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Calderón-Parra J, Domínguez F, González-Rico C, Arnaiz de las Revillas F, Goenaga MÁ, Alvarez I, Muñoz P, Alonso D, Rodríguez-García R, Miró JM, De Alarcón A, Antorrena I, Goikoetxea-Agirre J, Moral-Escudero E, Ojeda-Burgos G, Ramos-Martínez A. 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 2024; 11:ofae121. [PMID: 38500574 PMCID: PMC10946656 DOI: 10.1093/ofid/ofae121] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2023] [Accepted: 03/12/2024] [Indexed: 03/20/2024] Open
Abstract
Background Several aspects of the occurrence and management of mycotic aneurysm (MA) in patients with infective endocarditis (IE) have not been studied. Objectives To determine the incidence and factors associated with MA presence and rupture and to assess the evolution of those initially unruptured MA. Methods Prospective multicenter cohort including all patients with definite IE between January 2008 and December 2020. Results Of 4548 IE cases, 85 (1.9%) developed MA. Forty-six (54.1%) had intracranial MA and 39 (45.9%) extracranial MA. Rupture of MA occurred in 39 patients (45.9%). Patients with ruptured MA had higher 1-year mortality (hazard ratio, 2.33; 95% confidence interval, 1.49-3.67). Of the 55 patients with initially unruptured MA, 9 (16.4%) presented rupture after a median of 3 days (interquartile range, 1-7) after diagnosis, being more frequent in intracranial MA (32% vs 3.3%, P = .004). Of patients with initially unruptured MA, there was a trend toward better outcomes among those who received early specific intervention, including lower follow-up rupture (7.1% vs 25.0%, P = .170), higher rate of aneurysm resolution in control imaging (66.7% vs 31.3%, P = .087), lower MA-related mortality (7.1% vs 16.7%, P = .232), and lower MA-related sequalae (0% vs 27.8%, P = .045). Conclusions MA occurred in 2% of the patients with IE. Half of the Mas occurred in an intracranial location. Their rupture is frequent and associated with poor prognosis. A significant proportion of initially unruptured aneurysms result from rupture during the first several days, being more common in intracranial aneurysms. Early specific treatment could potentially lead to better outcomes.
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Affiliation(s)
- Jorge Calderón-Parra
- Infectious Diseases Unit, Department of Internal Medicine, Puerta de Hierro University Hospital, Majadahonda, Spain
- Research Institute Puerta de Hierro-Segovia de Arana (IDIPHSA), Majadahonda, Spain
| | - Fernando Domínguez
- Research Institute Puerta de Hierro-Segovia de Arana (IDIPHSA), Majadahonda, Spain
- Department of Cardiology, Puerta de Hierro University Hospital, Majadahonda, Spain
| | - Claudia González-Rico
- Department of Infectious Diseases, University Hospital Marqués de Valdecilla, CIBER Infectious Diseases (CIBERINFEC, CB21/13/00068). Cantabria University, Santander, Spain
| | - Francisco Arnaiz de las Revillas
- Department of Infectious Diseases, University Hospital Marqués de Valdecilla, CIBER Infectious Diseases (CIBERINFEC, CB21/13/00068). Cantabria University, Santander, Spain
| | | | - I Alvarez
- Department of Infectious Diseases, OSI Donostialdea, San Sebastian, Spain
| | - Patricia Muñoz
- Department of Microbiology and Infectious Diseases, University Hospital Gregorio Marañón, CIBER Respiratory Diseases (CIBERES, CB06/06/0058), Complutense University, Madrid, Spain
| | - David Alonso
- Department of Microbiology and Infectious Diseases, University Hospital Gregorio Marañón, CIBER Respiratory Diseases (CIBERES, CB06/06/0058), Complutense University, Madrid, Spain
| | | | - José María Miró
- Department of Infectious Diseases, Clinic Hospital—IDIBAPS, University of Barcelona, Barcelona, Spain
| | - Arístides De Alarcón
- Infectious Diseases, Microbiology, and Parasitology Unit, University Hospital Virgen del Rocio, Seville University, Seville, Spain
| | - Isabel Antorrena
- Cardiology Department, University Hospital La Paz- IDIPAZ, Madrid, Spain
| | | | | | | | - Antonio Ramos-Martínez
- Infectious Diseases Unit, Department of Internal Medicine, Puerta de Hierro University Hospital, Majadahonda, Spain
- Research Institute Puerta de Hierro-Segovia de Arana (IDIPHSA), Majadahonda, Spain
- Faculty of Medicine, Autónoma University of Madrid, Madrid, Spain
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Consoli A, Coskun O, Perier M, Di Maria F, Gratieux J, Dean P, Pizzuto S, Badat N, Condette-Auliac S, Boulin A, Rodesch G. [Therapeutic and endovascular management of cerebral mycotic aneurysms]. Ann Cardiol Angeiol (Paris) 2020; 69:411-414. [PMID: 33131724 DOI: 10.1016/j.ancard.2020.10.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2020] [Accepted: 10/04/2020] [Indexed: 11/15/2022]
Abstract
Infective endocardites are associated with both ischemic and hemorrhagic neurological complications and also with cerebral abscesses and the development of "mycotic" aneurysms, which are detected in about 5 % of patients in the acute and sub-acute phase of the infection. Data about their natural history and their hemorrhagic risk are scarce and fragmented. The therapeutic management is represented by the medical treatment of the infection with interventional abstention, the surgical treatment and the endovascular approach by selective embolization of the aneurysm. No evidence is provided concerning the superiority of a specific approach. Mycotic aneurysms remain a diagnostic and therapeutic challenge and their management is necessarily based on a multidiscplinary approach.
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Affiliation(s)
- A Consoli
- Service de neuroradiologie diagnostique et thérapeutique, hôpital Foch, 40, rue Worth, 92151, Suresnes, France.
| | - O Coskun
- Service de neuroradiologie diagnostique et thérapeutique, hôpital Foch, 40, rue Worth, 92151, Suresnes, France
| | - M Perier
- Service de cardiologie, hôpital Foch, 40, rue Worth, 92151, Suresnes, France
| | - F Di Maria
- Service de neuroradiologie diagnostique et thérapeutique, hôpital Foch, 40, rue Worth, 92151, Suresnes, France
| | - J Gratieux
- Service de neuroradiologie diagnostique et thérapeutique, hôpital Foch, 40, rue Worth, 92151, Suresnes, France
| | - P Dean
- Service de neuroradiologie diagnostique et thérapeutique, hôpital Foch, 40, rue Worth, 92151, Suresnes, France
| | - S Pizzuto
- Unité de neuroradiologie, ospedale Civile S.Agostino-Estense, CHU Modène, université de Modène et Reggio Emilia, Via Pietro Giardini 1355, Modène, Baggiovara, 41126, Italie
| | - N Badat
- Service de neuroradiologie diagnostique et thérapeutique, hôpital Foch, 40, rue Worth, 92151, Suresnes, France
| | - S Condette-Auliac
- Service de neuroradiologie diagnostique et thérapeutique, hôpital Foch, 40, rue Worth, 92151, Suresnes, France
| | - A Boulin
- Service de neuroradiologie diagnostique et thérapeutique, hôpital Foch, 40, rue Worth, 92151, Suresnes, France
| | - G Rodesch
- Service de neuroradiologie diagnostique et thérapeutique, hôpital Foch, 40, rue Worth, 92151, Suresnes, France
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Iatrogenic Intracranial Aneurysm After External Ventricular Drain Placement: Traumatic or Mycotic Origin? Case Report and Literature Review. World Neurosurg 2020; 143:214-218. [PMID: 32750512 DOI: 10.1016/j.wneu.2020.07.179] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2020] [Revised: 07/23/2020] [Accepted: 07/26/2020] [Indexed: 11/23/2022]
Abstract
BACKGROUND Intracranial iatrogenic aneurysms (IIAs) developing after external ventricular drain (EVD) placement or removal have been only rarely reported. Most of these reports assumed a traumatic etiology; however, some have demonstrated an inflammatory origin. We have presented the case of an IIA that developed after an EVD had been inserted to treat acute hydrocephalus secondary to a ruptured arteriovenous malformation. We also performed a literature review and discussed how these IIAs might have an inflammatory rather than a traumatic etiology and how they might lie behind some of the cases of idiopathic hemorrhage observed after EVD manipulation. CASE DESCRIPTION A 48-year-old woman had presented with acute hydrocephalus secondary to bleeding from a vermian arteriovenous malformation. The EVD inserted for hydrocephalus management required several revisions because of malfunction. Four weeks later, a diagnostic arteriogram had incidentally revealed the existence of a 5-mm aneurysm in an anterior branch of the right callosomarginal artery, coincidental to the EVD trajectory. The patient underwent emergent endovascular treatment of the aneurysm, with complete occlusion and no complications deriving from the procedure. CONCLUSIONS IIAs associated with EVD placement or removal have been described as a rare complication of the procedure. Despite the scarce number of cases reported and the lack of histological examinations, common features such as a distal location, an incidental diagnosis, and a benign clinical course might suggest a mycotic or inflammatory origin rather than a traumatic etiology. Considering the high volume of EVDs placed annually, this complication might be more frequent than reported. Further studies investigating the association of risk factors for inflammatory aneurysms and hemorrhage incidence after EVD could provide information on this intriguing topic.
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Qian H, Wang L, Brooks KS, Zhao X, Shi X, Lei T. MCA-to-MCA Bypass with Interposition Graft for Ruptured Mycotic Middle Cerebral Artery Aneurysm. World Neurosurg 2018; 122:195. [PMID: 30391761 DOI: 10.1016/j.wneu.2018.10.167] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2018] [Revised: 10/22/2018] [Accepted: 10/23/2018] [Indexed: 12/27/2022]
Abstract
Mycotic aneurysm, also referred to as infected aneurysm, is a rare entity that may result from the bacterial infection or infective endocarditis.1-3 The treatment options include conservative medication and endovascular or direct microsurgical intervention.1,4,5 However, the optimal strategy remains unknown and cerebral revascularization may be required in some rare cases.6 In this surgical video, we demonstrate a distal middle cerebral artery (MCA) mycotic aneurysm that we treated by intracranial-intracranial bypass with an interpositional graft. Our patient is a 53-year-old male who presented with a 6-day history of severe headache. He was subsequently admitted to our institution. Preoperative computed tomography angiography showed a left temporal hematoma (>30 mL) and an opercular segment of the MCA (M3) aneurysm, which was highly suspicious for mycotic origin. A standard frontotemporal craniotomy was carried out with preservation of superficial temporal artery (STA). Following the sylvian fissure dissection, the aneurysm was exposed with the characteristics of a thick wall and an undefinable neck, which made direct clip application difficult. The aneurysm was resected initially, and 2 cut ends were reconnected by an STA graft. Following arterial reconstruction, intraoperative Doppler revealed a patent status of the interpositional graft vessel. Postoperatively, no neurologic deficit was observed and computed tomography angiography demonstrated total elimination of the aneurysm without stenosis of the graft vessel. Low-molecular dextran was prescribed rather than aspirin, as there was concern for hemorrhage. Antibiotic treatment was used for at least 4 weeks, and the patient was transferred to the inpatient cardiology team for management of endocarditis. A 4-month follow-up angiogram showed a patent STA and excellent left distal MCA blood flow (Video 1). The favorable outcome of this case revealed that MCA-to-MCA bypass with interpositional graft is a safe, effective method for the unclippable cerebral aneurysm. As other authors have asserted, a full dose of long-term antibiotic therapy remains essential following intervention.7 Meanwhile, dextran has proved to be a viable alternative for anticoagulation during perioperative management of bypass surgery.8,9.
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Affiliation(s)
- Hai Qian
- Department of Neurosurgery, Sanbo Brain Hospital, Capital Medical University, Beijing, People's Republic of China
| | - Long Wang
- Department of Neurosurgery, Sanbo Brain Hospital, Capital Medical University, Beijing, People's Republic of China
| | | | - Xiaochun Zhao
- Department of Neurosurgery, Sanbo Brain Hospital, Capital Medical University, Beijing, People's Republic of China
| | - Xiang'en Shi
- Department of Neurosurgery, Sanbo Brain Hospital, Capital Medical University, Beijing, People's Republic of China
| | - Ting Lei
- Department of Neurosurgery, Sanbo Brain Hospital, Capital Medical University, Beijing, People's Republic of China.
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Alawieh A, Chaudry MI, Turner RD, Turk AS, Spiotta AM. Infectious intracranial aneurysms: a systematic review of epidemiology, management, and outcomes. J Neurointerv Surg 2018; 10:708-716. [DOI: 10.1136/neurintsurg-2017-013603] [Citation(s) in RCA: 34] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2017] [Revised: 01/16/2018] [Accepted: 01/24/2018] [Indexed: 12/27/2022]
Abstract
Infectious intracranial aneurysms (IIAs) are a rare cerebrovascular complication of systemic infections induced by microbial infiltration and degradation of the arterial vessel wall. Studies on the epidemiology and management of IIAs are limited to case reports and retrospective single-center studies, and report a large variability in epidemiological features, management, and outcomes due to the limited sample size. We conducted a systematic review of all published papers on IIAs in the English literature using MEDLINE and SCOPUS database from January 1950 to June 2017. A total of 288 publications describing 1191 patients with IIA (1398 aneurysms) were included and reviewed for epidemiological features, disease features, treatment and outcome. All patients were merged into a single cohort and summary data are presented. The majority of reported IIAs are distally located, relatively small (<5 mm), involve the anterior circulation, are associated with a relatively high rate of rupture, and demonstrate a propensity to multiplicity of aneurysms. Sensitive diagnosis of IIAs requires digital subtraction angiography and not CT angiography or MR angiography. Treatment of ruptured, symptomatic, or enlarging IIAs has evolved over the last 50 years. Endovascular therapy is associated with a high success rate and low morbidity compared with microsurgical and medical management. A treatment algorithm for the management of patients with IIA in various contexts is proposed and the need for prospective multicenter studies is emphasized.
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Initial Treatment Strategy for Intracranial Mycotic Aneurysms: 2 Case Reports and Literature Review. World Neurosurg 2017; 106:1051.e9-1051.e16. [DOI: 10.1016/j.wneu.2017.07.016] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2017] [Revised: 06/30/2017] [Accepted: 07/03/2017] [Indexed: 11/19/2022]
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