Abstract
A 58-year-old male patient presented with phonemic paraphasia, pyrexia of 39.5 °C, chronic fatigue, and exhaustion. The patient reported experiencing mild but persistent left flank pain, weight loss of 14 kg, and excessive sweating during sleep for the past 6 months. Echocardiography revealed mobile vegetation on the mitral valve, and his blood culture was positive for Enterococcus faecalis. He was diagnosed as having infective endocarditis (IE), and intravenous antibiotic medication was started. He was also given oral anticoagulation agents due to an elevated serum D-dimer level. Initial abdominal and cranial MRI examinations revealed the presence of a previous splenic infarct and a left frontoparietal hemorrhagic infarction accompanied by time-of-flight (TOF) magnetic resonance angiography (MRA) signal abnormality among the changes. The cerebral infarction was suspected of being associated with a “mycotic” (inflammatory) aneurysm of the left middle cerebral artery (MCA) secondary to the IE. A digital subtraction angiography (DSA) examination was performed and confirmed the presence of two left-hand distally located MCA infectious intracranial aneurysms (IIA). The larger of the two aneurysms was successfully occluded by selective intrasaccular injection of nBCA/Lipiodol under adenosine-induced asystole to prevent hazardous migration of the embolic material during the embolization. The smaller and distally located aneurysm (2 mm fundus diameter) resolved spontaneously. The aneurysm treatment was well tolerated. Under continuous IV antibiotic infusion and with the complete resolution of the somatic symptoms, echocardiography revealed no mitral valve vegetation, suggesting the IE was under control. Long-term follow-up confirmed persistent aneurysm occlusion and the permanent clinical improvement of the patient. The management of IIA by parent vessel occlusion using glue injection under adenosine-induced asystole is the main topic of this chapter.
References
Cekirge HS, Saatci I, Ozturk MH, Cil B, Arat A, Mawad M, Ergungor F, Belen D, Er U, Turk S, Bavbek M, Sekerci Z, Beskonakli E, Ozcan OE, Ozgen T. Late angiographic and clinical follow-up results of 100 consecutive aneurysms treated with Onyx reconstruction: largest single-center experience. Neuroradiology. 2006;48(2):113–26. https://doi.org/10.1007/s00234-005-0007-6.
Champeaux C, Walker N, Derwin J, Grivas A. Successful delayed coiling of ruptured growing distal posterior cerebral artery mycotic aneurysm. Neurochirurgie. 2017;63(1):17–20. https://doi.org/10.1016/j.neuchi.2016.10.005.
Chapot R, Houdart E, Saint-Maurice JP, Aymard A, Mounayer C, Lot G, Merland JJ. Endovascular treatment of cerebral mycotic aneurysms. Radiology. 2002;222(2):389–96. https://doi.org/10.1148/radiol.2222010432
Ducruet AF, Hickman ZL, Zacharia BE, Narula R, Grobelny BT, Gorski J, Connolly ES Jr. Intracranial infectious aneurysms: a comprehensive review. Neurosurg Rev. 2010;33(1):37–46. https://doi.org/10.1007/s10143-009-0233-1.
Grandhi R, Zwagerman NT, Linares G, Monaco EA 3rd, Jovin T, Horowitz M, Jankowitz BT. Onyx embolization of infectious intracranial aneurysms. J Neurointerv Surg. 2014;6(5):353–6. https://doi.org/10.1136/neurintsurg-2013-010755.
Gross BA, Puri AS. Endovascular treatment of infectious intracranial aneurysms. Neurosurg Rev. 2013;36(1):11–9; discussion 19. https://doi.org/10.1007/s10143-012-0414-1.
Henkes H, Terstegge K, Felber S, Jänisch W, Nahser HC, Kühne D. “Mykotisches”, infektionsbedingtes intrakranielles Aneurysma. In: Henkes H, Kölmel HW, editors. Die entzündlichen Erkrankungen des Zentralnervensystems, Handbuch und Atlas, II-1. Landsberg/Lech: Ecomed; 1993. p. S1–71.
Lylyk P, Chudyk J, Bleise C, Serna Candel C, Aguilar Pérez M, Henkes H. Endovascular occlusion of pial arteriovenous macrofistulae, using pCANvas1 and adenosine-induced asystole to control nBCA injection. Interv Neuroradiol. 2017;23(6):644–9. https://doi.org/10.1177/1591019917720921.
Misser SK, Lalloo S, Ponnusamy S. Intracranial mycotic aneurysm due to infective endocarditis – successful NBCA glue embolisation. S Afr Med J. 2005;95(6):397–9.. 403-4
Molinari GF, Smith L, Goldstein MN, Satran R. Pathogenesis of cerebral mycotic aneurysms. Neurology. 1973;23:325–32. https://doi.org/10.1212/wnl.23.4.325.
Ragulojan R, Grupke S, Fraser JF. Systematic review of endovascular, surgical, and conservative options for infectious intracranial aneurysms and cardiac considerations. J Stroke Cerebrovasc Dis. 2019;28(3):838–44. https://doi.org/10.1016/j.jstrokecerebrovasdis.2018.11.035.
Tunkel AR, Kaye D. Neurologic complications of infective endocarditis. Neurol Clin. 1993;11(2):419–40.
Venkatesh SK, Phadke RV, Kalode RR, Kumar S, Jain VK. Intracranial infective aneurysms presenting with haemorrhage: an analysis of angiographic findings, management and outcome. Clin Radiol. 2000;55(12):946–53. https://doi.org/10.1053/crad.2000.0596.
Author information
Authors and Affiliations
Corresponding author
Editor information
Editors and Affiliations
Rights and permissions
Copyright information
© 2020 Springer Nature Switzerland AG
About this entry
Cite this entry
Sirakov, A., Elhasan, H.A., Aguilar Pérez, M., Serna Candel, C., Bäzner, H., Henkes, H. (2020). Middle Cerebral Artery (M3) Aneurysm: Two “Mycotic” Aneurysms of the Middle Cerebral Artery due to Bacterial Endocarditis; Endovascular Treatment of One Aneurysm with Glue (nBCA) Injection During Adenosine-Induced Asystole; Spontaneous Resolution of the Second Aneurysm. In: Henkes, H., Lylyk, P., Ganslandt, O. (eds) The Aneurysm Casebook. Springer, Cham. https://doi.org/10.1007/978-3-319-70267-4_165-1
Download citation
DOI: https://doi.org/10.1007/978-3-319-70267-4_165-1
Received:
Accepted:
Published:
Publisher Name: Springer, Cham
Print ISBN: 978-3-319-70267-4
Online ISBN: 978-3-319-70267-4
eBook Packages: Springer Reference MedicineReference Module Medicine