Treatment Strategies for Infectious Intracranial Aneurysms: Report of Three Cases and Review of the Literature

Abstract

We retrospectively reviewed the cases of three patients with infectious intracranial aneurysms (IIAs), and discuss the indications for surgical and endovascular treatments. We treated two men and one woman with a total of six aneurysms. The mean age was 43.3 years, ranging from 36 to 51 years. One patient presented initially with an intraparenchymal hemorrhage, one with mass effect, and the other one had four aneurysms (one causing subarachnoid hemorrhages and the other causing delayed intraparenchymal hemorrhages). The average size of all aneurysms was 12.2 mm (range, 2-50 mm). They were preferentially located in the distal posterior cerebral artery, and then, in the middle cerebral artery. All cases were caused by infective endocarditis. We selected endovascular treatments for five aneurysms and treated all but one within 24 h from detection. One aneurysm was treated by combined therapy with endovascular intervention and surgery. After treatment, none of the IIAs presented angiographical recurrence or re-bleeding. If feasible, endovascular treatment is probably the first choice, but a combined surgical and endovascular approach should be considered if surgery or endovascular treatment alone are not feasible. The method of treatment should be individualized. For cases with high risk of aneurysm rupture, treatment should be performed as soon as possible.

A rare case of Streptococcus anginosus infectious intracranial aneurysm: Proper management of a poor prognosis

“…Growing, symptomatic, or ruptured IIAs are typically treated endovascularly or surgically, with recent studies favoring endovascular treatment. [ 1 ] Chun et al . proposed an algorithm in which endovascular management be pursued in ruptured IIAs in non-eloquent areas without evidence of hematoma.…”

“…proposed an algorithm in which endovascular treatment is preferred for management of small, distal IIAs with or without concurrent cardiovascular instability. [ 1 ] In this current case, endovascular treatment was chosen due to the distal location and small vessel size, as well as the patient’s poor clinical condition.…”

Characteristics and Outcomes of Left Ventricular-Assist Device-Associated Cerebrovascular Events in Setting of Infectious Intracranial Aneurysms

“…However, the authors comment that if the IIA enlarges, fails to resolve, or ruptures on medical management, the next recommendation is typically for neurosurgical or neuro-endovascular treatment [20]. Regarding surgical intervention, it has been shown that endovascular management is associated with easier access to distal locations, higher success in the treatment of multiple aneurysms and lower hemorrhagic risk compared to microsurgical craniotomies, and can potentially be performed under non-general anesthesia, an important consideration in cardiac patients [20][21][22]. In terms of embolization material, detachable coils or liquid embolization agents such as N-butyl cyanoacrylate, Onyx, or others have been used [21].…”

“…Regarding surgical intervention, it has been shown that endovascular management is associated with easier access to distal locations, higher success in the treatment of multiple aneurysms and lower hemorrhagic risk compared to microsurgical craniotomies, and can potentially be performed under non-general anesthesia, an important consideration in cardiac patients [20][21][22]. In terms of embolization material, detachable coils or liquid embolization agents such as N-butyl cyanoacrylate, Onyx, or others have been used [21]. The friability of the vessel walls and wide neck structure can make surgical techniques such as clipping difficult [23].…”

“…The friability of the vessel walls and wide neck structure can make surgical techniques such as clipping difficult [23]. Aneurysms that are associated with large IPH or mass effect are considered for further surgical intervention if the parent vessel supplies eloquent areas and revascularization is required to spare the distal arteries, or if endovascular intervention is not technically feasible [21,22]. As has been demonstrated in this review, while many patients may remain on long-term anti-microbial regimens indefinitely, some may undergo endovascular and surgical intervention for IIA-associated CVE.…”