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.