Abstract 1122‐000053: Trends in Intervention Modality for Patients with Mycotic Aneurysms: A Nationwide Analysis

Introduction : Mycotic aneurysms, also known as infectious intracranial aneurysms, are sometimes responsible for intracranial hemorrhage in patients with infective endocarditis. Data regarding when and how to treat mycotic aneurysms most effectively are sparse. Given the widespread adoption of endovascular treatments for non‐infectious intracranial aneurysms and acute stroke, we hypothesized that endovascular treatment is increasingly utilized for patients with mycotic aneurysms. We examined trends in endovascular versus open neurosurgical treatment of mycotic aneurysms in patients with infective endocarditis. Methods : We performed a trends analysis using data from 2000–2015 from the National Inpatient Sample. The National Inpatient Sample is an all‐payer database that includes data for a representative sample of hospitalizations to non‐federal hospitals in the United States. We included all hospitalizations for patients with ruptured (on the basis of subarachnoid hemorrhage) or unruptured cerebral aneurysms alongside a diagnosis of infective endocarditis; diagnoses were ascertained using ICD‐9‐CM codes. Treatment modalities were categorized as endovascular versus open neurosurgical repair based on ICD‐9‐CM procedure codes. National Inpatient Sample survey weights were used to calculate nationally representative estimates. Logistic regression was used to evaluate the association between calendar year and intervention rate, presented as an odds ratio for each additional year. Results : We identified 1,015 hospitalizations for patients with a ruptured or unruptured cerebral aneurysm in the setting of infective endocarditis. Their mean age was 54.6 years (SD, 16.6), and 60.1% were male. The overall rate of intervention was 11.9% (95% CI, 9.6‐14.2%), and this rate did not change appreciably over time (p = 0.772). In comparing intervention modalities over time, there was a decrease in open neurosurgical repair (OR, 0.89; 95% CI, 0.84‐0.95; p = 0.001), offset by an increase in endovascular repair (OR, 1.07; 95% CI, 1.01‐1.14; p = 0.023) (Figure). Conclusions : Rates of mycotic aneurysm intervention during hospitalizations for infective endocarditis have not changed. However, the use of endovascular treatment has become more commonplace while the use of open neurosurgical treatments has decreased. Further directions include understanding whether this shift has improved patients’ outcomes and ultimately enumerating best practices for patients with mycotic aneurysms.

Abstract TP450: Characteristics and Disability Outcomes of Left Ventricular-Assist Device Associated Cerebrovascular Events in Setting of Infectious Intracranial Aneurysms: A Retrospective Single Center Study

Introduction: Stroke and infection are among the more common complications of LVAD therapy related to higher rates of mortality. The characteristics and disability outcomes of LVAD-associated cerebrovascular events and infections, particularly in the setting of infectious intracranial aneurysms (IIA), have not been defined. Methods: A single-center retrospective review of patients having undergone LVAD implantation between 2011-2017 was conducted using institutional registries and screened for hemorrhagic and ischemic strokes. Patients with hemorrhagic stroke were assessed for concurrent bacteremia; neurovascular imaging was then used to isolate patients with associated IIA. Review of comorbidities, imaging characteristics, and management were performed to determine predictors of disability outcomes, as defined by 90-day modified Rankin scales (mRS). Results: Of 383 patients with HeartMate II LVAD implantation, 46 all-cause stroke events were identified across 38 (12%) patients. 31 ICH events were identified, with 22 complicated by bacteremia (evidenced by chronic driveline infection and/or positive blood cultures on admission). Of patients with ICH and bacteremia, Staphylococcus aureus (n=12, 54.5%) and Pseudomonas aeruginosa (n= 10, 45.5%) infection were the highest associated causal organisms; severe disability or death (90-day mRS > 4) was seen in 16 (72.7%) patients. 7 (31.8 %) patients had confirmed findings of IIA on diagnostic cerebral angiogram, and were associated with distal MCA territory involvement (100%), concurrent Pseudomonas infection (83.3%), and INR > 3.0 (66.7%). Despite endovascular intervention in patients with IIA, 4 patients failed management and were withdrawn from care. Conclusion: Our results indicate Pseudomonas aeruginosa and Staphylococcus aureus bacteremia are associated with greater incidence of hemorrhage and neurological disability. Further investigation is warranted to better define management of these patients. Future considerations may include pre-implantation cerebrovascular imaging to assess for vascular pathology as a screen for higher risk patients, as well as more aggressive antibiotic therapy at bacteremia onset.