Bacterial cavernous sinus aneurysm treated by detachable balloon technique

Concomitant rapidly growing aneurysm of intracavernous carotid artery and cavernous sinus thrombosis: Case report and review of the literature

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.

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

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.

Evaluating the Safety and Efficacy of Various Endovascular Approaches for Treatment of Infectious Intracranial Aneurysms: A Systematic Review

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.

Turbulent Flow in a Cavernous Sinus Lesion: Does It Suggest Something?

A 14-year-old boy who had been complaining of double vision for the previous month was referred for neuro-ophthalmological evaluation. He was carrying a diagnosis of a cavernous sinus haemangioma causing a right VIth nerve palsy, based on imaging elsewhere. He reported having a boil at the angle of his mouth, which was associated with left-sided facial cellulitis, two weeks before the onset of the diplopia. His blood investigations showed a leukocytosis with elevated inflammatory markers. Re-evaluation of the magnetic resonance imaging suggested a sac-like out-pouching in the intracavernous part of the right internal carotid artery with differential intensity suggestive of turbulent flow. On the basis of the clinico-radiological findings, a diagnosis of mycotic aneurysm of the cavernous sinus part of internal carotid artery was made. A high index of suspicion is required to detect this rare clinical entity, which is associated with a potentially catastrophic clinical course.

Mycotic Aneurysm of Intracavernous Internal Carotid Artery Presenting as Cavernous Sinus Syndrome

Mycotic intracranial aneurysms are infectious aneurysms accounting for 0.7%–6.5% of all intracranial aneurysms and are most commonly located in distal branches of the middle cerebral arteries, particularly at the bifurcation area. They are caused by weakening of the vessel wall secondary to infection of a segment of the artery that can be endovascular as in infective endocarditis or extravascular as in meningitis or cavernous sinus thrombophlebitis. The rare occurrence of the mycotic cavernous internal carotid artery aneurysm, its variable clinical picture and limited knowledge of its natural course is a challenge for both diagnosis and management.

National treatment practices in the management of infectious intracranial aneurysms and infective endocarditis

Introduction

There is an absence of widely accepted guidelines for the management of infectious intracranial aneurysms (IIAs) owing to a dearth of high-quality evidence in the literature.

Objective

To better define the incidence of IIAs, treatment practices, and patient outcomes by performing a Nationwide Inpatient Sample (NIS) database query.

Methods

We queried the NIS database from 2002 to 2011 for all patients with theprimary diagnosisof infectious endocarditis (IE), subarachnoid hemorrhage (SAH), or unruptured cerebral aneurysm by ICD-9-CM codes. ICD-9 procedure codes were used to identify patients undergoing neurosurgical or cardiothoracic procedures.

Results

The query identified 393 patients withprimary diagnosisof IE, SAH or unruptured cerebral aneurysm treated during 2002–2011. The mean age of the patients was 53.5 years; 244 (62%) were male. The majority of patients presented with SAH (361; 91.9%). Only 73 (18.6%) patients underwent neurosurgical coiling or clipping for IIA. Of patients undergoing a neurosurgical procedure, 65 had SAH (constituting only 18% of patients with SAH) and 8 had unruptured aneurysms (constituting only 25% patients with unruptured aneurysms). Cardiac procedures were performed in only 72/393 patients (18.3%) patients. Only 67 (18.6%) of the patients with SAH and 5 (15.6%) with unruptured aneurysms underwent a cardiac corrective surgical procedure. Mortality was significantly higher in those patients managed conservatively (26.7%) than in those who underwent clipping or embolization (15.1%; p<0.001).

Conclusions

In this NIS database study, the majority of patients with IIAs were managed non-operatively, regardless of rupture status. Further investigation is warranted to standardize the management of these lesions.

Intracavernous internal carotid artery mycotic aneurysms: comprehensive review and evaluation of the role of endovascular treatment

Mycotic aneurysms may arise in the setting of many local or systemic infections. Those of the intracranial circulation are especially worrisome due to their potential to compress vital neural structures and their propensity for rupture with consequent hemorrhage. Mycotic aneurysms of the intracavernous internal carotid artery (ICA) represent an exceedingly rare clinical entity, described in less than fifty published cases. Typically presenting as a cavernous sinus syndrome with signs and symptoms of the underlying infection, they are often missed initially, with diagnosis and treatment commencing for the triggering infection or confused with cavernous sinus thrombophlebitis, which may be additionally coexistent, confounding timely diagnosis of the aneurysmal disease. Compared to non-mycotic aneurysms of the intracavernous ICA, which typically have a benign course, the infectious etiology of the mycotic variety increases their tendency to rupture, precludes surgical clipping as a viable treatment option, and requires institution of prolonged antibiotic therapy prior to definitive intervention. Their critical location, friability, and propensity to occur bilaterally result in an unpredictable risk of rapid neurological decline and death, making the timing and specific nature of treatment a unique dilemma facing the treating physician. This review seeks to discuss the natural history of and management strategies for mycotic aneurysms of the intracavernous ICA with special emphasis on the role, safety, and efficacy of endovascular therapies.

Intracranial microbial aneurysm (infectious aneurysm): current options for diagnosis and management

The histopathological characteristic of intracranial microbial aneurysm (MA)-infectious aneurysm is the presence of infection and destruction of the walls of the vessels. It can occur in the setting of predisposing infections that spread by endovascular mechanism (e.g., infective endocarditis) or extravascular mechanism (e.g., meningitis). MA is probably a better term than mycotic, infectious, or infective aneurysm as a wide variety of bacteria, fungi, mycobacteria, and virus can cause MA. Typically MAs are multiple, distal, and fusiform aneurysms, but the angiographic and clinical presentations can vary widely. The most common presentation of MA is intracranial bleed. CT angiography, MR angiography, or Digital subtraction angiography can be deployed to detect MA. By combining the clinical findings, imaging, and angiographic findings, it is possible to arrive at a correct diagnosis in most instances. MAs carry higher risk of rupture and fatal bleed when compared to other aneurysms. The treatment options include antimicrobial therapy, surgery, and endovascular therapy. The management strategy is based on large case series rather than controlled trials. All MA should receive appropriate antibiotic therapy. Ruptured MA with mass effect would require surgery in most situations, while those without mass effect and in non-eloquent locations could also be managed by endovascular therapy. Unruptured MA could be managed according to the size, location, and risk of bleeding-by antibiotic therapy, surgery, or endovascular therapy. Monitoring the resolution of the MA under antibiotic therapy by serial CT angiography is another option, but it carries higher risk of bleeding. Treatment of the underlying predisposing infection is an important component of therapy.

Diagnostic characteristics and management of intracranial aneurysms in children

Childhood aneurysms have special characteristics different from adults' aneurysms. Their features were found to significantly differ from aneurysms in adults especially in their gender prevalence, location, morphology and underlying etiology. Treatment options include both surgical and endovascular methods. Whenever possible, endovascular treatment for pediatric aneurysms is the recommended approach, since it offers both reconstructive and deconstructive techniques, durable results and better clinical outcome.

Endovascular treatment for bilateral mycotic intracavernous carotid aneurysms

✓Bilateral mycotic aneurysms of the intracavernous segment of the internal carotid artery (ICA) are exceedingly rare. The authors present the case of a 46-year-old man with bilateral mycotic intracavernous carotid aneurysms, which were treated with a stent-assisted vessel wall remodeling technique with preservation of the parent arteries. The patient recovered quite satisfactorily after completing the whole course of treatment. Based on an extensive review of the literature, no reported case of bilateral mycotic aneurysm of the intracavernous segment of the ICA has been treated with this mode of endovascular therapy. This mode of treatment could be a therapeutic alternative for intracavernous mycotic aneurysms.

Septic cavernous sinus thrombosis complicated by narrowing of the internal carotid artery, subarachnoid abscess and multiple pulmonary septic emboli

A 56-year-old woman was admitted because of a high fever, right ptosis, chemosis, proptosis and ocular muscle palsy. Cranial MRI revealed a cavernous sinus thrombosis and a subarachnoid abscess. Carotid angio-gram demonstrated marked stenosis as well as aneurismal formation of the right internal carotid artery at the intracavernous portion. Chest radiograph showed bilateral multiple pulmonary nodules, some of which contained a cavity. Blood culture was positive for Streptococcus constellatus. She was diagnosed with septic cavernous sinus thrombosis complicated by narrowing of the internal carotid artery, subarachnoid abscess and multiple pulmonary septic emboli. She recovered with partial ocular sequelae as a result of seven weeks of intravenous antimicrobial therapy.

Mycotic intracavernous carotid aneurysm

Intracavernous carotid mycotic aneurysms are rare and management is dictated by clinical presentation. This case involved a patient presenting with a symptomatic expanding proximal internal carotid artery aneurysm treated with antibiotics and balloon occlusion but with thromboembolic complications resulting in a fatal outcome. Points of discussion include difficulties faced in reaching a diagnosis, management options for mycotic aneurysms and the rationale in this case for choosing endovascular rather than surgical treatment. The use and limitations of trial balloon occlusion are discussed as well as complications of vessel occlusion, in particular thromboembolism. Also discussed is the importance of surveillance imaging and the impact of sepsis on overall management.

Evaluation of a technique to occlude the internal carotid artery of horses

OBJECTIVE

To evaluate an occlusion technique for the internal carotid artery of horses using an intravascular, detachable, self-sealing, latex balloon distally and ligatures proximally.

STUDY DESIGN

Experimental study.

ANIMALS

Six healthy adult horses.

METHODS

In each horse, the left internal carotid artery was occluded by placement of an intravascular, detachable, self-sealing, latex balloon distally and two ligatures proximally. Radiographs were taken on days 2, 5, 10, and 30 after surgery to evaluate balloon inflation and position. Endoscopic examination of the left guttural pouch was performed 10 days after surgery to evaluate the integrity of the internal carotid artery and surrounding tissues. At 30 days, the left and right, common, internal, and external carotid arteries were examined grossly and then processed for histologic evaluation.

RESULTS

Immediate and long-term occlusion of the left internal carotid artery was achieved in all horses. The surgical procedure was technically straightforward and no intraoperative or postoperative complications were encountered. The balloons remained inflated and in their original position throughout the study. Maturing to mature, organized thrombi were present in the left internal carotid artery in all horses at 30 days. The cerebral arterial circle and common carotid artery were patent at their junctions with the internal carotid artery in all horses.

CONCLUSIONS

Use of an intravascular, detachable, self-sealing, latex balloon distally and ligatures proximally is an effective technique for occluding the internal carotid artery of horses.

CLINICAL RELEVANCE

This technique may be useful for prevention of fatal hemorrhage in horses with lesions of the internal carotid artery.

Giant infectious intracavernous carotid artery aneurysm presenting as intractable epistaxis

Infectious intracavernous carotid artery aneurysms usually present with ophthalmoplegia and/or signs of cavernous sinus thrombosis. We report an unusual case in which a patient with AIDS presented with intractable epistaxis secondary to rupture of a giant infectious intracavernous carotid artery aneurysm. Culture of the aneurysm grew mycobacterium avium intracellulare (MAI). The patient was treated successfully by excision of the aneurysm and reconstruction of the internal carotid artery with a saphenous vein interposition graft.

Selective endovascular techniques in the treatment of cerebral mycotic aneurysms. Report of three cases

The aim of this study was to evaluate the role of endovascular treatment for intracranial mycotic aneurysms. The clinical and angiographic features of three patients with endocarditic vegetation (two with Streptococcus viridans and one with Staphylococcus) were reviewed retrospectively. Patients were selected for this treatment according to the clinical setting and aneurysm location. In two cases, selective catheterization of a distal middle cerebral and posterior cerebral artery branch with a microcatheter followed by superselective amobarbital testing of the parent vessel was preliminary to the occlusion of that vessel with autologous clot or glue. The third patient was treated by selective occlusion of the aneurysm by intra-aneurysmal placement of platinum minicoils. Two patients presented with intracranial hemorrhage and in one the lesion was found on computerized tomography. All three aneurysms had been excluded from the circulation at the 6-month follow-up review. The only complication from the procedure, despite the septic nature and distal localization, was balloon deflation in one patient, who was successfully retreated with coils. Endovascular embolization is indicated in patients who are at risk of hemorrhage and cannot undergo the standard procedure. The superselective amobarbital test allows selection of patients who will tolerate distal vessel occlusion. This endovascular procedure represents a safe and effective treatment for these lesions.