Intracranial infectious aneurysms a comprehensive

Authors: Andrew F Ducruet Zachary L Hickman Brad E Zacharia Reshma Narula Bartosz T Grobelny Justin Gorski E Sander Connolly

Publish Date: 2009/10/16

Volume: 33, Issue: 1, Pages: 37-

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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 populationbased 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 lifethreatening cerebrovascular lesions and further prospective studies are warranted to define outcome following both conservative and surgical or endovascular treatmentIn this wellwritten 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 decisionmaking process on any specific case is complex and definite treatment recommendations are not easily providedIn 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 endtoend anastomosis is a reasonable strategy In very distal small cortical vessels in noneloquent 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 dissectionIn 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 aneurysmsThe 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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