Request PDF on ResearchGate | On Jul 1, , Meritxell Mellado Joan and others published Aneurismas micóticos de ambos miembros inferiores secundarios. El aneurisma micótico es una causa rara y potencialmente letal si no se diagnostica de forma precoz; es la infección total de la pared arterial. [ ]. La mortalidad secundaria a un vasoespasmo e infarto cerebral consiguiente es del los aneurismas micóticos, las vasculitis no infecciosas, el tumor cerebral.
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Endovascular treatment for intracranial infectious aneurysms. Tratamento endovascular de aneurismas infecciosos intracranianos. To re-enforce an alternative, less aggressive treatment modality in the management of intracranial infectious aneurysms. We present a series of five patients with infectious endocarditis and intracranial infectious aneurysms mycotic aneurysms managed by means of endovascular treatment. Endovascular treatment was executed technically uneventfully in all patients.
Three patients had favorable clinical outcome: Endovascular techniques are an expanding option for the treatment of IIAs.
It has been especially useful for infectious endocarditis patients with IIA, who will be submitted to cardiac surgery with cardiopulmonary bypass and anticoagulation, with the risk cererales intracranial bleeding. Intracranial infectious aneurysms IIApreviously known as mycotic aneurysms, typically develop in the presence of bacterial endocarditis 1. The infectious aneurysms result miccoticos septic embolization of left valvar vegetations to the arterial vasa vasorum.
The arterial branching points are the most common place where these emboli impact. Most of these aneurysms are distal and involve the middle cerebral artery 1,2. IIAs can be treated with antibiotic therapy alone, with an unpredictable evolution: In patients treated with surgery or, more micotucos, endovascular techniques EVTocclusion of the IIAs can be achieved 7,8.
We report five cases of IIAs aneursimas with endocarditis, which were treated with endovascular techniques. The following diagnostic criteria for endocarditis were considered: In addition, a new pansystolic murmur in cardiac area and other general symptoms were also considered. The IIAs diagnoses were achieved with angiography in all cases. The following criteria were used: Since IIA usually forms within 48 hours of embolization time between the prodroms and the development of the aneurysmwe favored four-vessel cerebral angiography CAG in all patients with infective endocarditis who experienced a transient neurological cfrebrales deficit during the acute phase of the illness.
The exams were performed at least 48 hours after the event. If negative, a second angiography was done after antibiotic therapy had finished, or before the need of long-term anticoagulation patients with prosthetic heart valves. It was also recommended for patients with headache, red blood cells in the cerebrospinal fluid and in any case of non-focal neurological symptom before initiating anticoagulation This study included five patients four men and one woman, mean age 45 years, ranging from 33 to 59 years who were referred to our hospital between and with the diagnosis of infectious endocarditis and underwent endovascular treatment of IIA.
All patients had valve vegetations and clinical symptoms. In most cases, blood culture was negative. In only one case blood cultures were positive, and Enterococcus was isolated. The presumed cause of the negative blood cultures was previous antibiotics administration. No history of previous cardiac disease was observed.
All patients had mitral valve involvement and only one had aortic valve damage. One patient had diplopia and III cranial nerve palsy, and this was the only one who had a non-hemorrhagic presentation. The other four patients suffered severe headaches associated to loss aneuismas conscious as the initial neurological symptoms due to the aneurysm rupture.
The first mentioned patient was the only unruptured aneurysm in this series. None of the patients had the cerebral hemorrhage as the first symptom of endocarditis. Four of them were already in antibiotics therapy at the time of the neurological event therapy time ranged from 7 to 14 days, mean 9 days. The time between the beginning of the endocarditis and the neurological symptoms ranged from 30 to 60 days mean 45 days.
One patient entered the hospital after the aneurysm ruptured without previous antibiotics therapy. Two patients had a long-term follow-up angiogram. None of the patients had a rehemorrhage after treatment. All patients underwent four-vessel cerebral angiography with digital subtraction unit AngioStar, Siemens. All subjects had only one detected aneurysm. Most of these aneurysms were fusiforme, irregular-shaped and without neck 11making parent-vessel occlusion a frequent therapeutic choice.
A favorable neck-to-dome ratio was present in only 2 cases in which a selective standard coil embolization technique was performed.
The patient informed consent was obtained in all cases. Endovascular therapy was always performed under general anesthesia.
A cerebfales coaxial technique with femoral arterial puncture was used. The patients underwent anticoagulation with intravenous heparin to obtain an activated clotting time two to three times baseline.
The microcatheter was positioned inside the aneurysm for coiling or as close as possible in cases of parent vessel occlusion. Selective Wada test, to help to determine the eloquence of the parent vessel, was not performed. An immediate control angiogram was performed after each procedure, and heparin was discontinued. Data from all patients are described in the Table. Patient 1 had a basilar tip aneurysm, which was treated with selective coils embolization, with preservation of the parent vessel.
This patient had slowly resolution of the third nerve palsy. The other patients had distal aneurysms and were treated with cyanoacrylate in three cases and in one subject we used selective embolization with coils. Patient mmicoticos Fig 1 had a Fisher grade IV subarachnoid hemorrhage caused by a very small aneurysm less then 1 mm in diameter of the parieto-occiptal branch of the posterior cerebral xneurismas. Treatment with tiny drop cerebralss cyanoacrylate in the parent vessel was done.
However, after an open heart surgery he died due to sepsis and acute respiratory distress syndrome. The patient 3 recovered well after embolization of a very distal angular artery aneurysm 6 mm Fig 2without neurological disability.
Mycotic aneurysm as a complication of infective endocarditis – a case report
Three days after the procedure, she initiated seizures. The CT scan revealed a left frontal intracranial hemorrhage, away from the site of the embolization. Another cerebral angiography performed four days after the event showed no new IIA.
She recovered well from the bleeding, cerevrales good neurological recovery. The follow-up angiography, one year latter, showed neither aneurysm recanalization, nor a new aneurysm formation. Patient 4 had a distal aneurysm Fig 3 treated with nonselective embolization with cyanoacrylate successfully, but he died as a consequence of the initial hemorrhage. Patient 5 also had a distal aneurysm, located in the vermian branch of the left PICA, which bled causing a Fisher grade IV subarachnoid hemorrhage.
After selective micro catheterization of cererbales vermian branch of the PICA, cyanoacrylate was used to occlude both the aneurysm and the parent vessel. This patient had a near-complete neurological recovery, persisting with mild degree of cerebellar syndrome.
A 1-year follow-up angio-CT showed persistent occlusion micoticps the aneurysm and the parent vessel. Infectious endocarditis diagnosis is usually based on Duke’s criteria: Major criteria are isolation of aneuris,as organism in 2 separate cultures or persistently positive blood cultures and positive echocardiogram vegetation, abscess or new valvular regurgitation. Clinical criteria for infective endocarditis require two major criteria, or one major and three minor criteria, or five minor criteria.
Our diagnostic criteria for IIA were based on the association of infectious endocarditis with classically described IIA, being this a distal aneurysm, with irregular walls, without neck As there is involvement of the muscular layer after adventitia inflammation related to the septic emboli, the IIA is, actually, a pseudo-aneurysm.
Regarding the basilar tip aneurysm, the doubt of being infectious or a berry aneurysm discovered incidentally could be raised. We considered previously cited diagnostic criteria in the literature such as arterial stenosis close to the aneurysm 13rapid morphologic changes 14and we also considered development of new neurological symptom as a signal in this case, third nerve palsy. There are also other reports treating basilar tip aneurysm associated with infectious endocarditis In cerberales series, all micotucos were already in use of antibiotics when endovascular treatment was done.
Theoretically, the introduction of foreign material into an infected area could result in prolonged infection and abscess formation 6. We didn’t observe that complication in our five cases, as well as in other reports 6, Another cause of brain complication in untreated endocarditis is intracranial hemorrhage caused by septic emboli that achieve the cerebral arteries, during uncontrolled bacteremia, causing erosive arteritis 1, There is also a possibility of sterile emboli cause ischemic infarct that undergo secondary hemorrhagic transformation Naeurismas also can be obliterated by the hemorrhages that they produce, being hard to be identified 12, These could be explanations to the second bleeding of patient number 3, which was away from the site of first embolization, and no IIA was found aneuurismas a subsequent angiographic study.
Management of IIA is controversial and many algorithms were created to help verebrales of the treatment.
Some authors suggested treating unruptured aneurysm with only antibiotics therapy and serial cerebral angiograms 1, If the aneurysm has ruptured and no cerebral hematoma was formed or aneurixmas it is located in a non-eloquent area, EVT could be used. In the opposite way, surgery should be considered 1, In our series, EVT was always preferred, in any clinical condition or underlying disease.
The use of cyanoacryalate allowed the occlusion of both, the aneurysm and the parent vessel. In such a procedure, there is a theoretical risk of rupture associated with a rapid burst of increased pressure in the artery stump 6,16but we haven’t noticed that. The microcatheter was well positioned at the aneurysm’s neck and 2 to 6 coils were used to occlude the aneurysm micotiocs. The theoretical disadvantages of the micoticow include the risk of perforating the aneurysmatic sac, as the walls are inflamed and fragile, and the need of a larger inner diameter microcatheter to the procedure 6.
A favorite aspect of using coils is the possibility of allowing parent vessel preservation, reducing the chances of cerebral infarct as consequence of embolization 6. We haven’t had a perforation of the IIA during the embolization, neither because of coils, nor because of the increased pressure when using cyanoacrylate.
One patient died during cardiac surgery and one after embolization. The others had good neurological recovery GOS scores 4 or 5. In our algorithm, patients who do not have a hematoma producing mass effect or increased ICP and whose aneurysm does not involve an eloquent vascular territory are treated by a percutaneous approach.
Therefore, endovascular therapy is the first option for patients with ruptured aneurysms who are in stable condition. Several important advantages of endovascular therapy justify this approach.