Endovascular Therapy for Mycotic Aneurysms

Infectious intracranial aneurysms (IIA) [also known as mycotic aneurysms] comprise ~0.7-5.4% of all intracranial aneurysms.  There are currently no standardized treatment protocols.  A recent article from the Journal of Stroke and Cerebrovascular Diseases presented a case series of IIAs managed by coil embolization.

IIAs are commonly located on the peripheral branches of MCA.  [see Figure below]

1-s2.0-S1052305715006588-yjscd2391-fig-0001 (1)

Diagnoses:

  • Concurrent systemic infection
    • headache, fever, ?neurological deficit
    • symptoms of heart failure
  • Echocardiography
    • impaired LV ejection fraction
    • valvular abnormalities (i.e. MR)
    • vegetations
  • Blood culture growth
  • CT head, CT angio, MRI, MRA
    • unusually distal location of aneurysm on neuroimaging
    • may present with ICH, SAH, or cerebral infarction

 

Possible outcomes:

  • spontaneous resolution, diminished size or thrombosis
  • growth and rupture

Treatment:  

  • conservative treatment with antibiotics for nonruptured, small, minimally symptomatic aneurysms, repeat angio at a later date to document resolution
  • curative treatment for ruptured, symptomatic or enlarging IIAs
    • Mainstay of treatment is surgical – for ruptured IIAs in unstable patients, or failed endovascular therapy
      • microsurgical  neck clipping
      • excision of aneurysm
      • trapping +/- bypass surgery
    • endovascular therapy – should be first line? for ruptured IIAs in clinically stable patients

 

Endovasclar Therapy of IIAs:

  • endocarditis treated with antibiotics for a few weeks
  • Once infection is cleared, endovascular therapy is performed under GA
    • IV heparin to aPTT 2x control
    • 6 – or 7- Fr guiding catheter placed via R femoral artery
    • microcatheter advanced until neck of aneurysm is reached
    • optional [parent artery occlusion to see if any neurological deficit is induced]
    • embolization:
      • parent artery occlusion with occlusion of IIA [Guglielmi detachable coils was used in the study; onyx, n-butyl 2-cyanoacrylate or stents were not used]
      • aneurysm obliteration

Advantage of Endovascular coiling:  

  • most distal MCA aneurysms are located deep in the cortex, with SAH or ICH – difficult to locate aneurysm intraoperatively
  • safer for deep aneurysms or aneurysms in eloquent areas
  • shorter anesthetic time [for patients with multiple comorbidities]

Disadvantages of Endovascular Coiling:

  • cannot assess elevated ICP

 

 

References

Nonaka, Senshu et al. “Endovascular Therapy For Infectious Intracranial Aneurysm: A Report Of Four Cases”. Journal of Stroke and Cerebrovascular Diseases (2015): n. pag. Web. 19 Jan. 2016.

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