Treatment of intracranial mycotic aneurysm: Surgery or not

Abstract

Mycotic intracranial aneurysms are of infectious origin and, even nowadays, their treatment remains controversial with advocates for either surgical or medical treatment. We present the case of a 58-year-old patient who was admitted to the hospital with a left hemiparesis due to a large right parietal haematoma. An angiogram demonstrated a small vascular malformation localized on a distal parietal branch of the right Sylvian artery. The patient was operated on and recovered well. Nevertheless, a control angiogram demonstrated the disappearance of the previous malformation but showed a new saccular aneurysm localized on the right rolandic artery. At the same time the patient became septic and the diagnosis of endocarditis complicated by mycotic aneurysm was confirmed. The patient was then medically treated with antibiotics for two months and several angiograms showed the progressive disappearance of this aneurysm. Different treatments of intracranial mycotic aneurysms are finally reviewed and a therapeutic approach is discussed.

Endovascular Treatment of Cerebral Mycotic Aneurysms

“…Medical treatment is necessary for the underlying endocarditis and reduces the MA-related hemorrhagic risk (18). Some MAs may even resolve with antibiotic treatment (4,29,30). It can therefore be argued that EVT should be performed only after a full course of treatment with antibiotics.…”

Contemporary approaches to the management of neurosurgical complications of infective endocarditis

“…In fact, septic aneurysms can form and rupture up to 6 to 9 months after eradication of the valvular source of emboli [19,20]. Despite the variability, many guidelines exist for management of these patients with antibiotics and followup angiograms [21][22][23], with intervals ranging from 1 to 3 weeks. Bingham [23] in 1977 concluded that there did not seem to be a clear advantage to surgery in addition to antibiotics, and recommended surgery after 6 weeks of antibiotics if the aneurysm did not reduce in size.…”

Stereotactic angiographic localization as an adjunct to surgery of cerebral mycotic aneurysms: Case report and review of the literature

“…They occur in the setting of bacterial endocarditis, c o m p l i c a t i n g the m e d i c a l course of up to 25% of the patients affected with this disease [6,9,15,23,25,28,40]. N e urological manifestations of M A s can vary.…”

“…represent 2% to 10% of all intracranial aneurysms [9,15,19,28]. They occur in the setting of bacterial endocarditis, c o m p l i c a t i n g the m e d i c a l course of up to 25% of the patients affected with this disease [6,9,15,23,25,28,40].…”