Treatment of mycotic intracranial aneurysms

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Abstract
Two patients with mycotic intracranial aneurysms were successfully treated with only antibiotic therapy. One patient, who had subacute bacterial endocarditis, rheumatic valvular disease and an abscessed tooth, sustained a subarachnoid hemorrhage from a ruptured right middle cerebral artery trifurcation aneurysm. The other patient, who had Turner''s syndrome and probable congenital aortic stenosis, developed multiple neurological findings during an episode of acute bacterial endocarditis precipitated by an infected ingrown toenail; a false aneurysm of the distal left middle cerebral artery and 2 lesions involving the left superior cerebellar artery were found. A study of the literature showed that only 45 patients with mycotic intracranial aneurysms received adequate antibiotic therapy and angiographic documentation. Statistically there does not appear to be a clear-cut advantage to antibiotics plus surgical therapy over antibiotics alone; in 21 patients who underwent serial angiography, lesions were smaller in 6 and not visualized in 11. In 4 patients the aneurysms increase in size; in 2 others fresh lesions formed. The following diagnostic and therapeutic regimen is proposed: the earliest possible diagnosis of the underlying disorder; appropriate antibiotic therapy; early 4-vessel cerebral angiography and follow-up studies every 2-3 wk; definitive surgery without delay if the aneurysm is larger on the 1st repeat study; definitive operation upon completion of antibiotic therapy if the lesion is larger or the same size; and postoperative angiography to evaluate the effectiveness of treatment and to search for interim lesions.