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Shen Y, Hu F, Wu L, Nie H. Concomitant rapidly growing aneurysm of intracavernous carotid artery and cavernous sinus thrombosis: Case report and review of the literature. Medicine (Baltimore) 2024; 103:e39022. [PMID: 39058832 PMCID: PMC11272256 DOI: 10.1097/md.0000000000039022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/26/2024] [Accepted: 07/01/2024] [Indexed: 07/28/2024] Open
Abstract
RATIONALE Intracavernous infectious aneurysm (ICIA), represents a rare entity that is always described in the form of case reports in the literature. The coexistence of ICIA and cavernous sinus thrombosis (CST) is extremely rare and poorly understood. PATIENT CONCERNS A 53-year-old female patient presented to our hospital with headache, nausea and fatigue for 3 weeks. She complained of blurry vision and drooping eyelids before admission. Neurological examination revealed bilateral decreased visual acuity, limitation of extraocular movements and decreased sensation of forehead. Brain magnetic resonance imaging (MRI) showed mixed signal intensities in both cavernous sinuses and expansion of right superior ophthalmic vein, suggesting the formation of CST. One month later, computed tomography angiography (CTA) confirmed a large aneurysm was attached to the left intracavernous carotid artery (ICCA). DIAGNOESE This patient was diagnosed with ICIA and CST. INTERVENTIONS She was administered with intravenous meropenem and vancomycin and subcutaneous injection of low molecular heparin for 4 weeks. OUTCOMES One month later, her extraocular movement had significantly improved, without ptosis and conjunctival congestion. At 1-year follow-up, her ophthalmoplegia fully recovered. Fortunately, such large aneurysm did not rupture in spite of slight broadening. LESSONS The coexistence of ICIA and CST is extremely rare. Contiguous infection from adjacent tissues is the foremost cause of ICIA. A repeated angiographic examination is recommended under enough anti-infective treatment due to the characteristics of rapid emergence and fast growth of infectious aneurysms.
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Affiliation(s)
- Yaoyao Shen
- Department of Neurology, Jiangxi Provincial People’s Hospital, The First Affiliated Hospital of Nanchang Medical College, Nanchang, Jiangxi Province, China
- Department of Neurology, Xiangya Hospital, Central South University, Jiangxi, National Regional Center for Neurological Diseases, Nanchang, Jiangxi Province, China
| | - Fan Hu
- Department of Neurology, Jiangxi Provincial People’s Hospital, The First Affiliated Hospital of Nanchang Medical College, Nanchang, Jiangxi Province, China
- Department of Neurology, Xiangya Hospital, Central South University, Jiangxi, National Regional Center for Neurological Diseases, Nanchang, Jiangxi Province, China
| | - Lingfeng Wu
- Department of Neurology, Jiangxi Provincial People’s Hospital, The First Affiliated Hospital of Nanchang Medical College, Nanchang, Jiangxi Province, China
- Department of Neurology, Xiangya Hospital, Central South University, Jiangxi, National Regional Center for Neurological Diseases, Nanchang, Jiangxi Province, China
| | - Hongbing Nie
- Department of Neurology, Jiangxi Provincial People’s Hospital, The First Affiliated Hospital of Nanchang Medical College, Nanchang, Jiangxi Province, China
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Fujimi Y, Ozaki T, Izutsu N, Nakajima S, Kanemura Y, Kidani T, Kawamoto S, Nishizawa N, Kobayashi K, Fujinaka T. Fungal symptomatic intracranial aneurysm treated with a flow diverting stent: A case report. Surg Neurol Int 2024; 15:58. [PMID: 38468648 PMCID: PMC10927200 DOI: 10.25259/sni_942_2023] [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: 11/24/2023] [Accepted: 01/27/2024] [Indexed: 03/13/2024] Open
Abstract
Background Intracranial infectious aneurysms (IIAs) are very rare, and fungal aneurysms are infrequently reported. We report a case of an unruptured IIA caused by fungal rhinosinusitis and treated with a flow-diverting stent. Case Description An 81-year-old woman visited the ophthalmology department with impaired eye movement and ptosis and was placed under follow-up. A week later, she also developed a headache; magnetic resonance angiography revealed an aneurysm measuring 2 mm in the C4 portion of the right internal carotid artery. A 3-week follow-up with contrast-enhanced magnetic resonance imaging showed an increase in its size to 10 mm, and a contrast lesion was observed surrounding the right cavernous sinus. The patient started treatment with voriconazole and steroids on the same day. Ten weeks later, despite improvements in inflammation, the size of the aneurysm was unchanged; we, therefore, treated the aneurysm with a flow-diverting stent. Oculomotor nerve palsy improved, and the patient was discharged to a rehabilitation hospital 28 days after the placement, with a modified Rankin Scale of 4. A 1-year follow-up angiogram showed a partial decrease in the size of the aneurysm, with an O'Kelly-Marotta grading scale of B3. Conclusion IIAs grow rapidly, and the risk of rupture is high due to the weakening of the aneurysmal wall. To reduce the risks of rupture and recurrence after treatment, the infection should be treated before inserting a flow-diverting stent. Flow-diverting stent placement may be an effective treatment for IIA once the original infection has been cured.
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Affiliation(s)
- Yosuke Fujimi
- Department of Neurosurgery, National Hospital Organization (NHO) Osaka National Hospital, Osaka, Japan
| | - Tomohiko Ozaki
- Department of Neurosurgery, Osaka University Graduate School of Medicine, Suita, Japan
| | - Nobuyuki Izutsu
- Department of Neurosurgery, National Hospital Organization (NHO) Osaka National Hospital, Osaka, Japan
| | - Shin Nakajima
- Department of Neurosurgery, National Hospital Organization (NHO) Osaka National Hospital, Osaka, Japan
| | - Yonehiro Kanemura
- Department of Neurosurgery, National Hospital Organization (NHO) Osaka National Hospital, Osaka, Japan
- Department of Biomedical Research and Innovation, Institute for Clinical Research, National Hospital Organization (NHO) Osaka National Hospital, Osaka, Japan
| | - Tomoki Kidani
- Department of Neurosurgery, National Hospital Organization (NHO) Osaka National Hospital, Osaka, Japan
| | - Saki Kawamoto
- Department of Neurosurgery, National Hospital Organization (NHO) Osaka National Hospital, Osaka, Japan
| | - Naoki Nishizawa
- Department of Neurosurgery, National Hospital Organization (NHO) Osaka National Hospital, Osaka, Japan
| | - Koji Kobayashi
- Department of Neurosurgery, National Hospital Organization (NHO) Osaka National Hospital, Osaka, Japan
| | - Toshiyuki Fujinaka
- Department of Neurosurgery, National Hospital Organization (NHO) Osaka National Hospital, Osaka, Japan
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Lai PMR, Caragher S, Patel NJ, Du R, Ali Aziz-Sultan M. Safety Profile and Factors Associated With Good Outcome for Endovascularly Treated Infectious Intracranial Aneurysms. Neurosurgery 2022; 90:233-239. [PMID: 34995237 DOI: 10.1227/neu.0000000000001785] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2021] [Accepted: 09/13/2021] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Infectious intracranial aneurysms (IIAs), or mycotic aneurysms, are infectious inflammatory lesions that can cause devastating neurological damage or death. Recent systemic reviews have suggested endovascular treatment to be efficacious for IIA management. OBJECTIVE To compare the safety profile of different endovascular methods for treating ruptured and unruptured IIAs and factors associated with good clinical and radiographic outcomes. METHODS We conducted a retrospective single study of endovascularly treated ruptured and unruptured IIAs between 2003 and 2019. Univariate and multivariate analyses were used to study patient presentation, endovascular treatments used, and clinical and radiographic outcomes. RESULTS Thirty-eight patients with ruptured (n = 20) and unruptured (n = 18) IIAs treated with endovascular methods were included. One patient required retreatment after aneurysm recanalization, and 2 patients demonstrated new infarcts after embolization. There was no postprocedural radiographic hemorrhage or infarct and no difference in clinical and radiographic outcomes comparing treatment modality. Hypertension was associated with ruptured IIA status and worse clinical outcome at 6 mo (odds ratio: 0.03 [95% confidence interval: 0.002-0.52]). CONCLUSION In this study, the largest single-center series to date, we showed that endovascular intervention is a safe and effective strategy for both ruptured and unruptured IIAs. Hypertension was associated with ruptured status and worse clinical outcome. Procedures are generally well-tolerated and safe, with good outcomes for patients.
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Affiliation(s)
- Pui Man Rosalind Lai
- Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
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Desai B, Soldozy S, Desai H, Kumar J, Shah S, Raper DM, Park MS. Erratum to Evaluating the safety and efficacy of various endovascular approaches for the treatment of infectious intracranial aneurysms: a systematic review. World Neurosurgery. Volume 144, December 2020, Pages 293-298.e15. World Neurosurg 2021; 152:255-275. [PMID: 34148817 DOI: 10.1016/j.wneu.2020.12.052] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVE A review of endovascular cerebral mycotic aneurysm treatment with Onyx liquid embolic, N-butyl-2-cyanoacrylate (NBCA), or coil embolization has not been reported. The authors conduct a systematic review on endovascular treatment methods of mycotic aneurysms. METHODS A systematic literature review was performed using the PubMed and MEDLINE databases for studies published between 1986 and 2020. All studies assessing outcomes related to endovascular Onyx embolization, NBCA embolization, or coiling were included. RESULTS A total of 74 studies were ultimately selected, including 180 (67% male) patients comprising 243 aneurysms treated endovascularly. The mean age was 38.2 ± 17.6 years, and the most common symptom on presentation was headache (31%). Most aneurysms were located on the middle cerebral artery (52.5%), and over half presented with rupture (53.8%). Coiling was the most commonly employed technique (50.4%), and obliteration rates were comparable across coiling, NBCA, and Onyx (99.1%, 100%, 100%, respectively). Complication rates were also comparable (4.3% vs. 15.2% vs. 8.1%). CONCLUSION Embolization for infectious intracranial aneurysm appears to be an effective treatment option for mycotic aneurysms. Embolization rates were comparable between coiling, NBCA, and Onyx embolization. Noninferiority among these modalities cannot be demonstrated given the retrospective nature of this review, evolution of endovascular techniques over the years, and changes in treatment paradigms in the last 2 decades. Ideally, further prospective research will be needed to find which treatment method offers the lowest complication rates and the best outcomes for patients with mycotic aneurysms.
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Affiliation(s)
- Bhargav Desai
- Department of Neurological Surgery, University of Virginia Health System, Charlottesville, Virginia, USA
| | - Sauson Soldozy
- Department of Neurological Surgery, University of Virginia Health System, Charlottesville, Virginia, USA
| | - Harshal Desai
- Department of Neurological Surgery, University of Virginia Health System, Charlottesville, Virginia, USA
| | - Jeyan Kumar
- Department of Neurological Surgery, University of Virginia Health System, Charlottesville, Virginia, USA
| | - Smit Shah
- Department of Neurological Surgery, University of Virginia Health System, Charlottesville, Virginia, USA
| | - Daniel M Raper
- Department of Neurological Surgery, University of California, San Francisco, California, USA
| | - Min S Park
- Department of Neurological Surgery, University of Virginia Health System, Charlottesville, Virginia, USA.
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Samples DC, Ravindra VM, Thoms DJ, Tarasiewicz I, Grandhi R. Successful flow diversion treatment of ruptured infectious middle cerebral artery aneurysms with the use of Pipeline Flex with Shield technology. Interv Neuroradiol 2021; 27:225-229. [PMID: 33509016 DOI: 10.1177/1591019921990506] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023] Open
Abstract
BACKGROUND Rupture of infectious intracranial aneurysms (IIAs) is associated with a high likelihood of mortality. Endovascular treatment of IIAs via parent artery sacrifice offers good efficacy and outcomes; however, depending on the lesion's location, neurologic deficit may result. CASE DESCRIPTION We describe a pediatric patient with ruptured IIAs off the left middle cerebral artery (MCA) treated with coil embolization and endovascular flow diversion using the Pipeline Flex Embolization Device (PED) with Shield technology. We chose to place a flow diverter because 1) there was a second, more distal IIA not amenable to direct coil embolization, 2) there was significant potential for aneurysm regrowth and need for retreatment, and 3) we believed the diseased parent MCA needed to be reconstructed. CONCLUSIONS In the setting of previous hemicraniectomy, PED-Shield gave us the option to discontinue dual antiplatelet therapy should the patient require further neurosurgical intervention. Our case supports a role for PED-Shield to address ruptured pseudoaneurysms.
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Affiliation(s)
- Derek C Samples
- Department of Neurosurgery, University of Texas Health San Antonio, San Antonio, TX, USA
| | - Vijay M Ravindra
- Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, Salt Lake City, UT, USA
| | - Dewey J Thoms
- Department of Neurosurgery, University of Texas Health San Antonio, San Antonio, TX, USA
| | - Izabela Tarasiewicz
- Department of Neurosurgery, University of Texas Health San Antonio, San Antonio, TX, USA
| | - Ramesh Grandhi
- Department of Neurosurgery, University of Texas Health San Antonio, San Antonio, TX, USA.,Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, Salt Lake City, UT, USA
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Desai B, Soldozy S, Desai H, Kumar J, Shah S, Raper DM, Park MS. Evaluating the Safety and Efficacy of Various Endovascular Approaches for Treatment of Infectious Intracranial Aneurysms: A Systematic Review. World Neurosurg 2020; 144:293-298.e15. [PMID: 32818695 DOI: 10.1016/j.wneu.2020.07.228] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2020] [Revised: 07/28/2020] [Accepted: 07/30/2020] [Indexed: 10/23/2022]
Abstract
OBJECTIVE A review of endovascular cerebral mycotic aneurysm treatment with Onyx liquid embolic, N-butyl-2-cyanoacrylate (NBCA), or coil embolization has not been reported. The authors conduct a systematic review on endovascular treatment methods of mycotic aneurysms. METHODS A systematic literature review was performed using the PubMed and MEDLINE databases for studies published between 1986 and 2020. All studies assessing outcomes related to endovascular Onyx embolization, NBCA embolization, or coiling were included. RESULTS A total of 73 studies were ultimately selected including 180 (67% male) patients comprising 243 aneurysms treated endovascularly. The mean age was 38.2 ± 17.6 years, and the most common symptom on presentation was headache (31%). Most aneurysms were located on the middle cerebral artery (52.5%), and over half presented with rupture (53.8%). Coiling was the most commonly employed technique (50.4%), and obliteration rates were comparable across coiling, NBCA, and Onyx (99.1%, 100%, 100%, respectively). Complication rates were also comparable (4.3% vs. 15.2% vs. 8.1%). CONCLUSIONS Embolization for infectious intracranial aneurysm appears to be an effective treatment option for mycotic aneurysms. Embolization rates were comparable among coiling, NBCA, and Onyx embolization. Noninferiority among these modalities cannot be demonstrated given the retrospective nature of this review, evolution of endovascular techniques over the years, and changes in treatment paradigms in the past 2 decades. Ideally, further prospective research will be necessary to find which treatment method offers the lowest complication rates and the best outcomes for patients with mycotic aneurysms.
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Affiliation(s)
- Bhargav Desai
- Department of Neurological Surgery, University of Virginia Health System, Charlottesville, Virginia, USA
| | - Sauson Soldozy
- Department of Neurological Surgery, University of Virginia Health System, Charlottesville, Virginia, USA
| | - Harshal Desai
- Department of Neurological Surgery, University of Virginia Health System, Charlottesville, Virginia, USA
| | - Jeyan Kumar
- Department of Neurological Surgery, University of Virginia Health System, Charlottesville, Virginia, USA
| | - Smit Shah
- Department of Neurological Surgery, University of Virginia Health System, Charlottesville, Virginia, USA
| | - Daniel M Raper
- Department of Neurological Surgery, University of California, San Francisco, California, USA
| | - Min S Park
- Department of Neurological Surgery, University of Virginia Health System, Charlottesville, Virginia, USA.
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OuYang M, Wang Y. In Reply to the Letter to the Editor Regarding "Endovascular Treatment of Infectious Pseudoaneurysm of Internal Carotid Artery". World Neurosurg 2019; 127:675. [PMID: 31266123 DOI: 10.1016/j.wneu.2019.03.252] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2019] [Accepted: 03/25/2019] [Indexed: 11/19/2022]
Affiliation(s)
- Mang OuYang
- Department of Neurosurgery, First Affiliated Hospital of Nanchang University, Nanchang City, Jiangxi Province, China
| | - Yang Wang
- Department of Neurosurgery, First Affiliated Hospital of Nanchang University, Nanchang City, Jiangxi Province, China.
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Flow-Diverter Stenting of Intracavernous Internal Carotid Artery Mycotic Aneurysm. J Stroke Cerebrovasc Dis 2019; 28:e81-e82. [PMID: 31101401 DOI: 10.1016/j.jstrokecerebrovasdis.2019.04.026] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2019] [Revised: 04/14/2019] [Accepted: 04/21/2019] [Indexed: 11/27/2022] Open
Abstract
This is the first reported case in which a mycotic aneurysm refractory to the first medical treatment was treated with a Pipeline embolization device (PED), and the first case of a mycotic aneurysm from Brucella treated by endovascular therapy. A 35-year-old man presented with left eye pain and ptosis, and fever for 2 weeks. Before symptom onset, he visited Vietnam where he developed a flu-like illness; however, antibiotics were ineffective. We suspected Brucella as the most likely infectious etiology for the patient's intracavernous aneurysm. Since the aneurysm did not reduce in size following 2 weeks of antibiotic therapy, we placed a PED in the left internal carotid artery. Follow-up angiogram 4 months later showed no residual aneurysm, and cranial nerve palsies had completely resolved. From the results of this case, it appears that flow diverter stenting may be a safe and effective treatment of mycotic aneurysms of the cavernous segment of ICA.
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