Management of infectious intracranial aneurysms: a systematic review and network meta-analysis

Infectious intracranial aneurysms (IIAs) are highly morbid vascular lesions, and the comparative effectiveness of medical management (MM), surgery, and endovascular treatment (EVT) remains uncertain.

To perform a systematic review and network meta-analysis comparing the three main interventions for IIAs: MM, open surgery, and EVT.

A systematic review and frequentist network meta-analysis were conducted. Studies comparing MM, open surgery, and EVT in patients with IIAs were included. The primary outcome was treatment success, defined according to study-specific definitions and operationally harmonized as the absence of treatment failure. Secondary outcomes included mortality, rupture or re-rupture, recurrence, neurological deficits, and complications. Random-effects models estimated odds ratios (ORs) with 95% confidence intervals (CIs). Treatment ranking was assessed using P scores, and heterogeneity was quantified using I².

Thirteen observational studies were included. In an exploratory network meta-analysis, both EVT (OR=2.51; 95% CI 1.22 to 5.15) and surgery (OR=7.29; 95% CI 2.00 to 26.55) were associated with higher odds of treatment success compared with MM. EVT was associated with a lower risk of aneurysm rupture or re-rupture compared with MM (OR=0.42; 95% CI 0.18 to 0.96), whereas no statistically significant differences were observed between EVT and surgery. Given the non-randomized nature of the evidence and methodological heterogeneity across studies, these findings should be interpreted with caution.

EVT and surgery were associated with higher odds of treatment success compared with MM, whereas EVT was additionally associated with a lower risk of rupture or re-rupture. These findings should be interpreted cautiously given the observational nature of the available evidence.