Abstract
BACKGROUND: Infectious intracranial aneurysms (IIAs) are highly morbid vascular lesions, and the comparative effectiveness of medical management (MM), surgery, and endovascular treatment (EVT) remains uncertain.
OBJECTIVE: To perform a systematic review and network meta-analysis comparing the three main interventions for IIAs: MM, open surgery, and EVT.
METHODS: 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.
RESULTS: 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.
CONCLUSIONS: 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.