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 int racranial aneurysms. METHODS: Twenty patients with 27 infectious aneurysms were treated during a 10-year period. Bacterial endocarditis was the most common cause (65%). Mo st aneurysms presented with rupture (75%), and the middle cerebral artery w as 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/rese cted, 2 trapped/bypassed, 4 clipped, and 3 wrapped. Five patients were trea ted medically. Treatment-associated neurological morbidity was observed for two patients (10%), and two patients died (10%). Good outcomes were observ ed for 16 patients (80%). CONCLUSION: Factors that guide management decisions for these patients incl ude aneurysm rupture, hematomas with increased intracranial pressure, and t he eloquence of brain tissue supplied by the parent artery. Patients with u nruptured infectious aneurysms are initially treated medically, with antibi otics and serial angiography. Patients with ruptured aneurysms that are not associated with hematomas and that do not involve eloquent vascular territ ory are treated endovascularly. Patients with ruptured aneurysms are treate d 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 aneur ysms 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 endovascula r intervention. Favorable patient outcomes can be achieved with this multim odality management.