Initial Treatment Strategy for Intracranial Mycotic Aneurysms: 2 Case Reports and Literature Review

Culture Negative Infective Endocarditis Atypically Diagnosed From Mycotic Cerebral Aneurysm

Cerebral mycotic aneurysms (CMA) are a rare consequence of infective endocarditis (IE). We report a case of a 75-year-old left-handed male with comorbidities who was admitted to our facility with left-sided weakness, dysarthria, and left-sided facial droop. Initial computed tomography of the head without contrast and angiography of the head showed acute hemorrhage in the paramedian right frontal lobe with extension into the right lateral ventricle, occlusion of the left intracranial internal carotid artery, and an associated 0.3 cm aneurysm involving the distal right anterior cerebral artery. C-reactive protein and erythrocyte sedimentation rate were elevated but blood cultures showed no growth for more than five days. The patient underwent a two-vessel cerebral angiogram, primary coil embolization of the aneurysm, and selective catheterization of the left common carotid artery, right internal carotid artery, and right anterior cerebral artery. Transesophageal echocardiography showed an echogenic, highly mobile structure attached to the aortic valve suggestive of vegetation. The patient was subsequently started on a vancomycin regimen and stably discharged for further outpatient follow-up. This case highlights an uncommon presentation of CMA and the retroactive diagnosis of IE.

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

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.

Unusual Intracranial Manifestation of Infective Endocarditis

Objective:

The mycotic aneurysm is a rare intracranial pathology seen with pre-existing infective endocarditis. It has a high mortality rate due to its risk of rupture and needs early diagnosis and treatment.

Methods:

A 23-year male patient who presented with infective endocarditis subsequently developed a left parietal-temporal intracranial haemorrhage with suspicion of aneurysm after the course of antibiotic treatment as seen on Computed Tomography (CT) scan. Digital Subtraction Angiography (DSA) revealed a ruptured fusosaccular aneurysm in the distal parietal branches of the left Middle Cerebral Artery (MCA), for which glue embolization of the distal parent artery and aneurysm was done.

Result:

The interventional endovascular procedure was done with complete obliteration of the distal parent artery, mycotic aneurysm, and normal filling of the left internal cerebral artery (ICA) branches.

Conclusion:

Mycotic intracranial aneurysms (MIA) are a rare form of cerebrovascular pathology which needs early diagnosis with endovascular intervention when rupture occurs.

Endovascular treatment of infectious intracranial aneurysms complicating infective endocarditis: a series of 31 patients with 55 aneurysms

PURPOSE

Endovascular treatment (EVT) has become a major option in management of infectious intracranial aneurysms (IIAs) complicating infective endocarditis. We report a retrospective, single-center series of consecutive patients with IIAs treated by EVT.

METHODS

Patients were included from January 2009 to July 2020. IIAs were diagnosed on DSA. Each patient underwent a neurological assessment before and after EVT and was followed up by imaging within 15 days of EVT. Safety was assessed on the evolution of NIHSS score. A minor stroke was defined as a worsening of NIHSS < 4 points. Efficacy was defined as the absence of hemorrhagic event during cardiac surgery and the exclusion of the IIA on control imaging.

RESULTS

Sixty-two IIAs (30 ruptured) were diagnosed in 31 patients. Fifty-six IIAs were diagnosed on the first DSA and 6 on the early control exploration. EVT was achieved in 55 IIAs by parent artery occlusion with glue in 52 distal IIAs and coils in 3 proximal IIAs. IIAs were located in 90.9% of cases on a fourth-division branch of a cerebral artery. The neurological examination remained unchanged in 29 patients (93.5%), and 2 patients suffered minor stroke. EVT was performed before cardiac surgery in 20/22 patients. All treated IIAs were excluded on follow-up imaging. No hemorrhage was observed during cardiac surgery or in the aftermath. Seven (11.3%) unruptured IIAs were not embolized.

CONCLUSION

EVT of IIAs by occlusion of the parent artery is effective in preventing rupture and carries no significant neurological risk.

Iatrogenic Intracranial Aneurysm After External Ventricular Drain Placement: Traumatic or Mycotic Origin? Case Report and Literature Review

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.

Extra-cardiac endovascular infections in the critically ill

Vascular infections are associated with high complication rates and mortality. While there is an extensive body of literature surrounding cardiac infections including endocarditis, this is less so the case for other endovascular infections. The objective of this narrative review is to summarize the epidemiology, clinical features, and selected management of severe vascular infections exclusive of those involving the heart. Endovascular infections may involve either the arterial or venous vasculature and may arise in native vessels or secondary to implanted devices. Management is complex and requires multi-disciplinary involvement from the outset. Infective arteritis or device-related arterial infection involves removal of the infected tissue or device. In cases where complete excision is not possible, prolonged courses of antimicrobials are required. Serious infections associated with the venous system include septic thrombophlebitis of the internal jugular and other deep veins, and intracranial/venous sinuses. Source control is of paramount importance in these cases with adjunctive antimicrobial therapy. The role of anticoagulation is controversial although recommended in the absence of contraindications. An improved understanding of the management of these infections, and thus improved patient outcomes, requires multi-center, international collaboration.

Successful treatment of giant cavernous carotid artery aneurysm in a child using a flow diverter stent

Giant intracranial aneurysms are extremely rare in children. We present such a case, describe angiographic appearances and successful treatment using a flow diverter stent.