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Intracranial infectious aneurysms: a comprehensive review

Abstract

Intracranial infectious aneurysms, or mycotic aneurysms, are rare infectious cerebrovascular lesions which arise through microbial infection of the cerebral arterial wall. Due to the rarity of these lesions, the variability in their clinical presentations, and the lack of population-based epidemiological data, there is no widely accepted management methodology. We undertook a comprehensive literature search using the OVID gateway of the MEDLINE database (1950–2009) using the following keywords (singly and in combination): “infectious,” “mycotic,” “cerebral aneurysm,” and “intracranial aneurysm.” We identified 27 published clinical series describing a total of 287 patients in the English literature that presented demographic and clinical data regarding presentation, treatment, and outcome of patients with mycotic aneurysms. We then synthesized the available data into a combined cohort to more closely estimate the true demographic and clinical characteristics of this disease. We follow by presenting a comprehensive review of mycotic aneurysms, highlighting current treatment paradigms. The literature supports the administration of antibiotics in conjunction with surgical or endovascular intervention depending on the character and location of the aneurysm, as well as the clinical status of the patient. Mycotic aneurysms comprise an important subtype of potentially life-threatening cerebrovascular lesions, and further prospective studies are warranted to define outcome following both conservative and surgical or endovascular treatment.

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Correspondence to Andrew F. Ducruet.

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Comments

Saleem I. Abdulrauf, St. Louis, MO, USA

In this well-written report, Ducruet et al. provide a comprehensive review of the current literature regarding intracranial infectious aneurysms and their management strategies. As this article illustrates well, there is a paucity of data in the literature regarding this disease, and clearly, there are no prospective trials looking at the natural history of these types of aneurysms. Therefore, the decision-making process on any specific case is complex, and definite treatment recommendations are not easily provided.

In my opinion, given the presumed high risk of rupture of intracranial infectious (II) aneurysms, treatment needs to be instituted immediately. In otherwise healthy patients who can tolerate open surgical procedures, I would recommend, in addition to antibiotic treatment, microsurgical clipping/reconstruction/occlusion of the aneurysm. In general, these aneurysms tend to be very friable and tend to circumferentially involve the vessel in a fusiform pattern. They normally involve distal vessels. The aim ought to be to preserve the distal territory, if possible. So, if the sacrifice of the vessel is needed to completely obliterate the aneurysm, and if there is enough length of vessel available, then resection of the small aneurysm followed by end-to-end anastomosis is a reasonable strategy. In very distal small cortical vessels in non-eloquent areas, sacrifice of the vessel may be well tolerated. Since these aneurysms tend to involve distal vessels within the gyri, I would recommend the use of image guidance to minimize the size of the craniotomy and to decrease the amount of dissection.

In those patients who cannot tolerate open microsurgical intervention or those patients requiring immediate cardiothoracic surgical intervention for valve replacement, endovascular treatment ought to be the treatment of choice, especially in patients who present with symptomatic/ruptured aneurysms.

I commend the authors for providing this detailed literature review.

Massimo Collice, Milan, Italy

The authors have provided a thorough and practical review of intracranial infection aneurysms. The article does not add significant information on the natural history of these vascular lesions which remain undefined. However, considering the rarity of the disease, I believe that most neurosurgeons may gain advantage from the article in their clinical practice. The clinical management of patients harboring such lesions, suggested by the authors and likely followed by most, seems to be supported by available data in the literature and not only based on intuitive considerations. As to repair modality (surgical or endovascular), if the parent artery is a distal branch my personal view is that endovascular occlusion of aneurysm or parent vessel is the first therapeutic option.

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Ducruet, A.F., Hickman, Z.L., Zacharia, B.E. et al. Intracranial infectious aneurysms: a comprehensive review. Neurosurg Rev 33, 37 (2010). https://doi.org/10.1007/s10143-009-0233-1

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  • DOI: https://doi.org/10.1007/s10143-009-0233-1

Keywords

  • Aneurysm
  • Endovascular
  • Intracranial
  • Infectious
  • Mycotic aneurysm
  • Subarachnoid hemorrhage