Recovery from Ruptured Mycotic Aneurysm

Bacterial intracranial aneurysms

This is a retrospective study of 25 patients with bacterial intracranial aneurysms treated in a single department over a 20-year period. The clinical presentation, investigation and treatment of these patients is discussed. The outcome of the treatment is assessed and is thought to be not as poor as previously reported.

The diagnosis and treatment of cerebral mycotic aneurysms

Seventeen patients were treated for 28 documented cerebral mycotic aneurysms. Initial neurological symptoms were attributable to aneurysm rupture in only 7 patients, and in 3 of them symptoms did not suggest subarachnoid hemorrhage. Six patients presented with embolic infarction and 1 with meningitis; in 3 patients it was uncertain if aneurysm rupture occurred. Four patients had rupture of at least one aneurysm while receiving appropriate antibiotic treatment and another had rupture at the conclusion of therapy. Of 20 aneurysms followed angiographically or with computed tomography during medical treatment, 10 became smaller or disappeared and 10 remained unchanged or enlarged, 1 with fatal rupture. Eight ruptured aneurysms were surgically excised; 2 of the patients with ruptured aneurysms died and 2 had residual aphasia or cognitive impairment. All 4 patients whose only surgery was for an unruptured aneurysm made uneventful recoveries. Recognizing the retrospective and anecdotal nature of our data and the differing views of previous investigators, we recommend: (1) that careful neurological examination, computed tomography, and (unless contraindicated) lumbar puncture be performed on any patient with endocarditis; (2) that those with neurological abnormalities not attributable to systemic toxicity, including pleocytosis in the cerebrospinal fluid or apparent infarction on computed tomographic scans, undergo four-vessel cerebral angiography; (3) that single accessible mycotic aneurysms in medically stable patients be promptly excised, with individualization of multiple or proximal aneurysms; and (4) that repeat angiography be performed at the conclusion of antibiotic therapy in patients requiring long-term anticoagulation.(ABSTRACT TRUNCATED AT 250 WORDS)

Bacterial intracranial aneurysm

✓ The authors tabulate and analyze cases of bacterial intracranial aneurysm documented since 1954, and add four of their own. In 85 cases the overall mortality was 46%. Elimination of patients dying before reaching the hospital makes this figure spuriously low. Figures for patients hospitalized for endocarditis before neurological symptoms occurred suggest a true mortality of 80% from aneurysms that rupture and 30% if the aneurysm remains intact. Multiple reports of spontaneously resolving, enlarging, diminishing, multiple, and sequentially appearing aneurysms, all of which occurred in our fourth case, clarify the need for complete and sequential angiography. Computerized tomographic (CT) scanning in this disease has not been reported, but our experience with these scans demonstrates considerable potential value.

A protocol of complete cerebral angiography and CT scanning of these neurologically asymptomatic patients is proposed, in order to assess the true incidence of bacterial intracranial aneurysm, to learn more of its natural history, and to prevent some neurological catastrophes.