Septic complications after cardiac catheterization and percutaneous transluminal coronary angioplasty

Septic complications after cardiac catheterization and percutaneous transluminal coronary artery angioplasty are distinctly uncommon. However, we have recently treated nine patients with sepsis and life-threatening complications after cardiac catheterization alone or after catheterization and subsequent percutaneous transluminal coronary angioplasty. The common denominator in all patients was either repeat puncturing of the ipsilateral femoral artery or leaving the femoral artery sheath in for 1 to 5 days after the procedure. Two patients died as a direct result of their septic complications. One death occurred in a patient in whom bacterial endocarditis with congestive heart failure developed, and the other patient had a large retroperitoneal hematoma that became secondarily infected. Infected aneurysms that were successfully treated developed in three patients. Our study suggests that colonization of the needle tract by skin flora predisposes to septic complications if repeat arterial punctures are required or if a femoral artery sheath is left in place for more than 24 hours. Patients in whom sepsis develops after these procedures should be initially treated with antibiotics effective against gram-positive organisms. CT scanning or angiography should be considered for patients with persistent sepsis, septic emboli, and abdominal or flank pain. Infected aneurysms require resection or ligation because of the propensity of these aneurysms to rupture.     

Incidence and outcome of radial artery infections following cardiac surgery

BACKGROUND: Radial artery infections secondary to catheterization for blood pressure monitoring are rare but potentially serious complications. The objective of the study was to evaluate the incidence, the risk factors and the evolution of radial artery infections following cardiac surgery. METHODS: A retrospective review of 8300 patients undergoing cardiac surgery between 1998 and 2002 at the Montreal Heart Institute (MHI) was undertaken. All patients with superficial radial artery infections, infected radial artery pseudoaneurysms, and arterial catheter-related bacteremia were considered using prospective global surveillance of all nosocomial infections over the study period by an infection control nurse. RESULTS: Thirteen patients with radial infections were encountered (0.2%) with bacteremia occurring in 9 patients (0.15%). Five patients developed infected radial artery pseudoaneurysms (0.05%) and 5 patients developed subsequent sternal wound infections. Two patients died in their early postoperative evolution. Mean patient age was 67 years old and mean duration of cannulation was 5.8 days. Only 1 patient had diabetes. Seven of 13 patients were positive for Staphylococcus aureus (54%). All patients had undergone cardiopulmonary bypass (CPB) for various procedures. All superficial infections responded well to antibiotic therapy. Early surgical intervention is essential in cases of infected radial artery pseudoaneurysms. CONCLUSIONS: The postoperative state and cardiopulmonary bypass put patients at risk for infectious complications. Strict systematic changing of arterial lines on a timely basis is unwarranted in our opinion. A high suspicion index, aggressive surgical treatment of bacterial arteritis and appropriate intravenous antibiotics are essential to improve the prognosis.     

Surgical treatment for primary infected aneurysm of the descending thoracic aorta,abdominal aorta,and iliac arteries

OBJECTIVE AND METHOD: In this retrospective review, we report the surgical results of infected aortic aneurysms treated at a single center over 5 years. RESULTS: From October 1996 to October 2001, 19 patients with infected aortic aneurysm were treated with surgery, nine with suprarenal infections (four proximal descending thoracic aortic aneurysms, two distal descending thoracic aortic aneurysms, and three suprarenal abdominal aortic aneurysms) and 10 with infrarenal infections (eight infrarenal abdominal aortic aneurysms and two iliac artery aneurysms). All had a positive blood or tissue culture; 89% were febrile, 89% had leukocytosis, and 32% were hemodynamically unstable. The most common responsible pathogens were Salmonella organisms (74%) followed by Streptococcus species (11%). Nine of 10 infrarenal infections were caused by Salmonella organisms. Both infrarenal and suprarenal infections were treated with wide débridement of infected aorta, in situ prosthetic graft or patch repair, and prolonged intravenous antibiotics. Hospital survival rate was 95%: 100% for infrarenal and 89% for suprarenal infections. There was no perioperative intestinal ischemia or perioperative limb loss. Acute renal failure occurred in two patients with suprarenal infection. Late deaths have occurred in three patients with one early graft infection (5%) resulting in the only one in-hospital death at 4 months. Sixteen patients remain alive at mean follow-up of 17.8 months (range, 4-47 months). There have been no late aortic or graft infections. During the same period, there were five unoperated patients, four of whom died of shock during hospitalization. CONCLUSIONS: Infected aortic aneurysm is common in Taiwan, and Salmonella species were the most common responsible microorganisms. With surgical intervention and prolonged intravenous antibiotics, in situ graft replacement provided a good outcome. The incidence of prosthetic graft infection was low, even in patients with infections due to Salmonella species and with in situ graft replacement.     

Gram-negative bacterial infection of aortic aneurysms

Widespread use of antibiotics and change in pathogenesis altered the bacteriology of infected aortic aneurysms. In the past, bacterial endocarditis was the major source of emboli infecting the aorta. Now, gram-negative sepsis in elderly patients is often the initiating event of infection in atherosclerotic aneurysms. Four cases of gram-negative infection in aortic aneurysms were treated. The etiology, presentation, and surgical management are reviewed. Three abdominal aortic aneurysms were infected during urinary tract sepsis and one infection occurred with Salmonella septicemia. The clinical triad of fever, abdominal pain, and a pulsatile abdominal mass led to a preoperative diagnosis in three of four patients. Debridement of infected tissue and bypass through non-infected tissue planes remain the cornerstones of modern surgical management. Despite prompt diagnosis and proper surgical management, the mortality of gram-negative aortic infection remains high because of early rupture and extensive atherosclerotic disease.     

Cerebral revascularization using radial artery grafts for the treatment of complex intracranial aneurysms: techniques and outcomes for 17 patients

OBJECTIVE: The goal of this report is to illustrate the use of radial artery grafts as bypass conduits in the management of complex intracranial aneurysms and to describe a new "pressure distension technique" to eliminate postoperative vasospasm, which was a common problem early in our experience. METHODS: This study included a series of 17 patients who were surgically treated between 1994 and January 2001 for complex intracranial aneurysms. Five patients were surgically treated without the pressure distension technique; for 12 patients, the technique was used to reduce postoperative vasospasm. Fourteen of the patients had anterior circulation aneurysms, and three had posterior circulation aneurysms. Five of the patients had undergone previous attempts at direct clipping or excision and reconstruction of the aneurysm in question, and embolization had been performed for one patient with a carotid-cavernous fistula. Thirteen patients underwent permanent revascularization combined with proximal occlusion, trapping, or clipping, and four patients underwent temporary revascularization for cerebral protection during anticipated prolonged occlusion of the parent vessel during aneurysm dissection. Surgical techniques are described, with particular reference to vessel collection and bypass techniques. RESULTS: The outcomes for this group of patients, considering the complexity of the aneurysms and their "inoperability," with respect to direct clipping, were satisfactory. The aneurysms were completely obliterated for all patients, and the grafts were patent for all except one patient on postoperative angiograms. There were two deaths, one attributable to systemic sepsis and the other attributable to cardiac arrest during a transbronchial biopsy. The postoperative Glasgow Outcome Scale scores were either better or the same for all other patients, compared with their preoperative scores. Three of the five patients treated before the institution of the pressure distension technique experienced vasospasm of the graft, with two of those patients requiring angioplasty. For one of those patients, angioplasty led to rupture of the graft. Vasospasm was not observed for any of the 12 patients for whom the pressure distension technique was used. We observed no morbidity related to radial artery collection. CONCLUSION: Revascularization techniques are occasionally necessary for the surgical treatment of complicated intracranial aneurysms. The merits of the use of the radial artery as a bypass conduit are discussed. Radial artery grafts should be considered as alternatives to saphenous vein and superficial temporal artery grafts. The problem of vasospasm of the artery has been solved with the pressure distention technique.     

Arteritis due to Salmonella with aneurysm formation: two cases.

Although arterial infection due to Salmonella is rare, it remains one of the most common causes of primary mycotic aneurysms. The presentation is one of sepsis, cultures positive for Salmonella and rapid expansion or rupture of the aneurysm. The authors' experience at Victoria Hospital, London, Ont., includes two cases of aneurysms infected with Salmonella--one aneurysm of the aorta and the other of the common femoral artery. Both patients were treated by excision of the aneurysm, extra-anatomic reconstruction in an area remote from the infected field and long-term administration of appropriate antibiotics. One patient was alive and well 36 months after resection. The other died of multiple organ failure 10 days after resection. From a review of the English and French literature since 1948, 64 cases of abdominal aortic aneurysms infected with Salmonella were found; half of the patients survived the perioperative period. The diagnosis of mycotic aneurysm must be considered in any patient with an aneurysm and culture specimens positive for Salmonella. The authors favour wide débridement of the infected aneurysm with extra-anatomic reconstruction. This view is supported by a review of the literature. The appropriate antibiotic therapy is bactericidal rather than bacteriostatic.     

Arterial Infections in the New Millenium: An Old Problem Revisited

The natural history of infected aneurysms or arterial infections is characterized by rapid expansion leading to rupture, pseudoaneurysm formation, and sepsis. Treatment options include in situ grafting either with prosthetic or autogenous grafts or with cryopreserved allografts (CPAs), resection of the aneurysm with remote bypass grafting, and ligation. The purpose of this study was to review our recent experience with these infections and to present long-term follow-up with in situ CPAs. From January 2000 through June 2005, we treated nine patients with infected aneurysms and one patient with an infection without aneurysm formation. The infection involved the infrarenal abdominal aorta in six patients and the femoral artery in three patients. One patient had an infected splenic artery aneurysm. Aortic rupture occurred in five of the six patients with infected aortas. Two of the three patients with infected femoral aneurysms presented with recurrent hemorrhage. Of the six patients with aortic infections, five were treated with in situ CPAs. One patient was treated with aortic resection and axillofemoral grafting. Two patients with femoral aneurysms were treated with in situ CPAs, and the third patient underwent aneurysm resection and prosthetic grafting through the obturator foramen. The patient with the splenic aneurysm underwent combined valve replacement, aneurysm resection, and splenectomy. Three of the six patients with aortic infections died postoperatively, all of whom were septic at presentation. The cause of death in these three patients was multiple organ failure in two and overwhelming sepsis in one. The three survivors are alive and well with up to 5-year follow-up. The three patients with infected femoral aneurysms are alive and well with follow-up extending to 44 months. The patient with the splenic aneurysm is doing well. No recurrent infections have been noted among the survivors. The CPAs have remained structurally intact in all. The mortality rate among patients with abdominal aortic infections remains high and is likely related to their preoperative septic state. In situ grafting with CPAs appears to be a reasonable treatment option for arterial infections. CPAs appear to maintain their structural integrity and to be resistant to recurrent infection.     

Treatment of infected abdominal aneurysms by extraanatomic bypass, aneurysm excision, and drainage

Five patients with infected abdominal aortoiliac aneurysms were treated. The diagnosis was made preoperatively based upon fever, leukocytosis, positive blood culture findings, and presence of an aneurysm in all five patients. Two patients had salmonella species, two had staphylococcus species, and one had bacteroides species cultured from the blood and aneurysm contents. All patients were treated with appropriate antibiotics and a single operative procedure consisting of preliminary extraanatomic bypass followed by complete aneurysm excision and posterior drainage of the retroperitoneum. There were no operative deaths and no instances of aortic stump disruption, persistent retroperitoneal sepsis, or graft thrombosis. All patients were alive and well on last follow-up 15 months to 5 years postoperatively.     

Ruptured pseudoaneurysm complicating an infected radial artery catheter: case report and review of the literature

The authors present the 16th case of a pseudoaneurysm forming at the site of an infected radial artery catheter and only the third case that presented with rupture and hemorrhage requiring emergent operative repair. Radial artery catheters are quite safe, and most infections can be treated effectively with line removal and intravenous antibiotics. However, two factors correlate strongly with the subsequent development of pseudoaneurysms. Infection with Staphylococcus aureus was seen in 15 of 16 cases, and persistent signs of infection lasting more than 48 hours after the institution of antibiotic therapy and line removal were seen in 16 of 16 cases. Therefore, patients with S. aureus radial artery line infections with persistence of infection more than 48 hours after the induction of treatment are at high risk and should be observed closely for signs of pseudoaneurysm formation. Once a pseudoaneurysm has formed, surgical repair is required. Most recommend ligating the artery if there is pulsatile backbleeding from the distal stump and Allen's test shows good perfusion of the hand by the ulnar artery.     

Long-term patency of radial artery graft bypass for reconstruction of the internal carotid artery. Technical note

Reconstruction of the carotid artery by using a radial artery graft is a useful option that can produce reliable long-term patency for the surgical treatment of giant and/or large aneurysms of the cavernous and paraclinoid internal carotid artery (ICA). During the past 10 years, 43 patients with intracavernous and paraclinoid giant aneurysms of the ICA have been treated by reconstruction of the ICA with radial artery grafts after ligation of the cervical ICA. The long-term patency of the grafted radial artery was evaluated over more than a 5-year period (mean 7.2 years) in 20 of these patients by using magnetic resonance angiography or conventional angiography. There was no late occlusion of the graft in any of these cases. Stenotic graft changes were observed in two cases.     

Resolution of a recurrent/residual bacterial aneurysm during antibiotic therapy

Management of patients harboring infectious intracranial aneurysms remains controversial because of the technical problems associated with the obliteration of these lesions as well as their frequent regression during antibiotic therapy. A case of a ruptured bacterial aneurysm of the distal middle cerebral artery in which a segment of the artery was found to be inflamed and necrotic is presented. The ruptured portion of the sac was clipped, leaving a small tag of aneurysmal tissue. Five days later, this tag was found to have expanded into a second aneurysm. This second lesion resolved with antibiotic therapy. Because of the responsiveness of infected cerebral arteries to the appropriate antibiotics, a less than radical surgical tactic may be a successful alternative to excision of the diseased arterial segment followed by distal revascularization in treating these lesions.     

经微导管送入国产钨丝微螺旋圈治疗颅内囊状动脉瘤

报告１０例颅内囊状动脉瘤，其中后交通动脉瘤４例，前交通动脉瘤４例，大脑中动脉瘤１例，基底动脉分叉部动脉瘤１例，均行血管内治疗，应用自制钨丝螺旋圈闭塞动脉瘤，保持载瘤动脉通畅，全部治愈。     

Subclavian artery aneurysms

We report the management of 14 subclavian artery aneurysms (13 true, one false) occurring in seven male and seven female patients (average age, 48 years). The aetiology of the aneurysms included thoracic outlet syndrome in eight, atherosclerosis in five and infection in one patient. Twelve aneurysms were of extrathoracic location, while two aneurysms were intrathoracic. Symptoms related to subclavian artery aneurysms were present in 11 patients (compression in four, haemorrhage in one, and ischaemia in six patients), whereas three aneurysms were asymptomatic. All aneurysms were treated surgically. The supraclavicular approach was used in 11 cases, and the combined transsternal and supraclavicular approach was used in two cases. After aneurysm resection, the reconstruction was performed with end-to-end anastomosis in five cases and with saphenous vein or synthetic grafts in eight cases. One infected subclavian artery aneurysm was treated with carotid to axillary saphenous vein bypass after exclusion of the aneurysm. Five associated brachial embolectomies and one bypass from the axillary to the distal brachial artery were performed. In all thoracic outlet syndrome cases, decompression at the thoracic outlet was also performed. There was no operative mortality, and the early patency rate was 100%. The follow-up period was from 6 months to 10 years (mean, 3.92 years). During this period, one patient died of malignancy and one patient required reoperation due to aneurysmal degeneration of the saphenous vein graft. Surgical treatment is recommended for all patients with subclavian artery aneurysms to prevent potential complications.     

大脑中动脉巨大型动脉瘤的手术治疗

目的 探讨大脑中动脉巨大型动脉瘤的手术治疗方法.方法 回顾性分析2001年1月至2008年3月17例颅内大脑中动脉巨大型动脉瘤患者的手术方法和疗效.术前采用CT、CTA、MR、MRA、DSA及三维DSA检查,以了解动脉瘤的部位、大小,形状以及侧支代偿情况,制定个体化治疗方案.在手术入路上多采用改良翼点入路,其中行动脉瘤瘤颈直接或塑形夹闭者4例,动脉瘤孤立或孤立后切除4例,动脉瘤切除或孤立后血管重建7例,动脉瘤包裹2例.结果 CT和MRI能清楚地显示动脉瘤的形状、大小.DSA及三维DSA能显示瘤颈以及与附近血管和骨质的关系.根据格拉斯骨预后评分表评分,出院时恢复优良者12例,中度病残4例,重度病残1例,无死亡病例.结论 术前有必要进行详细的影像学检查,有助于术者规划手术方法,制定个体化治疗方案,采用不同术式取得良好预后.载瘤动脉暂时性阻断、动脉瘤切开血栓清除均有助于瘤颈夹闭.血管重建技术为大脑中动脉巨大型动脉瘤的手术治疗开辟了新途径,明显改善了手术效果.     

Infected femorodistal bypass: is graft removal mandatory?

Infected lower extremity bypass grafts have been associated with high rates of limb loss. Traditionally treatment has included graft excision. To compare aggressive local treatment, without graft removal, with more conventional graft excision, we reviewed 38 consecutive patients with 39 infected lower extremity bypasses treated during the last 10 years. The grafts used were prosthetic in 33 cases, vein in 4, and composite in 2. Median follow-up was 2.7 years. Twenty-eight infected grafts were treated with either complete (14) or partial (14) graft removal. Nine new grafts were placed. Recurrent infection developed in five cases, and two patients died of complications of graft infection. Ten of 20 limbs at risk were lost. Eleven patients with patent bypasses (4 vein, 2 composite, 5 prosthetic) were treated without graft excision. Treatment of five patients in this group included muscle transposition. Five patients were treated with incision and drainage of abscesses, and one had excision of a persistent sinus tract. One patient underwent major amputation 6.3 years after treatment of graft infection. Limb salvage was significantly higher (p = 0.012, log-rank test) than in patients treated with graft excision. One patient died, and no recurrent infections developed; these were not significant differences compared with those having graft excision. We conclude that aggressive local treatment of infected lower extremity bypass grafts, including drainage, debridement, and muscle transposition may treat infection in selected patients without the need for graft removal and with rates of limb salvage superior to those obtained with excisional therapy.     

大脑前动脉近端动脉瘤的显微外科治疗

目的探讨大脑前动脉近端动脉瘤(A1动脉瘤)的临床特征及外科手术技巧。方法1995年6月～2003年12月间共治疗颅内动脉瘤患者362例,其中A1动脉瘤占2．2％(8例),对A1动脉瘤患者的临床资料进行回顾性分析。结果所有动脉瘤均位于A1穿动脉的起始部,起源于内侧远端纹状体动脉的3例,内侧近端纹状体动脉的5例。术中发现后方指向的6例,下方指向的2例。8个动脉瘤均为囊性动脉瘤,其中6例为小动脉瘤,平均直径6．9mm。全组动脉瘤经手术夹闭,患者预后优7例,良1例。结论手术治疗A1动脉瘤保护A1穿动脉和选用合适的瘤夹是预防缺血性并发症的关键。     

Management of true aneurysms distal to the axillary artery

Objective: To delineate management strategies and outcomes for true aneurysms involving arteries of the upper extremity distal to the axillary artery. The management of these rare lesions has not been well established in the literature. Methods: Retrospective chart review was performed at tertiary referral centers. All patients who received the diagnosis of true upper extremity aneurysms distal to the axillary artery between 1975 and 1995 were included in the review. Nineteen patients were found; seven were excluded because no confirmatory diagnostic imaging study or operative exploration was performed. This represents the largest reported series of true upper extremity arterial aneurysms. Results: Twelve patients (9 men or boys) had 12 confirmed true aneurysms of the brachial or more distal arteries. The average diameters were as follows: brachial artery 4.6 cm, radial artery 2.0 cm, ulnar artery 1.4 cm, and digital artery 0.8 cm. The mean age was 51 years (range, 10 to 86 years). The most common presentation was the presence of a mass. This occurred among eight patients (67%). Four patients (33%) reported pain or paresthesia. One patient (8%) had cold intolerance only. Three patients (25%) had thromboembolic complications. Complications did not consistently correlate with size or presence of intramural thrombus. Three aneurysms (25%) were initially managed nonoperatively and followed for a mean period of 71 months. One of these required operative repair after 5 months because of progressive pain. Ten patients (83%) were treated surgically as follows: five underwent ligation and excision only, and five underwent excision and revascularization. Morbidity was minimal, and there were no perioperative deaths. Conclusion: True arterial aneurysms of the upper extremity distal to the axillary artery are rare and most commonly caused by blunt trauma. Fifty-eight percent of these lesions present with symptoms or complications. Thirty-three percent of asymptomatic lesions later become symptomatic. These factors combined with the minimal morbidity associated with repair suggest that operative repair should be routinely performed for these aneurysms. Revascularization can be performed selectively. (J Vasc Surg 1998;28:606-10.)     

Nonoperative management of visceral aneurysms and pseudoaneurysms.

During the period from 1975 to 1991, 41 patients with 60 visceral artery aneurysms were treated at the Affiliated Hospitals of Emory University. The total included 13 patients in whom 16 aneurysms were treated primarily by transarterial embolization. There were seven hepatic artery aneurysms, three splenic artery aneurysms, three gastroduodenal artery aneurysms, two left gastric artery aneurysms, and one right gastroepiploic artery aneurysm. Average age of these patients was 50 years; there were eight males and five females. Seven patients presented with gastrointestinal bleeding, and two patients presented with abdominal pain. In four patients, the aneurysm was an incidental finding. Etiology of the true or false aneurysms consisted of pancreatitis in two patients, trauma in three patients, connective tissue disease in one, and was unknown in the remainder. Embolization was performed in seven cases with Gianturco coils and Gelfoam, with coils alone in four, with Gelfoam alone in four, and with detachable balloons in one instance. Complete occlusion was achieved initially in 13 cases. Recanalization occurred in two patients over a mean follow-up period of 8.6 months, requiring re-embolization in one patient, whereas the other patient was managed expectantly. In three cases, embolization was unsuccessful: two cases required surgical correction, and one case was managed expectantly. Only one complication was related to the embolization procedure, which was a common hepatic arterial dissection that proceeded to the formation of a false aneurysm. Embolization as the primary treatment modality for visceral artery aneurysms should be considered in patients with the following diagnoses: pseudoaneurysms associated with pancreatitis, intrahepatic aneurysms, most splenic artery aneurysms, and gastric, gastroduodenal, and gastroepiploic aneurysms. The procedure has a low risk and may obviate a difficult surgical procedure, but it does not preclude surgical intervention should the need arise.     

Non-activated autologous platelet-rich plasma for the prevention of inguinal wound-related complications after endovascular repair of abdominal aortic aneurysms

The endovascular repair (EVAR) of abdominal aortic aneurysms (AAAs) usually involves the surgical exposure and catheterization of the femoral arteries. Several inguinal surgical wound-related complications have been reported postoperatively. The aim of this report was to evaluate the safety and efficacy of intraoperative application of autologous platelet-rich plasma (PRP) for the prevention of wound-related complications in AAA EVAR. The authors conducted a patient- and assessor-blinded controlled trial involving 100 subjects undergoing EVAR of an AAA. PRP was produced using an autologous platelet separator and was applied, without prior thrombin activation, in 50 patients eligible for inclusion. The results were compared with a control group of 50 patients who underwent AAA EVAR within the same time period. The primary outcome was the difference in postoperative hospital stay. Secondary outcomes included subjective assessment of wound healing and wound-related complications. Age, sex, and other comorbidities related to wound healing were not significantly different between cases and controls. One patient treated with PRP developed a unilateral wound infection with lymphorrhea, and two patients developed a bi-lateral superficial infection. Twelve patients within the control group developed a wound-related complication. The postoperative hospitalization was significantly lower in the PRP group. The overall surgical wound-related complications rate was also significantly lower in the PRP group. Application of non-thrombin-activated PRP seems to prevent major postoperative wound-related complications (p = .026) and shorten postoperative hospital stay duration after femoral artery exposure and catheterization for AAA EVAR (mean, 4.48 +/- 0.48 vs. 6.14 +/- 0.39 days).     

Current multimodality management of infectious intracranial aneurysms

OBJECTIVE: To implement an algorithm for and assess multimodality (medical, endovascular, and microsurgical) treatment of patients with infectious intracranial aneurysms. METHODS: Twenty patients with 27 infectious aneurysms were treated during a 10-year period. Bacterial endocarditis was the most common cause (65%). Most aneurysms presented with rupture (75%), and the middle cerebral artery was the most common location (70%). RESULTS: Five patients were treated endovascularly, with direct coiling for three patients and parent artery occlusion for two patients. Ten patients (15 aneurysms) were treated surgically, with 6 aneurysms being trapped/resected, 2 trapped/bypassed, 4 clipped, and 3 wrapped. Five patients were treated medically. Treatment-associated neurological morbidity was observed for two patients (10%), and two patients died (10%). Good outcomes were observed for 16 patients (80%). CONCLUSION: Factors that guide management decisions for these patients include aneurysm rupture, hematomas with increased intracranial pressure, and the eloquence of brain tissue supplied by the parent artery. Patients with unruptured infectious aneurysms are initially treated medically, with antibiotics and serial angiography. Patients with ruptured aneurysms that are not associated with hematomas and that do not involve eloquent vascular territory are treated endovascularly. Patients with ruptured aneurysms are treated surgically when there is a hematoma or the risk of ischemic complications in eloquent territory. Therefore, endovascular therapy is the first option for patients in stable condition with ruptured aneurysms; surgical therapy is the first option for patients in unstable condition with ruptured aneurysms and the second option for patients in stable condition who experience failure of endovascular therapy. Medically treated patients with enlarging or dynamic unruptured aneurysms also require direct surgical or endovascular intervention. Favorable patient outcomes can be achieved with this multimodality management.