Infectious Intracranial Aneurysms Research Articles

Abstract 128: Outcomes of Intervention versus Medical Management Alone for Infectious Intracranial Aneurysms ‐ A Nationwide Analysis

Introduction Infectious intracranial aneurysms (IIA) are one of several cerebrovascular complications associated with infective endocarditis (IE). IIA are initially treated with antibiotics given that treatment of the underlying infection is an important component of therapy. However, given the complex nature of these aneurysms, a multi‐disciplinary approach may be warranted for optimal outcomes, which includes coiling, embolization, clipping, or a combination of these measures. Herein, we aim to better understand outcomes in the use of medical management alone in this group of patients versus additional interventions. Methods Using data from the National Inpatient Sample from 2000 to 2020, we conducted an analysis comparing outcomes of intervention with medical management versus medical management alone for hospitalizations with infective endocarditis. A subgroup analysis of ruptured vs unruptured aneurysms was performed with primary endpoints being mortality and favorable outcome defined as discharge disposition to home without services. Treatment modalities were categorized as antibiotics, endovascular, and/or open neurosurgical repair based on ICD‐9 and ICD‐10 codes. Logistic regressions were utilized to assess the association between treatment modality and the outcomes of in‐hospital mortality and discharge disposition, while accounting for age and illness severity [quantified by All Patient Refined Diagnostic Related Groups (APR‐DRG) illness severity subclass]. Effect size was reported as adjusted odds ratio (aOR) with 95% confidence interval (CI). Results This analysis identified 2711 hospitalizations for IE, of which 315 (11.6%) were treated with antibiotics alone, versus 2715 (88.4%) which were treated with both antibiotics and intervention. IE patients undergoing intervention experienced significantly decreased mortality rates in comparison to those receiving antibiotics alone (6.3% v 9.9%; p =0.045), however rates of favorable outcomes did not differ (22.5% vs. 25.0%, p=0.343). In sub‐group analysis of ruptured IIA (n=633, 23.4% of total cohort), intervention yielded significantly lower mortality rates (10.6% v 24.8%, p<0.001) and a trend toward increased rates of favorable outcomes (14.3% v 9.1%, p=0.077). In sub‐group analysis of unruptured IIA, intervention resulted in lower absolute mortality rates (2.9% v 6.0%, p=.088) but no difference in favorable outcomes (28.9% v 29.1, p=0.957). Conclusion While treatment of IIA often involves a multidisciplinary approach, antibiotics as part of medical management remains integral. Our study showed that intervention in addition to medical management led to decreased mortality rates, especially in patients with ruptured IIA. Further directions for future studies include elucidating predictors of favorable outcomes for undergoing intervention and the most beneficial timing for the procedure during hospitalization.

Abstract 337: National Trends in Intervention Modality for Hospitalizations with Infectious Intracranial Aneurysms and Associated Outcomes

Introduction Data regarding how to treat infectious intracranial aneurysms most effectively remains sparse. With growing utilization of endovascular therapy for cerebrovascular disease, we examined trends in endovascular versus neurosurgical treatment of infectious aneurysms and investigated the impact of treatment modality on patient outcomes. Methods Using data from the National Inpatient Sample from 2000 to 2019, we conducted a trends analysis on rates of treatment modalities among all hospitalizations with infective endocarditis with ruptured or unruptured cerebral aneurysms. Treatment modalities were categorized as endovascular versus open neurosurgical repair based on ICD‐9 and ICD‐10 codes. Logistic regressions were utilized to assess the association between treatment modality and the outcomes of in‐hospital mortality and discharge disposition. Results We identified 24,461 hospitalizations with an infectious intracranial aneurysm in the setting of infective endocarditis. The mean age was 56.0 years (SD, 17.8) and 61.8% were male. The overall rate of intervention was 5.8% (95% CI, 5.0‐6.5%), and this did not change over time (p=0.669). There was a significant increase in the rate of endovascular repair (APC=3.6%; 95% CI, 1.2%‐8.1%) and a significant decrease in the rate of open neurosurgical repair (APC= ‐5.4%; 95% CI, ‐8.1% to ‐3.5%). Treatment modality was not associated with in‐hospital mortality (p=0.698) or non‐home discharge disposition (p=0.897). Conclusion Although rates of infectious intracranial aneurysm intervention for infective endocarditis did not change, utilization of endovascular treatment increased while the use of open neurosurgical treatment decreased. Further directions include elucidating predictors of favorable outcomes for those undergoing intervention as well as the most beneficial timing for the procedure during hospitalization.

Incidence, Management, and Outcomes of Pediatric Infectious Aneurysms.

Infectious intracranial aneurysms (IIAs) are rare cerebrovascular complications of infective endocarditis (IE) accounting approximatively for 0.5% to 6.5% of all aneurysms. In children, mycotic aneurysms secondary to IE are uncommon. This is a retrospective study of patients treated for pediatric IIA secondary to IE at our institution with an emphasis on presentation, etiologies, nuances in management, and outcomes. One hundred fifty-one patients were treated for IE secondary to congenital or acquired heart disease, of which 13 patients (8.6%) presented with intracranial hemorrhage. IIA occurred in 5 patients (2.6%) with IE. IIA accounted for 15% of intracranial aneurysms treated during the study period. Pediatric patients with ruptured IIAs have a high rate of rerupture, and early surgical intervention should be considered through an open or endovascular route when available.

Infectious endocarditis complicated with intracranial infected aneurysm rupture and sinus of valsalva aneurysm rupture

BackgroundInfectious endocarditis (IE) is an infectious disease caused by direct invasion of the heart valve, endocardium, or adjacent large artery endocardium by pathogenic microorganisms. Despite its relatively low incidence, it has a poor prognosis and a high mortality. Intracranial infectious aneurysms (IIA) and ruptured sinus of Valsalva aneurysm (RSVA) are rare complications of IE.Case presentationWe report a young male patient with symptoms of respiratory tract infection, heart murmurs and other symptoms and signs. The patient also had kidney function impairment and poor response to symptomatic therapy. Blood culture was negative, but echocardiography was positive, which met the diagnostic criteria for infective endocarditis. Moreover, an echocardiography showed a ruptured sinus of Valsalva aneurysm with a ventricular septal defect. Finally, secondary rupture of an IIA with multiple organ damage led to a poor clinical outcome.ConclusionTherefore, in the clinical setting, for young patients with unexplained fever, chest pain, or palpitations, we need to be highly vigilant, considering the possibility of infective endocarditis and promptly performing blood culture, echocardiography, cerebrovascular imaging and so on, in order to facilitate early proper diagnosis and treatment.

Combined Treatment of Ruptured Intracranial Infectious Aneurysm Accompanied by Intracerebral Hemorrhage: Endovascular Treatment and Neuroendoscopy

Intracranial infectious aneurysms (IIAs) are very rare. Most IIAs are associated with infective endocarditis (IE). The treatment of ruptured IIAs with intracerebral hemorrhage (ICH) remains challenging. Here, the authors aimed to describe a minimally invasive approach, combining endovascular treatment (EVT) with endoscopic techniques, for this complex issue. From January 2019 to December 2021, 3 cases of ruptured IIAs with intracerebral hemorrhage treated with EVT and neuroendoscopic hematoma evacuation at Guangdong Provincial People’s Hospital were included in this study. We retrospectively reviewed the clinical and imaging data and postoperative follow-up. All the IIAs were located in the middle cerebral arteries. The IIAs were secured by embolizing the aneurysms and occluding the parent artery. The ICH was evacuated using neuroendoscopy without postoperative rebleeding. After IIAs treatment, 2 patients underwent cardiac surgery, one at 10 days postoperatively and the other at 1 month postoperatively. At the 1-year follow-up, all patients resumed their normal lives. EVT and neuroendoscopic therapy for ruptured IIAs with ICH in patients is a useful complement to current treatment strategies.

Spontaneous Non-Aneurysmal Convexity Subarachnoid Hemorrhage: A Scoping Review of Different Etiologies beyond Cerebral Amyloid Angiopathy.

Spontaneous convexity subarachnoid hemorrhage (cSAH) is a vascular disease different from aneurysmal SAH in neuroimaging pattern, causes, and prognosis. Several causes might be considered in individual patients, with a limited value of the patient's age for discriminating among these causes. Cerebral amyloid angiopathy (CAA) is the most prevalent cause in people > 60 years, but reversible cerebral vasoconstriction syndrome (RCVS) has to be considered in young people. CAA gained attention in the last years, but the most known manifestation of cSAH in this context is constituted by transient focal neurological episodes (TFNEs). CAA might have an inflammatory side (CAA-related inflammation), whose diagnosis is relevant due to the efficacy of immunosuppression in resolving essudation. Other causes are hemodynamic stenosis or occlusion in extracranial and intracranial arteries, infective endocarditis (with or without intracranial infectious aneurysms), primary central nervous system angiitis, cerebral venous thrombosis, and rarer diseases. The diagnostic work-up is fundamental for an etiological diagnosis and includes neuroimaging techniques, nuclear medicine techniques, and lumbar puncture. The correct diagnosis is the first step for choosing the most effective and appropriate treatment.

Newly formed and ruptured infectious intracranial aneurysm in few days following first intracranial aneurysm embolization concurrent with middle cerebral artery occlusion: A regrettable case in a baby child

AbstractInfectious intracranial aneurysm (IIA) and embolic cerebral infarction are well‐known devastating complications of children suffering infective endocarditis. In this report, we describe a successfully embolized IIA concurrent with bilateral middle cerebral artery (MCA) occlusion. Unfortunately, a newly formed IIA located in the contralateral MCA bifurcation ruptured at the seventh day following embolization. A 6‐month‐old female child was admitted to hospital 3 days following acute right limb mobility disorder. An interventional surgery history of congenital heart disease was confirmed. She was immediately started on antibiotic therapy and the computed tomography agiography (CTA) scan showed occlusion of the upper branch of the left MCA. Unfortunately an IIA was located in the distal artery region (DAR) of the ipsilateral anterior cerebral artery. Angiography (digital subtraction angiography) was performed and the DAR IIA was embolized by OnyX‐18 with Magic 1.2 Fr. microcatheter. On the sixth day, magnetic resonance imaging during the hospital stay showed reduced infarction area with no other special sign. Desperately, a major seizure with opisthotonos attacked the baby on the seventh day after embolization. An immediate CTA scan showed massive hematoma in the right basal ganglia and a ruptured bifurcate aneurysm of the right MCA. The parents refused positive treatment and discharged in considering the critical situation. It should be noted that IIA can be fast formed anywhere in cerebral artery and dynamic angio‐image should be performed as supervision.

Abstract 147: Utilization and Application of Transcranial Doppler Emboli Monitoring for Infective Endocarditis

Introduction The rapid growth of the elderly population, an increase in cardiac disease, and notable use of intracardiac prosthetic devices has led to an increased prevalence of infective endocarditis (IE). Among the sequelae observed with an IE diagnosis, acute ischemic stroke (AIS), subarachnoid hemorrhage (SAH), intracerebral hemorrhage (ICH), vasculitis, septic emboli, cerebral abscess, and infectious intracranial aneurysms (IIA) continue to complicate overall management of this disease. Current literature on neurological complications of IE includes limited data on the defined role of neuroimaging in dictating inpatient management. Transcranial doppler (TCD) emboli monitoring with high intensity signals (HITS) offers a real time, radiation‐free, relatively low cost, non‐invasive imaging option to potentially risk stratify and identify candidates for earlier intervention to prevent further cerebrovascular (CV) complications. Methods We conducted an observational study of infective endocarditis cases admitted to our institution from April 2022 to May 2023 who had TCD with HITS completed. Baseline clinical characteristics (age, sex, date and timing of TCD with HITS study, date of last positive blood culture, organism of infection, other neuroimaging utilized) were recorded. Observations recorded included the results of the TCD with HITS studies, the overall incidence and timing of neurological complications (AIS, SAH, ICH, IIA, septic emboli, cerebral abscess), timing of valve surgery, and inpatient mortality rates. A positive HITS was defined as detection of cerebral microembolism during ultrasound monitoring of bilateral middle cerebral arteries (MCA) for 30 minutes using a TCD machine (VIASONIX Dolphin IQ). Results Between April 2022 to July 2023, we identified 22 patients with confirmed left‐sided infective endocarditis who underwent TCD with HITS. Mean age was 66 years (SD, 10), and 82% were men. Leading pathogen types were Enterococcus Faecalis (27%) and Staphylococcus Epidermidis (18%). CV complications were noted in 19/22 patients (86%), the most common being AIS (82%) and IPH (18%). Two patients (9%) were found to have a positive HITS study, both of which developed septic emboli that caused ischemic stroke in one case, and hemorrhagic stroke in the other case. Average days from admission to timing of TCD with HITS study was 8.5 days. 14/22 patients underwent valve surgery (64%) during the admission on average 9.2 days after TCD with HITS study in the negative HITS group versus 5 days in the positive HITS group. Of the positive HITS cases, one of them died inpatient. Conclusion The association between neurological complications in patients with IE and cerebral microemboli detected with TCD monitoring has yet to be elucidated. While our observational study was limited by our sample size, both of our IE patients who had positive TCD with HITS studies developed more severe CV complications, and aggressive care was sought out more urgently to further minimize complications. Future directions include pursuing a prospective study incorporating TCD with HITS monitoring for patients with IE in order to risk‐stratify neurological complications and safety of valve surgery.

Intravenous Drug Use‐Associated Endocarditis Leads to Increased Intracranial Hemorrhage and Neurological Comorbidities

Background The United States is experiencing a rapidly increasing rate of opioid drug abuse. Intravenous drug use (IVDU)‐related endocarditis can lead to significant neurological complications with high morbidity and mortality. When patient care necessitates anticoagulation, the standards for radiographic screening and the risk for intracranial hemorrhage are not clearly elucidated. Methods We conducted a retrospective cohort study involving patients treated for infective endocarditis at a single institution from 2014 to 2018. Patients were grouped based in history of IVDU and their demographics and clinical predictors for intracranial hemorrhage were analyzed. Results A total of 351 patients met inclusion criteria for this study, of whom 170 patients (48%) had a history of IVDU‐associated endocarditis. IVDU was associated with an increased prevalence of intracranial hemorrhage (25.9% versus 13.9%; P =0.005), including intraparenchymal hemorrhage (12.4% versus 5.1%; P =0.012), subarachnoid hemorrhage (17.6 versus 4.4%; P =0.001), and cerebral microbleeds (14.1% versus 7.2%; P =0.022). IVDU was also associated with an increased incidence of infectious intracranial aneurysm (10.6% versus 1.8%; P =0.001) and brain abscesses (4.7% versus 1.1%; P =0.025). Multivariate analysis showed that the presence of intracranial septic emboli (odds ratio [OR], 18.47 [8.4–40.250]; P =0.001) and infectious intracranial aneurysm (OR, 12.38 [3.24–47.28]; P =0.001) as significant predictive factors for intracranial hemorrhage after presenting with endocarditis. Conclusion The opioid epidemic has increased the incidence of infective endocarditis and resultant neurovascular complications. IVDU‐associated endocarditis is associated with increased hemorrhagic stroke and more frequent neurodiagnostic imaging.

Rapid development of an intracranial infectious aneurysm secondary to Streptococcus constellatus infection.

Rapid development of an intracranial infectious aneurysm secondary to Streptococcus constellatus infection.

MRI of unruptured infectious intracranial aneurysms in infective endocarditis. A case-control study

PurposeTo evaluate the usefulness of T2* and FLAIR sequences in the detection of unruptured infectious intracranial aneurysms (UIIAs) in infective endocarditis (IE) including the relationships between the lesion patterns within subarachnoid spaces and the presence of UIIA. MethodsRetrospective review of 15 consecutive patients with definite IE undergoing MR imaging (FLAIR, T2*, DWI, CE-MRA, 3D-T1, CE-3DT1 sequences), in whom DSA detected infectious intracranial aneurysms (IIA). Aneurysmal features (diameter, location, morphology on DSA) and signal patterns onT2*, FLAIR and conventional MR sequences at the site of the UIIA, follow-up MRI and IE background, were analyzed.A control-group of 15 IE-patients without IIA at DSA served for comparison. ResultsAmong 17 UIIAs studied, T2* sequence displayed a susceptibility vessel sign in 15/17 (88.2%), both distal and proximal, which matched with the IIA visualized on DSA. Three patterns of hyposignal areas were identified: (a) signet-ring or target-sign appearance (n = 7), (b) homogeneous, round-, oval- or pear-shaped area (n = 4), and (c) heterogeneous area (n = 4). A FLAIR hyperintensity of the lumen and of the adjacent cortex was present in 6 (35.3%) and 9 (53%) UIIAs, respectively. On T1 (12 UIIAs) a rounded hyposignal (n = 2), within the UIIA lumen matched with the FLAIR hypersignal.Using both T2* and FLAIR had an incremental value with 100% sensitivity and specificity. ConclusionThe susceptibility vessel sign is an MR imaging pattern frequently observed at the site of UIIAs in IE-patients.Both T2* and FLAIR may have the potential to depict UIIAs, regardless of their location and shape.

A Case of Ruptured Infectious Intracranial Aneurysm Related Multiple Fungus after Septic Embolism

A Case of Ruptured Infectious Intracranial Aneurysm Related Multiple Fungus after Septic Embolism

First case of successful usage of a low-profile flow-diverting stent for treatment of intracranial infectious aneurysm in patient with a mechanical heart valve. Clinical case and literature review

Infectious aneurysms (IA) are cerebral aneurysms that are formed due to the infectious inflammation of the arterial wall. They are a rather rare pathology and in most cases prove to be a complication of infectious (bacterial) endocarditis of the left heart chambers. Timely diagnosis of IA in the pre-hemorrhagic period is problematic due to the variability of the clinical picture of IA, frequent blurred or low-symptomatic clinical course, the possibility of IA formation in the remote period after septic embolism, even despite the background of antibiotic therapy. The presented clinical case illustrates the first successful use of a low-profile flow-diverting stent for the treatment of a young patient with a mechanical heart valve and an infectious aneurysm of the left middle cerebral artery, developed at the site of septic embolism in the acute period of septic bacterial endocarditis accompanied by ischemic stroke. This observation demonstrates the effectiveness of the chosen method of treatment, peculiarities of adequate preoperative preparation, possible postoperative complications and detailed correction of anticoagulant and antiplatelet therapy.

Management and Long-Term Outcomes of Patients With Infectious Intracranial Aneurysms.

Infectious intracranial aneurysms (IIAs) are rare complications of infective endocarditis (IE). Data on management and long-term outcomes remain limited. To retrospectively study long-term outcomes of IIAs in patients treated medically or surgically. Adult cases of IE and/or IIAs admitted to Emory or Grady Healthcare Systems between May 2015 and May 2020 were reviewed for demographic, clinical, and radiographic variables for up to 2 years. Primary outcome measure was 2-year survival. Among 1714 cases of IE, intracerebral hemorrhage occurred in 322 patients and IIAs in 17 patients. The presence of IIAs in IE was associated with higher odds of disposition to hospice/death (odds ratio = 6.9). Including non-IE patients, 24 patients had 38 IIAs mainly involving the distal middle cerebral artery and 16 were ruptured on admission. IIAs were predominantly treated with antibiotics as the primary approach. Open microsurgery was the primary approach for 5 aneurysms and was used as salvage in 7 IIAs. Endovascular management was the primary approach for 2 IIAs and used as salvage for 5 IIAs with antibiotic failure. Medical management had high rate of treatment failure (15/31) which predominantly occurred within 2 weeks of onset. The 2-year survival in this cohort was 70% (17/24). IIAs are rare complications of IE with a poor prognosis. Patients treated with antibiotics have higher risk of treatment failure requiring salvage surgical or endovascular intervention. Medical treatment failure occurred mostly within 2 weeks of onset and had a negative prognostic value emphasizing the need for close follow-up and early surgical or endovascular management.

Intracranial infectious aneurysm caused by infective endocarditis resulting in intracerebral rebleeding following previous surgery for intracerebral hemorrhage: A case report and literature review.

Intracranial infectious aneurysm (IIA) is one of the most severe complications of infective endocarditis (IE). Approximately 2-9% of patients with IE have IIA, which possibly results in severe neurological deficits. Currently, the most common treatment for IIA is endovascular treatment, while excision surgery is less common. The present study describes the case of a 33-year-old male patient who underwent a primary evacuation of an intracerebral hemorrhage (ICH) in the right temporal lobe. The patient was diagnosed with IE and IIA by examinations with an enhanced computed tomography scan, echocardiography and blood culture. In the recovery period after surgery, the patient suffered intracerebral rebleeding and underwent a surgery of IIA excision. The patient finally achieved a good prognosis without severe neurological dysfunction. In summary, IIAs are extremely rare entities, and a rare cause of spontaneous ICH. Previous research has demonstrated that the majority of ruptured IIAs receive endovascular treatment rather than conventional surgery. In the case presented herein, IIA surgical excision was successfully performed and complete pathological results were obtained, which has rarely been reported in the literature. The present case report reinforces the validity of traditional craniotomy according to the characteristics of IIAs.

Cerebral Blood Vessels and Infection

Infectious intracranial aneurysms(IIAs)are rare cerebrovascular complications of systemic infections induced by microbial infiltration and degradation of the arterial vessel wall. Prospective or population-wide studies of the epidemiology, natural history, or management of IIAs have not been conducted. In this study, we present the epidemiological and angiographical features, management, and outcomes of IIAs based on published case series and retrospective studies. Most IIAs were small in size(< 5 mm), with aneurysms located in the middle cerebral artery followed by the posterior cerebral artery. Endovascular interventions for IIAs have increased since coils, liquid embolic materials, and microcatheter became more sophisticated, allowing them to reach more distal branches. Open surgery is still required in cases with large clots or in cases involving branches feeding the eloquent areas, which cannot be sacrificed. These multimodal approaches for managing IIAs have achieved satisfactory results. Septic cavernous sinus thrombosis is also a rare, life-threatening complication of head and neck infections. Several antibiotics and antivirals are used in combination with anticoagulants. However, no consensus has been reached because of a lack of randomized controlled trials and large population-based studies.

P.121 Ruptured intracranial infectious aneurysms: single Canadian center experience

Background: Ruptured Intracranial Infected Aneurysms (IIAs) are relatively rare, but they portend high mortality. To our knowledge, there are no Canadian case-series on IIA, as well there is a relative paucity of international published experiences. Our purpose is to share the experience of a single Canadian tertiary centre in managing ruptured IIA and to conduct a systematic review. Methods: We did a retrospective case review series of adult patients with ruptured IIA treated at our institution. Secondly, we conducted a systematic review of literature on ruptured IIA between 2011-2021 inclusive. Results: At our institution, of a total 8 cases with ruptured IIA, 4 were treated endovascularly and 2 by surgical bypass. For the systematic review, we included 9 non-comparative studies with a total of 509 patients (318 males) and at least 437 ruptured IIA aneurysms. Favourable outcome was specified for 63.3% of patients (n=57). Regarding ruptured IIA, favourable clinical outcome was described in 59.3% (n=16). Conclusions: This study highlights a single Canadian tertiary centre experience in the management of IIA and compares it to the global trends of the last 10 years in a systematic review.

Ruptured intracranial infectious aneurysms: Single Canadian center experience.

Background: Ruptured intracranial infected aneurysms (IIAs) are relatively rare, but they portend high mortality. To the best of our knowledge, there is no Canadian case series on IIA, as well there is a relative paucity of international published experiences. Our purpose is to share the experience of a single Canadian tertiary center in managing ruptured IIA and to conduct a systematic review.Methods: We did a retrospective case review series of adult patients with ruptured IIA treated at our institution. Second, we conducted a systematic review of the literature on ruptured IIA between 2011 and 2021 inclusive.Results: At our institution, of a total eight cases with ruptured IIA, four were treated endovascularly and two by surgical bypass. For the systematic review, we included nine noncomparative studies with a total of 509 patients (318 males) and at least 437 ruptured IIA aneurysms. Favorable outcome was specified for 63.3% of patients (n = 57). Regarding ruptured IIA, favorable clinical outcome was described in 59.3% (n = 16).Conclusion: This study highlights a single Canadian tertiary center experience in the management of IIA and compares it to the global trends of the past 10 years in a systematic review.

Endovascular therapy for intracranial infectious aneurysms associated with a left ventricular assist device: illustrative case.

BACKGROUNDCerebrovascular events and infection are among the most common complications of left ventricular assist device (LVAD) therapy. The authors reported on a patient with an infectious intracranial aneurysm (IIA) associated with LVAD infection that was successfully occluded by endovascular therapy.OBSERVATIONSA 37-year-old man with severe heart failure received an implantable LVAD. He was diagnosed with candidemia due to driveline infection 44 months after LVAD implantation, and empirical antibiotic therapy was started. After 4 days of antibiotic treatment, the patient experienced sudden dizziness. Computed tomography (CT) revealed subarachnoid hemorrhage in the right frontal lobe, and CT angiography revealed multiple aneurysms in the peripheral lesion of the anterior cerebral artery (ACA) and middle cerebral artery. Two weeks and 4 days after the first bleeding, aneurysms on the ACA reruptured. Each aneurysm was treated with endovascular embolization using n-butyl cyanoacrylate. Subsequently, the patient had no rebleeding of IIAs. The LVAD was replaced, and bloodstream infection was controlled. He received a heart transplant and was independent 2 years after the heart transplant.LESSONSLVAD-associated IIAs have high mortality and an increased risk of surgical complications. However, endovascular obliteration may be safe and thus improve prognosis.

Simultaneous intracerebral and subarachnoid hemorrhages caused by multiple infectious intracranial aneurysms treated endovascularly and by microsurgical clipping: illustrative case.

BACKGROUNDInfected intracranial aneurysms are relatively rare but tend to occur in multiple locations. Establishing an optimal treatment strategy for multiple ruptured aneurysms is often challenging, especially when simultaneous ruptures occur in different locations. We report a case of simultaneous intracerebral and subarachnoid hemorrhages caused by the rupture of multiple infected intracranial aneurysms.OBSERVATIONSA 23-year-old male with a 2-week history of chronic fever presented with sudden onset of severe headache and visual disturbance. Computed tomography showed intracerebral hemorrhage in the right occipital lobe and subarachnoid hemorrhage in the area of the left Sylvian fissure. Further investigation documented Staphylococcus bacteremia, verrucae on the mitral valve, and aneurysms arising from the right posterior cerebral artery (PCA) and the left middle cerebral artery (MCA). A larger aneurysm arising from the PCA was successfully occluded endovascularly, but subsequent endovascular occlusion of the MCA aneurysm was unsuccessful because some important branches were observed extending from the aneurysm. The left MCA aneurysm was then obliterated by angioplastic clipping via left pterional craniotomy. The patient showed a favorable neurological recovery after treatment.LESSONSIn such complex cases of infectious aneurysms, the method and timing of treatment need to be carefully determined based on the medical condition.