Clinical characteristics and treatment of infectious intracranial aneurysm related to infective endocarditis_Chinese Journal of Clinical Thoracic and Cardiovascular Surgery

Authors：

QING Hongkun ¹ , WANG Weiteng ² , CHEN Fanyu ¹ , GAN Lixi ¹ , YE Lanxin ¹ , CHEN Oudi ³ ,  CHEN Guangzhong ⁴ ,  JIAN Xuhua ¹

1. Department of Cardiac Surgery, Guangdong Cardiovascular Institute, Guangdong Provincial People’s Hospital (Guangdong Academy of Medical Sciences), Southern Medical University, Guangzhou, 510010, P. R. China;
2. Beijing Key Laboratory of Preclinical Research and Evaluation for Cardiovascular Implant Materials, Animal Experimental Centre, National Centre for Cardiovascular Disease, Department of Cardiac Surgery, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100730, P. R. China;
3. Department of Echocardiography, Guangdong Cardiovascular Institute, Guangdong Provincial People’s Hospital (Guangdong Academy of Medical Sciences), Southern Medical University, Guangzhou, 510010, P. R. China;
4. Department of Neurosurgery, Guangdong Provincial People’s Hospital (Guangdong Academy of Medical Sciences), Southern Medical University, Guangzhou, 510010, P. R. China;

Corresponding author：

CHEN Guangzhong, Email: chenguangzhong@gdph.org.cn; JIAN Xuhua, Email: jianxuhua@gdph.org.cn

Keywords：

Infective endocarditis; infectious intracranial aneurysm; intracranial hemorrhage; endovascular therapy

DOI：

10.7507/1007-4848.202312001

Video：

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Objective To summarize the clinical features of infectious intracranial aneurysm (IIA) related to infective endocarditis (IE) and share our experiences in the diagnosis and treatment of IIA. Methods A retrospective analysis was conducted on the clinical data of 554 patients who underwent cardiac surgery for IE at the Department of Cardiac Surgery, Guangdong Provincial People's Hospital from September 2018 to August 2023. Patients with secondary IIA were included and reviewed. Based on the treatment strategies, patients were stratified into two groups: an antibiotic-only group and an endovascular treatment group. Results The cohort comprised 21 males and 10 females, with a median age of 33 years (IQR 26-53). Fifteen (48.4%) patients showed no significant neurological symptoms before IIA diagnosis. Seven patients received antibiotic therapy alone, while 24 underwent additional endovascular embolization, achieving technical success in 23 (95.8%) patients. The median interval between endovascular embolization and cardiac surgery was 2 days (IQR 0-6), with 9 patients undergoing concurrent procedures. In the antibiotic-only group, 3 (42.9%) patients suffered fatal IIA rupture. In contrast, only 1 (4.2%) death due to aneurysm rupture occurred in the endovascular treatment group. All surviving patients recovered well without new neurological deficits. Conclusion Routine neuroimaging screening for IIA is critical in IE patients. For those requiring cardiac surgery, endovascular embolization combined with antimicrobial therapy represents a reasonable strategy to mitigate rupture risks and improve outcomes.

1.	Delgado V, Ajmone Marsan N, de Waha S, et al. 2023 ESC guidelines for the management of endocarditis. Eur Heart J, 2023, 44(39): 3948-4042.
2.	Hui FK, Bain M, Obuchowski NA, et al. Mycotic aneurysm detection rates with cerebral angiography in patients with infective endocarditis. J Neurointerv Surg, 2015, 7(6): 449-452.
3.	Peters PJ, Harrison T, Lennox JL. A dangerous dilemma: Management of infectious intracranial aneurysms complicating endocarditis. Lancet Infect Dis, 2006, 6(11): 742-748.
4.	Alawieh A, Chaudry MI, Turner RD, et al. Infectious intracranial aneurysms: A systematic review of epidemiology, management, and outcomes. J Neurointerv Surg, 2018, 10(7): 708-716.
5.	Li JS, Sexton DJ, Mick N, et al. Proposed modifications to the Duke criteria for the diagnosis of infective endocarditis. Clin Infect Dis, 2000, 30(4): 633-638.
6.	Church W. Aneurysm of the right cerebral artery in a boy of thirteen. Trans Path Soc Lond, 1869, 20: 109.
7.	Stengel A, Wolferth CC. Mycotic (bacterial) aneurysms of intravascular origin. Arch Intern Med (Chic), 1923, 31(4): 527-554.
8.	Ares WJ, Cabrera EA, Desai S, et al. Intravenous drug use is novel predictor of infectious intracranial aneurysms in patients with infective endocarditis. World Neurosurg, 2018, 118: e813-e817.
9.	Ragulojan R, Grupke S, Fraser JF. Systematic review of endovascular, surgical, and conservative options for infectious intracranial aneurysms and cardiac considerations. J Stroke Cerebrovasc Dis, 2019, 28(3): 838-844.
10.	Rice CJ, Cho SM, Marquardt RJ, et al. Clinical course of infectious intracranial aneurysm undergoing antibiotic treatment. J Neurol Sci, 2019, 403: 50-55.
11.	Ducruet AF, Hickman ZL, Zacharia BE, et al. Intracranial infectious aneurysms: A comprehensive review. Neurosurg Rev, 2010, 33(1): 37-46.
12.	Tunkel AR, Kaye D. Neurologic complications of infective endocarditis. Neurol Clin, 1993, 11(2): 419-440.
13.	中华医学会胸心血管外科分会瓣膜病外科学组. 感染性心内膜炎外科治疗中国专家共识. 中华胸心血管外科杂志, 2022, 38(3): 146-155.Group of Valve Surgery, Chinses Society for Thoracic and Cardiovascular Surgery. Chinese expert consensus on surgical treatment of infective endocarditis. Chin J Thorac Cardiovasc Surg, 2022, 38(3): 146-155.
14.	Kume Y, Fujita T, Fukushima S, et al. Intracranial mycotic aneurysm is associated with cerebral bleeding post-valve surgery for infective endocarditis. Interact Cardiovasc Thorac Surg, 2018, 27(5): 635-641.
15.	Park W, Ahn JS, Park JC, et al. Treatment strategy based on experience of treating intracranial infectious aneurysms. World Neurosurg, 2017, 97: 351-359.
16.	Batista S, Oliveira LB, Filho JAA, et al. Endovascular treatment of mycotic aneurysms: An update meta-analysis. Clin Neurol Neurosurg, 2024, 236: 108068.
17.	Alawieh AM, Dimisko L, Newman S, et al. Management and long-term outcomes of patients with infectious intracranial aneurysms. Neurosurgery, 2023, 92(3): 515-523.
18.	Serrano F, Guédon A, Saint-Maurice JP, et al. Endovascular treatment of infectious intracranial aneurysms complicating infective endocarditis: A series of 31 patients with 55 aneurysms. Neuroradiology, 2022, 64(2): 353-360.
19.	Petr O, Brinjikji W, Burrows AM, et al. Safety and efficacy of endovascular treatment for intracranial infectious aneurysms: A systematic review and meta-analysis. J Neuroradiol, 2016, 43(5): 309-316.
20.	Kannoth S, Thomas SV. Intracranial microbial aneurysm (infectious aneurysm): Current options for diagnosis and management. Neurocrit Care, 2009, 11(1): 120-129.

1. Delgado V, Ajmone Marsan N, de Waha S, et al. 2023 ESC guidelines for the management of endocarditis. Eur Heart J, 2023, 44(39): 3948-4042.
2. Hui FK, Bain M, Obuchowski NA, et al. Mycotic aneurysm detection rates with cerebral angiography in patients with infective endocarditis. J Neurointerv Surg, 2015, 7(6): 449-452.
3. Peters PJ, Harrison T, Lennox JL. A dangerous dilemma: Management of infectious intracranial aneurysms complicating endocarditis. Lancet Infect Dis, 2006, 6(11): 742-748.
4. Alawieh A, Chaudry MI, Turner RD, et al. Infectious intracranial aneurysms: A systematic review of epidemiology, management, and outcomes. J Neurointerv Surg, 2018, 10(7): 708-716.
5. Li JS, Sexton DJ, Mick N, et al. Proposed modifications to the Duke criteria for the diagnosis of infective endocarditis. Clin Infect Dis, 2000, 30(4): 633-638.
6. Church W. Aneurysm of the right cerebral artery in a boy of thirteen. Trans Path Soc Lond, 1869, 20: 109.
7. Stengel A, Wolferth CC. Mycotic (bacterial) aneurysms of intravascular origin. Arch Intern Med (Chic), 1923, 31(4): 527-554.
8. Ares WJ, Cabrera EA, Desai S, et al. Intravenous drug use is novel predictor of infectious intracranial aneurysms in patients with infective endocarditis. World Neurosurg, 2018, 118: e813-e817.
9. Ragulojan R, Grupke S, Fraser JF. Systematic review of endovascular, surgical, and conservative options for infectious intracranial aneurysms and cardiac considerations. J Stroke Cerebrovasc Dis, 2019, 28(3): 838-844.
10. Rice CJ, Cho SM, Marquardt RJ, et al. Clinical course of infectious intracranial aneurysm undergoing antibiotic treatment. J Neurol Sci, 2019, 403: 50-55.
11. Ducruet AF, Hickman ZL, Zacharia BE, et al. Intracranial infectious aneurysms: A comprehensive review. Neurosurg Rev, 2010, 33(1): 37-46.
12. Tunkel AR, Kaye D. Neurologic complications of infective endocarditis. Neurol Clin, 1993, 11(2): 419-440.
13. 中华医学会胸心血管外科分会瓣膜病外科学组. 感染性心内膜炎外科治疗中国专家共识. 中华胸心血管外科杂志, 2022, 38(3): 146-155.Group of Valve Surgery, Chinses Society for Thoracic and Cardiovascular Surgery. Chinese expert consensus on surgical treatment of infective endocarditis. Chin J Thorac Cardiovasc Surg, 2022, 38(3): 146-155.
14. Kume Y, Fujita T, Fukushima S, et al. Intracranial mycotic aneurysm is associated with cerebral bleeding post-valve surgery for infective endocarditis. Interact Cardiovasc Thorac Surg, 2018, 27(5): 635-641.
15. Park W, Ahn JS, Park JC, et al. Treatment strategy based on experience of treating intracranial infectious aneurysms. World Neurosurg, 2017, 97: 351-359.
16. Batista S, Oliveira LB, Filho JAA, et al. Endovascular treatment of mycotic aneurysms: An update meta-analysis. Clin Neurol Neurosurg, 2024, 236: 108068.
17. Alawieh AM, Dimisko L, Newman S, et al. Management and long-term outcomes of patients with infectious intracranial aneurysms. Neurosurgery, 2023, 92(3): 515-523.
18. Serrano F, Guédon A, Saint-Maurice JP, et al. Endovascular treatment of infectious intracranial aneurysms complicating infective endocarditis: A series of 31 patients with 55 aneurysms. Neuroradiology, 2022, 64(2): 353-360.
19. Petr O, Brinjikji W, Burrows AM, et al. Safety and efficacy of endovascular treatment for intracranial infectious aneurysms: A systematic review and meta-analysis. J Neuroradiol, 2016, 43(5): 309-316.
20. Kannoth S, Thomas SV. Intracranial microbial aneurysm (infectious aneurysm): Current options for diagnosis and management. Neurocrit Care, 2009, 11(1): 120-129.

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