Ultra-Rapid Developing Infectious Aneurysms

Excerpt

A 30-year-old male with Cardiobacterium hominis mitral valve endocarditis of the aortic and mitral valve developed recurrent face and arm tingling related to scattered hemorrhagic brain infarcts on magnetic resonance imaging (MRI) (Fig. 1). The sulcal subarachnoid hemorrhage triggered a cerebral angiogram which showed a 4-mm aneurysm arising from a frontal branch of the right middle cerebral artery (Fig. 2). Patient was transferred to our institution. Despite 2 weeks of intravenous ceftriaxone, urgent valve repair was indicated due to severe aortic regurgitation and the persistent presence of a large vegetation. This decision prompted a second cerebral angiogram 1 day before surgery. The presumed infectious aneurysm was stable in size, had sluggish filling and no clearly identifiable feeding artery, and thus the decision was made not to intervene endovascularly. Valve repair was uncomplicated, and he awakened neurologically intact. Hours after arrival to the cardiac intensive care unit he became comatose from a cerebral hematoma. On examination, he had small pupils with minimal light responses, intact corneal reflexes and oculocephalic responses but no motor responses and deteriorated further developing a fixed dilated pupil. The hematoma was urgently evacuated. The prior known infectious aneurysm was identified but unruptured and was subsequently extirpated. Postoperative computed tomography (CT) angiogram suggested a new aneurysm which was found on cerebral angiogram and subsequently occluded with onyx (Fig. 2). His postoperative course was uncomplicated—he was admitted to a neurorehabilitation center with a residual hemiparesis and neglect and he continued to improve.

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