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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Andreou A, Ioannidis I, Mitsos A (2007) Endovascular treatment of peripheral intracranial aneurysms. AJNR Am J Neuroradiol 28(2):355–361
Asai T, Usui A, Miyachi S, Ueda Y (2002) Endovascular treatment for intracranial mycotic aneurysms prior to cardiac surgery. Eur J Cardiothorac Surg 21(5):948–950
Aspoas AR, de Villiers JC (1993) Bacterial intracranial aneurysms. Br J Neurosurg 7(4):367–376
Barrow DL, Prats AR (1990) Infectious intracranial aneurysms: comparison of groups with and without endocarditis. Neurosurgery 27(4):562–572, discussion 572–3
Bartakke S, Kabde U, Muranjan MN, Bavdekar SB (2002) Mycotic aneurysm: an uncommon cause for intra-cranial hemorrhage. Indian J Pediatr 69(10):905–907
Brust JC, Dickinson PC, Hughes JE, Holtzman RN (1990) The diagnosis and treatment of cerebral mycotic aneurysms. Ann Neurol 27(3):238–246
Chapot R, Houdart E, Saint-Maurice JP, Aymard A, Mounayer C, Lot G, Merland JJ (2002) Endovascular treatment of cerebral mycotic aneurysms. Radiology 222(2):389–396
Chun JY, Smith W, Halbach VV, Higashida RT, Wilson CB, Lawton MT (2001) Current multimodality management of infectious intracranial aneurysms. Neurosurgery 48(6):1203–1213, discussion 1213–4
Corr P, Wright M, Handler LC (1995) Endocarditis-related cerebral aneurysms: radiologic changes with treatment. AJNR Am J Neuroradiol 16(4):745–748
Dhomne S, Rao C, Shrivastava M, Sidhartha W, Limaye U (2008) Endovascular management of ruptured cerebral mycotic aneurysms. Br J Neurosurg 22(1):46–52
Erdogan HB, Erentug V, Bozbuga N, Goksedef D, Akinci E, Yakut C (2004) Endovascular treatment of intracerebral mycotic aneurysm before surgical treatment of infective endocarditis. Tex Heart Inst J 31(2):165–167
Frazee JG, Cahan LD, Winter J (1980) Bacterial intracranial aneurysms. J Neurosurg 53(5):633–641
Hara Y, Hosoda K, Wada T, Kimura H, Kohmura E (2006) Endovascular treatment for a unusually large mycotic aneurysm manifesting as intracerebral hemorrhage—case report. Neurol Med Chir (Tokyo) 46(11):544–547
Hung SC, Tai CT (1998) Infective endocarditis complicated with thalamic infarction and mycotic aneurysm rupture: a case report. Zhonghua Yi Xue Za Zhi (Taipei) 61(1):53–58
Kannoth S, Iyer R, Thomas SV, Furtado SV, Rajesh BJ, Kesavadas C, Radhakrishnan VV, Sarma PS (2007) Intracranial infectious aneurysm: presentation, management and outcome. J Neurol Sci 256(1–2):3–9
Kannoth S, Thomas SV (2009) Intracranial microbial aneurysm (infectious aneurysm): current options for diagnosis and management. Neurocrit Care 11:120–129
Kannoth S, Thomas SV, Nair S, Sarma PS (2008) Proposed diagnostic criteria for intracranial infectious aneurysms. J Neurol Neurosurg Psychiatry 79(8):943–946
Lin BH, Vieco PT (1995) Intracranial mycotic aneurysm in a patient with endocarditis caused by Cardiobacterium hominis. Can Assoc Radiol J 46(1):40–42
Luders JC, Steinmetz MP, Mayberg MR (2005) Awake craniotomy for microsurgical obliteration of mycotic aneurysms: technical report of three cases. Neurosurgery 56(1 Suppl):E201, discussion E201
Mahadevan A, Tagore R, Siddappa NB, Santosh V, Yasha TC, Ranga U, Chandramouli BA, Shankar SK (2008) Giant serpentine aneurysm of vertebrobasilar artery mimicking dolichoectasia—an unusual complication of pediatric AIDS. Report of a case with review of the literature. Clin Neuropathol 27(1):37–52
Mincheff TV, Cooler AW (2008) Ruptured mycotic aneurysm presenting initially with bacterial meningitis. Am Surg 74(1):73–75
Misser SK, Lalloo S, Ponnusamy S (2005) Intracranial mycotic aneurysm due to infective endocarditis—successful NBCA glue embolisation. S Afr Med J 95(6):397–399, 403–4
Modi G, Ranchod K, Modi M, Mochan A (2008) Human immunodeficiency virus associated intracranial aneurysms: report of three adult patients with an overview of the literature. J Neurol Neurosurg Psychiatry 79(1):44–46
Monsuez JJ, Vittecoq D, Rosenbaum A, Goujon C, Wolff M, Witchitz S, Modai J (1989) Prognosis of ruptured intracranial mycotic aneurysms: a review of 12 cases. Eur Heart J 10(9):821–825
Morawetz RB, Karp RB (1984) Evolution and resolution of intracranial bacterial (mycotic) aneurysms. Neurosurgery 15(1):43–49
Nakahara I, Taha MM, Higashi T, Iwamuro Y, Iwaasa M, Watanabe Y, Tsunetoshi K, Munemitsu T (2006) Different modalities of treatment of intracranial mycotic aneurysms: report of 4 cases. Surg Neurol 66(4):405–409, discussion 409–10
Oohara K, Yamazaki T, Kanou H, Kobayashi A (1998) Infective endocarditis complicated by mycotic cerebral aneurysm: two case reports of women in the peripartum period. Eur J Cardiothorac Surg 14(5):533–535
Peters PJ, Harrison T, Lennox JL (2006) A dangerous dilemma: management of infectious intracranial aneurysms complicating endocarditis. Lancet Infect Dis 6(11):742–748
Phuong LK, Link M, Wijdicks E (2002) Management of intracranial infectious aneurysms: a series of 16 cases. Neurosurgery 51(5):1145–1151, discussion 1151–2
Piastra M, Chiaretti A, Tortorolo L (2000) Ruptured intracranial mycotic aneurysm presenting as cerebral haemorrhage in an infant: case report and review of the literature. Childs Nerv Syst 16(3):190–193
Powell S, Rijhsinghani A (1997) Ruptured bacterial intracranial aneurysm in pregnancy. A case report. J Reprod Med 42(7):455–458
Quah BS, Selladurai BM, Jayakumar CR, Mahendra Raj S (1993) Left ventricular outflow tract (LVOT) vegetations and spontaneous obliteration of a large ruptured intracranial mycotic aneurysm in a case of infective endocarditis. Singapore Med J 34(2):172–174
Salgado AV, Furlan AJ, Keys TF (1987) Mycotic aneurysm, subarachnoid hemorrhage, and indications for cerebral angiography in infective endocarditis. Stroke 18(6):1057–1060
Scotti G, Li MH, Righi C, Simionato F, Rocca A (1996) Endovascular treatment of bacterial intracranial aneurysms. Neuroradiology 38(2):186–189
Subramaniam S, Puetz V, Dzialowski I, Barber PA (2006) Cerebral microhemorrhages in a patient with mycotic aneurysm: relevance of T2-GRE imaging in SBE. Neurology 67(9):1697
Sugg RM, Weir R, Vollmer DG, Cacayorin ED (2006) Cerebral mycotic aneurysms treated with a neuroform stent: technical case report. Neurosurgery 58(2):E381, discussion E381
Trivedi MP, Carroll C, Rutherford S (2008) Infective endocarditis complicated by rupture of intracranial mycotic aneurysm during pregnancy. Int J Obstet Anesth 17(2):182–187
Tunkel AR, Kaye D (1993) Neurologic complications of infective endocarditis. Neurol Clin 11(2):419–440
Venger BH, Aldama AE (1988) Mycotic vasculitis with repeated intracranial aneurysmal hemorrhage. Case report. J Neurosurg 69(5):775–779
Venkatesh SK, Phadke RV, Kalode RR, Kumar S, Jain VK (2000) Intracranial infective aneurysms presenting with haemorrhage: an analysis of angiographic findings, management and outcome. Clin Radiol 55(12):946–953
Wajnberg E, Rueda F, Marchiori E, Gasparetto EL (2008) Endovascular treatment for intracranial infectious aneurysms. Arq Neuropsiquiatr 66(4):790–794
Yen PS, Teo BT, Chen SC, Chiu TL (2007) Endovascular treatment for bilateral mycotic intracavernous carotid aneurysms. Case report and review of the literature. J Neurosurg 107(4):868–872
Yoon JO (2006) Not just an aneurysm, but an infected one: a case report and literature. J Vasc Nurs 24(1):2–8, quiz 9–10
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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, 37–46 (2010). https://doi.org/10.1007/s10143-009-0233-1
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DOI: https://doi.org/10.1007/s10143-009-0233-1