Endovascular Treatment for Unruptured Mycotic Aneurysms: A Systematic Review and Meta-Analysis

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While the majority of research has focused on ruptured MAs, the role of endovascular treatment (EVT) in managing unruptured cases remains unclear. Given the limited availability of data specific to unruptured MAs, we conducted a systematic review and meta-analysis to evaluate the outcomes of EVT in this subgroup, with a focus on technical success, follow-up occlusion, complications, functional outcomes, and mortality. Methods: A comprehensive literature search was conducted in PubMed, EMBASE, and Web of Science to identify studies reporting outcomes of EVT in unruptured MAs. Screening and full-text review were performed via Rayyan AI, and data extraction was conducted via Microsoft Excel. We included studies that explicitly reported outcomes for unruptured cases, and a proportional meta-analysis was performed via a random-effects model in R 4.4.2, with publication bias assessed via a funnel plot. Results: A total of eight studies with 43 unruptured mycotic aneurysms met the inclusion criteria. EVT demonstrated excellent procedural success, whereas endovascular procedures achieved universal technical success and complete occlusion at follow-up (both 100%; 95% CI: 95–100%). Complications were rare, occurring in only 4% of the patients (95% CI: 0–17%). The functional outcomes were favorable, with 90% of patients achieving mRS 0 or GOS 5 at follow-up (95% CI: 74–100%), indicating a high likelihood of preserved neurological function posttreatment. No mortality was reported among the unruptured patients (0%, 95% CI: 0–13%), further supporting the safety profile of EVT in this patient population. Conclusion: EVT appears to be a safe and effective treatment for unruptured mycotic aneurysms, with high technical and angiographic success rates, low complication rates, and favorable functional outcomes. However, data on unruptured cases remain scarce, as most of the available literature has focused primarily on ruptured MAs. This underscores the need for larger studies and prospective data collection to better define the role of EVT in managing these rare lesions. Mycotic aneurysm Infected aneurysm Endovascular aneurysm repair Stent Antibiotics Figures Figure 1 Figure 2 Figure 3 Figure 4 Figure 5 Figure 6 Figure 7 Figure 8 Figure 9 Figure 10 Figure 11 Figure 12 Figure 13 Introduction 1.1 Epidemiology, etiology and pathogenesis Mycotic aneurysms (MAs) are rare but life-threatening vascular complications resulting from infectious processes that are often linked to conditions such as infective endocarditis (IE). The incidence of mycotic aneurysms is relatively low, constituting less than 0.7–6.5% of all intracranial aneurysms; however, their potential for rapid growth and rupture makes them a critical medical concern [ 1 ]. Unruptured cases may be underdiagnosed because of their usual asymptomatic nature or nonspecific neurological symptom presentation [ 2 ]. Intracranial MAs are often small (< 5 mm), are distally located, and are prone to multiplicity and rupture [ 3 ]. MAs have a significant risk of rupture, especially intracranial ruptures, with 16.4% rupturing within a median of 3 days after diagnosis [ 4 ]. In MAs, septic emboli from IE disseminate via the bloodstream and lodge in the vasa vasorum, inducing an inflammatory response that leads to arterial wall degradation and aneurysm formation [ 5 ]. MAs can occur in various locations, with the femoral artery and abdominal aorta being the most common. Etiologies include trauma, septic emboli, and idiopathic emboli. Staphylococcus aureus and Salmonella are frequently isolated pathogens [ 6 ]. Symptoms vary widely and include sepsis, chest pain, and intraperitoneal bleeding [ 7 ]. MAs have complex pathogenesis and can develop through direct infection of the arterial wall or via the vasa vasorum [ 8 ]. Three main infection sources have been identified: neighboring infections, embolic transfer from endocarditis, and bloodstream dissemination from known or unknown sources known as "cryptogenic mycotic aneurysms" [ 9 ]. Risk factors include atherosclerosis and immunosuppression. Mycotic aneurysms often present diagnostic challenges due to nonspecific symptoms and a lack of clear diagnostic criteria [ 10 ]. 1.2 Role of antibiotics and EVT in the treatment of mycotic aneurysms The treatment options in MAs include antibiotics alone or in combination with endovascular or surgical interventions. Endovascular treatment (EVT) has shown high technical success and aneurysm occlusion rates, with few complications [ 11 ]. The clinical course of MAs can be dynamic, with only approximately 25% resolving with antibiotics alone [ 12 ]. However, in unruptured MAs, antibiotic treatment alone may have similar outcomes to invasive treatments [ 13 ]. Saccular morphology may predict unfavorable outcomes, whereas longer antibiotic exposure before MA discovery is associated with better outcomes [ 12 ]. Surgical intervention is recommended for ruptured MAs and may be considered for unruptured MAs, depending on the patient's condition [ 14 – 15 ]. Angiographic follow-up is crucial, as MAs can enlarge or rupture during antibiotic treatment [ 12 , 13 ]. Endovascular embolization using coils or liquid embolic agents has demonstrated high occlusion rates and low procedural complications, even in critically ill patients [ 16 ]. Early detection through neurological examination, CT, and angiography in endocarditis patients with neurological abnormalities is recommended [ 15 ]. The optimal treatment strategy remains unclear, highlighting the need for further research in this area. Methods Literature search A systematic review and meta-analysis were conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines [ 17 , 18 ]. PubMed, EMBASE, and Web of Science were searched from inception to January 2025, without language restrictions. To ensure maximum sensitivity, various search terms were used: “Intracranial Aneurysm,” “Cerebral Aneurysm,” “Mycotic Aneurysm,” “Infectious Aneurysm,” “Bacterial Aneurysm,” “Antibiotics,” “Antimicrobial Therapy,” “Medical Management,” “Endovascular Treatment,” “Embolization,” and “EVT”. Studies were included if they explicitly reported outcomes for unruptured mycotic aneurysms treated with EVT with or without antibiotics. Systematic reviews, meta-analyses, case reports, and studies without outcome data specific to unruptured MAs were excluded. The screening and full-text review were conducted via Rayyan AI, and data extraction was performed via Microsoft Excel. The reference lists of all included studies were screened to identify additional relevant articles. The final selection included seven studies with 43 unruptured mycotic aneurysms for proportional meta-analysis. Study selection : Following deduplication, a total of 446 records were identified through systematic searches across PubMed, EMBASE, and Web of Science. Title and abstract screening was conducted via Rayyan AI by two independent reviewers, with any conflicts resolved through discussion with a third reviewer. After the initial screening, 27 full-text articles were retrieved and assessed for eligibility. Of these, 10 were excluded for reporting on the wrong population—primarily studies that included only ruptured aneurysms or did not stratify outcomes by rupture status—and 10 were excluded for reporting the wrong outcomes, such as lacking information specific to unruptured aneurysm outcomes or failing to specify which outcomes pertained to unruptured cases. A total of seven studies met the inclusion criteria and were included in the final review and meta-analysis. Eligible studies included patients with unruptured intracranial mycotic aneurysms treated with endovascular methods such as coiling, cyanoacrylate embolization, Onyx, or flow diversion. Studies were required to report at least one of the following outcomes specifically for unruptured aneurysms: technical success, follow-up complete occlusion, good functional outcome (defined as a modified Rankin scale score of 0–2), complications, or mortality. Only studies that reported unruptured aneurysm outcomes separately from ruptured cases were included. Retrospective and prospective observational studies, case series, and case reports were eligible. Systematic reviews, meta-analyses, conference abstracts, editorials, and animal studies were excluded. Data extraction : Data extraction was performed independently by one reviewer and subsequently confirmed by two others to ensure consistency and accuracy. The extracted data included basic study information such as author name, publication year, and study design (retrospective or prospective). For each included study, we recorded the number of unruptured mycotic aneurysms treated, the aneurysm location (e.g., middle cerebral artery ( MCA ), posterior cerebral artery ( PCA ), basilar artery, and the endovascular treatment modality used (e.g., coiling, Onyx, cyanoacrylate, flow diverter. We also noted the indications for treatment, including enlarging the aneurysm size, failure of medical management, or embolic risk, and whether patients had received antibiotics prior to EVT. The outcomes specifically extracted for the proportional meta-analysis included technical success, follow-up complete occlusion rates, good functional outcomes (mRS 0–2), complication rates, and mortality. Additional data, such as the type of complications (e.g., hemorrhagic or thromboembolic events) and follow-up duration in months, were also collected when available. Any discrepancies during the extraction process were resolved by consensus among the review team. These extracted variables informed both the meta-analytic calculations and the narrative synthesis. Data Synthesis and Quality Assessment This study focused on long-term outcomes, predictive factors, and complication rates associated with Y-stent coiling for bifurcation aneurysms. The level of evidence was assessed via the 2011 Oxford Centre for Evidence-Based Medicine guidelines. Since all included studies were retrospective or observational, the risk of bias was evaluated via Joanna Briggs Institute checklists for cohort and case series studies. A meta-analysis was performed when the data were sufficiently homogeneous; otherwise, a qualitative synthesis was conducted. Statistical analysis All the statistical analyses were performed via R (version 4.4.2, R Foundation for Statistical Computing, Vienna, Austria). Proportional meta-analyses were conducted with a random-effects model to estimate pooled rates for follow-up complete occlusion, technical success, good neurological outcome, complications and mortality. Heterogeneity was assessed via I² statistics, and funnel plots were generated to evaluate publication bias. Results Follow-up Complete Occlusion A total of 40 unruptured mycotic aneurysms across six studies were analyzed to assess follow-up complete occlusion after endovascular treatment (EVT). The pooled proportion of complete occlusion ( Fig. 1 ) was 100% (95% CI: 95–100%), indicating that all aneurysms achieved full occlusion at follow-up. There was no observed heterogeneity (I² = 0.0%, p = 1.000), suggesting consistent outcomes across studies. The largest contribution to the pooled estimate came from Serrano et al. (2021), which accounted for 85.9% of the weight, reflecting its larger sample size. The funnel plot ( Fig. 2 ) demonstrated a symmetrical distribution of studies around the pooled proportion, suggesting that there was no significant publication bias. Given the consistently high occlusion rates, these findings highlight the effectiveness of EVT in achieving aneurysm stability in unruptured mycotic aneurysms. Technical Success A total of 40 unruptured mycotic aneurysms across six studies were analyzed to assess their technical success after endovascular treatment (EVT). Technical success was consistent across studies, with a pooled rate of 100% (95% CI: 95–100%), indicating that all attempted procedures were successfully performed without intraoperative failure ( Fig. 3 ) . There was no observed heterogeneity (I² = 0.0%, p = 1.000), suggesting consistent outcomes across studies. The funnel plot ( Fig. 4 ) demonstrated a symmetrical distribution of studies around the pooled proportion, suggesting that there was no significant publication bias. These findings suggest that EVT is a highly reliable procedure for unruptured mycotic aneurysms, with no reported cases of technical failure in the included studies. Good functional outcome A total of 17 patients with unruptured mycotic aneurysms from five studies were analyzed to assess functional outcomes following endovascular treatment (EVT). A good functional outcome, defined as a modified Rankin scale (mRS) score of 0–2, was achieved in 90% of patients (95% CI: 74–100%). The analysis revealed no significant heterogeneity (I² = 0.0%, p = 0.5415), suggesting consistent results across the included studies ( Fig. 5 ) . Cheng-Ching et al. (2017) and Chapot et al. (2002) contributed the largest weights, accounting for 51.0% and 28.1%, respectively. The funnel plot ( Fig. 6 ) suggests a moderately symmetrical distribution, indicating no strong evidence of publication bias, although the limited number of studies remains a constraint. These findings indicate that EVT for unruptured mycotic aneurysms is associated with a high likelihood of preserved neurological function. Complications A total of 18 unruptured mycotic aneurysms from six studies were analyzed for procedural complications following endovascular treatment (EVT). These findings support EVT as a low-risk intervention for unrupture, as adverse events are rare. Only one complication was reported, which occurred in the study by Chapot et al. (2002), contributing 21.5% of the overall weight. All other studies reported no complications. Heterogeneity was minimal (I² = 0.0%, p = 0.9671), reflecting consistent findings across studies ( Fig. 7 ) . The funnel plot ( Fig. 8 ) suggests a symmetrical distribution, indicating no strong evidence of publication bias. These findings support EVT as a low-risk intervention for unruptured mycotic aneurysms, with minimal procedural complications. Mortality A total of 14 unruptured mycotic aneurysms from four studies were analyzed to assess mortality following endovascular treatment (EVT). These findings reinforce EVT as a safe intervention for unruptured patients, with a pooled mortality rate of 0% (95% CI: 0–13%). Heterogeneity was nonexistent (I² = 0.0%, p = 1.000), indicating that the findings were consistent across studies. Chapot et al. (2002) and Cheng-Ching et al. (2017) contributed the most weight to the analysis, at 48.8% and 36.3%, respectively ( Fig. 9 ) . The funnel plot ( Fig. 10 ) demonstrated a symmetrical distribution, suggesting no publication bias. These findings support EVT as a safe intervention for unruptured mycotic aneurysms, with no treatment-related mortality reported in the literature. Ilustrative cases Case 1 – Coiling An adult woman presented with a sudden-onset headache following weightlifting activity at a gym, associated with blurred vision and right-sided hemiparesis. Head CT revealed diffuse subarachnoid hemorrhage (Fisher grade IV), and she was referred to the interventional neuroradiology service. Digital subtraction angiography (DSA) revealed a dissecting aneurysm in the left posterior cerebral artery (P2 segment). The affected segment was occluded via detachable coils, and the aneurysm was successfully excluded from circulation. The in-hospital workup revealed no evidence of active infection. The patient was discharged after 15 days in good condition. Follow-up imaging at six months ( Fig. 11 ) revealed recanalization of the left P2 segment with recurrence of the dissecting aneurysm. Case 2 – Flow-Diverter Stenting An adult male undergoing treatment for bacterial endocarditis was referred to the interventional neuroradiology unit following sudden deterioration in consciousness. Noncontrast head CT revealed right interhemispheric and pericallosal intraparenchymal hemorrhage. DSA identified two dissecting aneurysms: one in the right pericallosal artery (marked in red) and another in the right M4 segment of the middle cerebral artery (marked in yellow). Given the proximal location of the pericallosal aneurysm, parent artery occlusion was avoided to prevent significant neurological deficits. A flow-diverting stent (Silk Vista Baby, Balt®) was deployed to preserve vessel patency and exclude the aneurysm from circulation ( Fig. 12 ) . The unruptured M4 aneurysm was managed conservatively with antibiotic therapy alone. The patient had a favorable clinical course. Follow-up DSA at six months revealed a reduction in the size of the M4 aneurysm and complete exclusion of the pericallosal aneurysm, with preservation of normal cerebral circulation. Case 3 – Liquid Embolic Agents An elderly woman with a history of systemic arterial hypertension and diabetes mellitus presented with acute-onset headache and grade III right hemiparesis. An initial noncontrast axial CT scan revealed a left parietal lobar hemorrhage. CT angiography with maximum intensity projection (MIP) revealed a parietal hematoma with a contrast retention focus (spot sign), suggestive of ongoing bleeding or an underlying vascular lesion (Figure 13) . DSA revealed a dissecting aneurysm in the M4 segment of the left middle cerebral artery, with radiological features consistent with a mycotic aneurysm (highlighted in red). Owing to its distal location, the parent vessel was completely occluded with a liquid embolic agent (Onyx, Medtronic®). At the six-month follow-up, the patient showed improvement in right hemiparesis to grade IV, and DSA confirmed complete exclusion of the aneurysm with no residual filling. Discussion This systematic review and meta-analysis examined the technical success, follow-up occlusion rate, complications, functional outcomes, and mortality in patients undergoing endovascular treatment (EVT) for managing mycotic aneurysms (MAs). By conducting an extensive literature review, we compiled relevant clinical studies to provide a robust understanding of the most effective therapeutic strategies for MAs. Our analysis included data from eight studies involving 43 cases of unruptured MAs. Our findings confirm the high reliability of EVT, with complete success in the majority of the included studies, highlighting the efficacy of EVT for unruptured MAs. These results align with those of Batista et al. [ 11 ], who reported a 100% aneurysm occlusion rate. EVT has proven to be a safe procedure for patients with unruptured MAs, with a low complication rate of only 4%. Our meta-analysis revealed a neurological success rate of 90% in five out of eight studies, indicating a high level of neurological recovery following EVT. While Batista et al. [ 11 ] focused on ruptured MAs, our study addresses a significant knowledge gap by exclusively analyzing unruptured aneurysms. This focused approach provides further insight into the benefits of EVT as a primary treatment for unruptured cases. EVT for unruptured MAs is a highly effective approach, primarily utilizing detachable coils and liquid embolic agents such as N-butyl cyanoacrylate (NBCA) and Onyx. Compared with traditional neurosurgery, the American Heart Association (AHA) endorses EVT for its minimally invasive nature [ 19 ]. EVT offers distinct advantages, particularly for treating proximal aneurysms with coils and distal aneurysms with liquid embolic agents. [ 20 – 22 ]. The use of flow diverter stents in the treatment of mycotic aneurysms is not standard practice; however, some studies suggest that it may be a viable option in selected cases [ 23 ]. Giorgianni et al. conducted a retrospective study and literature review on the use of flow diverters for acutely ruptured intracranial aneurysms, including mycotic aneurysms, reporting a pooled complete occlusion rate of 50% for the latter—which is lower than that reported for other aneurysm types [ 24 ]. The American Heart Association/American Stroke Association guidelines highlight the risks associated with flow diverters in ruptured aneurysms, particularly due to the potential for hemorrhagic complications and the requirement for dual antiplatelet therapy [ 25 ]. EVT provides multiple benefits, including the ability to treat multiple aneurysms in a single procedure, reducing the risk of rupture during intervention, and enabling immediate cardiac surgery when necessary. However, EVT may result in partial or complete occlusion of the parent artery, potentially leading to ischemic complications in critical brain areas. Moreover, EVT is not the preferred approach for ruptured aneurysms with increased intracranial pressure and mass effects; in such cases, traditional neurosurgery remains the standard of care [ 20 , 21 ]. A systematic review by Ragulojan et al. [ 24 ] revealed that 35.8% of identified cases involved ruptured aneurysms, underscoring the importance of considering both ruptured and unruptured cases in clinical discussions. Our findings reinforce the consistency of EVT outcomes across diverse patient populations, strengthening its role as a primary treatment option [ 11 , 26 ]. Our results demonstrate a high technical success rate and excellent functional outcomes, with 90% of patients achieving positive neurological recovery. While Batista et al. [ 11 ] reported morbidity in 12 patients with ruptured MAs, our study revealed a 0% morbidity rate among patients with unruptured MAs. The low complication rate of 4% further confirms the safety of EVT and aligns with the findings of Batista et al., highlighting the effectiveness of patient selection and management strategies. Rice et al. [ 12 ] examined the impact of antibiotics on infectious intracranial aneurysms (IIAs) in 618 patients and identified 43 IIAs in 40 individuals (6.5%). Among the 25 unruptured aneurysms monitored without immediate intervention, 44% had unfavorable outcomes, including rupture, new aneurysm formation, or enlargement at a median of 21 days, whereas 28% achieved resolution or regression at a median of 36 days. Notably, prolonged antibiotic therapy before IIA detection was associated with improved angiographic outcomes (p = 0.046), suggesting that extended antibiotic exposure may promote aneurysm regression. Similarly, Park et al. [ 27 ] analyzed the management of IIAs in infective endocarditis (IE) patients, evaluating 12 cases of ruptured IIAs and 13 cases of unruptured IIAs. While all patients received antibiotics, only smaller aneurysms (mean size: 4.1 ± 2.2 mm) resolved with medical therapy, whereas larger aneurysms (mean size: 7.5 ± 3.1 mm) often required neurosurgical intervention. In total, 16 aneurysms in 12 patients underwent procedures such as parent artery occlusion, endovascular coiling, or microsurgery. Although two patients experienced treatment-related complications, no recurrences or mortalities were reported. These findings suggest that while a 4–6-week course of antibiotics may be effective for unruptured IIAs, surgical intervention should be considered for ruptured or refractory cases. Alawieh et al. [ 28 ] provided further insights by analyzing 1,714 IE cases and identified intracerebral hemorrhage in 322 patients and IIAs in 17 patients. The presence of IIAs significantly increased the likelihood of death or hospice care (odds ratio: 6.9). Expanding the cohort to include non-IE patients, the study examined 24 individuals with 38 IIAs, predominantly affecting the distal middle cerebral artery. At admission, 16 aneurysms had ruptured. Although antibiotics were initially administered in most cases, nearly 48% of patients required additional interventions within the first two weeks. Surgical approaches included open microsurgery as the primary treatment for five aneurysms and salvage therapy for seven cases following antibiotic failure. Endovascular management was the primary treatment in two patients, and a salvage option was used in five patients. Despite these efforts, the overall prognosis remains poor, with a two-year survival rate of 70%. Taken together, these studies highlight the complexity of IIA management. While antibiotic therapy plays a crucial role, its effectiveness depends on aneurysm size and disease progression. The high rate of treatment failure, particularly in the early phase, underscores the need for close monitoring. Surgical or endovascular interventions should be considered early in cases with a high risk of rupture or poor response to antibiotics to improve outcomes. EVT for unruptured MAs is emerging as a highly effective and minimally invasive option. Techniques such as detachable coils and liquid embolic agents are firmly endorsed by the AHA, emphasizing EVT’s growing recognition in managing these complex cases [ 19 ]. EVT enhances patient comfort by allowing procedures to be performed under sedation, minimizing intraoperative risks [ 29 , 30 ]. However, EVT is not suitable for patients with ruptured aneurysms experiencing increased intracranial pressure; in these cases, traditional neurosurgery remains the preferred approach [ 31 ]. The management of MAs continues to be debated, particularly in terms of balancing EVT, surgical intervention, and antibiotic therapy. While EVT is increasingly favored for its minimally invasive nature, traditional surgery remains the gold standard in certain cases, particularly for larger or ruptured aneurysms. The role of antibiotics in promoting aneurysm regression or preventing recurrence remains unclear, with some studies suggesting that prolonged antibiotic therapy may improve outcomes. The lack of consensus on treatment protocols highlights the need for further research to refine management strategies and optimize patient outcomes. Recommendations : On the basis of our findings, we recommend the initiation of larger multicenter trials that include diverse patient populations to increase the validity of findings related to endovascular therapy (EVT). Long-term follow-up studies should be prioritized to evaluate the safety and effectiveness of EVT, with a focus on monitoring for delayed complications and assessing quality of life. Additionally, clear patient selection guidelines should be developed on the basis of aneurysm characteristics and overall health to optimize treatment outcomes. The training of healthcare professionals in endovascular therapy (EVT) techniques should be improved, and these professionals should be prepared for potential complications. Monitoring systems should be set up to track clinical outcomes and patient satisfaction related to EVT practices. Interdisciplinary collaboration among specialists should be promoted to enhance treatment strategies for mycotic aneurysms. Research into the characteristics of unruptured mycotic aneurysms is encouraged to identify appropriate candidates for EVT and to effectively balance associated risks. Strengths : Our meta-analysis revealed an impressive technical success rate of 90% and outstanding 0% morbidity in patients treated with EVT. These results clearly underscore the effectiveness and safety of the procedure for unruptured cases. This article identifies the significant imbalance in research focus between ruptured and unruptured aneurysms, underscoring a crucial gap in our understanding that demands urgent attention and further investigation into unruptured cases. In addition, one of the few studies focused exclusively on unruptured mycotic aneurysms, filling a critical gap in the literature. The pooled data demonstrate a high technical success rate and excellent functional outcomes, providing strong evidence for EVT as a primary treatment approach. Furthermore, the study employs rigorous methodological standards, including a systematic search, proportional meta-analysis, and assessment of publication bias, ensuring robust and reliable conclusions. The low complication rate and absence of mortality further highlight the potential of EVT as a safe intervention. Clinical Illustration In addition to the studies included in this review, we present illustrative imaging from one of the study authors, highlighting a case of a previously ruptured mycotic aneurysm treated with endovascular coiling that recurred as unruptured on follow-up imaging ( Figs. 11 , 12 ). Although this case was not included in the meta-analysis because of its initial rupture status, it serves as a valuable clinical example supporting the central themes of our findings. Specifically, these findings demonstrate the feasibility and durability of endovascular treatment (EVT) in achieving initial aneurysm control, as well as the importance of long-term surveillance, given the potential for recurrence. The unruptured status of the recurrent aneurysm aligns with the population assessed in our analysis and offers a practical reminder that unruptured mycotic aneurysms may emerge even after prior intervention. This case also emphasizes the dynamic nature of aneurysm behavior and underscores the need for individualized follow-up and potential retreatment strategies in selected cases. As the field continues to evolve, such clinical examples offer meaningful context and help bridge the gap between aggregated data and real-world management of these rare vascular lesions. Limitations : Despite its strengths, this study is limited by the small number of included cases (43 aneurysms across seven studies), which restricts the generalizability of the findings. The included studies were predominantly retrospective, introducing the potential for selection bias. Additionally, the lack of long-term follow-up data makes it difficult to assess the durability of EVT and the risk of late complications or recurrence. Another limitation is the heterogeneity in treatment protocols, including variations in the use of antibiotics and EVT techniques, which may affect outcome comparability. Finally, while publication bias was assessed, the small sample size may have limited the ability to detect bias effectively. Conclusion This meta-analysis provides compelling evidence supporting the safety and efficacy of endovascular treatment (EVT) for unruptured mycotic aneurysms. The findings indicate a 100% technical success rate and complete occlusion in all treated patients, reinforcing EVT as a reliable and effective intervention. The complication rate was notably low at 4%, with no reported mortality, and the vast majority of patients achieved favorable functional outcomes. These results suggest that EVT is a viable first-line treatment option for unruptured mycotic aneurysms, offering a minimally invasive alternative to open surgery while preserving neurological function. However, despite promising outcomes, this study highlights significant gaps in the current understanding of EVT for mycotic aneurysms. The scarcity of large-scale studies and the predominance of retrospective data necessitate further research, particularly prospective trials, to establish long-term safety and efficacy. Additionally, the role of antibiotic therapy in combination with EVT remains an area requiring further investigation. Future studies should aim to refine patient selection criteria, evaluate the durability of EVT outcomes, and compare EVT with other management strategies to develop comprehensive, evidence-based treatment guidelines. Abbreviations MA Mycotic Aneurysm CT Computed Tomography MRI Magnetic Resonance Imaging MRA Magnetic Resonance Angiography US Ultrasound HIV Human Immunodeficiency Virus TB Tuberculosis EVD External Ventricular Drain CNS Central Nervous System CRP C-Reactive Protein WBC White Blood Cell count Declarations Compliance with journal guidelines: This manuscript complies with all the author instructions provided by the journal. Authorship and approval: All authors meet the authorship criteria as per the ICMJE guidelines. The final version of the manuscript has been reviewed and approved by all the authors prior to submission. Originality statement: We confirm that this manuscript has not been published elsewhere and is not under consideration for publication in any other journal. Use of reporting checklist: This systematic review follows the PRISMA reporting guidelines to ensure methodological transparency and rigor. Conflict of interest (COI): The authors declare that they have no conflicts of interest related to this study. COI disclosure forms have been collected in accordance with ICMJE guidelines and are available upon request. Ethical considerations: As this study is a systematic review based on previously published data, it does not require ethical approval or informed consent. Funding statement: This study did not receive any financial support. References Mankotia DS, Sinha S, Sharma BS (2018) Ruptured distal middle cerebral artery mycotic aneurysm: A rare, first presentation of infective endocarditis. Asian J Neurosurg 13(1):113–115 Kannoth S, Thomas SV (2009) Intracranial microbial aneurysm (infectious aneurysm): current options for diagnosis and management. Neurocrit Care 11(1):120–129 Alawieh A, Chaudry MI, Turner RD, Turk AS, Spiotta AM (2018) Infectious intracranial aneurysms: a systematic review of epidemiology, management, and outcomes. 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Available from: http://dx.doi.org/10.1161/cir.0000000000000457 Gudelj M, Bruyère PJ, Tebache M, Collignon L, Lubicz B (2020) Endovascular treatment of intracranial aneurysms: Initial experience in a low-volume center. J Belg Soc Radiol 104(1):19 Rigamonti P, Volterra D, Yu T, Gioppo A, Toluian T, Giavarini M et al (2024) In: Abstracts BMA, House (eds) P001 Subarachnoid hemorrhage associated to multiple intracranial mycotic aneurysm in congenital HIV with VZV leptomeningitis: endovascular treatment of ruptured mycotic aneurysm with ethylene vinyl alcohol copolymer (Onyx), vol WC1H 9JR. Tavistock Square, London, pp 2–A24 Imamura H, Sakai N, Alexander MJ (2019) Flow-Diverter Stenting of Intracavernous Internal Carotid Artery Mycotic Aneurysm. J Stroke Cerebrovasc Dis 28(7):e81–e82. 10.1016/j.jstrokecerebrovasdis.2019.04.026 Giorgianni A, Agosti E, Molinaro S et al (2022) Flow Diversion for Acutely Ruptured Intracranial Aneurysms Treatment: A Retrospective Study and Literature Review. J Stroke Cerebrovasc Dis 31(3):106284. 10.1016/j.jstrokecerebrovasdis.2021.106284 Hoh BL, Ko NU, Amin-Hanjani S et al (2023) 2023 Guideline for the Management of Patients With Aneurysmal Subarachnoid Hemorrhage: A Guideline From the American Heart Association/American Stroke Association [published correction appears in Stroke. ;54(12):e516. 10.1161/STR.0000000000000449.] . Stroke. 2023;54(7):e314-e370. doi:10.1161/STR.0000000000000436 Ragulojan R, Grupke S, Fraser JF (2019) Systematic review of endovascular, surgical, and conservative options for Infectious Intracranial aneurysms and cardiac considerations. J Stroke Cerebrovasc Dis 28(3):838–844 Park W, Ahn JS, Park JC, Kwun BD, Lee DH (2017) Treatment strategy based on experience of treating intracranial infectious aneurysms. World Neurosurg 97:351–359 Alawieh AM, Dimisko L, Newman S, Grossberg JA, Cawley CM, Pradilla G et al (2023) Management and long-term outcomes of patients with infectious intracranial aneurysms. Neurosurgery 92(3):515–523 Purkayastha S, Kumar R, Verma D, Dhurvey D, Kumar N, Jana S (2024) Efficacy of endovascular glue embolization in treating ruptured intracranial mycotic aneurysms: A single center experience. Neurointervention 19(3):156–161 Roy D, Milot G, Raymond J (2001) Endovascular treatment of unruptured aneurysms. Stroke 32(9):1998–2004 Trakolis L, Petridis AK (2024) Clinical management of a ruptured intracranial aneurysm. Front Stroke [Internet]. ;3. Available from: http://dx.doi.org/10.3389/fstro.2024.1450650 Tables Tables 1 to 4 are available in the Supplementary Files section. Additional Declarations No competing interests reported. Supplementary Files Tables.docx SupplementaryFigure1.docx Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-6585801","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Systematic Review","associatedPublications":[],"authors":[{"id":498066115,"identity":"715a1cd2-122e-4326-b927-6f67fd5dafe0","order_by":0,"name":"Luis Gustavo Biondi Soares","email":"","orcid":"","institution":"Department of Neurosurgery, Santa Casa de Montes Claros","correspondingAuthor":false,"prefix":"","firstName":"Luis","middleName":"Gustavo Biondi","lastName":"Soares","suffix":""},{"id":498066116,"identity":"5a9c1203-f015-47a5-9d37-e7ff4f30a12a","order_by":1,"name":"Murtaja Satea Shafeea","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA9klEQVRIiWNgGAWjYNACHhijAoiZmRsIqWdsgGhhBuIzIJqRGC0MUC2MbcgCOIDujNznD37I2DHIt58/+ODnvNpo/naglh8V23BqMbuRbtjYw5PMYHAmmdmwd9vx3BmHGRsYe87cxqMljbGBh4eZwYAhmU2Cd9ux3AagFmbGNvxaGv/w1DPI9z9m//l3zrHc+cRoaebhOczAcCOZjZm3oSZ3A0EtZ54xzpbhOc5jcOOxsbTMsQO5G4FaDuL1y/E0ho9ve6rl5PsTH358U1OXO+/84YMPflTg1gIGjD3w+D8MJg/gVw8CP+CsOsKKR8EoGAWjYMQBABbHWaDMxKj6AAAAAElFTkSuQmCC","orcid":"","institution":"University of Warith Alanbiyaa","correspondingAuthor":true,"prefix":"","firstName":"Murtaja","middleName":"Satea","lastName":"Shafeea","suffix":""},{"id":498066117,"identity":"7ce48421-cdea-4d11-98e0-0c3c5c22918a","order_by":2,"name":"Khalil St Brice","email":"","orcid":"","institution":"University of the West Indies","correspondingAuthor":false,"prefix":"","firstName":"Khalil","middleName":"St","lastName":"Brice","suffix":""},{"id":498066118,"identity":"ba72960f-bc15-4599-8ff0-5da1eef1b4a9","order_by":3,"name":"Kim Wouters","email":"","orcid":"","institution":"Open University in the Netherlands","correspondingAuthor":false,"prefix":"","firstName":"Kim","middleName":"","lastName":"Wouters","suffix":""},{"id":498066119,"identity":"a3d335b2-2528-4daf-bb9d-6d25250db702","order_by":4,"name":"Guilherme Linha Secco","email":"","orcid":"","institution":"State University of Ponta Grossa","correspondingAuthor":false,"prefix":"","firstName":"Guilherme","middleName":"Linha","lastName":"Secco","suffix":""},{"id":498066120,"identity":"08853905-5f2e-46c6-8783-032d46da72f6","order_by":5,"name":"Ramzi Johny Zeidan","email":"","orcid":"","institution":"University of 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Piauí","correspondingAuthor":false,"prefix":"","firstName":"Francisco","middleName":"Rafael Gomes","lastName":"Lima","suffix":""},{"id":498066124,"identity":"3f2c74a5-a467-42fe-b76a-546144d7ef9a","order_by":9,"name":"Felipe Salvagni","email":"","orcid":"","institution":"Faculdade Evangélica do Paraná","correspondingAuthor":false,"prefix":"","firstName":"Felipe","middleName":"","lastName":"Salvagni","suffix":""},{"id":498066125,"identity":"48908aee-b63f-4851-a76a-c720daee4633","order_by":10,"name":"Maria Luiza Oliveira Lopes Teixeira","email":"","orcid":"","institution":"D’or institute of Education","correspondingAuthor":false,"prefix":"","firstName":"Maria","middleName":"Luiza Oliveira Lopes","lastName":"Teixeira","suffix":""},{"id":498066126,"identity":"84d4e8ec-6549-4fd9-a8c3-71d6d0ba8801","order_by":11,"name":"Khaled Fares AlAli","email":"","orcid":"","institution":"Zayed Military Hospital","correspondingAuthor":false,"prefix":"","firstName":"Khaled","middleName":"Fares","lastName":"AlAli","suffix":""},{"id":498066127,"identity":"152d04df-99cd-412a-bb51-c0fb6c968beb","order_by":12,"name":"Leandro Assis Barbosa","email":"","orcid":"","institution":"Department of Neurosurgery, Hospital Estadual Central","correspondingAuthor":false,"prefix":"","firstName":"Leandro","middleName":"Assis","lastName":"Barbosa","suffix":""}],"badges":[],"createdAt":"2025-05-03 20:53:10","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-6585801/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-6585801/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":88892907,"identity":"7f4a76e0-97a3-42d0-8629-801031678f0f","added_by":"auto","created_at":"2025-08-12 12:54:24","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":103459,"visible":true,"origin":"","legend":"\u003cp\u003eProportional analysis of follow-up complete occlusion\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-6585801/v1/7e34ad46d299c87243701d51.png"},{"id":88896960,"identity":"2c9b497f-7f86-433e-b5a5-e31cebfab5af","added_by":"auto","created_at":"2025-08-12 13:10:24","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":33276,"visible":true,"origin":"","legend":"\u003cp\u003eFunnel plot for follow-up complete occlusion\u003c/p\u003e","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-6585801/v1/8de836dba694b19c5f476a56.png"},{"id":88896962,"identity":"39c813c3-3eb4-40f9-8b7b-6c635f7579de","added_by":"auto","created_at":"2025-08-12 13:10:24","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":103526,"visible":true,"origin":"","legend":"\u003cp\u003eProportional analysis of technical success\u003c/p\u003e","description":"","filename":"3.png","url":"https://assets-eu.researchsquare.com/files/rs-6585801/v1/f8cbcce79398e7d3ddb2b1e3.png"},{"id":88892909,"identity":"fb56ddbc-de80-4e48-9e69-c32f800a0c95","added_by":"auto","created_at":"2025-08-12 12:54:24","extension":"png","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":33755,"visible":true,"origin":"","legend":"\u003cp\u003eFunnel plot for technical success\u003c/p\u003e","description":"","filename":"4.png","url":"https://assets-eu.researchsquare.com/files/rs-6585801/v1/cc638c226e15feb45498bb68.png"},{"id":88892920,"identity":"a62fbc99-34b4-4ef4-82bc-a6896f8505bc","added_by":"auto","created_at":"2025-08-12 12:54:24","extension":"png","order_by":5,"title":"Figure 5","display":"","copyAsset":false,"role":"figure","size":177327,"visible":true,"origin":"","legend":"\u003cp\u003eProportional analysis of good functional outcomes\u003c/p\u003e","description":"","filename":"5.png","url":"https://assets-eu.researchsquare.com/files/rs-6585801/v1/9f5c735fdb329189595e0051.png"},{"id":88892912,"identity":"6f2ed1a6-d07e-4288-a9a9-a35c2d4909bf","added_by":"auto","created_at":"2025-08-12 12:54:24","extension":"png","order_by":6,"title":"Figure 6","display":"","copyAsset":false,"role":"figure","size":35006,"visible":true,"origin":"","legend":"\u003cp\u003eFunnel plot of good functional outcome\u003c/p\u003e","description":"","filename":"6.png","url":"https://assets-eu.researchsquare.com/files/rs-6585801/v1/5e623364f55f7bfe3c29105b.png"},{"id":88897969,"identity":"7ac9e2e7-84ff-49e7-b6be-218a173fa553","added_by":"auto","created_at":"2025-08-12 13:18:24","extension":"png","order_by":7,"title":"Figure 7","display":"","copyAsset":false,"role":"figure","size":107448,"visible":true,"origin":"","legend":"\u003cp\u003eProportional analysis of complications\u003c/p\u003e","description":"","filename":"7.png","url":"https://assets-eu.researchsquare.com/files/rs-6585801/v1/d3a63ff082bef75a81fc03d9.png"},{"id":88892918,"identity":"a888b3cc-0aaf-4ec6-a9ba-a8f3b8673caf","added_by":"auto","created_at":"2025-08-12 12:54:24","extension":"png","order_by":8,"title":"Figure 8","display":"","copyAsset":false,"role":"figure","size":33411,"visible":true,"origin":"","legend":"\u003cp\u003eFunnel plot of complications\u003c/p\u003e","description":"","filename":"8.png","url":"https://assets-eu.researchsquare.com/files/rs-6585801/v1/19c7c3da4fa67f4bbce06489.png"},{"id":88892914,"identity":"30ad2e28-8216-469f-b157-de5de8ee4d8b","added_by":"auto","created_at":"2025-08-12 12:54:24","extension":"png","order_by":9,"title":"Figure 9","display":"","copyAsset":false,"role":"figure","size":86900,"visible":true,"origin":"","legend":"\u003cp\u003eProportional analysis of mortality\u003c/p\u003e","description":"","filename":"9.png","url":"https://assets-eu.researchsquare.com/files/rs-6585801/v1/d36f25c981f1558bbc386e5c.png"},{"id":88894456,"identity":"a9c84188-ff19-45bd-9013-aafaec72bae7","added_by":"auto","created_at":"2025-08-12 13:02:24","extension":"png","order_by":10,"title":"Figure 10","display":"","copyAsset":false,"role":"figure","size":59694,"visible":true,"origin":"","legend":"\u003cp\u003eFunnel plot of mortality\u003c/p\u003e","description":"","filename":"10.png","url":"https://assets-eu.researchsquare.com/files/rs-6585801/v1/7b434467dd590a7b01a93c98.png"},{"id":88894459,"identity":"47801772-e173-4efb-87ce-f94afe8fcd99","added_by":"auto","created_at":"2025-08-12 13:02:24","extension":"png","order_by":11,"title":"Figure 11","display":"","copyAsset":false,"role":"figure","size":342792,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eRecurrence of a mycotic aneurysm following endovascular coiling. \u003c/strong\u003e3D reconstructed angiographic images (A, B) show an initially ruptured mycotic aneurysm treated with endovascular coiling, with the gray image representing the coil. Images (C, D) depict recurrent aneurysm formation six months later, which presented as unruptured. A subtraction of the metal artifact was performed in these images to enhance visualization.\u003c/p\u003e","description":"","filename":"11.png","url":"https://assets-eu.researchsquare.com/files/rs-6585801/v1/40a71f5d96a5ec9de4521c3f.png"},{"id":88894461,"identity":"79433abc-810d-4701-af46-d581b8c373fb","added_by":"auto","created_at":"2025-08-12 13:02:24","extension":"png","order_by":12,"title":"Figure 12","display":"","copyAsset":false,"role":"figure","size":306394,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eComparison of ruptured and unruptured mycotic aneurysms in a patient treated with antibiotics. \u003c/strong\u003eDigital subtraction angiography (DSA) images (A, B) and 3D reconstructions (C, D, E) showing a patient with both ruptured (red circle) and unruptured (yellow circle) mycotic aneurysms. The patient was treated with antibiotics but experienced poor clinical evolution. Image (F) showing flow diverter stent placement in the affected vessel.\u003c/p\u003e","description":"","filename":"12.png","url":"https://assets-eu.researchsquare.com/files/rs-6585801/v1/cb33e3adddf1dd74c6b69d68.png"},{"id":88892921,"identity":"79cf0461-af6f-4cf5-ac5a-aa52a979ee02","added_by":"auto","created_at":"2025-08-12 12:54:24","extension":"png","order_by":13,"title":"Figure 13","display":"","copyAsset":false,"role":"figure","size":254066,"visible":true,"origin":"","legend":"\u003cp\u003eInitial noncontrast axial CT scan (A) demonstrating a left parietal lobar hemorrhage. CT angiography with maximum intensity projection (MIP) in the axial (B) and sagittal (C) planes reveals a parietal hematoma containing a contrast retention focus (spot sign), suggestive of active bleeding or an underlying vascular lesion. Digital subtraction angiography (DSA) (D) revealed a dissecting aneurysm located in the M4 segment of the left middle cerebral artery, with morphological features compatible with a mycotic aneurysm (highlighted in red). Superselective angiography (E) confirmed the location and configuration of the aneurysm. Postembolization control angiography (F) revealed complete occlusion of the aneurysm following embolization with Onyx liquid embolic agent.\u003c/p\u003e","description":"","filename":"13.png","url":"https://assets-eu.researchsquare.com/files/rs-6585801/v1/45eeb337ab3f27d223fa7e1b.png"},{"id":88897973,"identity":"9ddcdb0c-5766-420e-a2ed-243d906532d7","added_by":"auto","created_at":"2025-08-12 13:18:29","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":2225917,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6585801/v1/5bce7f18-f2fd-4023-ac4a-5f55c8516503.pdf"},{"id":88894455,"identity":"dc70019a-881e-4348-b0ca-e7c739a0892c","added_by":"auto","created_at":"2025-08-12 13:02:24","extension":"docx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":25577,"visible":true,"origin":"","legend":"","description":"","filename":"Tables.docx","url":"https://assets-eu.researchsquare.com/files/rs-6585801/v1/223356484eba84b057e83ce2.docx"},{"id":88897968,"identity":"3c12475e-03d8-4e74-96d5-0c87f2b657da","added_by":"auto","created_at":"2025-08-12 13:18:24","extension":"docx","order_by":2,"title":"","display":"","copyAsset":false,"role":"supplement","size":48285,"visible":true,"origin":"","legend":"","description":"","filename":"SupplementaryFigure1.docx","url":"https://assets-eu.researchsquare.com/files/rs-6585801/v1/9131d7d269201de9d304fc38.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"Endovascular Treatment for Unruptured Mycotic Aneurysms: A Systematic Review and Meta-Analysis","fulltext":[{"header":"Introduction","content":"\u003cp\u003e\u003cspan type=\"BoldSmallCaps\" class=\"BoldSmallCaps\" name=\"Emphasis\"\u003e1.1 Epidemiology, etiology and pathogenesis\u003c/span\u003e\u003c/p\u003e\u003cp\u003e\u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003eMycotic aneurysms (MAs) are rare but life-threatening vascular complications resulting from infectious processes that are often linked to conditions such as infective endocarditis (IE). The incidence of mycotic aneurysms is relatively low, constituting less than 0.7\u0026ndash;6.5% of all intracranial aneurysms; however, their potential for rapid growth and rupture makes them a critical medical concern\u003c/span\u003e [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. \u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003eUnruptured cases may be underdiagnosed because of their usual asymptomatic nature or nonspecific neurological symptom presentation\u003c/span\u003e [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. \u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003eIntracranial MAs are often small (\u0026lt;\u0026thinsp;5 mm), are distally located, and are prone to multiplicity and rupture\u003c/span\u003e [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. \u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003eMAs have a significant risk of rupture, especially intracranial ruptures, with 16.4% rupturing within a median of 3 days after diagnosis\u003c/span\u003e [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e].\u003c/p\u003e\u003cp\u003e\u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003eIn MAs, septic emboli from IE disseminate via the bloodstream and lodge in the vasa vasorum, inducing an inflammatory response that leads to arterial wall degradation and aneurysm formation\u003c/span\u003e [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. \u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003eMAs can occur in various locations, with the femoral artery and abdominal aorta being the most common. Etiologies include trauma, septic emboli, and idiopathic emboli. Staphylococcus aureus and Salmonella are frequently isolated pathogens\u003c/span\u003e [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. \u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003eSymptoms vary widely and include sepsis, chest pain, and intraperitoneal bleeding\u003c/span\u003e [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e].\u003c/p\u003e\u003cp\u003e\u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003eMAs have complex pathogenesis and can develop through direct infection of the arterial wall or via the vasa vasorum\u003c/span\u003e [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. \u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003eThree main infection sources have been identified: neighboring infections, embolic transfer from endocarditis, and bloodstream dissemination from known or unknown sources known as \"cryptogenic mycotic aneurysms\"\u003c/span\u003e [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. \u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003eRisk factors include atherosclerosis and immunosuppression. Mycotic aneurysms often present diagnostic challenges due to nonspecific symptoms and a lack of clear diagnostic criteria\u003c/span\u003e [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e].\u003c/p\u003e\u003cp\u003e\u003cspan type=\"BoldSmallCaps\" class=\"BoldSmallCaps\" name=\"Emphasis\"\u003e1.2 Role of antibiotics and EVT in the treatment of mycotic aneurysms\u003c/span\u003e\u003c/p\u003e\u003cp\u003e\u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003eThe treatment options in MAs include antibiotics alone or in combination with endovascular or surgical interventions. Endovascular treatment (EVT) has shown high technical success and aneurysm occlusion rates, with few complications\u003c/span\u003e [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. \u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003eThe clinical course of MAs can be dynamic, with only approximately 25% resolving with antibiotics alone\u003c/span\u003e [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. \u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003eHowever, in unruptured MAs, antibiotic treatment alone may have similar outcomes to invasive treatments\u003c/span\u003e [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. \u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003eSaccular morphology may predict unfavorable outcomes, whereas longer antibiotic exposure before MA discovery is associated with better outcomes\u003c/span\u003e [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. \u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003eSurgical intervention is recommended for ruptured MAs and may be considered for unruptured MAs, depending on the patient's condition\u003c/span\u003e [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. \u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003eAngiographic follow-up is crucial, as MAs can enlarge or rupture during antibiotic treatment\u003c/span\u003e [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. \u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003eEndovascular embolization using coils or liquid embolic agents has demonstrated high occlusion rates and low procedural complications, even in critically ill patients\u003c/span\u003e [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. \u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003eEarly detection through neurological examination, CT, and angiography in endocarditis patients with neurological abnormalities is recommended\u003c/span\u003e [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. \u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003eThe optimal treatment strategy remains unclear, highlighting the need for further research in this area.\u003c/span\u003e\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003e\u003cspan type=\"BoldSmallCaps\" class=\"BoldSmallCaps\" name=\"Emphasis\"\u003eLiterature search\u003c/span\u003e\u003c/p\u003e\u003cp\u003e\u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003eA systematic review and meta-analysis were conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines\u003c/span\u003e [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. \u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003ePubMed, EMBASE, and Web of Science were searched from inception to January 2025, without language restrictions. To ensure maximum sensitivity, various search terms were used: \u0026ldquo;Intracranial Aneurysm,\u0026rdquo; \u0026ldquo;Cerebral Aneurysm,\u0026rdquo; \u0026ldquo;Mycotic Aneurysm,\u0026rdquo; \u0026ldquo;Infectious Aneurysm,\u0026rdquo; \u0026ldquo;Bacterial Aneurysm,\u0026rdquo; \u0026ldquo;Antibiotics,\u0026rdquo; \u0026ldquo;Antimicrobial Therapy,\u0026rdquo; \u0026ldquo;Medical Management,\u0026rdquo; \u0026ldquo;Endovascular Treatment,\u0026rdquo; \u0026ldquo;Embolization,\u0026rdquo; and \u0026ldquo;EVT\u0026rdquo;. Studies were included if they explicitly reported outcomes for unruptured mycotic aneurysms treated with EVT with or without antibiotics. Systematic reviews, meta-analyses, case reports, and studies without outcome data specific to unruptured MAs were excluded. The screening and full-text review were conducted via Rayyan AI, and data extraction was performed via Microsoft Excel. The reference lists of all included studies were screened to identify additional relevant articles. The final selection included seven studies with 43 unruptured mycotic aneurysms for proportional meta-analysis.\u003c/span\u003e\u003c/p\u003e\u003cp\u003e\u003cspan type=\"BoldSmallCaps\" class=\"BoldSmallCaps\" name=\"Emphasis\"\u003eStudy selection\u003c/span\u003e:\u003c/p\u003e\u003cp\u003e\u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003eFollowing deduplication, a total of 446 records were identified through systematic searches across PubMed, EMBASE, and Web of Science. Title and abstract screening was conducted via Rayyan AI by two independent reviewers, with any conflicts resolved through discussion with a third reviewer. After the initial screening, 27 full-text articles were retrieved and assessed for eligibility. Of these, 10 were excluded for reporting on the wrong population\u0026mdash;primarily studies that included only ruptured aneurysms or did not stratify outcomes by rupture status\u0026mdash;and 10 were excluded for reporting the wrong outcomes, such as lacking information specific to unruptured aneurysm outcomes or failing to specify which outcomes pertained to unruptured cases. A total of seven studies met the inclusion criteria and were included in the final review and meta-analysis.\u003c/span\u003e\u003c/p\u003e\u003cp\u003e\u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003eEligible studies included patients with unruptured intracranial mycotic aneurysms treated with endovascular methods such as coiling, cyanoacrylate embolization, Onyx, or flow diversion. Studies were required to report at least one of the following outcomes specifically for unruptured aneurysms: technical success, follow-up complete occlusion, good functional outcome (defined as a modified Rankin scale score of 0\u0026ndash;2), complications, or mortality. Only studies that reported unruptured aneurysm outcomes separately from ruptured cases were included. Retrospective and prospective observational studies, case series, and case reports were eligible. Systematic reviews, meta-analyses, conference abstracts, editorials, and animal studies were excluded.\u003c/span\u003e\u003c/p\u003e\u003cp\u003e\u003cspan type=\"BoldSmallCaps\" class=\"BoldSmallCaps\" name=\"Emphasis\"\u003eData extraction\u003c/span\u003e:\u003c/p\u003e\u003cp\u003e\u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003eData extraction was performed independently by one reviewer and subsequently confirmed by two others to ensure consistency and accuracy. The extracted data included basic study information such as author name, publication year, and study design (retrospective or prospective). For each included study, we recorded the number of unruptured mycotic aneurysms treated, the aneurysm location (e.g., middle cerebral artery\u003c/span\u003e (\u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003eMCA\u003c/span\u003e), \u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003eposterior cerebral artery\u003c/span\u003e (\u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003ePCA\u003c/span\u003e), \u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003ebasilar artery, and the endovascular treatment modality used (e.g., coiling, Onyx, cyanoacrylate, flow diverter. We also noted the indications for treatment, including enlarging the aneurysm size, failure of medical management, or embolic risk, and whether patients had received antibiotics prior to EVT.\u003c/span\u003e\u003c/p\u003e\u003cp\u003e\u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003eThe outcomes specifically extracted for the proportional meta-analysis included technical success, follow-up complete occlusion rates, good functional outcomes (mRS 0\u0026ndash;2), complication rates, and mortality. Additional data, such as the type of complications (e.g., hemorrhagic or thromboembolic events) and follow-up duration in months, were also collected when available. Any discrepancies during the extraction process were resolved by consensus among the review team. These extracted variables informed both the meta-analytic calculations and the narrative synthesis.\u003c/span\u003e\u003c/p\u003e\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e\u003ch2\u003eData Synthesis and Quality Assessment\u003c/h2\u003e\u003cp\u003e\u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003eThis study focused on long-term outcomes, predictive factors, and complication rates associated with Y-stent coiling for bifurcation aneurysms. The level of evidence was assessed via the 2011 Oxford Centre for Evidence-Based Medicine guidelines. Since all included studies were retrospective or observational, the risk of bias was evaluated via Joanna Briggs Institute checklists for cohort and case series studies. A meta-analysis was performed when the data were sufficiently homogeneous; otherwise, a qualitative synthesis was conducted.\u003c/span\u003e\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec4\" class=\"Section2\"\u003e\u003ch2\u003eStatistical analysis\u003c/h2\u003e\u003cp\u003e\u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003eAll the statistical analyses were performed via R (version 4.4.2, R Foundation for Statistical Computing, Vienna, Austria). Proportional meta-analyses were conducted with a random-effects model to estimate pooled rates for follow-up complete occlusion, technical success, good neurological outcome, complications and mortality. Heterogeneity was assessed via I\u0026sup2; statistics, and funnel plots were generated to evaluate publication bias.\u003c/span\u003e\u003c/p\u003e\u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003e\u003cspan type=\"BoldSmallCaps\" class=\"BoldSmallCaps\" name=\"Emphasis\"\u003eFollow-up Complete Occlusion\u003c/span\u003e\u003c/p\u003e\n\u003cp\u003e\u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003eA total of 40 unruptured mycotic aneurysms across six studies were analyzed to assess follow-up complete occlusion after endovascular treatment (EVT). The pooled proportion of complete occlusion\u003c/span\u003e \u003cspan type=\"BoldSmallCaps\" class=\"BoldSmallCaps\" name=\"Emphasis\"\u003e(\u003c/span\u003eFig. \u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003e\u003cspan type=\"BoldSmallCaps\" class=\"BoldSmallCaps\" name=\"Emphasis\"\u003e)\u003c/span\u003e \u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003ewas 100% (95% CI: 95\u0026ndash;100%), indicating that all aneurysms achieved full occlusion at follow-up. There was no observed heterogeneity (I\u0026sup2; = 0.0%, p\u0026thinsp;=\u0026thinsp;1.000), suggesting consistent outcomes across studies. The largest contribution to the pooled estimate came from Serrano et al. (2021), which accounted for 85.9% of the weight, reflecting its larger sample size. The funnel plot\u003c/span\u003e \u003cspan type=\"BoldSmallCaps\" class=\"BoldSmallCaps\" name=\"Emphasis\"\u003e(\u003c/span\u003eFig. \u003cspan class=\"InternalRef\"\u003e2\u003c/span\u003e\u003cspan type=\"BoldSmallCaps\" class=\"BoldSmallCaps\" name=\"Emphasis\"\u003e)\u003c/span\u003e \u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003edemonstrated a symmetrical distribution of studies around the pooled proportion, suggesting that there was no significant publication bias. Given the consistently high occlusion rates, these findings highlight the effectiveness of EVT in achieving aneurysm stability in unruptured mycotic aneurysms.\u003c/span\u003e\u003c/p\u003e\n\u003cp\u003e\u003cspan type=\"BoldSmallCaps\" class=\"BoldSmallCaps\" name=\"Emphasis\"\u003eTechnical Success\u003c/span\u003e\u003c/p\u003e\n\u003cp\u003e\u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003eA total of 40 unruptured mycotic aneurysms across six studies were analyzed to assess their technical success after endovascular treatment (EVT). Technical success was consistent across studies, with a pooled rate of 100% (95% CI: 95\u0026ndash;100%), indicating that all attempted procedures were successfully performed without intraoperative failure\u003c/span\u003e \u003cspan type=\"BoldSmallCaps\" class=\"BoldSmallCaps\" name=\"Emphasis\"\u003e(\u003c/span\u003eFig. \u003cspan class=\"InternalRef\"\u003e3\u003c/span\u003e\u003cspan type=\"BoldSmallCaps\" class=\"BoldSmallCaps\" name=\"Emphasis\"\u003e)\u003c/span\u003e. \u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003eThere was no observed heterogeneity (I\u0026sup2; = 0.0%, p\u0026thinsp;=\u0026thinsp;1.000), suggesting consistent outcomes across studies. The funnel plot\u003c/span\u003e \u003cspan type=\"BoldSmallCaps\" class=\"BoldSmallCaps\" name=\"Emphasis\"\u003e(\u003c/span\u003eFig. \u003cspan class=\"InternalRef\"\u003e4\u003c/span\u003e\u003cspan type=\"BoldSmallCaps\" class=\"BoldSmallCaps\" name=\"Emphasis\"\u003e)\u003c/span\u003e \u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003edemonstrated a symmetrical distribution of studies around the pooled proportion, suggesting that there was no significant publication bias. These findings suggest that EVT is a highly reliable procedure for unruptured mycotic aneurysms, with no reported cases of technical failure in the included studies.\u003c/span\u003e\u003c/p\u003e\n\u003cp\u003e\u003cspan type=\"BoldSmallCaps\" class=\"BoldSmallCaps\" name=\"Emphasis\"\u003eGood functional outcome\u003c/span\u003e\u003c/p\u003e\n\u003cp\u003e\u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003eA total of 17 patients with unruptured mycotic aneurysms from five studies were analyzed to assess functional outcomes following endovascular treatment (EVT). A good functional outcome, defined as a modified Rankin scale (mRS) score of 0\u0026ndash;2, was achieved in 90% of patients (95% CI: 74\u0026ndash;100%). The analysis revealed no significant heterogeneity (I\u0026sup2; = 0.0%, p\u0026thinsp;=\u0026thinsp;0.5415), suggesting consistent results across the included studies\u003c/span\u003e \u003cspan type=\"BoldSmallCaps\" class=\"BoldSmallCaps\" name=\"Emphasis\"\u003e(\u003c/span\u003eFig. \u003cspan class=\"InternalRef\"\u003e5\u003c/span\u003e\u003cspan type=\"BoldSmallCaps\" class=\"BoldSmallCaps\" name=\"Emphasis\"\u003e)\u003c/span\u003e. \u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003eCheng-Ching et al. (2017) and Chapot et al. (2002) contributed the largest weights, accounting for 51.0% and 28.1%, respectively. The funnel plot\u003c/span\u003e \u003cspan type=\"BoldSmallCaps\" class=\"BoldSmallCaps\" name=\"Emphasis\"\u003e(\u003c/span\u003eFig. \u003cspan class=\"InternalRef\"\u003e6\u003c/span\u003e\u003cspan type=\"BoldSmallCaps\" class=\"BoldSmallCaps\" name=\"Emphasis\"\u003e)\u003c/span\u003e \u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003esuggests a moderately symmetrical distribution, indicating no strong evidence of publication bias, although the limited number of studies remains a constraint. These findings indicate that EVT for unruptured mycotic aneurysms is associated with a high likelihood of preserved neurological function.\u003c/span\u003e\u003c/p\u003e\n\u003cp\u003e\u003cspan type=\"BoldSmallCaps\" class=\"BoldSmallCaps\" name=\"Emphasis\"\u003eComplications\u003c/span\u003e\u003c/p\u003e\n\u003cp\u003e\u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003eA total of 18 unruptured mycotic aneurysms from six studies were analyzed for procedural complications following endovascular treatment (EVT). These findings support EVT as a low-risk intervention for unrupture, as adverse events are rare. Only one complication was reported, which occurred in the study by Chapot et al. (2002), contributing 21.5% of the overall weight. All other studies reported no complications. Heterogeneity was minimal (I\u0026sup2; = 0.0%, p\u0026thinsp;=\u0026thinsp;0.9671), reflecting consistent findings across studies\u003c/span\u003e \u003cspan type=\"BoldSmallCaps\" class=\"BoldSmallCaps\" name=\"Emphasis\"\u003e(\u003c/span\u003eFig. \u003cspan class=\"InternalRef\"\u003e7\u003c/span\u003e\u003cspan type=\"BoldSmallCaps\" class=\"BoldSmallCaps\" name=\"Emphasis\"\u003e)\u003c/span\u003e. \u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003eThe funnel plot\u003c/span\u003e \u003cspan type=\"BoldSmallCaps\" class=\"BoldSmallCaps\" name=\"Emphasis\"\u003e(\u003c/span\u003eFig. \u003cspan class=\"InternalRef\"\u003e8\u003c/span\u003e\u003cspan type=\"BoldSmallCaps\" class=\"BoldSmallCaps\" name=\"Emphasis\"\u003e)\u003c/span\u003e \u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003esuggests a symmetrical distribution, indicating no strong evidence of publication bias. These findings support EVT as a low-risk intervention for unruptured mycotic aneurysms, with minimal procedural complications.\u003c/span\u003e\u003c/p\u003e\n\u003cp\u003e\u003cspan type=\"BoldSmallCaps\" class=\"BoldSmallCaps\" name=\"Emphasis\"\u003eMortality\u003c/span\u003e\u003c/p\u003e\n\u003cp\u003e\u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003eA total of 14 unruptured mycotic aneurysms from four studies were analyzed to assess mortality following endovascular treatment (EVT). These findings reinforce EVT as a safe intervention for unruptured patients, with a pooled mortality rate of 0% (95% CI: 0\u0026ndash;13%). Heterogeneity was nonexistent (I\u0026sup2; = 0.0%, p\u0026thinsp;=\u0026thinsp;1.000), indicating that the findings were consistent across studies. Chapot et al. (2002) and Cheng-Ching et al. (2017) contributed the most weight to the analysis, at 48.8% and 36.3%, respectively\u003c/span\u003e \u003cspan type=\"BoldSmallCaps\" class=\"BoldSmallCaps\" name=\"Emphasis\"\u003e(\u003c/span\u003eFig. \u003cspan class=\"InternalRef\"\u003e9\u003c/span\u003e\u003cspan type=\"BoldSmallCaps\" class=\"BoldSmallCaps\" name=\"Emphasis\"\u003e)\u003c/span\u003e. \u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003eThe funnel plot\u003c/span\u003e \u003cspan type=\"BoldSmallCaps\" class=\"BoldSmallCaps\" name=\"Emphasis\"\u003e(\u003c/span\u003eFig. \u003cspan class=\"InternalRef\"\u003e10\u003c/span\u003e\u003cspan type=\"BoldSmallCaps\" class=\"BoldSmallCaps\" name=\"Emphasis\"\u003e)\u003c/span\u003e \u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003edemonstrated a symmetrical distribution, suggesting no publication bias. These findings support EVT as a safe intervention for unruptured mycotic aneurysms, with no treatment-related mortality reported in the literature.\u003c/span\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eIlustrative\u003c/strong\u003e \u003cspan type=\"BoldSmallCaps\" class=\"BoldSmallCaps\" name=\"Emphasis\"\u003ecases\u003c/span\u003e\u003c/p\u003e\n\u003ch3\u003eCase 1 \u0026ndash; Coiling\u003c/h3\u003e\n\u003cp\u003e\u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003eAn adult woman presented\u003c/span\u003e with a sudden-onset \u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003eheadache following weightlifting activity at a gym, associated with blurred vision and right-sided hemiparesis. Head CT revealed diffuse subarachnoid hemorrhage (Fisher grade IV), and she was referred to the interventional neuroradiology service. Digital subtraction angiography (DSA) revealed a dissecting aneurysm in the left posterior cerebral artery (P2 segment). The affected segment was occluded via detachable coils, and the aneurysm was successfully excluded from circulation. The in-hospital workup revealed no evidence of active infection. The patient was discharged after 15 days in good condition. Follow-up imaging at six months\u003c/span\u003e \u003cspan type=\"BoldSmallCaps\" class=\"BoldSmallCaps\" name=\"Emphasis\"\u003e(\u003c/span\u003eFig. \u003cspan class=\"InternalRef\"\u003e11\u003c/span\u003e\u003cspan type=\"BoldSmallCaps\" class=\"BoldSmallCaps\" name=\"Emphasis\"\u003e)\u003c/span\u003e \u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003erevealed recanalization of the left P2 segment with recurrence of the dissecting aneurysm.\u003c/span\u003e\u003c/p\u003e\n\u003ch3\u003eCase 2 \u0026ndash; Flow-Diverter Stenting\u003c/h3\u003e\n\u003cp\u003e\u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003eAn adult male undergoing treatment for bacterial endocarditis was referred to the interventional neuroradiology unit following sudden deterioration in consciousness. Noncontrast head CT revealed right interhemispheric and pericallosal intraparenchymal hemorrhage. DSA identified two dissecting aneurysms: one in the right pericallosal artery (marked in red) and another in the right M4 segment of the middle cerebral artery (marked in yellow). Given the proximal location of the pericallosal aneurysm, parent artery occlusion was avoided to prevent significant neurological deficits. A flow-diverting stent (Silk Vista Baby, Balt\u0026reg;) was deployed to preserve vessel patency and exclude the aneurysm from circulation\u003c/span\u003e \u003cspan type=\"BoldSmallCaps\" class=\"BoldSmallCaps\" name=\"Emphasis\"\u003e(\u003c/span\u003eFig.\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e12\u003c/span\u003e\u003cspan type=\"BoldSmallCaps\" class=\"BoldSmallCaps\" name=\"Emphasis\"\u003e)\u003c/span\u003e. \u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003eThe unruptured M4 aneurysm was managed conservatively with antibiotic therapy alone. The patient had a favorable clinical course. Follow-up DSA at six months revealed a reduction in the size of the M4 aneurysm and complete exclusion of the pericallosal aneurysm, with preservation of normal cerebral circulation.\u003c/span\u003e\u003c/p\u003e\n\u003cdiv id=\"Sec8\" class=\"Section2\"\u003e\n \u003ch2\u003eCase 3 \u0026ndash; Liquid Embolic Agents\u003c/h2\u003e\n \u003cp\u003eAn elderly woman with a history of systemic arterial hypertension and diabetes mellitus presented with acute-onset headache and grade III right hemiparesis. An initial noncontrast axial CT scan revealed a left parietal lobar hemorrhage. CT angiography with maximum intensity projection (MIP) revealed a parietal hematoma with a contrast retention focus (spot sign), suggestive of ongoing bleeding or an underlying vascular lesion \u003cstrong\u003e(Figure 13)\u003c/strong\u003e. DSA revealed a dissecting aneurysm in the M4 segment of the left middle cerebral artery, with radiological features consistent with a mycotic aneurysm (highlighted in red). Owing to its distal location, the parent vessel was completely occluded with a liquid embolic agent (Onyx, Medtronic\u0026reg;). At the six-month follow-up, the patient showed improvement in right hemiparesis to grade IV, and DSA confirmed complete exclusion of the aneurysm with no residual filling.\u003c/p\u003e\n\u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003e\u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003eThis systematic review and meta-analysis examined the technical success, follow-up occlusion rate, complications, functional outcomes, and mortality in patients undergoing endovascular treatment (EVT) for managing mycotic aneurysms (MAs). By conducting an extensive literature review, we compiled relevant clinical studies to provide a robust understanding of the most effective therapeutic strategies for MAs. Our analysis included data from eight studies involving 43 cases of unruptured MAs. Our findings confirm the high reliability of EVT, with complete success in the majority of the included studies, highlighting the efficacy of EVT for unruptured MAs. These results align with those of Batista et al.\u003c/span\u003e [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e], \u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003ewho reported a 100% aneurysm occlusion rate. EVT has proven to be a safe procedure for patients with unruptured MAs, with a low complication rate of only 4%.\u003c/span\u003e\u003c/p\u003e\u003cp\u003e\u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003eOur meta-analysis\u003c/span\u003e \u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003erevealed a neurological success rate of 90% in five out of eight studies, indicating a high level of neurological recovery following EVT. While Batista et al.\u003c/span\u003e [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e] \u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003efocused on ruptured MAs, our study addresses a significant knowledge gap by exclusively analyzing unruptured aneurysms. This focused approach provides further insight into the benefits of EVT as a primary treatment for unruptured cases.\u003c/span\u003e\u003c/p\u003e\u003cp\u003e\u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003eEVT for unruptured MAs is a highly effective approach, primarily utilizing detachable coils and liquid embolic agents such as N-butyl cyanoacrylate (NBCA) and Onyx. Compared with traditional neurosurgery, the American Heart Association (AHA) endorses EVT for its minimally invasive nature\u003c/span\u003e [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. \u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003eEVT offers distinct advantages, particularly for treating proximal aneurysms with coils and distal aneurysms with liquid embolic agents.\u003c/span\u003e [\u003cspan additionalcitationids=\"CR21\" citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e].\u003c/p\u003e\u003cp\u003e\u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003eThe use of flow diverter stents in the treatment of mycotic aneurysms is not standard practice; however, some studies suggest that it may be a viable option in selected cases\u003c/span\u003e [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]. \u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003eGiorgianni et al. conducted a retrospective study and literature review on the use of flow diverters for acutely ruptured intracranial aneurysms, including mycotic aneurysms, reporting a pooled complete occlusion rate of 50% for the latter\u0026mdash;which is lower than that reported for other aneurysm types\u003c/span\u003e [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e]. \u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003eThe American Heart Association/American Stroke Association guidelines highlight the risks associated with flow diverters in ruptured aneurysms, particularly due to the potential for hemorrhagic complications and the requirement for dual antiplatelet therapy\u003c/span\u003e [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e].\u003c/p\u003e\u003cp\u003e\u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003eEVT provides multiple benefits, including the ability to treat multiple aneurysms in a single procedure, reducing the risk of rupture during intervention, and enabling immediate cardiac surgery when necessary. However, EVT may result in partial or complete occlusion of the parent artery, potentially leading to ischemic complications in critical brain areas. Moreover, EVT is not the preferred approach for ruptured aneurysms with increased intracranial pressure and mass effects; in such cases, traditional neurosurgery remains the standard of care\u003c/span\u003e [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e, \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e].\u003c/p\u003e\u003cp\u003e\u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003eA systematic review by Ragulojan et al.\u003c/span\u003e [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e] \u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003erevealed that 35.8% of identified cases involved ruptured aneurysms, underscoring the importance of considering both ruptured and unruptured cases in clinical discussions. Our findings reinforce the consistency of EVT outcomes across diverse patient populations, strengthening its role as a primary treatment option\u003c/span\u003e [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e].\u003c/p\u003e\u003cp\u003e\u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003eOur results demonstrate a high technical success rate and excellent functional outcomes, with 90% of patients achieving positive neurological recovery. While Batista et al.\u003c/span\u003e [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e] \u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003ereported morbidity in 12 patients with ruptured MAs, our study revealed a 0% morbidity rate among patients with unruptured MAs. The low complication rate of 4% further confirms the safety of EVT and aligns with the findings of Batista et al., highlighting the effectiveness of patient selection and management strategies.\u003c/span\u003e\u003c/p\u003e\u003cp\u003e\u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003eRice et al.\u003c/span\u003e [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e] \u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003eexamined the impact of antibiotics on infectious intracranial aneurysms (IIAs) in 618 patients and identified 43 IIAs in 40 individuals (6.5%). Among the 25 unruptured aneurysms monitored without immediate intervention, 44% had unfavorable outcomes, including rupture, new aneurysm formation, or enlargement at a median of 21 days, whereas 28% achieved resolution or regression at a median of 36 days. Notably, prolonged antibiotic therapy before IIA detection was associated with improved angiographic outcomes (p\u0026thinsp;=\u0026thinsp;0.046), suggesting that extended antibiotic exposure may promote aneurysm regression.\u003c/span\u003e\u003c/p\u003e\u003cp\u003e\u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003eSimilarly, Park et al.\u003c/span\u003e [\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e] \u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003eanalyzed the management of IIAs in infective endocarditis (IE) patients, evaluating 12 cases of ruptured IIAs and 13 cases of unruptured IIAs. While all patients received antibiotics, only smaller aneurysms (mean size: 4.1\u0026thinsp;\u0026plusmn;\u0026thinsp;2.2 mm) resolved with medical therapy, whereas larger aneurysms (mean size: 7.5\u0026thinsp;\u0026plusmn;\u0026thinsp;3.1 mm) often required neurosurgical intervention. In total, 16 aneurysms in 12 patients underwent procedures such as parent artery occlusion, endovascular coiling, or microsurgery. Although two patients experienced treatment-related complications, no recurrences or mortalities were reported. These findings suggest that while a 4\u0026ndash;6-week course of antibiotics may be effective for unruptured IIAs, surgical intervention should be considered for ruptured or refractory cases.\u003c/span\u003e\u003c/p\u003e\u003cp\u003e\u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003eAlawieh et al.\u003c/span\u003e [\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e] \u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003eprovided further insights by analyzing 1,714 IE cases and identified intracerebral hemorrhage in 322 patients and IIAs in 17 patients. The presence of IIAs significantly increased the likelihood of death or hospice care (odds ratio: 6.9). Expanding the cohort to include non-IE patients, the study examined 24 individuals with 38 IIAs, predominantly affecting the distal middle cerebral artery. At admission, 16 aneurysms had ruptured. Although antibiotics were initially administered in most cases, nearly 48% of patients required additional interventions within the first two weeks. Surgical approaches included open microsurgery as the primary treatment for five aneurysms and salvage therapy for seven cases following antibiotic failure. Endovascular management was the primary treatment in two patients, and a salvage option was used in five patients. Despite these efforts, the overall prognosis remains poor, with a two-year survival rate of 70%.\u003c/span\u003e\u003c/p\u003e\u003cp\u003e\u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003eTaken together, these studies highlight the complexity of IIA management. While antibiotic therapy plays a crucial role, its effectiveness depends on aneurysm size and disease progression. The high rate of treatment failure, particularly in the early phase, underscores the need for close monitoring. Surgical or endovascular interventions should be considered early in cases with a high risk of rupture or poor response to antibiotics to improve outcomes.\u003c/span\u003e\u003c/p\u003e\u003cp\u003e\u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003eEVT for unruptured MAs is emerging as a highly effective and minimally invasive option. Techniques such as detachable coils and liquid embolic agents are firmly endorsed by the AHA, emphasizing EVT\u0026rsquo;s growing recognition in managing these complex cases\u003c/span\u003e [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. \u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003eEVT enhances patient comfort by allowing procedures to be performed under sedation, minimizing intraoperative risks\u003c/span\u003e [\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e, \u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e]. \u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003eHowever, EVT is not suitable for patients with ruptured aneurysms experiencing increased intracranial pressure; in these cases, traditional neurosurgery remains the preferred approach\u003c/span\u003e [\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e]. \u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003eThe management of MAs continues to be debated, particularly in terms of balancing EVT, surgical intervention, and antibiotic therapy. While EVT is increasingly favored for its minimally invasive nature, traditional surgery remains the gold standard in certain cases, particularly for larger or ruptured aneurysms. The role of antibiotics in promoting aneurysm regression or preventing recurrence remains unclear, with some studies suggesting that prolonged antibiotic therapy may improve outcomes. The lack of consensus on treatment protocols highlights the need for further research to refine management strategies and optimize patient outcomes.\u003c/span\u003e\u003c/p\u003e\u003cp\u003e\u003cspan type=\"BoldSmallCaps\" class=\"BoldSmallCaps\" name=\"Emphasis\"\u003eRecommendations\u003c/span\u003e:\u003c/p\u003e\u003cp\u003e\u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003eOn the basis of our findings, we recommend the initiation of larger multicenter trials that include diverse patient populations to increase the validity of findings related to endovascular therapy (EVT). Long-term follow-up studies should be prioritized to evaluate the safety and effectiveness of EVT, with a focus on monitoring for delayed complications and assessing quality of life. Additionally, clear patient selection guidelines should be developed on the basis of aneurysm characteristics and overall health to optimize treatment outcomes. The training of healthcare professionals in endovascular therapy (EVT) techniques should be improved, and these professionals should be prepared for potential complications. Monitoring systems should be set up to track clinical outcomes and patient satisfaction related to EVT practices. Interdisciplinary collaboration among specialists should be promoted to enhance treatment strategies for mycotic aneurysms. Research into the characteristics of unruptured mycotic aneurysms is encouraged to identify appropriate candidates for EVT and to effectively balance associated risks.\u003c/span\u003e\u003c/p\u003e\u003cp\u003e\u003cspan type=\"BoldSmallCaps\" class=\"BoldSmallCaps\" name=\"Emphasis\"\u003eStrengths\u003c/span\u003e:\u003c/p\u003e\u003cp\u003e\u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003eOur meta-analysis revealed an impressive technical success rate of 90% and outstanding 0% morbidity in patients treated with EVT. These results clearly underscore the effectiveness and safety of the procedure for unruptured cases.\u003c/span\u003e\u003c/p\u003e\u003cp\u003e\u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003eThis article identifies the significant imbalance in research focus between ruptured and unruptured aneurysms, underscoring a crucial gap in our understanding that demands urgent attention and further investigation into unruptured cases.\u003c/span\u003e\u003c/p\u003e\u003cp\u003e\u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003eIn addition, one of the few studies focused exclusively on unruptured mycotic aneurysms, filling a critical gap in the literature. The pooled data demonstrate a high technical success rate and excellent functional outcomes, providing strong evidence for EVT as a primary treatment approach. Furthermore, the study employs rigorous methodological standards, including a systematic search, proportional meta-analysis, and assessment of publication bias, ensuring robust and reliable conclusions. The low complication rate and absence of mortality further highlight the potential of EVT as a safe intervention.\u003c/span\u003e\u003c/p\u003e\u003cp\u003e\u003cspan type=\"BoldSmallCaps\" class=\"BoldSmallCaps\" name=\"Emphasis\"\u003eClinical Illustration\u003c/span\u003e\u003c/p\u003e\u003cp\u003e\u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003eIn addition to the studies included in this review, we present illustrative imaging from one of the study authors, highlighting a case of a previously ruptured mycotic aneurysm treated with endovascular coiling that recurred as unruptured on follow-up imaging (\u003c/span\u003eFigs.\u0026nbsp;\u003cspan refid=\"Fig11\" class=\"InternalRef\"\u003e11\u003c/span\u003e,\u003cspan refid=\"Fig12\" class=\"InternalRef\"\u003e12\u003c/span\u003e\u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003e). Although this case was not included in the meta-analysis because of its initial rupture status, it serves as a valuable clinical example supporting the central themes of our findings. Specifically, these findings demonstrate the feasibility and durability of endovascular treatment (EVT) in achieving initial aneurysm control, as well as the importance of long-term surveillance, given the potential for recurrence. The unruptured status of the recurrent aneurysm aligns with the population assessed in our analysis and offers a practical reminder that unruptured mycotic aneurysms may emerge even after prior intervention. This case also emphasizes the dynamic nature of aneurysm behavior and underscores the need for individualized follow-up and potential retreatment strategies in selected cases. As the field continues to evolve, such clinical examples offer meaningful context and help bridge the gap between aggregated data and real-world management of these rare vascular lesions.\u003c/span\u003e\u003c/p\u003e\u003cp\u003e\u003cspan type=\"BoldSmallCaps\" class=\"BoldSmallCaps\" name=\"Emphasis\"\u003eLimitations\u003c/span\u003e:\u003c/p\u003e\u003cp\u003e\u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003eDespite its strengths, this study is limited by the small number of included cases (43 aneurysms across seven studies), which restricts the generalizability of the findings. The included studies were predominantly retrospective, introducing the potential for selection bias. Additionally, the lack of long-term follow-up data makes it difficult to assess the durability of EVT and the risk of late complications or recurrence. Another limitation is the heterogeneity in treatment protocols, including variations in the use of antibiotics and EVT techniques, which may affect outcome comparability. Finally, while publication bias was assessed, the small sample size may have limited the ability to detect bias effectively.\u003c/span\u003e\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003e\u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003eThis meta-analysis provides compelling evidence supporting the safety and efficacy of endovascular treatment (EVT) for unruptured mycotic aneurysms. The findings indicate a 100% technical success rate and complete occlusion in all treated patients, reinforcing EVT as a reliable and effective intervention. The complication rate was notably low at 4%, with no reported mortality, and the vast majority of patients achieved favorable functional outcomes. These results suggest that EVT is a viable first-line treatment option for unruptured mycotic aneurysms, offering a minimally invasive alternative to open surgery while preserving neurological function.\u003c/span\u003e\u003c/p\u003e\u003cp\u003e\u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003eHowever, despite promising outcomes, this study highlights significant gaps in the current understanding of EVT for mycotic aneurysms. The scarcity of large-scale studies and the predominance of retrospective data necessitate further research, particularly prospective trials, to establish long-term safety and efficacy. Additionally, the role of antibiotic therapy in combination with EVT remains an area requiring further investigation. Future studies should aim to refine patient selection criteria, evaluate the durability of EVT outcomes, and compare EVT with other management strategies to develop comprehensive, evidence-based treatment guidelines.\u003c/span\u003e\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cdiv class=\"DefinitionList\"\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eMA\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eMycotic Aneurysm\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eCT\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eComputed Tomography\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eMRI\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eMagnetic Resonance Imaging\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eMRA\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eMagnetic Resonance Angiography\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eUS\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eUltrasound\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eHIV\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eHuman Immunodeficiency Virus\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eTB\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eTuberculosis\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eEVD\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eExternal Ventricular Drain\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eCNS\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eCentral Nervous System\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eCRP\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eC-Reactive Protein\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eWBC\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eWhite Blood Cell count\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003c/div\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eCompliance with journal guidelines:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis manuscript complies with all the author instructions provided by the journal.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthorship and approval:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll authors meet the authorship criteria as per the ICMJE guidelines. The final version of the manuscript has been reviewed and approved by all the authors prior to submission.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eOriginality statement:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe confirm that this manuscript has not been published elsewhere and is not under consideration for publication in any other journal.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eUse of reporting checklist:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis systematic review follows the PRISMA reporting guidelines to ensure methodological transparency and rigor.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConflict of interest (COI):\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no conflicts of interest related to this study. COI disclosure forms have been collected in accordance with ICMJE guidelines and are available upon request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthical considerations:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAs this study is a systematic review based on previously published data, it does not require ethical approval or informed consent.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding statement:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study did not receive any financial support.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eMankotia DS, Sinha S, Sharma BS (2018) Ruptured distal middle cerebral artery mycotic aneurysm: A rare, first presentation of infective endocarditis. Asian J Neurosurg 13(1):113\u0026ndash;115\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eKannoth S, Thomas SV (2009) Intracranial microbial aneurysm (infectious aneurysm): current options for diagnosis and management. Neurocrit Care 11(1):120\u0026ndash;129\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eAlawieh A, Chaudry MI, Turner RD, Turk AS, Spiotta AM (2018) Infectious intracranial aneurysms: a systematic review of epidemiology, management, and outcomes. J Neurointerv Surg 10(7):708\u0026ndash;716\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eCalder\u0026oacute;n-Parra J, Dom\u0026iacute;nguez F, Gonz\u0026aacute;lez-Rico C, Arnaiz de Las Revillas F, Goenaga M\u0026Aacute;, Alvarez I et al (2024) Epidemiology and risk factors of mycotic aneurysm in patients with infective endocarditis and the impact of its rupture in outcomes. Analysis of a national prospective cohort. Open Forum Infect Dis 11(3):ofae121\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eLee WK, Mossop PJ, Little AF, Fitt GJ, Vrazas JI, Hoang JK et al (2008) Infected (mycotic) aneurysms: spectrum of imaging appearances and management. Radiographics 28(7):1853\u0026ndash;1868\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eBrown SL, Busuttil RW, Baker JD, Machleder HI, Moore WS, Barker WF (1984) Bacteriologic and surgical determinants of survival in patients with mycotic aneurysms. J Vasc Surg 01(4):541\u0026ndash;547\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eKaufman SL, White RI Jr, Harrington DP, Barth KH, Siegelman SS (1978) Protean manifestations of mycotic aneurysms. AJR Am J Roentgenol 131(6):1019\u0026ndash;1025\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eNakata Y, Shionoya S, Kamiya K (1968) Pathogenesis of mycotic aneurysm. Angiology 19(10):593\u0026ndash;601\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eKordzadeh A, Kalyan JP, Jonas A, Hanif MA, Prionidis I (2015) Cryptogenic mycotic aneurysm of the superior mesenteric artery. 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Available from: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttp://dx.doi.org/10.3389/fstro.2024.1450650\u003c/span\u003e\u003cspan address=\"10.3389/fstro.2024.1450650\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"},{"header":"Tables","content":"\u003cp\u003eTables 1 to 4 are available in the Supplementary Files section.\u003c/p\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":true,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Mycotic aneurysm, Infected aneurysm, Endovascular aneurysm repair, Stent, Antibiotics","lastPublishedDoi":"10.21203/rs.3.rs-6585801/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6585801/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground:\u003c/h2\u003e\u003cp\u003e\u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003eMycotic aneurysms (MAs) are rare, life-threatening vascular complications of systemic infections that are most commonly associated with endocarditis. While the majority of research has focused on ruptured MAs, the role of endovascular treatment (EVT) in managing unruptured cases remains unclear. Given the limited availability of data specific to unruptured MAs, we conducted a systematic review and meta-analysis to evaluate the outcomes of EVT in this subgroup, with a focus on technical success, follow-up occlusion, complications, functional outcomes, and mortality.\u003c/span\u003e\u003c/p\u003e\u003ch2\u003eMethods:\u003c/h2\u003e\u003cp\u003e\u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003eA comprehensive literature search was conducted in PubMed, EMBASE, and Web of Science to identify studies reporting outcomes of EVT in unruptured MAs. Screening and full-text review were performed via Rayyan AI, and data extraction was conducted via Microsoft Excel. We included studies that explicitly reported outcomes for unruptured cases, and a proportional meta-analysis was performed via a random-effects model in R 4.4.2, with publication bias assessed via a funnel plot.\u003c/span\u003e\u003c/p\u003e\u003ch2\u003eResults:\u003c/h2\u003e\u003cp\u003e\u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003eA total of eight studies with 43 unruptured mycotic aneurysms met the inclusion criteria. EVT demonstrated excellent procedural success, whereas endovascular procedures achieved universal technical success and complete occlusion at follow-up (both 100%; 95% CI: 95\u0026ndash;100%). Complications were rare, occurring in only 4% of the patients (95% CI: 0\u0026ndash;17%). The functional outcomes were favorable, with 90% of patients achieving mRS 0 or GOS 5 at follow-up (95% CI: 74\u0026ndash;100%), indicating a high likelihood of preserved neurological function posttreatment. No mortality was reported among the unruptured patients (0%, 95% CI: 0\u0026ndash;13%), further supporting the safety profile of EVT in this patient population.\u003c/span\u003e\u003c/p\u003e\u003ch2\u003eConclusion:\u003c/h2\u003e\u003cp\u003e\u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003eEVT appears to be a safe and effective treatment for unruptured mycotic aneurysms, with high technical and angiographic success rates, low complication rates, and favorable functional outcomes. However, data on unruptured cases remain scarce, as most of the available literature has focused primarily on ruptured MAs. This underscores the need for larger studies and prospective data collection to better define the role of EVT in managing these rare lesions.\u003c/span\u003e\u003c/p\u003e","manuscriptTitle":"Endovascular Treatment for Unruptured Mycotic Aneurysms: A Systematic Review and Meta-Analysis","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-08-12 12:54:19","doi":"10.21203/rs.3.rs-6585801/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"59014483-2cef-4ad6-847b-d7fb52269991","owner":[],"postedDate":"August 12th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2025-08-12T12:54:19+00:00","versionOfRecord":[],"versionCreatedAt":"2025-08-12 12:54:19","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-6585801","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6585801","identity":"rs-6585801","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}