Acute subdural hematoma and intracerebral hemorrhage. Rare complications of rhinocerebral mucormycosis

Ruptured Mycotic Aneurysm of the Distal Circulation in a Patient with Mucormycosis Without Direct Skull Base Extension: Case Report

BACKGROUND AND IMPORTANCE

Infectious intracranial aneurysms are a rare subset of intracranial aneurysms caused by bacterial, fungal, or viral sources. Intracranial aneurysms of fungal etiology carry a high mortality risk and typically occur in immunocompromised patients via direct extension of skull base infections, or more rarely, after intracranial surgery.

CLINICAL PRESENTATION

We present the case of a 27-yr-old female with systemic lupus erythematous and primary pulmonary mucormycosis, who suffered a subarachnoid hemorrhage from a ruptured fusiform distal middle cerebral artery aneurysm. Despite undergoing a successful extracranial-to-intracranial bypass and aneurysm excision, the patient ultimately died following progressive disseminated infection and a secondary intracranial hemorrhage of unknown etiology. Pathological examination of the excised artery confirmed Mucor infection.

CONCLUSION

To the best of our knowledge, this case represents one of the first mycotic cerebral aneurysms from mucormycosis in a patient without an underlying skull base infection or previous intracranial surgery. Despite optimal surgical management, clinical outcomes for mycotic cerebral aneurysms are largely dependent on the success of medical therapies at controlling systemic disease.

Vasculitis owing to infection

Infections are a recognized cause of secondary vasculitis. A variety of pathogens have a propensity to involve blood vessels. Vasculitis, non-vasculitic vasculopathy, and mycotic aneurysms lead to infarction and hemorrhage of nervous system tissue. Treatment of infection-related vasculitis should include appropriate antimicrobial therapy directed against the offending pathogen, and appropriate management of cerebrovascular complications.

Survival factors in rhino-orbital-cerebral mucormycosis

Mucormycosis is a highly aggressive fungal infection affecting diabetic, immunocompromised, and, occasionally, healthy patients. This infection is associated with significant mortality. We have reviewed 208 cases in the literature since 1970, 139 of which were presented in sufficient detail to assess prognostic factors, and added data from six of our patients. The histories of these 145 patients were analyzed for the following variables: 1) underlying conditions associated with mucormycotic infections; 2) incidence of ocular and orbital signs and symptoms; 3) incidence of nonocular signs and symptoms; 4) interval from symptom onset to treatment; and 5) the pattern of sinus involvement seen on imaging studies and noted at the time of surgery. Factors related to a lower survival rate include: 1) delayed diagnosis and treatment; 2) hemiparesis or hemiplegia; 3) bilateral sinus involvement; 4) leukemia; 5) renal disease; and 6) treatment with deferoxamine. The association of facial necrosis with a poor prognosis fell just short of statistical significance, but appears clinically important. This is the first review that documents the heretofore intuitive claim that early diagnosis is necessary to cure this disease. Standard treatment with amphotericin B and aggressive surgery are reviewed and adjunctive therapeutic modalities are discussed, including local amphotericin B irrigation, hyperbaric oxygen, and optimizing the immunosuppressive regimen in transplant patients. Hyperbaric oxygen was found to have a favorable effect on prognosis. In addition, possible treatment options for patients with declining renal function are reviewed.

Intracerebral hematoma following evacuation of chronic subdural hematoma

The prognosis after evacuation of a chronic subdural hematoma is generally good, yet occasionally post-operative complications do occur. Intracerebral hematoma following such evacuation is rare and two cases are reported. It is suggested that this complication could be due to the disturbances of intracerebral vascular homeostasis occurring after rapid evacuation of subdural hematomas where there has been a large shift of the brain stem.

Multiple intracranial aneurysms due to Coccidioides immitis infection. Case report

True mycotic (fungal) aneurysms are distinctly uncommon. The case of a young woman with multiple intracranial aneurysms of Coccidioides immitis origin is presented. Coccidioides immitis organisms are not uncommon central nervous system pathogens and usually cause basilar meningitis and hydrocephalus. There are no previous reports of a coccidioidal mycotic aneurysm. The management of intracranial coccidioidomycosis and fungal aneurysms is reviewed.

Rhino-orbital zygomycosis

A 63-year-old diabetic man presented with sinusitis with orbital and intracranial signs progressing over one week, due to zygomycosis. Despite control of the diabetes, surgical excision of infected tissue and antifungal therapy he died in the fifth week of illness. Pathological study showed extensive fungal infiltration of periorbital structures and mycotic thrombosis of many blood vessels with associated necrosis and infarction of fat and extraocular muscles.

Rhinocerebral mucormycosis: three case reports and subject review

Rhinocerebral mucormycosis (RCM) in the diabetic patient can be a particularly aggressive and devastating disease. The emergency physician will typically see patients with RCM in its earliest stages masquerading as a variety of other, less serious diseases. Early diagnosis is the key to a successful outcome. Three such cases seen in the emergency department are reviewed with attention to their initial clinical presentation and treatment. In addition, the historical, pathophysiologic, clinical, and therapeutic aspects of RCM are reviewed.

Acute hypertensive subdural hematoma from arterial rupture shortly after the onset of cerebral subcortical hemorrhage: leakage of contrast medium during angiography

A case is reported of a Japanese female in whom acute right subdural hematoma due to the spontaneous rupture of the posterior branch of the right central artery occurred shortly after the onset of hypertensive subcortical hemorrhage of the right occipital lobe. Marked hypertension persisted. There was no evidence of subdural hematoma when a small collection of extravasated contrast medium from the cortical artery was revealed during right carotid angiography. Soon thereafter the patient became comatose and developed decerebrate posturing. Computed tomography scan was done immediately and a large subdural hematoma was identified. There was a gratifying response to prompt recognition and neurosurgical therapy of the condition. The pinpoint rupture of the cortical artery is considered to have occurred during marked hypertension. Previous 39 cases with subdural hematomas from arterial rupture, 27 traumatic and 12 spontaneous nontraumatic, are reviewed.