Mycotic aneurysms of the internal carotid artery. Case report

Endovascular treatment of a mycotic intracavernous carotid artery aneurysm using a stent graft

Intracavernous carotid artery mycotic aneurysms are rare and management is determined by clinical presentation. We describe the first documented proximal intracranial mycotic aneurysm treated by a balloon expandable Aneugraft PCS covered stent. An 11-year-old female child presented with acute onset fever, headache, chemosis followed by diplopia, right-sided ptosis with ophthalmoplegia. Magnetic resonance imaging revealed bilateral cavernous sinus thrombosis. Subsequent work-up included serial computed tomographic arteriography and digital subtraction angiography which revealed a progressively enlarging intracavernous carotid aneurysm. An Aneugraft PCS covered stent was successfully deployed endovascularly, and complete exclusion of the aneurysm was achieved while maintaining the patency of the parent artery. The use of covered stents in intracranial vasculature can be an effective and safe treatment modality for exclusion of the mycotic aneurysm in selected cases.

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.

Infectious Aneurysm of the Cavernous Carotid Artery in a Child Treated With a New-Generation of Flow-Diverting Stent Graft

OBJECTIVE

To report a unique case of wide-necked mycotic cerebral aneurysm treated with a new generation of intracranial stent.

CLINICAL PRESENTATION

A 10-year-old girl presented with meningitis complicated by an infectious intracavernous large aneurysm revealed by cranial nerve palsy.

INTERVENTION

The aneurysm was treated by a new-generation, flow-diverting, endoluminal implant (SILK; BALT EXTRUSION, Montmorency, France) placed across the aneurysm neck without coiling. Angiographic controls showed complete thrombosis of the aneurysmal sac with dramatic improvement of symptoms a couple of weeks after the procedure. Follow-up magnetic resonance imaging and digital subtraction angiography 3 months after the procedure, confirmed total occlusion of the aneurysm with normal circulation in the parent vessel

CONCLUSION

This is a simple and highly effective way to exclude an aneurysm from the parent vessel without the difficulties observed with the semi-rigid stents. Flow-disrupting stent grafting may be a safe and effective alternative treatment for large intracranial aneurysms.

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.

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.

Blindness associated with enlarging mycotic aneurysm after cavernous sinus thrombosis

PURPOSE

We report a patient with an enlarging internal carotid mycotic aneurysm secondary to septic cavernous sinus thrombosis presenting with acute visual loss.

DESIGN

Single observational case report.

METHODS

Retrospective review of the medical record and review of the literature.

RESULTS

A 19-year-old man with residual left sixth nerve palsy and decreased vision in his left eye caused by left cavernous sinus thrombosis secondary to pansinusitis was seen 2 weeks after discharge with acute decreased visual acuity in the right eye. A workup revealed an enlarging left carotid/ophthalmic aneurysm that compressed the optic chiasm and right optic nerve. The patient was taken to the interventional angiography suite, where his left internal carotid artery was occluded endovascularly. The patient's vision improved on discharge.

CONCLUSIONS

Visual loss caused by a mycotic carotid aneurysm is an infrequent sequelae after cavernous sinus thrombosis and is not well described in the literature. To our knowledge, this is the first reported case of acute visual loss associated with a mycotic ophthalmic aneurysm. The result of treatment was good in this case, with the patient's visual acuity returning to pretreatment status.

Pseudomonas aeruginosa causing a right carotid artery mycotic aneurysm after a dental extraction procedure

Mycotic aneurysms of the carotid arteries are rare. We describe a right carotid artery mycotic aneurysm in a 70-year-old man. His symptoms began immediately after a complicated molar extraction and persisted until the diagnosis was made and surgical resection and repair were undertaken. Pseudomonas aeruginosa was isolated from multiple blood cultures and excised tissues. We review another 73 cases uncovered by an extensive literature search. Bacteremia, recent surgery, head and neck infections, dental infections, and endocarditis are the most common predisposing conditions. Computed tomography and magnetic resonance imaging are techniques for accurately confirming the suspicion of any aneurysm, but angiography is the gold standard. Primary resection of the aneurysm with native vein interposition, in conjunction with prolonged antibiotic therapy, is the preferred strategy. A total of 6 cases thus far, including ours, have been clearly associated with dental surgical procedures. These cases are characterized by rapidly enlarging neck masses in the presence of fever. Microorganisms, particularly gram-negative rods, in contrast to normal oral flora, eg, streptococci and anaerobes, are often isolated. With prompt diagnosis and treatment, outcome is often satisfactory.

[Bacterial cerebral aneurysms without infectious endocarditis: analysis of a case and review of the literature]

INTRODUCTION

Bacterial intracerebral aneurysms, which are a common complication of infectious endocarditis, are unusual without Osler's disease.

EXEGESIS

From the case report of a man with a bilateral bacterial intracranial aneurysm without endocarditis resulting in an hypopituitarism, we undertook a literature review of bacterial intracerebral aneurysms without endocarditis.

CONCLUSION

Although this review has found few cases, this kind of aneurysms seems to have different features from those secondary to infective endocarditis: younger age of incidence, majority of Staphylococcus aureus, clinical presentation as a thrombophlebitis of the cavernous sinus, location of aneurysm on bigger cerebral 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.

Mycotic aneurysms of the intracavernous carotid artery: a case report and review of the literature

A case of mycotic aneurysm of the intracavernous carotid artery is reported and the literature is reviewed on this uncommon entity. Nineteen cases have been reported, most often occurring in the clinical setting of meningitis. Management recommendations include angiographic confirmation of aneurysm and follow-up with magnetic resonance imaging during antibiotic therapy. Evidence of aneurysm enlargement is an indication for endovascular trapping of the aneurysm or carotid occlusion.

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 cavernous sinus aneurysm treated by detachable balloon technique

We describe a patient who developed bilateral cavernous sinus septic thrombosis secondary to a suppurative lesion on the left cheek. Despite clinical improvement, left oculomotor symptoms recurred suddenly. A carotid artery aneurysm within the cavernous sinus was diagnosed by means of magnetic resonance imaging and confirmed by digital angiography. Follow-up angiograms showed an initial decrease in the aneurysm size, with subsequent enlargement. A latex contrast-filled balloon was successfully placed within the aneurysm, preserving the carotid parent artery blood flow. Our case illustrates the usefulness of the detachable balloon technique in the treatment of bacterial aneurysms of the cavernous sinus as an alternative treatment to carotid artery ligation.

Bacterial aneurysms of the intracavernous carotid artery

✓ Six cases of bacterial intracavernous carotid artery aneurysms of extravascular origin secondary to cavernous sinus thrombophlebitis are reported along with a review of 12 similar cases collected from the literature. Of the authors' six cases, there were three children and three adults. Meningitis was found in five patients. All patients received prolonged antibiotic therapy. Spontaneous resolution of the aneurysm occurred in one patient, thrombosis of the internal carotid artery in another, and progressive enlargement of the aneurysm was seen on sequential angiography in the other two. Evidence of associated arteritis was present in all of the patients. Carotid ligation for persistent ophthalmoplegia was carried out in two patients, of whom one had a giant aneurysm and the other progressive aneurysm enlargement. The results of treatment were good in all cases. The authors believe that carotid arteriography is obligatory in cases of cavernous sinus thrombophlebitis in which ophthalmoplegia persists despite adequate antibiotic therapy.

Cerebral chromoblastomycosis complicated by meningitis and multiple fungal aneurysms after resection of a granuloma. Case report

Cerebral chromoblastomycosis is a rare intracranial lesion. This lesion was found in a 23-year-old man, who presented with right proptosis and fainting attacks. Computerized tomography revealed a moderately enhanced irregular mass in the right frontal region. Angiography disclosed that the mass was avascular. At surgery, a hard elastic avascular tumor was totally removed piecemeal. Histological diagnosis was a granuloma of fungal origin. Characteristic brown pigments in the hyphae of fungus in the granuloma strongly suggested that the fungus was chromoblastomycosis. The postoperative course was complicated by meningitis and rupture of fungal aneurysms. The patient remained vegetative and died 2 1/2 years later. The literature on such fungal aneurysms is briefly reviewed; no previous case of fungal aneurysms associated with cerebral chromoblastomycosis could be found.

Ruptured mycotic aneurysm during a computed tomogram brain scan

Images

Bacterial intracranial aneurysms

The treatment of 13 patients with bacterial intracranial aneurysms is reported. The incidence of bacterial intracranial aneurysms was 4% of all patients admitted with intracranial aneurysms and 3% of all patients admitted with bacterial endocarditis. Each patient had neurological signs or symptoms suggestive of intracranial disease prior to the diagnosis of an aneurysm. Alpha Streptococcus was the most common infecting organism. All patients were treated with specific, high-dose antibiotics, and five patients underwent surgery as well. There were no surgical deaths. Six of eight nonsurgically treated patients died. A review of the literature confirms a high mortality for patients treated with only antibiotics, and a low mortality for elective surgery. The authors conclude that 1) patients with bacterial endocarditis, who develop sudden severe headache, focal neurological signs or symptoms, or seizures, should undergo serial cerebral angiography every 7 to 10 days throughout their hospitalization; 2) if an aneurysm is identified it should be excised whenever possible; and 3) patients with proximal or multiple aneurysms should be considered for surgery.

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.

Treatment of mycotic intracranial aneurysms

Two patients with mycotic intracranial aneurysms were successfully treated with only antibiotic therapy. One patient, who had subacute bacterial endocarditis, rheumatic valvular disease, and an abscessed tooth, sustained a subarachnoid hemorrhage from a ruptured right middle cerebral artery trifurcation aneurysm. The other patient, who had Turner's syndrome and probable congenital aortic stenosis, developed multiple neurological findings during an ipisode of acute bacterial endocarditis precipitated by an infected ingrown toenail; a false aneurysm of the distal left middle cerebral artery and two lesions involving the left superior cerebellar artery were found. A study of the literature shows that only 45 patients with mycotic intracranial aneurysms have received adequate antibiotic therapy and angiographic documentation. Statistically, there does not appear to be a clear-cut advantage to antibiotic plus surgical therpy over antibiotic alone. In fact, in 21 patients who underwent serial angiography, lesions were smaller in six and not visualized in 11. In four patients the aneurysms increased in size; in two others fresh lesions formed. The author proposes the following diagnostic and therapeutic regimen: 1) earliest possible diagnosis of the underlying disorder; 2) appropriate antibiotic therapy; 3) early four-vessel cerebral angiography and follow-up studies every 2 to 3 weeks; study; 5) definitive operation upon completion of antibiotic therapy if the lesion is larger or the same size; and 6) postoperative angiography to evaluate the effectiveness of treatment and to search for interim lesions.

Cerebral bacterial aneurysms in subacute bacterial endocarditis

Bacterial aneurysms are aneurysms which develop on a vascular wall weakened as a result of a bacterial infection. They can develop anywhere. This paper describes a female patient with subacute bacterial endocarditis and multiple cerebral aneurysms. Conservative treatment followed.