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Endovascular treatment of infectious intracranial aneurysms

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Abstract

Infectious intracranial aneurysms (IIA) are rare but a considerable source of morbidity and mortality as a result of rupture. Most patients with these lesions have considerable medical comorbidities, making endovascular approaches a crucial modality in their treatment armamentarium. Contributing our own case, we performed a comprehensive review of the literature to illustrate overall results and outcomes for patients with IIA treated with endovascular approaches. Incorporating our own case, we found 65 patients harboring 72 IIA across 31 reports. Fifty-one were treated via parent artery occlusion (71 %), 17 via direct aneurysm embolization (24 %), two via stent-coiling (3 %), and two with stent monotherapy (3 %). Twenty-nine IIAs were treated with n‐butylcyanoacrylate (NBCA) (40 %), 25 with coils (35 %), seven with Onyx or ethylene vinyl alcohol (10 %), five with detachable balloons (7 %), four with stents (6 %), and one with autologous clot (1 %). One case of incomplete aneurysm occlusion and two cases of recanalization were reported. Six symptomatic periprocedural ischemic events were reported (9 %), with only three resulting in permanent sequelae (5 %). No infectious complications were reported. Incorporating the natural history of the disease, 28 patients were neurologically intact (43 %), while seven had died at the time of follow-up (11 %). Endovascular treatment of ruptured, symptomatic, or enlarging IIA is an excellent treatment modality with high occlusion rates and low procedure-related complication rates. Distal IIA are more often treated with parent artery occlusion, in our hands, preferentially with Onyx, while proximal lesions may be treated with direct stent-coiling or even flow-diverting stent monotherapy.

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Author information

Authors and Affiliations

  1. Department of Neurological Surgery, Brigham and Women’s Hospital and Harvard Medical School, 75 Francis St, Boston, MA, 02115, USA

    Bradley A. Gross

  2. Department of Radiology, Brigham and Women’s Hospital and Harvard Medical School, Boston, MA, 02115, USA

    Ajit S. Puri

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Comments

Ketan R. Bulsara and Ryan Grant, New Haven, Connecticut

Thank you for the opportunity to comment on this paper. We congratulate Dr. Gross and Dr. Puri on a very well-written paper that summarizes the literature on the endovascular treatment of intracranial aneurysms. Having said that, endovascular treatment of these aneurysms is not a novel concept and has been present since at least 1989. Thus, it is not surprising that the authors only found 31 reports pertaining to 65 patients. This does not speak to the rarity of the aneurysms, but rather that there is very little new information to report about these patients.

Due to the work of our pioneers, the face of cerebrovascular neurosurgery is very different today. We are no longer in a situation where we can only offer one treatment modality for this potentially devastating pathology. The vast majority of these aneurysms will be treated through endovascular means. The outcome is better. In our generation, however, it is almost mandatory that cerebrovascular centers have proficiency in microsurgery, skull base approaches, and endovascular neurosurgery either in a single individual or in a multidisciplinary fashion. By doing so, as the authors allude, we can continue to optimize our patient outcomes by tailoring patient specific care.

Andrew F. Ducruet, Phoenix, Arizona, USA

The authors have contributed an extremely well-written systematic review of the endovascular treatment of intracranial infectious aneurysms (IIA). This represents a timely publication on an under-reported topic that stands to rapidly evolve with the continued development of endovascular technology. The lack of observed infectious complications associated with endovascular treatment of IIAs, including the few reports of stent-assisted reconstructive techniques, is particularly intriguing. It is important to remember, as acknowledged by the authors in their discussion, that a definitive understanding of the outcomes associated with endovascular treatment of IIAs awaits larger series with longer follow-up intervals.

Ralph W. König, Germany

This is a comprehensive review highlightening the different aspects of endovascular treatment of a rare vascular disease: Infectious Intracranial Aneurysms (IIA). The manuscript describes a total number of 72 IIAs in 65 patients. The literature assembled comprises manuscripts published between 1980 and 2012 and therefore reflects the ongoing progress in endovascular techniques from parent vessel occlusion with detachable balloons to vessel preserving techniques like flow diversion.

Nowadays in most IIAs (ruptured, symptomatic or growing) endovascular techniques are considered as treatment of choice due to the accompanying medical problems of those critically ill patients (sepsis, septic endocarditis). But microsurgical treatment should never be neglected especially in those cases with associated intracerebral hematoma (69% of ruptured IIAs in that series).

Simplistically two different types of IIAs exist requiring different techniques of treatment:

Cavernous ICA-Aneurysms (13%), mostly due to contiguous spread as a result of cavernous sinus thrombophlebitis or meningitis: there is some tendency towards vessel preserving techniques rather than parent vessel occlusion. Coiling, stent assisted coiling or flow diverters become more and more common in those aneurysms.

Distally located MCA (46%) or PCA aneurysms (26%) mainly due to septic emboli: These atypically located aneurysms can be treated very elegantly by selective occlusion of the aneurysm or distal parent vessel occlusion with ethylene vinyl alcohol or Onyx.

This review confirms the safety and efficacy of endovascular treatment in patients with IIAs. But due to the diversity of those infectious aneurysms different endovascular techniques have to be tailored to the individual patient and nevertheless microsurgical options should not be neglected.

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Gross, B.A., Puri, A.S. Endovascular treatment of infectious intracranial aneurysms. Neurosurg Rev 36, 11–19 (2013). https://doi.org/10.1007/s10143-012-0414-1

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