Key result
Preoperative intracranial aneurysm intervention is linked to ~93% lower hemorrhage and death before cardiac surgery.
Why the study?
Does preoperative intervention for infectious intracranial aneurysms reduce mortality and intracranial hemorrhage in patients with infective endocarditis undergoing cardiac surgery?
Cohort (n=40)
No
Does preoperative intervention for infectious intracranial aneurysms reduce mortality and intracranial hemorrhage in patients with infective endocarditis undergoing cardiac surgery?
Absolute Event Rate: 3.3% vs 50%
Securing infectious intracranial aneurysms prior to cardiac surgery, primarily via endovascular therapy, significantly reduces the risk of intracranial hemorrhage and mortality associated with postoperative anticoagulation.
Objective To retrospectively study the features and outcomes of infectious intracranial aneurysms (IIA) related to infective endocarditis (IE) and explore optimized management strategies. Methods cases of IE with IIAs admitted to our hospital between October 2018 and July 2024 were reviewed for demographic, clinical, and radiographic variables. Outcomes, including mortality and neurological complications, were analyzed. Results A total of 40 cases with 53 IIAs were identified. Twenty-five (63%) patients experienced intracranial hemorrhage (ICH) due to IIA rupture, resulting in 5 deaths (13% of all IIA patients, 20% of those with ruptures). ICH occurred in 10% (4/40), 22% (8/36), 33% (7/21) and 46% (6/13) of the unsecured patients before, during the first 2 weeks, in the 3rd-4th week, and after 4 weeks of antibiotic therapy, respectively. Thirty patients underwent intervention before cardiac surgery, with only 3% (1/30) experiencing new onset ICH and death. In contrast, among the 10 cases without preoperative intervention, 50% (5/10) developed new onset ICH during postoperative anticoagulation, resulting in 4 deaths. Craniotomy was utilized as salvage in 3 cases, 1 was successful, 1 had an IIA recurrence requiring additional endovascular intervention, and 1 resulted in death. Endovascular therapy served as the primary approach for 11 cases and as salvage for 20 cases with antibiotic or surgical failure. The median time interval between endovascular therapy and cardiac surgery was 1.5 days, with 10 patients undergoing one-stage hybrid surgery. Only 3% (1/31) patient who received endovascular therapy experienced IIA rupture and death postoperatively. Seven patients received antibiotic therapy alone, with only 4 (10%, 4/40) achieving cure. The remaining 3 were provided with palliative care due to massive ICH and poor prognosis. Conclusion IIAs are associated with high mortality, especially when ruptured. Given the significant risk of treatment failure with antibiotic therapy alone, more aggressive management strategies are warranted. Anticoagulation therapy further heightens the risk of IIA rupture, making it advisable to secure IIAs prior to cardiac surgery. Endovascular therapy has proven to be both safe and effective, allowing for the initiation of anticoagulation therapy immediately post-intervention. Thus, endovascular therapy may be considered the first-line choice for managing IIAs in patients with IE.
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Qing et al. (2025) conducted a cohort in Infectious intracranial aneurysms related to infective endocarditis (n=40). Preoperative intervention (endovascular therapy or craniotomy) vs. No preoperative intervention was evaluated on New onset intracranial hemorrhage and death. Preoperative intervention for infectious intracranial aneurysms before cardiac surgery was associated with a 3% rate of new-onset intracranial hemorrhage and death, compared to 50% without intervention.
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