Introduction Infectious intracranial aneurysms (IIAs) are a rare complication of infective endocarditis as well as systemic and intracranial infections. Outcome and management of IIAs in the pediatric population remain under-investigated, with insufficient management guidelines. In this work, we perform a systematic review and pooled analysis of published series of IIAs in the pediatric population with respect to presentation, management strategy, technical success, and outcomes.

Methods A systematic review of IIAs in pediatric populations was performed in accordance with the PRISMA guidelines. Publications in MEDLINE, SCOPUS, or Web of Science that included references to ‘Infectious Aneurysms’ or ‘Mycotic aneurysms’ were reviewed and screened for the presence of pediatric patients. Individual data were curated from the original literature and analyzed using univariate and multivariate analysis.

Results A total of 2548 publications were screened, of which 76 studies included at least one pediatric patient with IIAs. A total of 150 patients (191 IIAs) were reviewed with median age of 11, and 15% were infants (< 2 years old). The most common predisposing factor was meningitis/CNS infections in infants compared to infective endocarditis in older children (> 2 years old, p<0.05). Among reported cases, Staphylococcus Aureus was the most common pathogen (15%); 61% presented with rupture, 18% had multiple aneurysms, and 5% had concurrent infarcts from septic emboli. The MCA (50% of IIAs) was the most common location, while 18% occurred in the posterior circulation. The average size of reported aneurysms was 13.8mm (+/- 7). Medical management (antibiotics and serial imaging) was used as a primary treatment in 71% of cases (68% of ruptured IIAs) and as the only treatment in 41% of IIAs. The antibiotic failure rate (IIA progression, re-hemorrhage, or need for delayed surgery) was 48% of all IIAs (50% of ruptured). There was no difference in failure rate of medical management or mortality between the different pediatric age groups. Open microsurgical management was used in 43% of cases (20% as primary approach and 23% as rescue for medical failure). Endovascular management was used in 18% of cases (9% as primary and 9% as rescue treatment). Investigating the trend in management over time was notable for a significant decrease in the rate of primary medical management from 50-60% before 1990 to 30% after 2010, with an increase in rate of endovascular management from 0% before 1990 to 35% after 2010. This correlated with significant improvement in 1-year survival rate from 56% by 1990 to 88% after 2010. The 1-year mortality rate was highest for medically managed children (25%) compared to endovascular (10%) and open microsurgical treatment (9%).

Conclusions Management of pediatric infectious aneurysms has shifted over the past two decades with an increased preference toward early aneurysm securement via open or endovascular approaches with concurrent improvement in overall survival. Medical management alone (antibiotics) is associated with a relatively high failure rate and the need for delayed surgical or endovascular intervention secondary to aneurysm progression or re-rupture.

Disclosures R. El Annan: None. J. Assi: None. Y. Zohdy: None. L. Dimisko: None. J. Grossberg: None. D. Barrow: None. C. Cawley: None. A. Reisner: None. J. Chern: None. G. Pradilla: None. T. Garzon-Muvdi: None. B. Howard: None. A. Alawieh: None.