Intracranial infectious aneurysm: presentation, management and outcome

Vein of Galen aneurysmal malformation associated with brain abscess: A computed tomography case report

Vein of Galen malformation (VGM) is a rare congenital, uncommon intracerebral vascular anomaly rarely complicated with the development of brain abscess as secondary to primary infection or after endovascular treatment. We report a very rare finding of a vein of Galen aneurysm associated with a large brain abscess at the time of diagnosis. A 12-year-old boy with a high-grade fever, severe headache, and recurrent episodes of convulsions came into the radiology department of Kassala Advanced Diagnostic Center. On a Siemens 16-slice scanner, brain non-contrast enhanced computed tomography (NECT) and contrast enhanced CT (CECT) was used to determine the source of the acute headache and convulsions which revealed a right frontal peripherally enhancing cystic lesion measuring 5.7 × 4.7 × 5.3 cm2 surrounded by massive vasogenic edema causing mass effect with midline shift to the left side by 1.5 cm suggestive of brain abscess. There is evidence of another avidly enhancing lesion seen within the third ventricle continuous with a straight sinus surrounded by extensive vascular loops consistent with an aneurysm of the vein of Galen, it was causing compression of the cerebral aqueduct with upstream mild hydrocephalus with dilated both lateral ventricles. Late presentation, diagnosis, and treatment also lead to an increase in the morbidities and mortalities of such case conditions. Urgent intervention should be considered for better outcomes.

Etiologies of spontaneous acute intracerebral hemorrhage: A pictorial review

Spontaneous acute intracerebral hemorrhage (SAIH) is a common and life-threatening condition that affects more than three million patients each year. Of these, one in three patients die within one month of onset and the remaining two in three patients have varying degrees of disability and neurological impairment. The role of radiology is paramount in optimizing patient outcomes by diagnosing SAIH, its potential complications, and the most likely etiology. While the positive diagnosis of SAIH is straightforward, the etiologic diagnosis is broad, covering primary SAIH (hypertension, cerebral amyloid angiopathy) and secondary SAIH (vascular malformations, nonatheromatous vasculopathies, neoplasia, coagulation disorders, toxicants). This pictorial review illustrates the imaging of spontaneous SAIH with an emphasis on etiologic workup.

Rapid sequential development and rupture of mycotic aneurysms within a period of days in a patient with graft-versus-host disease and angiotropic Scedosporium apiospermum infection

Background:

Fungal origin mycotic aneurysms are rare and carry a high mortality rate. Scedosporium apiospermum is an ubiquitous fungus which has been described to cause devastating infections in immunocompromised hosts.

Case Description:

We report a case of a 23-year-old patient with Burkitt’s lymphoma and graft-versus-host disease admitted with intracerebral hemorrhage and sequential development of 12 anterior circulation aneurysms from disseminated Scedosporium infection. Despite aggressive surgical and antimicrobial treatment, the patient died 6 months later from multiorgan failure. The notable feature of this case is the rapid angioinvasiveness of the infection with new aneurysm formation within days of clear angiographic imaging despite the apparent lack of skull base osteomyelitis.

Conclusion:

We highlight the difficulties in treating fungal mycotic aneurysms and the associated high mortality. While a less aggressive approach might have been appropriate given the known poor outcomes, the age of the patients as well as the family wishes dictated the treatment decisions.

Difficulty of diagnosing a mucor-induced aneurysm arising in segment P4 of the posterior cerebral artery – A case report

Background:

Identification of causative pathogen for fungal aneurysm is frequently difficult. We reported the case of a fungal aneurysm caused by Mucor arising in segment P4 of the posterior cerebral artery (PCA) detected only by histopathological examination.

Case Description:

A 50-year-old female complained of nausea and vomiting. Computed tomography showed an intracranial hemorrhage in the left occipital lobe and acute hydrocephalus due to intraventricular hemorrhaging. Digital subtraction angiography performed after external drainage showed a cerebral aneurysm in segment P4 of the left PCA. Surgical excision of the aneurysm and end-to-end anastomosis of the PCA were performed. A histopathological examination revealed that the aneurysm had been caused by a Mucor infection.

Conclusion:

In fungal aneurysm cases, especially those involving Mucor infections, it is difficult to identify the causative fungal infection based on cultures, imaging, and serological tests. Therefore, surgical excision and histopathological diagnosis are important for diagnosing such cases if possible.

Simultaneous intracerebral and subarachnoid hemorrhages caused by multiple infectious intracranial aneurysms treated endovascularly and by microsurgical clipping: illustrative case

BACKGROUND

Infected intracranial aneurysms are relatively rare but tend to occur in multiple locations. Establishing an optimal treatment strategy for multiple ruptured aneurysms is often challenging, especially when simultaneous ruptures occur in different locations. We report a case of simultaneous intracerebral and subarachnoid hemorrhages caused by the rupture of multiple infected intracranial aneurysms.

OBSERVATIONS

A 23-year-old male with a 2-week history of chronic fever presented with sudden onset of severe headache and visual disturbance. Computed tomography showed intracerebral hemorrhage in the right occipital lobe and subarachnoid hemorrhage in the area of the left Sylvian fissure. Further investigation documented Staphylococcus bacteremia, verrucae on the mitral valve, and aneurysms arising from the right posterior cerebral artery (PCA) and the left middle cerebral artery (MCA). A larger aneurysm arising from the PCA was successfully occluded endovascularly, but subsequent endovascular occlusion of the MCA aneurysm was unsuccessful because some important branches were observed extending from the aneurysm. The left MCA aneurysm was then obliterated by angioplastic clipping via left pterional craniotomy. The patient showed a favorable neurological recovery after treatment.

LESSONS

In such complex cases of infectious aneurysms, the method and timing of treatment need to be carefully determined based on the medical condition.

Safety Profile and Factors Associated With Good Outcome for Endovascularly Treated Infectious Intracranial Aneurysms

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.

A rare case of Streptococcus anginosus infectious intracranial aneurysm: Proper management of a poor prognosis

Background:

Infectious intracranial aneurysms (IIAs), sometimes referred to as cerebral mycotic aneurysms, are an uncommon but feared compilation of bacterial endocarditis, occurring in up to 5% of all bacterial endocarditis cases. While IIAs carry a low risk of rupture, a ruptured mycotic aneurysm carries devastating neurologic consequences with up to an 80% mortality rate secondary to subarachnoid and intracerebral hemorrhage.

Case Description:

A 69-year-old man undergoing antibacterial therapy for Streptococcus anginosus endocarditis with aortic insufficiency and root abscess presented to the ED with multiple seizures and left-sided weakness. MRI of the head revealed right frontal and temporal abscesses with evidence of scattered septic emboli and subarachnoid hemorrhage. CTA of the head revealed a ruptured 1 mm distal middle cerebral artery mycotic aneurysm. Prior to undergoing surgery, the patient began to decline, becoming lethargic, and failing to respond to commands. The patient underwent endovascular Onyx embolization. After the procedure, the patient remained with partial status epilepticus and was discharged to rehabilitation. Over the following months, the patient made a great recovery and was able to undergo aortic and mitral valve replacement 5 months after neurosurgical intervention.

Conclusion:

This favorable outcome is the result of a tremendous deal of long-term coordination and efficient communication between neurosurgery, cardiology, neurology, physical medicine and rehabilitation, and primary care.

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.

Subarachnoid Hemorrhage in Bacterial Meningitis Patients

INTRODUCTION

Subarachnoid hemorrhage (SAH) has been described as an uncommon complication of community-acquired bacterial meningitis. However, the incidence, clinical course, and outcome are unclear.

METHODS

We assessed the clinical characteristics, incidence, and clinical outcome of patients with SAH complicating bacterial meningitis in a prospective nationwide cohort study from 2006 to 2018 in the Netherlands. Patients were identified through the Netherlands Reference Laboratory for Bacterial Meningitis, which receives around 90% of CSF isolates of all Dutch patients with bacterial meningitis, or after direct report by the treating physician.

RESULTS

SAH was diagnosed in 22 of 2,306 episodes (0.9%), of which 7 (32%) were diagnosed upon admission and 15 (68%) during admission. All patients showed clinical deterioration before SAH was diagnosed: altered mental status in 18 of 22 patients (82%), focal neurological symptoms in 2 (9%) and, new-onset fever with severe tachycardia in 1 (5%). Acute onset of headache was not reported in any of the patients. Distribution of blood was diffuse in the subarachnoid space in 7 patients (32%), multifocal in 8 patients (36%), and focal in 7 patients (32%) of 22 patients. In 6 patients (27%), CT angiography, MR angiography, or digital subtraction angiography was performed, showing a mycotic aneurysm in 1 patient (5%) and vasculitis in 1 patient (5%). Presence of SAH in bacterial meningitis patients was associated with a poor prognosis assessed at discharge: 12 of 22 patients with SAH died (54%) compared to 361 of 2,257 (16%, p < 0.001) without SAH, and 19 of 22 had an unfavorable outcome (86%) compared to 831 of 2,257 (37%, p < 0.001).

CONCLUSION

SAH is an uncommon complication in bacterial meningitis and is associated with high case fatality and morbidity.

Invasive sinus aspergillosis with mycotic aneurysm of the vertebral artery and subarachnoid hemorrhage - Case report

Invasive sinus aspergillosis is a rare life-threatening condition usually found in immunocompromised patients. The fungus spreads from paranasal sinuses into the central nervous system by direct extension or through blood vessels. Perineural spread is an uncommon mechanism of spread in invasive aspergillosis. A mycotic aneurysm is a dangerous complication of invasive sinus aspergillosis because of its insidious development and is often diagnosed only post-mortem after causing fatal intracranial hemorrhage. Intracranial vascular complications of invasive sinus aspergillosis require prompt recognition and treatment and should always be considered when a diagnosis of CNS aspergillosis is made. We present a case of invasive sinus aspergillosis in an apparently immunocompetent patient that manifested with a brain abscess, perineural spread of the infection, and mycotic aneurysm of the vertebral artery with subsequent rupture and fatal subarachnoid hemorrhage. This case highlights the possibility of perineural spread and hemorrhagic complications in invasive cerebral aspergillosis.

Successful endovascular treatment of pediatric basilar infectious (mycotic) aneurysm: a case report and review of the literature

BACKGROUND

Intracranial infectious aneurysms are rarely reported in children; in particular, they are very rare in infants. They are mostly related to infective endocarditis and are usually located in the anterior cerebral vasculature. A ruptured intracranial infectious aneurysm is a catastrophic event associated with high morbidity and mortality rates.

CASE REPORT

An 8-month-old female infant presented with a prolonged fever without any organ-specific symptoms. Two weeks after admission, she had a high-grade fever with drowsiness; the cerebrospinal fluid (CSF) examination indicated meningitis. Despite treatments with empiric antibiotic and antiviral agents, both her condition and the repeated CSF profiles worsened. The ineffective medications were promptly changed to susceptible antibiotic after the CSF culture showed Pseudomonas aeruginosa. Three days after the diagnosis of meningitis, the patient suddenly developed seizures and alteration of consciousness. The computerized tomography and angiography (CT and CTA) of the brain demonstrated a diffuse subarachnoid hemorrhage (SAH) with intraventricular hemorrhage (IVH) and a lobulated fusiform aneurysm at the proximal basilar artery, suggestive of a ruptured basilar infectious aneurysm. Endovascular treatment was planned and a transarterial occlusion of the vertebrobasilar junction was performed in order to disrupt inflow of the aneurysm. After endovascular intervention, her clinical symptoms gradually improved and the patient was discharged after completing a 4-week course of antibiotics. At the 6-week follow-up, she was doing well without neurological deficit.

CONCLUSION

To our knowledge, this is the first reported case of a ruptured basilar infectious aneurysm in an infant secondary to Pseudomonas meningitis, successfully treated with parent artery occlusion.

Characteristics and Outcomes of Left Ventricular-Assist Device-Associated Cerebrovascular Events in Setting of Infectious Intracranial Aneurysms

Background and purpose: The study aims to identify the characteristics and neurological outcomes of the left ventricular-assist device (LVAD)-associated cerebrovascular events (CVE) and infections, particularly in the setting of infectious intracranial aneurysms (IIA).

Methods: A single-center retrospective review of patients having undergone LVAD implantation between 2011 and 2017 was conducted using institutional registries and screened for CVE. Patients with CVE were assessed for concurrent bacteremia; neurovascular imaging was then used to isolate patients with IIA. A review of comorbidities, imaging characteristics, and management were performed to determine predictors of neurological outcomes, as defined by the 90-day modified Rankin scale (mRS) scores.

Results: Of the 383 HeartMate II LVAD implantations performed, 43 all-cause stroke events were identified across 35 (9%) patients. The majority of the events were hemorrhagic CVE (n=28) with 21 events complicated by bacteremia. Of patients with hemorrhagic CVE and bacteremia, Staphylococcus aureus (n=10) and Pseudomonas aeruginosa (n= 8) infection were the most frequently associated organisms. Severe disability or death (90-day mRS > 4) was observed in 15 patients (63%). Seven patients had confirmed findings of IIA on diagnostic cerebral angiogram and were associated with distal middle cerebral artery (MCA) territory involvement (n=6; 86%) with concurrent Staphylococcus (n=5, 71%) and/or Pseudomonas (n=4, 57%) infections. Overall, a higher incidence of acute and chronic bacteremia was observed in the hemorrhagic CVE subgroup compared to the ischemic CVE subgroup (74% vs 36% & 71% vs 29%, respectively; p <0.05). Despite endovascular and/or surgical intervention in patients with IIA, four patients failed management and elected for comfort measures.

Conclusion: Our results indicate that P. aeruginosa and S. aureus bacteremia are associated with a greater incidence of intracranial hemorrhage and worse neurological outcomes. Future management considerations may include pre-implantation cerebrovascular imaging to assess vascular pathology including prior aneurysms and intracranial atherosclerotic disease burden as a screen for higher-risk patients, as well as more aggressive antibiotic therapy at bacteremia onset.

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.

MRI in intracranial tuberculosis: Have we seen it all?

Tuberculosis is emerging worldwide across diverse populations and geographies; unrestricted by the social divide and the geographical barriers in today's interconnected world. This rise in its prevalence can be linked to multiple factors including urbanisation, spurt in global travel, population explosion, migration and HIV infection. The varied and complex clinical presentation of intracranial tuberculosis tricks even the best of the clinicians. This along with the other facets associated with its management including drug resistance, paradoxical reaction, underlying HIV infection can make it particularly challenging. Imaging has a definitive role in the evaluation and follow-up of intracranial tuberculosis and MRI is the cornerstone in this regard. Typical features of intracranial tuberculosis are well-described. However, it is not infrequent to encounter atypical and bizarre presentations, both clinically and on imaging. A holistic clinical and imaging review of difficult cases, including newer MRI techniques, is necessary for the neuroradiologist, neurologist and the neurosurgeon to arrive at the right diagnosis in a timely fashion.

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.

Fungal mycotic aneurysm in a patient with Aspergillus terreus chronic meningoencephalitis

Background:

Central nervous system involvement due to aspergillosis is an extremely serious entity, particularly in patients with severe neutropenia, hematological diseases, or post-transplant cases. Immunocompetent patients can be infected by intense exposure, particularly iatrogenic after invasive procedures.

Case Description:

We present the case of a 26-year-old male with a 1 year appendectomy background, which required epidural anesthesia. After that surgery, insidious headache presented, requiring mild analgesics for adequate control. In the following weeks, headaches increased and tomographic imaging revealed hydrocephalus. A ventriculoperitoneal shunt was placed, and empirical treatment for neurocysticercosis was established, but diagnosis was never confirmed. Sequentially, shunt dysfunction occurred twice, for which shunt replacement was performed. Cerebrospinal fluid and shunt’s catheter were cultured. Some days later, a filamentous fungus was isolated and finally identified as Aspergillus sp. Intravenous amphotericin B and fluconazole at therapeutic dosage were administered; however, a torpid clinical evolution was observed. After a 2-week antifungal scheme, the fungus was identified as Aspergillus terreus. The patient developed sudden rostrocaudal deterioration. Computed tomography imaging was done, revealing a 70 cc hematoma in the right operculoinsular region, midline shift, and a 9 mm saccular aneurysm at the bifurcation of the middle cerebral artery.

Conclusion:

Cerebral aspergillosis is a serious disease with high mortality in patients, particularly those without identifiable risk factors. The iatrogenic forms are serious, due to the delay of clinical diagnosis. It is important to have a high index of suspicion in patients with a history of invasive procedures such as epidural anesthesia or surgery, and who develop a persistent chronic headache or chronic meningitis.

Acute convexity subarachnoid hemorrhage (cSAH) in infectious endocarditis (IE): imaging features and follow-up

AIM

To assess: (1) the prevalence of convexity subarachnoid hemorrhage (cSAH) in infective endocarditis (IE); (2) its relationship with IE features; (3) the associated lesions; (4) whether cSAH is a predictor of future hemorrhage; (5) whether cSAH could cause cortical superficial siderosis (cSS).

METHODS

We retrospectively evaluated the MRI data in 240 IE-patients: At baseline, the location of cSAH and associated lesions; at follow-up, the occurrence of new lesions and of cSS. Patients with and without cSAH were compared.

RESULTS

There were 21 cSAH-IE patients without (Group 1a) and 10 with intracranial infectious aneurysms (IIAs) (Group 1b). cSAH was revealed by headache (16.1%), confusion (9.7%), acute meningeal syndrome (3.2%) and was incidental in 71%. In most cases, the cSAH was: in the frontal (61.3%) and the parietal lobe (16.1%), unifocal, and mainly localized within a single sulcus (80.7%), appearing as a thick intrasulcal dark line on T2* in 70% of IIA patients. Valvular vegetations (87.1%, p < 0.0001), vegetations length ≥ 15 mm (58.1%, p < 0.0001) and mitral valve involvement (61.3%; p = 0.05) were significantly associated. There was no significant difference between the two groups in terms of pathogen distribution, valve characteristics and clinical expression. Associated lesions were: CMBs (77.4%), DWILs (51.6%), brain hemorrhages (16.1%) brain micro-abscesses (3.2%) meningitis (3.2%), visceral emboli (45.2%). At follow-up: no SAH recurrence or neurological event. cSS disappeared in 7/12 cases.

CONCLUSION

cSAH in IE is mostly an incidental finding but may be the telltale sign of an IIA. cSAH is not a marker of poor prognosis in non-IIA patients.

Differentiating between Mycotic and Dissecting Aneurysms in a Case of Ruptured Distal Superior Cerebral Artery Aneurysm

Objective

We present a case of subarachnoid hemorrhage (SAH) due to ruptured mycotic aneurysm found in the distal superior cerebellar artery (SCA).

Case Presentation

A 64-year-old man was admitted to our hospital with sudden unconsciousness. He had a history of alcoholism but no family history of SAH. Computed tomography (CT) showed apparent SAH; however, CT angiography (CTA) showed no apparent cause of SAH except for two small aneurysms in the same branch of the left distal SCA. We suspected mycotic aneurysm and prescribed antibiotics. It was difficult to diagnose the condition as mycotic aneurysm because there were no vegetations or caries at the time of admission. Because there were two aneurysms in the same branch with partial dilatation and stenosis, we suspected dissecting aneurysm, but continued to administer antibiotics for possible mycotic aneurysm. After the first operation, we diagnosed mycotic aneurysm because a vegetation and valve degeneration was found.

Conclusion

It is difficult to distinguish mycotic aneurysms from dissecting aneurysms because of similar appearance on imaging, especially if no vegetation is found. Nevertheless, it is important to start treatment for mycotic aneurysm. If there is the possibility of mycotic aneurysm, appropriate antibiotics should be administered, and endovascular treatment could be considered for patients with deteriorating conditions.

Rapid formation and rupture of an infectious basilar artery aneurysm from meningitis following suprasellar region meningioma removal: a case report

Background

Infectious basilar artery (BA) aneurysm has been occasionally reported to be generated from meningitis following transcranial operation. However, infectious BA aneurysm formed by intracranial infection after endoscopic endonasal operation has never been reported.

Case presentation

A 53-year-old man who was diagnosed with suprasellar region meningioma received tumor removal via endoscopic endonasal approach. After operation he developed cerebrospinal fluid (CSF) leak and intracranial infection. The patient ultimately recovered from infection after anti-infective therapy, but a large fusiform BA aneurysm was still formed and ruptured in a short time. Interventional and surgical measures were impossible due to the complicated shape and location of aneurysm and state of his endangerment, therefore, conservative anti-infective therapy was adopted as the only feasible method. Unfortunately, the aneurysm did not disappear and the patient finally died from repeating subarachnoid hemorrhage (SAH).

Conclusion

Though extremely rare, it was emphasized that infectious aneurysm can be formed at any stage after transnasal surgery, even when the meningitis is cured. Because of the treatment difficulty and poor prognosis, it was recommended that thorough examination should be timely performed for suspicious patient to make correct diagnosis and avoid fatal SAH.

Clinical course of infectious intracranial aneurysm undergoing antibiotic treatment

INTRODUCTION

Infectious intracranial aneurysm (IIA, or mycotic aneurysm) is a cerebrovascular complication of infective endocarditis. We aimed to describe the clinical course of IIAs during antibiotic treatment.

METHODS

We reviewed medical records of persons with infective endocarditis who underwent cerebral angiography at a single tertiary referral center from 2011 to 2016. Aneurysms were followed with subsequent angiography for unfavorable outcome (growth, rupture, no change, or new IIA formation) or favorable outcome (regression or resolution) until endovascular therapy, aneurysm resolution, or end of observation.

RESULTS

Of 618 patients included, 40 (6.5%) had 43 IIAs. Eighteen (42%) aneurysms underwent initial endovascular treatment. Twenty-five unruptured aneurysms were followed for a median 18 antibiotic days after IIA discovery (interquartile range [IQR] 4-32). Eleven (44%) aneurysms had unfavorable outcome (1 rupture, 2 new IIA formation, 6 enlargement, and 2 no change) at median 21 days (IQR 5-32). Favorable angiographic outcome was seen in 7 (28%) patients (6 resolution, 1 regression) at median 36 days (IQR 24-41). Seven aneurysms had no angiographic reevaluations but showed no evidence of rupture during clinical follow-up for median 4 days (IQR 3-12) until hospital discharge. Saccular morphology was associated with unfavorable aneurysmal outcome (p = 0.013). Longer duration of antibiotic exposure prior to IIA discovery was associated with favorable aneurysmal outcome (p = 0.046).

CONCLUSION

IIAs represent a dynamic disease. Only a quarter of IIAs resolve with antibiotics alone. Saccular aneurysmal morphology might predict unfavorable aneurysmal outcome. IIA found after longer antibiotic therapy has higher likelihood of resolution or regression on antibiotic treatment.

Systematic Review of Endovascular, Surgical, and Conservative Options for Infectious Intracranial Aneurysms and Cardiac Considerations

INTRODUCTION

With rising rates of intravenous drug use, Infectious Intracranial aneurysms (IIAs) are a relevant topic for investigation. We performed a systematic review to better understand current practice patterns and limits of current published literature.

METHOD

131 publications with a total of 499 patients (665 aneurysms) were included. Of the 499 patients, 83 were single case reports, and 20.5% of the total had multiple aneurysms. 35.8% of all aneurysms were ruptured. Of those reporting treatment, options included conservative antibiotic therapy (30.0%), open surgical intervention (31.1%), and endovascular occlusion (31.8%). Chronologically, publication of IIAs has increased. Usage of endovascular therapies has grown, while conservative and surgical management have declined in the literature. Overall, 56.2% of aneurysms for which conservative therapy was initiated eventually either underwent intervention or death of patient occurred.

RESULTS

The issue of cardiac valve surgery in relationship to aneurysm therapy was discussed in 20.8% (80 patients) of all 384 infectious endocarditis patients; of which 15.0% (12) underwent valve surgery before aneurysm treatment and 85.0 patients (68)% underwent valve surgery after aneurysm treatment. For 51 of the patients where valve surgery followed aneurysm management, the corresponding aneurysm treatment modality could be determined; 58.8% (30) of whom were managed endovascularly. 32.7% (26) of all cases reporting cardiac surgery details underwent cardiac surgery during their admission with the IIA.

CONCLUSIONS

Overall, increasing trend of endovascular management of IIAs is evident, and a strong temporal preference exhibited by providers to perform cardiac surgery subsequently to IIA management.

Infectious intracranial aneurysms: a systematic review of epidemiology, management, and outcomes

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.

Current Treatment Strategies for Intracranial Aneurysms: An Overview

Intracranial aneurysm is a leading cause of stroke. Its treatment has evolved over the past 2 decades. This review summarizes the treatment strategies for intracranial aneurysms from 3 different perspectives: open surgery approach, transluminal treatment approach, and new technologies being used or trialed. We introduce most of the available treatment techniques in detail, including contralateral clipping, wrapping and clipping, double catheters assisting coiling and waffle-cone technique, and so on. Data from major trials such as Analysis of Treatment by Endovascular approach of Non-ruptured Aneurysms (ATENA), Internal Subarachnoid Trial (ISAT), Clinical and Anatomical Results in the Treatment of Ruptured Intracranial Aneurysms (CLARITY), and Barrow Ruptured Aneurysm Trial (BRAT) as well as information from other clinical reports and local experience are reviewed to suggest a clinical pathway for treating different types of intracranial aneurysms. It will be a valuable supplement to the current existing guidelines. We hope it could help assisting real-time decision-making in clinical practices and also encourage advancements in managing the disease.

Endovascular Embolization of Intracranial Infectious Aneurysms in Patients Undergoing Open Heart Surgery Using n-Butyl Cyanoacrylate

INTRODUCTION

Mycotic aneurysms are a serious complication of infective endocarditis with increased risk of intracranial hemorrhage. Patients undergoing open heart surgery for valve repair or replacement are exposed to anticoagulants, increasing the risk of aneurysm bleeding. These patients may require endovascular or surgical aneurysm treatment prior to heart surgery, but data on this approach are scarce.

METHODS

Retrospective review of consecutive patients with infectious endocarditis and mycotic aneurysms treated endovascularly with Trufill n-butyl cyanoacrylate (n-BCA) at the Cleveland Clinic between January 2013 and December 2015.

RESULTS

Nine patients underwent endovascular treatment of mycotic aneurysms with n-BCA (mean age of 39 years). On imaging, 4 patients had intracerebral hemorrhage, 2 had multiple embolic infarcts, and the rest had no imaging findings. Twelve mycotic aneurysms were detected (3 patients with 2 aneurysms). Seven aneurysms were in the M4 middle cerebral artery segment, 4 in the posterior cerebral artery distribution, and 1 in the callosomarginal branch. n-BCA was diluted in ethiodized oil (1:1 to 1:2). Embolization was achieved in a single rapid injection with immediate microcatheter removal. Complete aneurysm exclusion was achieved in all cases without complications. All patients underwent open heart surgery and endovascular embolization within a short interval, 2 with both procedures on the same day. There were no new hemorrhages after aneurysm embolization.

CONCLUSIONS

Endovascular embolization of infectious intracranial aneurysms with liquid embolics can be performed successfully in critically ill patients requiring immediate open heart surgery and anticoagulation. Early embolization prior to and within a short interval from open heart surgery is feasible.

Imaging of Intracranial Hemorrhage

Intracranial hemorrhage is common and is caused by diverse pathology, including trauma, hypertension, cerebral amyloid angiopathy, hemorrhagic conversion of ischemic infarction, cerebral aneurysms, cerebral arteriovenous malformations, dural arteriovenous fistula, vasculitis, and venous sinus thrombosis, among other causes. Neuroimaging is essential for the treating physician to identify the cause of hemorrhage and to understand the location and severity of hemorrhage, the risk of impending cerebral injury, and to guide often emergent patient treatment. We review CT and MRI evaluation of intracranial hemorrhage with the goal of providing a broad overview of the diverse causes and varied appearances of intracranial hemorrhage.

Evaluation and Treatment of the Acute Cerebral Infarction with Convexal Subarachnoid Hemorrhage

Non-traumatic convexal subarachnoid hemorrhage (CSAH) is a comparatively infrequent with various vascular and nonvascular causes, it rarely occurs concomitant to acute ischemic stroke. We report a case of a 59-year-old woman, visited emergency room with right side subjective weakness spontaneously. Magnetic resonance diffusion-weighted images revealed an acute infarction of anterior cerebral arterial territory. Computed tomographic angiography showed a left frontal CSAH without any vascular lesions. And other laboratory studies were non-specific. We treated with dual antiplatelet drugs (cilostazole [Otsuka Pharmaceutical Co., Ltd. tokyo, Japan] and Aspirin [Bayer Pharma AG., Leverkusen, Germany]). She has done well for a follow-up period. (5 months) This case demonstrates the CSAH with acute infarction is rare but need to work up to identify the etiology and antiplatelet dugs are taken into account for treatments.

Interdisciplinary Treatment of Intracranial Infectious Aneurysms

OBJECTIVE

Intracranial infectious aneurysms (IIAs) are a rare clinical entity without a definitive treatment guideline. In this study, we evaluate the treatment options of these lesions based on our own clinical experience and review the current knowledge of therapy as portrayed in the literature.

METHODS

We conducted a single-center retrospective analysis of all patients with an IIA and performed a systematic review of the literature using the MEDLINE database. We undertook a comprehensive literature search using the OVID gateway of the MEDLINE database (1950-October 2015) using the following keywords (in combination): 'infectious', 'mycotic', 'cerebral aneurysm', 'intracranial aneurysm'. 1,721 potentially relevant abstracts were identified and 63 studies were selected for full review. The studies were analysed regarding ruptured versus unruptured aneurysms, aneurysm localization and treatment, as well as clinical and radiological outcome.

RESULTS

Our institutional series consisted of 6 patients (median age 57 [32-76]) treated between 2011 and 2015. All patients presented with ruptured IIAs located on the middle cerebral artery (MCA, 5 patients) and anterior cerebral artery (ACA, 1 patient). Five patients were treated by clipping and resecting the aneurysm, 1 patient underwent coiling. All patients received antibiotic therapy and 1 patient died. We further identified 814 patients (median age 35.5 [0-81]) in 63 studies. Locations of the aneurysms were mentioned in 55 studies. The most frequent locations of the aneurysms were: MCA (63.5%), posterior cerebral artery (14%), ACA (9.0%) and others (13.5%). Treatment for IIAs was described in 62 studies: antibiotic treatment (56.1%), a combination of antibiotics and surgery (20.9%) or antibiotics and endovascular treatment (23.0%). Outcome was mentioned in 82.4% of the patients with a mortality rate of 16.8%. An evaluation of treatment outcome was limited due to the heterogeneity of patients in the published case series.

CONCLUSION

Antibiotic therapy of patients with IIA is mandatory. However, due to the complexity of the disease and its accompanying comorbidities, a general treatment algorithm could not be defined. Analogous to non-mycotic aneurysms, further treatment decisions require an interdisciplinary approach involving neurosurgeons, interventionists and infectious disease specialists.

Management of infectious intracranial aneurysms in the pediatric population

INTRODUCTION

Infectious intracranial aneurysms (IIAs) account for approximately 15 % of all pediatric intracranial aneurysms. Histologically, they are pseudoaneurysms that develop in response to an inflammatory reaction within the adventitia and muscularis layers, ultimately resulting in disruption of both the internal elastic membrane and the intima. The majority of pediatric IIAs are located within the anterior circulation, and they can be multiple in 15-25 % of cases.

BACKGROUND

The most common presentation for an IIA is intracerebral and/or subarachnoid hemorrhage. In children with a known diagnosis of infective endocarditis who develop new neurological manifestations, it is imperative to exclude the existence of an IIA. The natural history of untreated infectious aneurysms is ominous; they demonstrate a high incidence of spontaneous rupture. High clinical suspicion, prompt diagnosis, and adequate treatment are of paramount importance to prevent devastating neurological consequences.

DISCUSSION

The prompt initiation of intravenous broad-spectrum antibiotics represents the mainstay of treatment. Three questions should guide the management of pediatric patients with IIAs: (a) aneurysm rupture status, (b) the presence of intraparenchymal hemorrhage or elevated intracranial pressure, and (c) relationship of the parent vessel to eloquent brain tissue. Those three questions should orient the treating physician into either antibiotic therapy alone or in combination with microsurgical or endovascular interventions. This review discusses important aspects of the epidemiology, the diagnosis, and the management of IIAs in the pediatric population.

Lessons learned from 150 continuous-flow left ventricular assist devices: a single institutional 7 year experience

Continuous-flow (CF) left ventricular assist devices (LVADs) have become the standard of care for patients with advanced heart failure refractory to optimal medical therapy. The goal of this study was to review our 7 year single institutional experience with CF LVADs. Mean age was 50.4 + 12.5 (17-69) years for bridge-to-transplantation (BTT) patients and 57.6 + 10.4 (31-81) years for destination therapy (DT) patients (p < 0.001). Overall, 38 patients (26%) were female and 58 (41%) were African American. Etiology of heart failure was ischemic in 54 patients (37%) and nonischemic in 93 patients (63%). Overall survival at 30 days, 6 months, 12 months, and 2 years was 93%, 89%, 84%, and 81%, respectively. Gastrointestinal bleeding (GIB) was the most common complication (24%), followed by stroke (18%), right ventricular (RV) failure (18%), ventilator-dependent respiratory failure (10%), reoperation for bleeding (10%), and driveline infection (9%). These data demonstrate excellent survival with low mortality for both BTT and DT patients on long-term LVAD support. However, for LVAD therapy to become the gold standard for long-term treatment of end-stage heart failure and a plausible alternative to heart transplantation, we need to continue to improve the incidence of frequent postoperative complications, such as RV failure, driveline infections, strokes, and GIB.

Isolated Cortical Venous Thrombosis as a Mimic for Cortical Subarachnoid Hemorrhage

Isolated cortical venous thrombosis is very rare and poorly understood. The clinical presentation is also not well described in the literature. We report here a case of isolated cortical venous thrombosis that mimicked cortical subarachnoid hemorrhage (SAH). A 62-year-old man with a history of chronic subdural hemorrhage visited our hospital with headache. Brain computed tomography (CT) revealed a linear hyperdense area in the right central sulcus (cord sign), suggestive of isolated cortical SAH. Magnetic resonance imaging (MRI) revealed susceptibility in the corresponding area. CT angiography revealed no specific finding. However, transfemoral cerebral angiography (TFCA) identified filling defects in the right cortical veins. Under isolated cortical venous thrombosis, anticoagulation therapy was used to prevent the propagation of thrombosis. The patient had no recurrence of symptoms. If a cord sign is present on noncontrast CT images, further studies (MRI/magnetic resonance venography or TFCA) should be performed in a step-wise manner. Such considerations could prevent a fatal outcome and poor prognosis.

Fungal Mycotic Aneurysm of the Internal Carotid Artery Associated with Sphenoid Sinusitis in an Immunocompromised Patient: A Case Report and Review of the Literature

In immunocompromised patients, invasive molds such as Aspergillus and Mucor can lead to locally aggressive angioinvasive infections that are often life-threatening. A particularly devastating complication is the development of a fungal mycotic aneurysm resulting from invasion of the arterial wall. Due to anatomic contiguity, the sphenoid sinus provides potential access for these fungi, which often colonize the respiratory sinuses, into the cavernous sinus and internal carotid artery (ICA), thus leading to the formation of ICA aneurysms. The ideal treatment of fungal ICA aneurysms includes a combination of surgical debridement and long-term effective antifungal therapy, but the role of endoscopic resection and the duration of antimicrobials are poorly defined. Here, we present the case of a 71-year-old immunocompromised patient who developed an ICA mycotic aneurysm, associated with a proven invasive fungal infection (presumptively Mucorales) of the sphenoid sinuses, as defined by EORTC/MSG criteria, and who survived after undergoing coil embolization with parent vessel sacrifice of the aneurysm in combination with liposomal amphotericin B. We also review the literature for published cases of invasive fungal sphenoid sinusitis associated with mycotic aneurysms of the ICA and provide a comparative analysis .

Intracranial Infectious Aneurysm in Orbital Cellulitis

Infectious intracranial aneurysm and cavernous sinus thrombosis are rare complications of orbital cellulitis. We report the case of a 46-year-old male presenting with sinusitis and orbital cellulitis complicated by the development of an orbital mass. Following orbitotomy with debulking, the patient underwent bony orbital decompression for increasing proptosis postoperatively. While his exam stabilized, the patient developed complete ptosis and extraocular motor palsy in the contralateral eye after undergoing bilateral sinus debridement. Imaging was notable for the presence of a pseudoaneurysm of the internal carotid artery, which was treated with a stent. This report demonstrates rare complications of orbital cellulitis. These patients should be monitored carefully with noninvasive imaging studies, such as cerebral angiography, for early detection of vascular abnormalities that can progress rapidly.

Rapid growth of an infectious intracranial aneurysm with catastrophic intracranial hemorrhage

Infectious intracranial aneurysms are rare vascular lesions that classically occur in patients with infective endocarditis. We present a 49-year-old man with altered mental status and headache with rapid growth and rupture of an infectious intracranial aneurysm with catastrophic intracranial hemorrhage, and review issues related to open neurosurgical and endovascular interventions.

Resolution of a fungal mycotic aneurysm after a contaminated steroid injection: a case report

BACKGROUND

In the past ten years there have been three separate outbreaks of fungal contaminated steroid injections from compounding pharmacies. The 2012 outbreak of central nervous system fungal infections associated with contaminated methylprednisolone produced by a United States compounding pharmacy has led to 750 infections (151 with meningitis and paraspinal infections and 325 cases with paraspinal infections without meningitis) and 64 deaths as of October 23, 2013. Exserohilum rostratum has been the predominant pathogen identified by culture, polymerase chain reaction or antibody tests. According to previous reports, cerebral involvement with phaeohyphomycosis has a high risk of morbidity and mortality.

CASE PRESENTATION

We report a 41 year-old Caucasian woman who received a lumbar methylprednisolone injection from a contaminated lot in August 2012. She was diagnosed with fungal meningitis by cerebrospinal fluid pleocytosis and positive (1, 3) beta-D-glucan after cultures and polymerase chain reaction were negative. Two weeks after onset of therapy, she developed a 4.1 mm superior cerebellar artery mycotic aneurysm associated with new stroke symptoms, which resolved with thirty-two weeks of antifungal treatment.

CONCLUSIONS

This is the rare case report of successful medical management of a cerebral mycotic aneurysm with stroke symptoms related to a presumed phaeohyphomycosis in an immunocompetent individual. Further studies are needed to determine the utility of cerebrospinal fluid (1, 3) beta-D-glucan in diagnosing and monitoring patients with meningitis thought to be related to fungal infection.

Infective endocarditis

Infective endocarditis is a serious disease of the endocardium of the heart and cardiac valves, caused by a variety of infectious agents, ranging from streptococci to rickettsia. The proportion of cases associated with rheumatic valvulopathy and dental surgery has decreased in recent years, while endocarditis associated with intravenous drug abuse, prosthetic valves, degenerative valve disease, implanted cardiac devices, and iatrogenic or nosocomial infections has emerged. Endocarditis causes constitutional, cardiac and multiorgan symptoms and signs. The central nervous system can be affected in the form of meningitis, cerebritis, encephalopathy, seizures, brain abscess, ischemic embolic stroke, mycotic aneurysm, and subarachnoid or intracerebral hemorrhage. Stroke in endocarditis is an ominous prognostic sign. Treatment of endocarditis includes prolonged appropriate antimicrobial therapy and in selected cases, cardiac surgery. In ischemic stroke associated with infective endocarditis there is no indication to start antithrombotic drugs. In previously anticoagulated patients with an ischemic stroke, oral anticoagulants should be replaced by unfractionated heparin, while in intracranial hemorrhage, all anticoagulation should be interrupted. The majority of unruptured mycotic aneurysms can be treated by antibiotics, but for ruptured aneurysms, endovascular or neurosurgical therapy is indicated.

Ruptured mycotic cerebral aneurysm development from pseudoocclusion due to septic embolism

Background:

Cerebral mycotic aneurysms are rare sequelae of systemic infections that can cause profound morbidity and mortality with rupture. Direct bacterial extension and vessel integrity compromise from septic emboli have been implicated as mechanisms for formation of these lesions. We report the 5-day development of a ruptured mycotic aneurysm arising from a septic embolism that caused a focal M1 pseudoocclusion.

Case Description:

A 14-year-old girl developed acute left-sided hemiparesis while hospitalized for subacute bacterial endocarditis that was found after she presented with a 2-week history of fever, myalgia, shortness of breath, and lethargy. Mitral valve vegetations were confirmed in the setting of hemophilus bacteremia. Brain magnetic resonance (MR) imaging and angiography confirmed middle cerebral artery infarct with focal pseudoocclusion of the distal M1 segment. Given that further middle cerebral artery territory was at risk, a trial of heparin was attempted for revascularization but required discontinuation owing to hemorrhagic conversion. Decline of the patient's mental status necessitated craniectomy for decompression. Postoperatively, her mental status improved with residual left hemiparesis. On the third postoperative day (5 days after MR angiography), the patient's neurologic condition acutely declined, with development of right-sided mydriasis. Computed tomography (CT) angiography revealed a ruptured 19 × 16 mm pseudoaneurysm arising from the M1 site of the previous occlusion. Emergent coiling of aneurysm and parent vessel followed by hematoma evacuation ensued. At discharge, the patient had residual left hemiparesis but intact speech and cognition.

Conclusion:

Focal occlusions due to septic emboli should be considered high-risk for mycotic aneurysm formation, prompting aggressive monitoring with neuroimaging and treatment when indicated.

Ruptured mycotic aneurysm of the distal middle cerebral artery manifesting as subacute subdural hematoma

Mycotic aneurysms are rare inflammatory neurovascular lesions. Ruptured mycotic aneurysm manifesting as subdural hematoma is extremely rare. A 72-year-old male patient was admitted to our hospital with headache and drowsiness. Computer tomography (CT) of brain and CT angiography revealed subdural hematoma and an aneurysm located at the M4 segment of the left middle cerebral artery (MCA). Cerebral angiogram revealed 2 aneurysms; one located at the left distal MCA and the other at the bifurcation of left MCA. Laboratory studies showed leukocytosis and elevated inflammatory factors. The patent was treated with antibiotic therapy for 4 weeks. The follow-up CT and cerebral angiography showed that the mycotic aneurysm was completely resolved, and the patient was nearly free of symptoms.

Mycotic aneurysm: a rare and dreaded complication of infective endocarditis

Mycotic cerebral aneurysm is a rare and potentially fatal complication of infective endocarditis. A young man was diagnosed with culture negative infective endocarditis of mitral valve with cerebral aneurysm. The patient was started on conservative management, but he died owing to intracerebral haemorrhage. In the absence of large randomised trials, there is a lack of consensus regarding the management of unruptured aneurysms. Since mycotic aneurysms are known to resolve or decrease in size with antimicrobial therapy, several institutions advice the conservative approach. A few case reports like the present case have shown that the risk of aneurysmal rupture and death is considerably high with the conservative approach. Endovascular therapy has shown to reduce the mortality in this subgroup. These patients should be managed aggressively with endovascular or surgical procedure along with antimicrobial therapy.

Endovascular treatment of cerebral hemorrhage in a patient with a left ventricular assist device: report of a case

Cerebral hemorrhage is a common lethal complication associated with left ventricular assist device (LVAD) management. We performed cerebral angiography on patients with LVAD who developed cerebral hemorrhage and determined that ruptured aneurysms were the cause in some cases. Endovascular management of patients with LVAD can be a therapeutically useful approach for cerebral hemorrhage caused by aneurysm rupture.

Retrospective review of cerebral mycotic aneurysms in 26 patients: focus on treatment in strongly immunocompromised patients with a brief literature review

BACKGROUND AND PURPOSE

Cerebral mycotic aneurysms are a rare and deadly type of aneurysm that have no definitive treatment guidelines. Our purpose was to retrospectively review known or suspected cases of CMA in order to identify patient populations that may be associated with higher morbidity and mortality. We hope that the identification of patients with these risk factors will lead to early stratification upon presentation, and more urgent treatment of their CMAs. We also hoped to identify any benefit or complication that was specific to either the endovascular or neurosurgical repair of CMAs.

MATERIALS AND METHODS

A retrospective multi-institutional study was performed examining cases of CMA during a 15-year period. Patients were considered strongly immunocompromised if there were long-term severely immunocompromised states: AIDS, chemotherapy, or steroid immunosuppression. Patients were excluded if angiographic findings suggested an alternative diagnosis or if an infectious etiology was unknown. Antibiotics were considered "noninvasive treatment." Endovascular and neurosurgical repair were considered "invasive treatment." Data were recorded by reviewing electronic medical records and imaging reports.

RESULTS

Twenty-six patients with 40 CMAs were included. Three patients were considered strongly immunocompromised and presented with 4 CMAs, which demonstrated larger average size and more rapid growth; 3 of these patients' aneurysms were treated invasively in the acute period, with the one that was not ruptured causing death. Technical success (aneurysm occlusion without rupture or recanalization) and clinical success (no neurologic complication attributable to the intervention) were obtained equally endovascularly and neurosurgically. Clipping was aborted in favor of coiling for 1 patient. Anticoagulation needed reversal before 2 patients underwent craniotomy for clipping after valve replacement. For CMAs treated with antibiotics alone with angiographic follow-up (n=11), initial aneurysm size was unrelated to persistence and 64% completely regressed.

CONCLUSIONS

We recommend initial invasive treatment for CMAs in strongly immunocompromised patients. Testing for underlying immunocompromised states is warranted in patients with CMAs. Endovascular treatment is favored over neurosurgical treatment in patients requiring acute cardiac valve repair due to delays with anticoagulation reversal.

Etiologies of intracerebral hematomas

Intracerebral hemorrhage (ICH) remains a life-threatening disease that carries significant morbidity and mortality despite recent diagnostic and management advances. Various conditions are associated with increased risk of intracerebral hemorrhage. Understanding the etiology of these conditions and their pathophysiological contribution to ICH will likely lead to better therapeutic and preventative measures and improve the morbidity and mortality associated with intracerebral hemorrhage. We will review the current literature regarding important etiologies/risk factors of intracerebral hemorrhage.