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Table of Contents    
LETTER TO EDITOR
Year : 2021  |  Volume : 69  |  Issue : 6  |  Page : 1882-1884

Surgery in True Fungal Intracerebral Aneurysm: Prevents Rerupture or Instigates Dreaded Inflammation


1 Department of Neurosurgery, PGIMER, Chandigarh, India
2 Department of Radiology, PGIMER, Chandigarh, India

Date of Submission05-Sep-2020
Date of Decision17-Mar-2021
Date of Acceptance11-Apr-2021
Date of Web Publication23-Dec-2021

Correspondence Address:
Dr. Sushant Sahoo
Room NO - 27, 5th Floor, F-Block, Nehru Hospital, PGIMER, Chandigarh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0028-3886.333451

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How to cite this article:
Sahoo S, Salunke P, Ahuja CK, Siroliya A. Surgery in True Fungal Intracerebral Aneurysm: Prevents Rerupture or Instigates Dreaded Inflammation. Neurol India 2021;69:1882-4

How to cite this URL:
Sahoo S, Salunke P, Ahuja CK, Siroliya A. Surgery in True Fungal Intracerebral Aneurysm: Prevents Rerupture or Instigates Dreaded Inflammation. Neurol India [serial online] 2021 [cited 2022 Jan 20];69:1882-4. Available from: https://www.neurologyindia.com/text.asp?2021/69/6/1882/333451




Dear Sir,

Vasculitis and throbmosis of vessel leading to ischemic stroke is well known with intracerebral fungal infections.[1] However, ruptured aneurysm is rare presentation in them. Surgery have poor outcome due to dissemination of inflammation leading to fungal meningoencephalitis.[2],[3] However, a ruptured aneurysm with possible fungal etiology would still warrant early surgical intervention to prevent rerupture.

A 23-year-old female presented to our emergency with complains of sudden onset headache, vomiting with an MRI and MR angio suggestive of right M1 saccular aneurysm with hematoma [Figure 1]c, [Figure 1]d. At presentation, she had neck stiffness and was alert without any focal neurological deficits (H&H 2, WFNS 1). She did not have any comorbidity. In addition to the hematoma on CT scan [Figure 1]a, [Figure 1]b, CTA showed right M1 fusiform dilatation with saccular outpouching [Figure 1]e. She underwent right pterional craniotomy and clipping of the aneurysm. A whitish, fibrous mass was encountered at the base of frontal lobe close to the carotid cistern [Figure 1]f. The neck could be dissected and clipped [Figure 1]g. The fundus and the mass were sent for histopathological examination. Frozen section suggested fungal lesion. Antifungal therapy was started immediately. After an uneventful course, she developed hemiparesis and altered sensorium on postoperative day 4. CT showed infarction of the right fronto parietal region. She continued to further worsen for the next 3 days despite antifungals and died on post op day 7. Histopathology revealed chronic invasive granulomatous aspergillosis [Figure 2]a,[Figure 2]b,[Figure 2]c,[Figure 2]d.
Figure 1: a&b: CT scan showing right frontal resolving hematoma with intraventricular hemorrhage. c& d: T2W MRI showing doubtful lesion at the base of right frontal lobe (c) with right M1 aneurysmal dilatation (red arrow in d). e: CT angio showing fusiform dilatation of the right M1 with sacular outpouching (yellow arrow). f&g: intraoperative image showing the fungal lesion (blue star in f) and M1 aneurysm (yellow arrow in g)

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Figure 2: a–d: Histopathology image showing chronic invasive granulomatous aspergillosis with numerous epitheloid cell granulomas comprising of giant cells with phagocytosed slender fungal hyphae. The morphology of the fungal hyphae could be appreciated as slender, septate with acute angled branching (c&d, yellow arrow)

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Infectious intracranial aneurysms are rare with incidence rate of approximately 4–5% of total intracerebral aneurysms.[2] Hematogenous spread or contiguous involvement by fungal mass also lead to intracerebral aneurysms and its rupture. Aspergillus species are the commonest fungal infection associated with these aneurysms followed by Mucor. Early diagnosis and treatment with antifungals is necessary to prevent disseminated fungal meningitis and encephalitis leading to death after surgery.[3],[4]

In this case, open surgery and handling of the lesion resulted in dissemination of fungus leading to lethal meningoencephalitis. In retrospect, the suspected frontal hematoma on MRI probably was the fungal mass and inflamed sphenoid mucosa was also noted [Figure 3]a, [Figure 3]b. The adjacent M1 was probably invaded directly by the fungus and resulted in aneurysmal dilatation. Open surgery for ruptured aneurysm due to suspected fungal involvement should be avoided. We believe neuroradiological intervention with antifungals is a better alternative, thereby preventing postsurgical fulminant fungal meningoencephalitis.
Figure 3: Sagittal T2W MRI showing sphenoidal sinus mucosal inflammation (yellow arrow in a) and contiguous fungal mass (orange arrow in b)

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Financial support and sponsorship

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Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Li W, Shafi N, Periakaruppan R, Valyi-Nagy T, Groth J, Testai FD. Cerebral aspergillosis in a diabetic patient leading to cerebral artery occlusion and ischemic stroke: A case report and literature review. J Stroke Cerebrovasc Dis 2015;24:e39-43.  Back to cited text no. 1
    
2.
Ducruet AF, Hickman ZL, Zacharia BE, Narula R, Grobelny BT, Gorski J, et al. Intracranial infectious aneurysms: A comprehensive review. Neurosurg Rev 2010;33:37-46.  Back to cited text no. 2
    
3.
Rangwala SD, Strickland BA, Rennert RC, Ravina K, Bakhsheshian J, Hurth K, et al. Ruptured mycotic aneurysm of the distal circulation in a patient with mucormycosis without direct skull base extension: Case report. Oper Neurosurg (Hagerstown) 2019;16:E101-7.  Back to cited text no. 3
    
4.
Radotra BD, Salunke P, Parthan G, Dutta P, Vyas S, Mukherjee KK. True mycotic aneurysm in a patient with gonadotropinoma after trans-sphenoidal surgery. Surg Neurol Int 2015;28:193.  Back to cited text no. 4
    


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