A case of multiple mycotic intracranial aneurysms

A patient with multiple mycotic aneurysms associated with infective endocarditis is reported. A 45-year-old man was admitted on February 16, 2001 under the diagnosis of infective endocarditis. After a-streptococcus was identified by a blood culture, he was treated with high doses of antibiotics. However, 2 weeks after admission, he suddenly suffered from headache and mild left hemiparesis. A CT showed a parenchymal hematoma in the right parietal lobe. Cerebral angiograpby demonstrated aneurysms of the bilateral middle cerebral artery and the left posterior cerebral artery. At first, we trapped and resected the ruptured right middle cerebral aneurysm. After the surgery, we tried to treat two unruptured aneurysms by endovascular treatment. During the provocation test for the posterior cerebral artery, the arterial wall was perforated by a guide wire. The parent artery was occluded by coils at this site. Although the aneurysm was still filled by retrograde blood flow, it finally disappeared six months after treatment. The left middle cerebral artery aneurysm could not be treated because the provocation test showed cognitive deficits. The patient recovered from infective endocarditis after four-months of antibiotic therapy, and the unruptured aneurysm had not changed in size for 11 months. Recently, the outcome of patients with intracramai mycotic aneurysm is improved by development of multimodality management. Especially, endovascular therapy may become an effective treatment for unruptured aneurysms, but it is necessary to take risks, such as arterial perforation into consideration.