Eur J Cardiothorac Surg 2002;21:948-950
© 2002 Elsevier Science NL
Endovascular treatment for intracranial mycotic aneurysms prior to cardiac surgery
Toshimasa Asaia*,
Akihiko Usuia,
Shigeru Miyachib,
Yuichi Uedaa
a Department of Cardiothoracic Surgery, Nagoya University School of Medicine, Nagoya 466-8550, Japan
b Department of Neurosurgery, Nagoya University School of Medicine, Nagoya 466-8550, Japan
Received 3 January 2002;
received in revised form 1 February 2002;
accepted 5 February 2002.
* Corresponding author. Tel.: +81-52-744-2375; fax: +81-52-744-2383
e-mail: asaitm{at}med.nagoya-u.ac.jp
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Abstract
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The management of patients with infective endocarditis complicated by intracranial mycotic aneurysms is controversial. We present the case of a 21-year-old man who suffered from mitral regurgitation with small vegetations due to infective endocarditis. The problem was associated with a ruptured aneurysm on the right anterior cerebral artery and an unruptured aneurysm on the left middle cerebral artery. Endovascular embolization of these aneurysms and subsequent mitral valve repair led to a successful outcome.
Key Words: Infective endocarditis • Mycotic aneurysm • Endovascular treatment
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1. Introduction
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Management of patients with infective endocarditis, who require a valve operation and have intracranial mycotic aneurysms, presents several problems. It is not clear which treatment is most effective for these aneurysms, and optimal timing of the necessary cardiac surgery is not always possible. Endovascular treatment for intracranial mycotic aneurysms has recently been developed, improving the outcome [1–4]. We report a case with successful endovascular embolization of mycotic aneurysms prior to valve repair for mitral endocarditis.
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2. Case report
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A 21-year-old man was admitted to a regional hospital with mild left hemiparesis and dysarthria. Computed tomography (CT) of the head showed an infarct in the right basal ganglia. Cerebral angiography showed occlusion of the right middle cerebral artery (MCA) but no evidence of aneurysms. On admission, the man had subfever and initially received a broad-spectrum cephalosporin. No cardiac murmur could be heard. Three months earlier, he had suffered pyrexia for 2 weeks following the extraction of a tooth. Three weeks after admission, he developed chest discomfort, and a systolic murmur was audible at the cardiac apex. Transthoracic echocardiography demonstrated moderate mitral regurgitation associated with vegetation of the mitral valve and the left atrium. Streptococcus uberis was grown from a blood culture. Antibiotic therapy was begun with ampicillin and gentamicin, but the man suffered a sudden right hemiplegia 2 weeks later. CT showed a new right frontal subcortical hematoma.
The patient was transferred to our institution for further treatment. His consciousness was unimpaired. Cerebral angiography revealed an aneurysm of the right anterior cerebral artery (ACA) that appeared to be the hemorrhagic source, and an unruptured aneurysm of the left MCA (Fig. 1A,B
). Comparison with an echocardiogram at the former hospital showed that the mitral regurgitation was unchanged, but the vegetations had reduced in size (Fig. 2 ). Hemodynamic status was stable, and the inflammatory signs improved gradually. Although valve operation was indicated, the patient was not in urgent need of it. After discussion with neurosurgeons, we therefore decided to continue with the medical therapy and monitor the size of the aneurysms. One week later, repeat angiography showed that the aneurysms had increased in size, and later that day the neurosurgical team obliterated both aneurysms with endovascular treatment. Endovascular embolization was considered appropriate because the aneurysms were located distally in both cerebral hemispheres. The catheter was super-selectively advanced to the parent artery of each aneurysm. Embolization was performed using N-butyl-cyanoacrylate glue for the right ACA aneurysm, and platinum coils plus glue for the left MCA aneurysm; both affected arteries, including the aneurysms, were completely trapped. Two weeks later, angiography confirmed exclusion of the aneurysms (Fig. 1C,D). The cardiac operation could then be performed, and took place the day after. Endocarditis had caused a perforation of the posteromedial commissure, and small vegetations were found on the mitral leaflets and the posterior wall of the left atrium. The vegetations on both leaflets were shaved off. The rim of the perforation was excised and commissuroplasty was performed without prosthesis. The portion of the posterior wall of the left atrium with vegetations was excised and directly sutured.
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Fig. 1. (A) Right internal carotid arteriogram showing a ruptured anterior cerebral artery aneurysm (arrow). (B) Left internal carotid arteriogram showing an unruptured middle cerebral artery aneurysm (arrow). (C,D) Internal carotid arteriograms 2 weeks after endovascular embolization. Both aneurysms are completely obliterated.
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Fig. 2. Transthoracic echocardiogram showing vegetations on the mitral leaflets and the posterior wall of the left atrium (arrows).
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Cultures of the vegetations yielded no bacteria. Postoperative echocardiography revealed a functional mitral valve with no recurrence of endocarditis. No further cerebral complications arose. Hemiplegia was improved by rehabilitation, and 2 months after the operation the patient was transferred to the original hospital to continue rehabilitation.
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3. Discussion
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The patients with infective endocarditis who do not respond to medical therapy, and have progressive heart failure, persistent sepsis, mobile vegetations, or annular abscess, usually need rapid surgery. Unfortunately, cerebral complications make the timing of cardiac surgery difficult. Heparinization and hypotension during cardiopulmonary bypass or postoperative anticoagulant therapy are liable to amplify the cerebral damage. Several studies [5,6] have examined the timing of surgery in patients with infective endocarditis and cerebral complications, and make recommendations based on surgical outcome. Gillinov et al. [6] suggested that a ruptured intracranial mycotic aneurysm should be resected or clipped before cardiac surgery, and that the craniotomy and valve operation should normally take place 2–3 weeks later. On the other hand, mycotic aneurysms may resolve or decrease in size with appropriate antibiotics. Certain aneurysms that still persist nevertheless require surgical treatment, and in fact it is impossible to predict which aneurysms will shrink or disappear. Brust et al. [7] therefore recommend that single accessible distal mycotic aneurysms in medically stable patients should be promptly excised. Along with craniotomy and prolonged medical therapy, endovascular treatment has recently been used, and has been applied to patients with hemodynamic deterioration or mycotic aneurysms which are difficult to approach surgically [1–4]. Endovascular treatment for intracranial mycotic aneurysms, which differs from treatment for berry aneurysms, warrants occlusion of the parent arteries, since these aneurysms rarely have a neck. If sacrifice of the proximal parent arteries is liable to cause infarction of their distal territories, a bypass operation should be considered.
In our patient, we observed changes in size of the aneurysms 1 week before endovascular embolization, and we then waited for 2 weeks before cardiac surgery. If the patient had suffered hemodynamic deterioration or larger vegetations, we would have been more likely to intervene and operate promptly. The management of unruptured mycotic aneurysms is also complex. Here, we considered that the risk of rupture of the left MCA aneurysm outweighed the risk of endovascular embolization.
Decisions of how to manage such patients must be based on retrospective clinical studies and the assessment of individual patients with neurosurgical consultation. To reduce the risk of intracranial mycotic aneurysms rupturing in the perioperative period, these aneurysms should be treated prior to cardiac surgery; craniotomy has often been carried out [6,8,9]. However, with these aneurysms, a less invasive treatment is particularly beneficial so that, depending on the characteristics of the aneurysms, endovascular treatment is sometimes the best option.
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Abstract
1. Introduction
