Introduction Infectious intracranial aneurysms (IIAs) are rare complications of infective endocarditis or systemic infection. To date, data are limited regarding management as well as long-term outcomes of patients with ruptured or unruptured IIAs. We explored, at multicenter level, the presentation, technical and clinical outcomes of patients with IIAs management by conservative or surgical intervention.
Methods This is a multicenter retrospective study of patients presenting with IIAs between January 2016 and December 2022 at seven tertiary care centers in the United States. Medical record, procedure notes, and imaging findings were reviewed for demographics, aneurysm features, management and clinical and technical outcomes. Patients were managed either via sole medical management (MM) which included antibiotics and serial imaging, endovascular embolization and antibiotics, or open microsurgery and antibiotics. Technical outcome include aneurysm obliteration at follow-up vascular imaging, and primary clinical outcome was the modified Rankin Score (mRS) at 90 days dichotomized into good outcome (mRS 0-2) and poor outcome (mRS 3-6).
Results A total of 66 patients with 116 IIAs (Age: 42+/-17, 67% Males) were treated at all sites during the study period. Comorbid IE was present in 67%, and 12% had a Left Ventricular Assist Device. IIAs presented with rupture in 73% of cases, were discovered during stroke workup in 9%, or were incidentally discovered in 18%. Most IIAs (64%) were diagnosed with a cerebral angiogram, 30% with MR angiography, and 6% with CT angiography. Multiple aneurysms were detected in 36% of subjects. Aneurysms predominantly involved the M3/4 segment (62%), followed by M2 (9%), and A2/3 (8%) while 11% involved the posterior circulation (7% in P2/3). The average size of aneurysms was 4.2 mm +/- 3.5; 73% were less than 5mm in size while 7% were above 10 mm. Primary medical management was used in 63% of IIAs, of which 43% failed medical management with progression of aneurysm or rupture/re-rupture with average time to fail of 24+/- 23 days (42% within 2 weeks). Endovascular treatment was used in 22% of cases as primary treatment (36% as both primary and rescue of failed medical management), whereas open microsurgery was used as primary treatment in 14% of cases (21% as both primary and rescue of failed medical management). Recurrence or progression was noted in 12% of the endovascular group, and 4% of microsurgery group with average follow-up of 200 days. The overall 1-year mortality rate was 21%, and 48% had a mRS 0-2 at 90 days. Multivariate model for prediction of failure of MM, aneurysms with larger size (aOR=1.5,p=0.002) and posterior circulation aneurysms (aOR=6.9,p=0.001) were independent predictor of antibiotic failure. On multivariate logistic regression controlling for demographics, comorbidities, aneurysm size, location and morphology, and treatment group, predictors of 1-year mortality included failed medical management (aOR=6.1,p=.005), age (aOR=1.07,p<0.001), and black race (aOR=3.95,p=0.03).
Conclusion Patients with IIAs are at high risk of aneurysm rupture or re-hemorrhage despite treatment with antibiotics. Antibiotic failure occurred in 43% of medically treated patients, and failure was associated with 6 times higher odds of mortality in 1 year.
Disclosures A. Alawieh: None. L. Dimisko: None. Y. Zohdy: None. H. Saad: None. S. Newman: None. J. Grossberg: None. C. Cawley: None. G. Pradilla: None. C. Fox: None. C. Perez-Vaga: None. J. Burkhardt: None. M. Salem: None. P. Jabbour: None. K. El Naamani: None. R. Schmidt: None. M. Gooch: None. R. Starke: None. A. Abdelsalam: None. V. Lu: None. M. Levitt: None. A. Spiotta: None. V. Hertzberg: None. D. Barrow: None. B. Howard: None.
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