J Cerebrovasc Endovasc Neurosurg.  2020 Jun;22(2):90-96. 10.7461/jcen.2020.22.2.90.

Unusual presentation of infectious intracranial aneurysm with sequential hemorrhagic and ischemic components

Affiliations
  • 1Department of Neurosurgery, Dankook University College of Medicine, Dankook University Hospital, Cheonan, Korea
  • 2Department of Neurosurgery, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea

Abstract

Infectious intracranial aneurysm (IIA), a rare type of cerebral aneurysm, is often observed in patients with infective endocarditis. Hemorrhage or infarction often occurs; however, the presentation of both hemorrhagic and ischemic components is rare. A 41-year-old man with progressive motor weakness, dysarthria, and severe headache was admitted to our hospital. Brain computed tomography scan revealed a scanty subarachnoid hemorrhage (SAH), and diffusion magnetic resonance imaging confirmed acute cerebral infarction around the external capsule and insular lobe. A digital subtraction cerebral angiogram revealed an obstruction in the middle cerebral artery (MCA). The patient’s neurological symptoms improved remarkably on the fifth day, and a follow-up angiogram revealed recanalized MCA with pseudoaneurysm, which was not observed on the previous angiogram. A blood culture result confirmed bacteremia, and the patient was then diagnosed with infective endocarditis. The pseudoaneurysm was treated with anastomosis of the superficial temporal artery and MCA with trapping of the parent artery. He was discharged with no neurological deficits. Herein, we present a patient with IIA, who sequentially developed SAH and cerebral infarction, and underwent extracranial-intracranial bypass with trapping of the parent artery. Although the treatment strategy for IIA is controversial, the treatment plan should be cautiously discussed with the patient. In addition, the assessment of an underlying infectious disease is required.

Keyword

Infectious intracranial aneurysm; Subarachnoid hemorrhage; Cerebral infarction

Figure

  • Fig. 1 Brain computed tomography scan revealed a scanty subarachnoid hemorrhage in the left Sylvian cistern and focal low density around the external capsule.

  • Fig. 2 The left internal carotid artery angiogram showed an obstruction in the middle cerebral artery (arrow in A and B).

  • Fig. 3 Diffusion magnetic resonance imaging confirmed acute cerebral infarction around the external capsule and insular lobe, however, the extent of the infarcted lesion remained the same although the neurologic symptoms aggravated (A and B).

  • Fig. 4 Moderate mitral regurgitation with vegetation on the mitral valve was confirmed on transthoracic echocardiography, with a diagnosis of infective endocarditis (arrow).

  • Fig. 5 A brain magnetic resonance angiography, with vessel wall imaging, showed recanalization of the frontal M2 with a fusiform aneurysm on the thirteenth day of admission (A). Follow-up digital subtraction cerebral angiography showed the recanalization of the frontal M2 with a fusiform aneurysm (B). We considered the lesion to be infectious intracranial aneurysm (IIA) caused by infective endocarditis. We performed surgical trapping of the IIA after anastomosis of the frontal branch of the superficial temporal artery and middle cerebral artery.

  • Fig. 6 Yellowish, inflammatory change in the arachnoid membrane was grossly observed around the left Sylvian vein (A). And the aneurysm was enveloped with inflammatory tissues with severe adhesion. Note there are also hemosiderin pigmentation on the arachnoid (B).

  • Fig. 7 Trapping of the parent artery using a clip was performed, and postoperative cerebral angiography confirmed the successful anastomosis of the superficial temporal artery-middle cerebral artery bypass (A) without visualization of the aneurysm sac (B).


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