Interventional vs Medical Management of Infectious Intracranial Aneurysms

P. Ricardo Pereira; Ocílio Ribeiro Gonçalves; Rafael Reis de Oliveira; Kaike Eduardo da Silva Lobo; Gabriel Caruso Novaes Tudella; Paweł Marek Łajczak; Guilherme Gonzaga de Menezes Souza; Iago Nathan Simon Petry; João Vítor Andrade Fernandes; Irving Gabriel Calisaya-Madariaga; Luis Felipe Vieira Nunes Porto; IZABELY DOS REIS DE PAULA; Julia Sader Neves Ferreira; Laiz Barros Cavalcanti; Leonardo Bastos Santos; ROBSON SANTOS LUZ FILHO; Erwah Kalsoum; Christopher S. Ogilvy; Adam Andrea Dmytriw; Frédéric Clarençon; Luca Scarcia · American Journal of Neuroradiology (2026) · DOI: 10.3174/ajnr.a9337

Resumen

BACKGROUND: Infectious intracranial aneurysms (IIAs) are rare vascular lesions carrying high risks of rupture, intracranial hemorrhage, and mortality. Their low incidence and the absence of randomized controlled trials leave the optimal management strategy uncertain. PURPOSE: The purpose was to systematically review and synthesize comparative observational evidence on interventional (surgical or endovascular) vs medical management of IIAs. DATA SOURCES: PubMed, Embase, and the Cochrane Library were searched from inception to August 4, 2025, using controlled vocabulary and free-text terms. Reference lists of relevant reviews and included articles were manually screened. STUDY SELECTION: Comparative observational cohort studies reporting outcomes between at least 1 interventional strategy (surgical or endovascular) and medical management alone in patients with IIAs were included. Case reports, small case series without a comparator group, conference abstracts, and review articles were excluded. DATA ANALYSIS: statistic. Sensitivity analyses were conducted using leave-1-out methods. Risk of bias was assessed with the Risk Of Bias In Non-randomized Studies of Interventions (ROBINS-I) tool; certainty of evidence was evaluated using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) framework. DATA SYNTHESIS: Thirteen retrospective observational studies (748 patients) were included. Interventional management was associated with higher treatment success (RR 1.36; 95% CI, 1.13-1.65), lower mortality (RR 0.56; 0.36-0.88), fewer overall complications (RR 0.28; 0.13-0.59), and lower rupture/rerupture risk (RR 0.42; 0.22-0.79). Recurrence, aneurysm enlargement, and permanent neurologic deficits were infrequently reported and characterized by substantial imprecision. Most studies carried moderate or serious risk of bias, primarily due to confounding and nonrandomized treatment allocation. LIMITATIONS: All included studies were retrospective and nonrandomized, with substantial confounding by indication. Individual-patient data were unavailable, precluding adjusted or subgroup analyses. Outcome definitions and follow-up durations were inconsistently reported across studies. Publication bias cannot be excluded. CONCLUSIONS: In observational cohorts, interventional management of IIAs was consistently associated with more favorable short-term clinical and angiographic outcomes compared with medical management alone. However, substantial risk of bias and confounding by indication limit these findings, which do not support causal inference and should be regarded as hypothesis generating.

Instituciones: Universidad Peruana Cayetano Heredia