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J Thorac Cardiovasc Surg 1995;110:557-559
© 1995 Mosby, Inc.
BRIEF COMMUNICATIONS |
Kumamoto, Japan
From the First Department of Surgery, Kumamoto University School of Medicine, Kumamoto, Japan.
One of the most serious complications of infective endocarditis is mycotic cerebrovascular aneurysm, which can cause a lethal subarachnoid hemorrhage (SAH).
1 The treatment of mycotic aneurysms in hemodynamically unstable patients is controversial because solid guidelines based on large prospective studies are lacking. Patients show a wide variety in size, number, and location of these intracranial lesions, in addition to varying in basic cardiac function. We report a case of ruptured mycotic aneurysm caused by infective endocarditis in a patient whose cardiac function was too severely compromised to permit an open craniotomy.
A 42-year-old man was admitted with a history of general fatigue, dyspnea, fever, and night sweats for a week. He had a high body temperature of 38 ° C and cardiac murmurs indicative of aortic and mitral regurgitation. A chest radiograph demonstrated cardiomegaly and severe pulmonary edema. An echocardiogram revealed vegetation and severe regurgitation of both the aortic and mitral valves. A diagnosis of infective endocarditis was confirmed by the isolation of Streptococcus viridans in multiple arterial blood cultures. The patient was treated in the intensive care unit with high doses of antibiotics (ampicillin 10 gm/day and tobramycin 120 mg/day), diuretics, and catecholamines to control bacteremia and acute heart failure. After 6 days of intensive care, the patient's body temperature dropped below 37 ° C and further blood cultures were negative for pathogens. The patient's pulmonary edema and cardiomegaly also were alleviated. The patient was moved to a general floor, and double valve replacement was scheduled for the following week.
Early the next morning, however, the patient became comatose and had a temperature of 386 ° C, tachycardia, hypertension, and respiratory distress. Mechanical ventilation under endotracheal intubation was started. Computed tomography demonstrated a massive SAH. Subsequent cerebral angiography revealed a 5 mm aneurysm arising from the P2 portion of the right posterior cerebral artery (Fig. 1). The patient was transferred to the intensive care unit. Despite conservative therapy, including respiratory support and administration of diuretics and catecholamines, the patient's condition was considered to be too hemodynamically unstable to allow him to undergo general anesthesia and an emergency craniotomy for direct clipping of the aneurysm. Emergency double valve replacement with heparin for cardiopulmonary bypass was also considered potentially dangerous in light of the intracranial lesion. After discussion with neurosurgeons, an endovascular approach was selected to control the intracranial lesion by embolization of the aneurysm and parent artery. This endovascular procedure was performed on the day following the onset of SAH. A Tracker catheter (Target Therapeutics Inc., San Jose, Calif.) was inserted onto the involved vessel just proximal to the aneurysm. The parent artery was embolized with ethylene vinyl alcohol until blood flow was arrested. Angiography after the embolization revealed complete obliteration of the aneurysm (Fig. 2).
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Mycotic aneurysms of the cerebral arteries occur in 2% to 10% of patients with infective endocarditis. 1-3 Rupture of mycotic aneurysm is associated with a grave prognosis and an 80% mortality rate. 1 Although progressive heart failure and systemic embolism are well-established indications for valve replacement in patients with bacterial endocarditis, treatment of mycotic aneurysms is still controversial because of the wide variability in the conditions of these aneurysms, ruptured or unruptured, their numbers and locations, and the extent of associated cardiac failure. There is uncertainty regarding the operative priority in patients with both intracranial aneurysm and acute heart failure. If a craniotomy for direct clipping is performed first, perioperative management could be insufficient to control progressive heart failure. On the other hand, if valve replacement is selected first, cardiopulmonary bypass with systemic heparinization could cause lethal neurologic deficits. There are no guidelines for decision in cases of such critically ill patients as the one described here.
Frizzell and colleagues 4 described an endovascular technique for embolizing a mycotic intracranial aneurysm in a patient with infective endocarditis without heart failure. If bacteremia and heart failure can be controlled by conservative means, several treatment options are available, including a direct approach, an endovascular approach, and simple observation with high-dose intravenous antibiotics. 5 In a critical situation such as this case, however, less invasive treatment might be advisable. Urgent cerebral angiography and an endovascular approach to mycotic aneurysms, especially for solitary and peripheral lesions, is an acceptable option for some patients with active endocarditis and severely damaged hearts.
References
This article has been cited by other articles:
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  T. Asai, A. Usui, S. Miyachi, and Y. Ueda Endovascular treatment for intracranial mycotic aneurysms prior to cardiac surgery Eur. J. Cardiothorac. Surg., May 1, 2002; 21(5): 948 - 950. [Abstract] [Full Text] [PDF]
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 R. Chapot, E. Houdart, J.-P. Saint-Maurice, A. Aymard, C. Mounayer, G. Lot, and J.-J. Merland Endovascular Treatment of Cerebral Mycotic Aneurysms Radiology, February 1, 2002; 222(2): 389 - 396. [Abstract] [Full Text] [PDF]
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