Pathogenesis of cerebral mycotic aneurysms

Molinari, Gaetano F.; Smith, L; Goldstein, Marvin N.; Satran, Richard

doi:10.1212/wnl.23.4.325

Cited by 199 publications

(56 citation statements)

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“…Hematogenous spread results from septic microemboli to the vasa vasorum, with spread of infection internally through the vessel wall, or as a result of septic emboli that lodge at a distal branching point, with spread of infection through the adventitia through the muscularis of the vessel wall. 122,125,133 ICMAs have a different morphological appearance and anatomic location compared with congenital berry aneurysms. ICMAs are usually saccular with a poorly defined wide base or absent neck or fusiform shape with a thin friable wall, are more peripherally located, and can be multiple in number, whereas congenital berry aneurysms are more often single, more proximally located, and usually saccular with a well-defined neck.…”

Section: Clinical Statements and Guidelinesmentioning

confidence: 99%

Vascular Graft Infections, Mycotic Aneurysms, and Endovascular Infections: A Scientific Statement From the American Heart Association

Wilson¹,

Bower²,

Creager³

et al. 2016

Circulation

373

307

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The use of synthetic material for reconstructive vascular surgery was first reported during the early 1950s. Infection involving vascular graft prostheses is an infrequent but devastating complication of reconstructive vascular graft surgery and is associated with a high morbidity and, in some situations, mortality. Improvements in surgical techniques and graft design, including the use of native venous or arterial tissue, have reduced the frequency of infection and severity of complications from vascular graft infection (VGI). However, these advances have also led to more frequent vascular graft procedures occurring in a patient population with multiple underlying comorbidities that would have previously disqualified them as candidates for vascular reconstructive surgery. Underlying comorbidities, such as diabetes mellitus or immune compromise, increase the risk of infection and serious infection-related complications. The major complications of VGI include sepsis, amputation, disruption of infected anastomotic suture line with rupture or pseudoaneurysm formation, embolization of infected thrombi, reinfection of reconstructed vascular grafts, enteric fistulae to the small or large bowel, bacteremic spread of infection to other sites, and death. VGIs can be categorized broadly into those that occur in an extracavitary location, primarily in the groin or lower extremities, or in an intracavitary location, primarily within the abdomen or less commonly within the thorax. frequencyThe frequency of VGI depends on the anatomic location of the graft. The infection rate is 1.5% to 2% for most extracavitary grafts and as high as 6% with vascular grafts in the groin. [1][2][3][4][5][6][7][8][9] For intracavitary grafts, the infection rate is ≈1% to 5%. 1-6 Graft infection is most common after emergency procedures and after reoperation. [1][2][3][4]10 Aortic graft erosion or fistulous communication into the duodenum or other areas of the bowel reportedly occurs in 1% to 2% of patients after aortic reconstruction. 11,12 MicrobiologyThe microbiological cause of VGI has evolved over the years. 1 In early published studies, Staphylococcus aureus was the predominant microorganism recovered. 1,13 Improvements in surgical technique, administration of prophylactic antistaphylococcal antimicrobial therapy, and other factors have resulted in a changing microbiological epidemiology. Vascular graft surgery performed on patients with multiple underlying comorbidities and the increased frequency of emergency procedures have contributed to the changing spectrum of infection. Other factors such as changes in hospital flora, surgery in patients with complicated vascular anatomy, and multiple revisions of previous vascular surgery have resulted in a more diverse microbio- clInIcal stateMents anD GuIDelInes logical spectrum of infection, which includes multidrugresistant strains, polymicrobial infection, and Candida species. Gram-positive cocci accounts for at least two thirds of VGIs. 1,13 Infections caused by coagulase-negative staphylococ...

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Section: Clinical Statements and Guidelinesmentioning

confidence: 99%

Vascular Graft Infections, Mycotic Aneurysms, and Endovascular Infections: A Scientific Statement From the American Heart Association

Wilson¹,

Bower²,

Creager³

et al. 2016

Circulation

373

307

View full text Add to dashboard Cite

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“…Histological sections in animal models of cerebral MA have shown an acute inflammatory response to bacterial invasion of the muscularis layer with early aneurysmal dilatation as early as 24 hours after septic embolism development. 2 Rupture of MA can be devastating and accounts for 5% of the neurological complications in patients with IE. A recent meta-analysis reported a 13% mortality in patients with MA, 1 and ≤80% mortality if rupture occurs.…”

Section: Discussionmentioning

confidence: 99%

Dynamic Angiographic Nature of Cerebral Mycotic Aneurysms in Patients With Infective Endocarditis

John

Walsh

Hui

et al. 2016

Stroke

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A 41-year-old male with nonischemic cardiomyopathy and left ventricular assist device on coumadin presented with constitutional symptoms for 1 week. Blood cultures were drawn. The next day, he developed severe headache (Hunt-Hess grade II), and noncontrast head computed tomography (CT) showed Fisher grade II subarachnoid hemorrhage over bilateral frontal convexities. International Normalized Ratio was 9. The blood cultures grew methicillin-resistant Staphylococcus aureus within a day. He was diagnosed with an infected left ventricular assist device and started on intravenous vancomycin. Brain CT angiography was negative for any vessel abnormality. Cerebral angiography on post bleed day 1 showed areas of subocclusive emboli in the left M3 segment of the middle cerebral artery (MCA) and left pericallosal artery, but did not reveal any identifiable source for subarachnoid hemorrhage. On post bleed day 2, the patient developed left frontal seizures that eventually progressed to status epilepticus. Repeat CT head showed a new intraparenchymal hemorrhage within the left frontal operculum, measuring 1.8 cm in diameter. Repeat cerebral angiography on post bleed day 2 revealed a new left M3 fusiform mycotic aneurysm (MA) in the exact location of the previously seen left M3 segment embolus. The pericallosal branch embolus had progressed to near vessel occlusion rather than aneurysm formation. The patient's family withdrew care because of his poor cardiac and neurological status ( Figure 1). Case 2A 31-year-old female with history of Tetrology of Fallot that had been repaired when she was a child, and previous infective endocarditis secondary to intravenous drug abuse requiring aortic valve replacement, presented with constitutional symptoms after relapsing with intravenous drug abuse. Blood cultures grew Streptococcus viridans and peptostreptococcus, and she was diagnosed with prosthetic aortic valve infective endocarditis along with perivalvular abscess. She was started on intravenous ceftriaxone. Magnetic resonance imaging of the brain was performed for a recent episode of transient aphasia and showed multiple punctate foci of susceptibility in bilateral cerebral and cerebellar hemispheres compatible with microhemmorhages, and 1 foci of old left posterior parieto-occipital subarachnoid hemorrhage. Brain magnetic resonance angiography was negative for any vessel abnormality. Cerebral angiography demonstrated 1 fusiform MA (2 mm) of the right M4 parieto-occipital MCA branch, and 1 saccular MA (2 mm) of the left superior M2 MCA branch. Medical management with antibiotics was recommended given the risk of surgical/endovascular treatment and because cardiac surgery was not imminent. Repeat cerebral angiography 2 weeks later was stable, however, repeat cerebral angiography 4 weeks from the first angiogram showed significant enlargement of the right MCA MA, whereas the left MCA MA had completely resolved. The right MCA aneurysm was treated with coiling and Onyx embolization. She underwent aortic valve replacement the next day ...

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“…Consequently, intense inflammation in the media and adventitia destroys the integrity of the arterial wall and weakens it. The resulting aneurysms are mostly fusiform, eccentric or typical pseudoaneurysms (Chun et al,2001;Molinari et al,1973).…”

Section: A B Cmentioning

confidence: 99%