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      Ruptured Intracranial Mycotic Aneurysm in Infective Endocarditis: A Natural History

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          Abstract

          Mycotic aneurysms are a rare cause of intracranial aneurysms that develop in the presence of infections such as infective endocarditis. They account for a small percentage of all intracranial aneurysms and carry a high-mortality rate when ruptured. The authors report a case of a 54-year-old man who presented with infective endocarditis of the mitral valve and acute stroke. He subsequently developed subarachnoid hemorrhage during antibiotic treatment, and a large intracranial aneurysm was discovered on CT Angiography. His lesion quickly progressed into an intraparenchymal hemorrhage, requiring emergent craniotomy and aneurysm clipping. Current recommendations on the management of intracranial Mycotic Aneurysms are based on few retrospective case studies. The natural history of the patient's ruptured aneurysm is presented, as well as a literature review on the management and available treatment modalities.

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          Most cited references20

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          Intracranial infectious aneurysms: a comprehensive review.

          Intracranial infectious aneurysms, or mycotic aneurysms, are rare infectious cerebrovascular lesions which arise through microbial infection of the cerebral arterial wall. Due to the rarity of these lesions, the variability in their clinical presentations, and the lack of population-based epidemiological data, there is no widely accepted management methodology. We undertook a comprehensive literature search using the OVID gateway of the MEDLINE database (1950-2009) using the following keywords (singly and in combination): "infectious," "mycotic," "cerebral aneurysm," and "intracranial aneurysm." We identified 27 published clinical series describing a total of 287 patients in the English literature that presented demographic and clinical data regarding presentation, treatment, and outcome of patients with mycotic aneurysms. We then synthesized the available data into a combined cohort to more closely estimate the true demographic and clinical characteristics of this disease. We follow by presenting a comprehensive review of mycotic aneurysms, highlighting current treatment paradigms. The literature supports the administration of antibiotics in conjunction with surgical or endovascular intervention depending on the character and location of the aneurysm, as well as the clinical status of the patient. Mycotic aneurysms comprise an important subtype of potentially life-threatening cerebrovascular lesions, and further prospective studies are warranted to define outcome following both conservative and surgical or endovascular treatment.
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            Intracranial microbial aneurysm (infectious aneurysm): current options for diagnosis and management.

            The histopathological characteristic of intracranial microbial aneurysm (MA)-infectious aneurysm is the presence of infection and destruction of the walls of the vessels. It can occur in the setting of predisposing infections that spread by endovascular mechanism (e.g., infective endocarditis) or extravascular mechanism (e.g., meningitis). MA is probably a better term than mycotic, infectious, or infective aneurysm as a wide variety of bacteria, fungi, mycobacteria, and virus can cause MA. Typically MAs are multiple, distal, and fusiform aneurysms, but the angiographic and clinical presentations can vary widely. The most common presentation of MA is intracranial bleed. CT angiography, MR angiography, or Digital subtraction angiography can be deployed to detect MA. By combining the clinical findings, imaging, and angiographic findings, it is possible to arrive at a correct diagnosis in most instances. MAs carry higher risk of rupture and fatal bleed when compared to other aneurysms. The treatment options include antimicrobial therapy, surgery, and endovascular therapy. The management strategy is based on large case series rather than controlled trials. All MA should receive appropriate antibiotic therapy. Ruptured MA with mass effect would require surgery in most situations, while those without mass effect and in non-eloquent locations could also be managed by endovascular therapy. Unruptured MA could be managed according to the size, location, and risk of bleeding-by antibiotic therapy, surgery, or endovascular therapy. Monitoring the resolution of the MA under antibiotic therapy by serial CT angiography is another option, but it carries higher risk of bleeding. Treatment of the underlying predisposing infection is an important component of therapy.
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              Current multimodality management of infectious intracranial aneurysms.

              To implement an algorithm for and assess multimodality (medical, endovascular, and microsurgical) treatment of patients with infectious intracranial aneurysms. Twenty patients with 27 infectious aneurysms were treated during a 10-year period. Bacterial endocarditis was the most common cause (65%). Most aneurysms presented with rupture (75%), and the middle cerebral artery was the most common location (70%). Five patients were treated endovascularly, with direct coiling for three patients and parent artery occlusion for two patients. Ten patients (15 aneurysms) were treated surgically, with 6 aneurysms being trapped/resected, 2 trapped/bypassed, 4 clipped, and 3 wrapped. Five patients were treated medically. Treatment-associated neurological morbidity was observed for two patients (10%), and two patients died (10%). Good outcomes were observed for 16 patients (80%). Factors that guide management decisions for these patients include aneurysm rupture, hematomas with increased intracranial pressure, and the eloquence of brain tissue supplied by the parent artery. Patients with unruptured infectious aneurysms are initially treated medically, with antibiotics and serial angiography. Patients with ruptured aneurysms that are not associated with hematomas and that do not involve eloquent vascular territory are treated endovascularly. Patients with ruptured aneurysms are treated surgically when there is a hematoma or the risk of ischemic complications in eloquent territory. Therefore, endovascular therapy is the first option for patients in stable condition with ruptured aneurysms; surgical therapy is the first option for patients in unstable condition with ruptured aneurysms and the second option for patients in stable condition who experience failure of endovascular therapy. Medically treated patients with enlarging or dynamic unruptured aneurysms also require direct surgical or endovascular intervention. Favorable patient outcomes can be achieved with this multimodality management.
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                Author and article information

                Journal
                Case Report Med
                CRM
                Case Reports in Medicine
                Hindawi Publishing Corporation
                1687-9627
                1687-9635
                2010
                22 September 2010
                : 2010
                : 168408
                Affiliations
                1University of Southern California Keck School of Medicine, Los Angeles, CA 90089, USA
                2Division of Geriatric, Hospitalist, Palliative, and General Internal Medicine, Department of Medicine, LAC+USC Medical Center, University of Southern California Keck School of Medicine, 1200 N. State St. IRD 310, Los Angeles, CA 90033, USA
                3Department of Neurology, LAC+USC Medical Center, University of Southern California Keck School of Medicine, Los Angeles, CA 90033, USA
                Author notes

                Academic Editor: J. W. M. Van Der Meer

                Article
                10.1155/2010/168408
                2946581
                20885918
                97172188-0a4f-4028-9eb7-625c7cefcb55
                Copyright © 2010 Isabel Kuo et al.

                This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

                History
                : 18 April 2010
                : 16 August 2010
                : 27 August 2010
                Categories
                Case Report

                Medicine
                Medicine

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