Endovascular approach for an intracranial mycotic aneurysm associated with infective endocarditis

Abstract

One of the most serious complications of infective endocarditis is mycotic cerebrovascular aneurysm, which can cause a lethal subarachnoid hemorrhage (SAH). ~ The treatment of mycotic aneurysms in hemodynamically unstable patients is controversial because solid guidelines based on large prospective studies are lacking. Patients show a wide variety in size, number, and location of these intracranial lesions, in addition to varying in basic cardiac function. We report a case of ruptured mycotic aneurysm caused by infective endocarditis in a patient whose cardiac function was too severely compromised to permit an open craniotomy. A 42-year-old man was admitted with a history of general fatigue, dyspnea, fever, and night sweats for a week. He had a high body temperature of 38°C and cardiac murmurs indicative of aortic and mitral regurgitation. A chest radiograph demonstrated cardiomegaly and severe pulmonary edema. An echocardiogram revealed vegetation and severe regurgitation of both the aortic and mitral valves. A diagnosis of infective endocarditis was confirmed by the isolation of Streptococcus viridans in :multiple arterial blood cultures. The patient was treated in the intensive care unit with high doses of antibiotics (ampicillin 10 gm/day and tobramycin 120 mg/day), diuretics, and catecholamines to control bacteremia and acute heart failure. After 6 days of intensive care, the patient's body temperature dropped below 37 ° C and further blood cultures were negative for pathogens. The patient's pulmonary edema and cardiomegaly also were alleviated. The patient was moved to a general floor, and double valve replacement was scheduled for the following week. Early the next morning, however, the patient became comatose and had a temperature of 38.6 ° C, tachycardia, hypertension, and respiratory distress. Mechanical ventilation under endotracheal intubation was started. Computed t0mography demonstrated a massive SAH. Subsequent cerebral angiography revealed a 5 mm aneurysm arising from the P2 portion of the right posterior cerebral artery (Fig. 1). The patient was transferred to the intensive care unit. Despite conservative therapy, including respiratory support and administration of diuretics and catecholam;mes, the patient's condition was considered to be too hCmodynamically unstable to allow him to undergo general anesthesia and an emergency craniotomy for direct clipping of the aneurysm. Emergency double valve