentioning

confidence: 99%

Vascular Graft Infections, Mycotic Aneurysms, and Endovascular Infections: A Scientific Statement From the American Heart Association

Wilson¹,

Bower²,

Creager³

et al. 2016

Circulation

357

307

View full text Add to dashboard Cite

show abstract

“…After screening of the titles and abstracts, 63 studies were selected for full review [1,3,4,7,10,11,14,15,16,17,18,19,20,21,22,23,24,25,26,27,28,29,30,31,32,33,34,35,36,37,38,39,40,41,42,43,44,45,46,47,48,49,50,51,52,53,54,55,56,57,58,59,60,61,62,63,64,65,66,67,68,69,70,71]. Thirty studies with 2 or more patients and 33 case reports with a total number of 814 patients were identified.…”

Section: Resultsmentioning

confidence: 99%

Interdisciplinary Treatment of Intracranial Infectious Aneurysms

Hamisch¹,

Mpotsaris

Timmer³

et al. 2016

Cerebrovasc Dis

View full text Add to dashboard Cite

Objective: Intracranial infectious aneurysms (IIAs) are a rare clinical entity without a definitive treatment guideline. In this study, we evaluate the treatment options of these lesions based on our own clinical experience and review the current knowledge of therapy as portrayed in the literature. Methods: We conducted a single-center retrospective analysis of all patients with an IIA and performed a systematic review of the literature using the MEDLINE database. We undertook a comprehensive literature search using the OVID gateway of the MEDLINE database (1950-October 2015) using the following keywords (in combination): ‘infectious', ‘mycotic', ‘cerebral aneurysm', ‘intracranial aneurysm'. 1,721 potentially relevant abstracts were identified and 63 studies were selected for full review. The studies were analysed regarding ruptured versus unruptured aneurysms, aneurysm localization and treatment, as well as clinical and radiological outcome. Results: Our institutional series consisted of 6 patients (median age 57 [32-76]) treated between 2011 and 2015. All patients presented with ruptured IIAs located on the middle cerebral artery (MCA, 5 patients) and anterior cerebral artery (ACA, 1 patient). Five patients were treated by clipping and resecting the aneurysm, 1 patient underwent coiling. All patients received antibiotic therapy and 1 patient died. We further identified 814 patients (median age 35.5 [0-81]) in 63 studies. Locations of the aneurysms were mentioned in 55 studies. The most frequent locations of the aneurysms were: MCA (63.5%), posterior cerebral artery (14%), ACA (9.0%) and others (13.5%). Treatment for IIAs was described in 62 studies: antibiotic treatment (56.1%), a combination of antibiotics and surgery (20.9%) or antibiotics and endovascular treatment (23.0%). Outcome was mentioned in 82.4% of the patients with a mortality rate of 16.8%. An evaluation of treatment outcome was limited due to the heterogeneity of patients in the published case series. Conclusion: Antibiotic therapy of patients with IIA is mandatory. However, due to the complexity of the disease and its accompanying comorbidities, a general treatment algorithm could not be defined. Analogous to non-mycotic aneurysms, further treatment decisions require an interdisciplinary approach involving neurosurgeons, interventionists and infectious disease specialists.

show abstract

“…Patients who require valve surgery or other type of open heart surgery may be more critically ill and at higher morbidity and mortality risk as compared to those who may not need cardiac surgery, and this may account for the lack of studies including these patients. A recently published paper by Singla et al [12], performed using the Nationwide Inpatient Sample database on the national treatment practices in the management of infectious intracranial aneurysms and infective endocarditis, revealed that the majority of patients with infectious intracranial aneurysms were managed conservatively. In this cohort, 18.6% underwent endovascular embolization or surgical clipping of the aneurysm independently of the rupture status, with only 18% of ruptured aneurysms and 25% of unruptured aneurysms undergoing treatment to exclude the aneurysm.…”

Section: Discussionmentioning

confidence: 99%

“…In addition, cardiac procedures were only performed in 18.6% of patients with ruptured aneurysms and 15.6% of those with unruptured aneurysms. Only 1.5% of patients had cardiac surgery and aneurysm treatment within the same admission [12]. …”

Section: Discussionmentioning

confidence: 99%

Endovascular Embolization of Intracranial Infectious Aneurysms in Patients Undergoing Open Heart Surgery Using n-Butyl Cyanoacrylate

et al. 2017

View full text Add to dashboard Cite

Introduction: Mycotic aneurysms are a serious complication of infective endocarditis with increased risk of intracranial hemorrhage. Patients undergoing open heart surgery for valve repair or replacement are exposed to anticoagulants, increasing the risk of aneurysm bleeding. These patients may require endovascular or surgical aneurysm treatment prior to heart surgery, but data on this approach are scarce. Methods: Retrospective review of consecutive patients with infectious endocarditis and mycotic aneurysms treated endovascularly with Trufill n-butyl cyanoacrylate (n-BCA) at the Cleveland Clinic between January 2013 and December 2015. Results: Nine patients underwent endovascular treatment of mycotic aneurysms with n-BCA (mean age of 39 years). On imaging, 4 patients had intracerebral hemorrhage, 2 had multiple embolic infarcts, and the rest had no imaging findings. Twelve mycotic aneurysms were detected (3 patients with 2 aneurysms). Seven aneurysms were in the M4 middle cerebral artery segment, 4 in the posterior cerebral artery distribution, and 1 in the callosomarginal branch. n-BCA was diluted in ethiodized oil (1:1 to 1:2). Embolization was achieved in a single rapid injection with immediate microcatheter removal. Complete aneurysm exclusion was achieved in all cases without complications. All patients underwent open heart surgery and endovascular embolization within a short interval, 2 with both procedures on the same day. There were no new hemorrhages after aneurysm embolization. Conclusions: Endovascular embolization of infectious intracranial aneurysms with liquid embolics can be performed successfully in critically ill patients requiring immediate open heart surgery and anticoagulation. Early embolization prior to and within a short interval from open heart surgery is feasible.

show abstract

National treatment practices in the management of infectious intracranial aneurysms and infective endocarditis

Abstract: In this NIS database study, the majority of patients with IIAs were managed non-operatively, regardless of rupture status. Further investigation is warranted to standardize the management of these lesions.

Cited by 50 publications

References 29 publications

Vascular Graft Infections, Mycotic Aneurysms, and Endovascular Infections: A Scientific Statement From the American Heart Association

Vascular Graft Infections, Mycotic Aneurysms, and Endovascular Infections: A Scientific Statement From the American Heart Association

Interdisciplinary Treatment of Intracranial Infectious Aneurysms

Endovascular Embolization of Intracranial Infectious Aneurysms in Patients Undergoing Open Heart Surgery Using n-Butyl Cyanoacrylate

Contact Info

Product

Resources

About