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 »  Introduction
 »  Case report
 »  Discussion
 »  References

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Year : 2000  |  Volume : 48  |  Issue : 3  |  Page : 276-8

Mycotic aneurysm on posterior cerebral artery : resolution with medical therapy.


Department of Neurology, Nizam's Institute of Medical Sciences, Panjgutta, Hyderabad, 500082, India.

Correspondence Address:
Department of Neurology, Nizam's Institute of Medical Sciences, Panjgutta, Hyderabad, 500082, India.

  »  Abstract

Mycotic aneurysms on the branches of vertebro basilar artery are rare. A patient of infective endocarditis with mycotic aneurysm on the posterior cerebral artery is described. The aneurysm resolved with medical therapy. Controversies regarding the management of mycotic aneurysms are discussed.

How to cite this article:
Meena A K, Sitajayalakshmi S, Prasad V S, Murthy J M. Mycotic aneurysm on posterior cerebral artery : resolution with medical therapy. Neurol India 2000;48:276


How to cite this URL:
Meena A K, Sitajayalakshmi S, Prasad V S, Murthy J M. Mycotic aneurysm on posterior cerebral artery : resolution with medical therapy. Neurol India [serial online] 2000 [cited 2020 Dec 2];48:276. Available from: https://www.neurologyindia.com/text.asp?2000/48/3/276/1521




   »   Introduction Top

Intracranial mycotic aneurysms are uncommon complications of infective endocarditis.[1] The management problem of mycotic aneurysms differs from that of saccular aneurysms. Mycotic aneurysms tend to disappear when infective endocarditis is treated adequately with antibiotics.[2],[3],[4] It has been shown on the basis of probability estimates that surgical treatment of a mycotic aneurysm, once it has been demonstrated, is more harmful than medical treatment only.[5] This report describes successful treatment of mycotic aneurysm on posterior cerebral artery with medical therapy in a patient with infective endocarditis.


   »   Case report Top

A 19 year old male was admitted for high grade fever with chills and rigors, headache and vomitings of one week duration. Two days before admission he developed altered sensorium. He underwent closed mitral volvotomy for rheumatic mitral stenosis. On examination he was ill, febrile, and normotensive. He was restless, obtunded and was not responding to verbal commands. Ocular fundi were normal. Pupils were of normal size and reactive to light. Doll's eye movements were normal. Motor system examination revealed paucity of movements on left side. Deep tendon reflexes were slightly brisk on the left side and plantars were bilaterally extensor. His neck was stiff and Kernigs sign was positive. Cardiovascular examination revealed pansystolic murmur at the apex and early diastolic murmur at aortic area. Chest examination was essentially normal. Spleen was palpable.
Investigations showed a blood leukocyte count of 18,000/mm3. Erythrocyte sedimentation rate was 66 mm in the first hour. Blood cultures grew Staphylococcus aureus. Plain and contrast CT scans of the brain were normal. CSF analysis showed normal biochemistry and a cell count of 450/mm3 with 80% neutrophils. 2D echo and trans oesophageal echo (TEE) revealed severe mitral regurgitation, moderate aortic stenosis, and mild tricuspid regurgitation. Large vegetations were present on the anterior leaflet of the aortic valve and there was perforation of left coronary cusp.
He was given intravenous ceftriaxone and gentamicin. He showed steady improvement over the next few days. On seventh day he complained of severe headache and lapsed into deep coma (Glasgow coma score 4). He developed right 3rd nerve palsy. CT scan of the brain showed blood in the perimesencephalic cisterns with mild ventriculomegaly. Cerebral angiogram showed aneurysm arising from P1 segment of right posterior cerebral artery [Figure - 1]. He was treated conservatively with supportive care and antibiotics. He showed steady improvement. Repeat cerebral angiogram showed complete resolution of the aneurysm [Figure - 2]. At the last follow-up, his left sided weakness had completely improved but he still had residual right 3rd nerve palsy.


   »   Discussion Top

Mycotic aneurysms are a rare complication of infective endocarditis and the reported frequency varies from 1.6% to 18%.[3],[6] Most often they are located on the distal branches of middle cerebral artery, and are multiple and bilateral.[3],[7],[8],[9] Mycotic aneurysms on the branches of vertebrobasilar artery are extremely rare and only few cases have been documented.[10],[11],[12] In a large series of 17 patients with 29 mycotic aneurysms, only one had aneurysm on the superior cerebellar artery.[4] Kuki et al[13] documented a case with multiple cerebral mycotic aneurysms in both carotid and vertebrobasilar system. The patient reported by Kowada et al[14] had multiple mycotic aneurysms; one on the anterior branch of insular artery, and aneurysms at the periphery of bilateral posterior cerebral arteries. This patient improved with medical therapy.
Neurological symptoms may be absent in patients with mycotic aneurysms and when symptoms are present they are hardly specific.[4] One might consider cerebral angiography in patients suffering from infective endocarditis to detect intracranial mycotic aneurysms before a catastrophic rupture occurs. Whether these patients should undergo cerebral angiography is an unresolved question. Some authors advocate angiography only in patients suffering from neurological symptoms.[1],[4],[9] Others recommended complete cerebral angiography even in patients who are neurologically asymptomatic.[5],[6],[15] Recently van der Meulen et al[5] estimated the probability of survival 12 weeks after the diagnosis of infective endocarditis on the basis of data available in the literature. For a 40 year old female patient with hemispheric deficits, the survival probablity is higher without angiography (83.75% vs 83.65%). The specific mortality of intracranial mycotic aneurysms is relatively small but increases by 40% (from 0.35% to 0.38%) if angiography is performed. Based on these observations they suggested that cerebral angiography should not be performed routinely in patients with infective endocarditis. Patients who require cerebral angiography are yet to be identified.
The management of myocotic aneurysm varies. There is ample evidence that complete resolution of mycotic aneurysm can be effected with medical therapy.[2],[4],[10],[16]
Some authors have recommended observation with serial angiography during medical therapy and surgery for aneurysms that enlarge or remain patent.[15] However aneurysms treated medically have been shown to resolve even upto a year after cessation of antibiotic therapy.[2] Others have argued for prompt surgical removal.[1],[6],[7] In one of the largest series[4] of twenty aneurysms followed angiographically or with computed tomography during medical treatment, 10 became smaller or disappeared and 10 remained unchanged or enlarged. There was one death in the later group. Of the 5 patients who developed aneurysmal rupture during or at the conclusion of medical therapy, 2 died. There is no way to identify in advance those aneurysms that will become smaller or disappear with appropriate antibiotic therapy and those that will rupture without angiographic enlargement. Based on these observations they recommended that single accessible distal mycotic aneurysm in medically stable patients to be promptly excised. Recommendation for patients with multiple or proximal aneurysms has to be individualized. Recently, van der Meulen et al,[5] on the basis of probability estimates, suggested that surgical treatment of a mycotic aneurysm once it has been demonstrated is more harmful than medical treatment only.
Based on the published observations, we conclude that noninvasive modalities like magnetic resonance angio or CT angio should be the modalities to detect unruptured mycotic aneurysms in patients with infective endocarditis. Once aneurysm is demonstrated, these patients should be treated aggressively with appropriate antibiotics and should undergo serial studies while on medical therapy and also after conclusion of therapy. Surgical options should be individualized.

 

  »   References Top

1.Frezee JG, Cahan LD, Winter J : Bacterial intracranial aneurysms. J Neurosurg1980; 53 : 633-641.   Back to cited text no. 1    
2.Morawetz RE, Karp RB : Evolution and resolution of bacterial (mycotic) aneurysms. Neurosurgery1984; 15 : 43-49.   Back to cited text no. 2    
3.Hart RG, Kagan-Hallet K, Joerns SE : Mechanisms of intracranial haemorrhage in infective endocarditis. Stroke 1987; 18 : 1048-1056.   Back to cited text no. 3    
4.Burst JC, Taylor Dickinson PC, Hughes JEO et al : The diagnosis and treatment of cerebral mycotic aneurysms. Ann Neurol1990; 27 : 238-246.   Back to cited text no. 4    
5.van der Meulen JHP, Weststrate W, van Gijn J et al : Is cerebral angiography indicated in infective endocarditis?. Stroke1992; 23 : 1662-1667.   Back to cited text no. 5    
6.Bohmfalk GL, Storey JL, Wissinger JP et al : Bacterial intracranial aneurysm. J Neurosurg1978; 48 : 369-382.   Back to cited text no. 6    
7.Roach MR, Drake CG : Ruptured cerebral aneurysms caused by micro organisms. N Engl J Med1965; 273 : 240244.   Back to cited text no. 7    
8.Pruit AA, Rubin RH, Karchmeer AW et al : Neurologic complications of bacterial endocarditis. Medicine 1978; 57 : 329-343.   Back to cited text no. 8    
9.Salgado AV, Furlan AJ, Keys RF : Mycotic aneurysms, subarachnoid haemorrhage and indications for cerebral angiography in infective endocarditis. Stroke 1987; 18 : 1057-1067.   Back to cited text no. 9    
10.Hojer C, Bewermeyer H, Hildebrandt G et at : Rupture and successful operation of mycotic aneurysm of the superior cerebellar artery. Nervenarzt 1993; 64 : 404-406.   Back to cited text no. 10    
11.Barami K, Ko K : Ruptured mycotic aneurysm presenting as an intraparenchymal haemorrhage and nonadjacent acute subdural haematoma: case report and review of the literature. Surg Neurol1994; 41(4) : 290-293.   Back to cited text no. 11    
12.Cloft HJ, Kallmes DF, Jensen ME et al : Endovascular treatment of ruptured, peripheral cerebral aneurysms: Parent artery occlusion with short guglielmi detachable coils. Am J Neuradiol 1999; 20(2) : 308-310.   Back to cited text no. 12    
13.Kuki S, Yoshda K, Sujuki K : Successful surgical management for multiple cerebral mycotic aneurysms in both carotid and vertebrobasilar system in infective endocarditis. Eur J Cardiothor Surg1994; 8 : 508-510.   Back to cited text no. 13    
14.Kowada M, Watanabe K, Takashash M et al : Multipleintracranial mycotic aneurysms: Report of a case. No Shinkei Geka1975; 3 : 255-260.   Back to cited text no. 14    
15.Bingham WF : Treatment of mycotic intracranial aneurysms. J Neurosurg1977; 46 : 427-437.   Back to cited text no. 15    
16.Pootrakul A, Carter LP : Bacterial intracranial aneurysm : importance of sequential angiography. Surg Neurol1982; 17 : 429-431.   Back to cited text no. 16    

 

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