Aust. Radiol. (1975), 19,255
Ruptured Mycotic I n t r a c d Aneurysm K. K. Nc,M.B.B.S. (SPORE),D.M.R.D. (ENG.),F.F.R.(LONDON) W. K. WONG,M.B.B.S. (SPORE),D.M.R.D. (ENG.) and F.F.R. HILIARY SKENE-SMITH, M.R.C.P. (LONDON), Department of Radiology, Faculty ofMedicine, University ofMalaya INTRODUCTION The causes of non-traumatic intracranial haemorrhage are numerous. A ruptured mycotic aneurysm is rare and it can bleed into the subarachnoid space, into the brain substance and even into the subdural space ( ~ i ~ 1960). & we wish to report a case of a ruptured intracranial mycotic aneurysm in a patient with a ventricular septal defect. Case History A 15-year-old Chinese female presented with a five-month history of intermittent fever. She had twice been admitted to another hospital, where the diagnosis of subacute bacterial endocarditis complicating an asymptomatic ventricular septal defect had been made. She had been vigorously treated with antibiotics and on her discharge was afebrile. On her admission to University Hospital she was again pyrexial with a temperature of 100.4"F. Examination revealed no embolic phenomenon and the only abnormal finding was a grade 3/6 pansystolic murmur, maximal in the 3rd and 4th left intercostal spaces. Laboratory examination revealed a haemoglobin of 9.1 G%, a normal white cell count and a raised ESR of 141 nim/hr. Urinalysis was normal. Repeated blood cultures failed to grow any anaerobic or aerobic organisms. A clinical diagnosis of subacute bacterial endocarditis was made and she was treated with intravenous penicillin and became afebrile. She was well on this treatment until three weeks after admission, when she suddenly developed a severe headache and slumng of speech immediately followed by generalised fits. She rapidly deteriorated and started to decerebrate. Physical examination demonstrated fight facial nerYe of upper neuron type and right hemiparesis. Her left Pupil was dilated and showed sluggish response A usfralasian Radiology, Vol. XIX,No. 3, September,
to light. There were haemorrhagic spots on the inferior temporal part Of the right fundus. A left carotid angogram and 2, revealed a Nptured aneurysm in a peripheral branch Of the left middle cerebra' artery with intracerebral haematoma in the left parietotemprd region* A large intracerebd 'lot in the parieto-temporal re@on Of the left hemisphere, partly organised and partly fresh, with surrounding necrotic brain tissue, was evacuated via a left parietal craniotomy. She failed to improve and died two days later. Consent for autopsy Was refused.
FIGURE 1-Antero-post*or view of left carotid mogram. Note: (1) Displacement of the left anterior cerebral artery across midline. (2) The distal location of the left middle cerebral artery aneurysm indicated by arrow. I975
255
RUPTURED MYCOTIC INTRACRANIAL ANEURYSM
FIGURE2-Lateral view of left caroiid angiogram. Nole: ( 1) Aneurysm in a peripheral branch of left middle cerebral artery indicated by arrow. (2) Elevation of the middle cerebral artery. and (3) Widely spread and stretched peripheral branches of the middle cerebral artery.
COMMENT The diagnosis of bacterial endocarditis in this patient was made because of a pre-existing congenital heart lesion associated with five months’ intermittent fever and a raised blood sedimentation rate. The repeatedly negative blood cultures were du:: most probably to previous antibiotic therapy. The development of right hemiparesis and right facial nerve palsv of upper motor neuron type associated with rapid deterioration following headache and a fit was due to the intracerebral clot in the parieto-temporal region of the left cerebral 256
hemisphere, from the ruptured mycotic aneurysm of the peripheral branch of the left middle cerebral artery.
DISCUSSION Rupture of an intracranial mycotic aneurysm is a well-recognised complication of bacterial endocarditis (Kirkes 1852, Church 1870). The pathogenesis of an intracranial mycotic aneurysm has now been well established (Nakata Y.et al., 1968; Gaetano et at., 1970). Septic emboli, invariably from the heart, become lodged in a peripheral branch of a cerebral
Australasian Radiology, Vol. X I X , N o . 3, September, 1975
K. K. NGAND W. K. WONG artery, especially the middle cerebral, with re- cotic aneurysms is stressed. The importance of sulting short-segment occlusion. Infection of the bilateral carotid angiography in all patients arterial wall occurs via the vasa vasorum. In- with bacterial endocarditis who exhibit signs tense inflammation starting in the adventitia of cerebral embolism is emphasised. spreads inwards to the tunica media causing weakness of the vessel wall with aneurysm ACKNOWLEDGEMENT formation. The inflammation can even invade to express our thanks to Assoc. We wish the elastic membrane, resulting in rupture of the mycotic aneurysm and hence intracranial Prof. Wong Hee Ong for allowing us access to case note of her patient, and to Mrs. Pearly haemorrhage. Tho0 for typing the manuscript. Cerebral mycotic aneurysms occur most frequently in the distal branches of the middle REFERENCES cerebral artery, though occasionally they may occur in the distal branches of the anterior ‘Chrrch, W. S. (1870): On the “Formation of aneurysms and especially of intracranial aneurysms i i cerebral artery. They tend to increase rapidly early life.” Sr. Barrhoiowrnew’s Hospital Rep., 6 , in size and rupture while under observation, re99. sulting in intracerebral haematoma and sub- ’Hampson, J. R., and Harrison, M. I. G. (1967): arachnoid haemorrhage. Associated occlusion “Sterile blood culture in bacterial endocarditis.” of distal branches of the affected cerebral Quart. J . M e d . , 36, 167. artery may occur, with resulting cerebral in- Houriha-e, J. Brian (March, 1970) : “Ruptured Mycotic lctracranial Aneurysm.” Vascular Surgery, farction. Vol. 4, 21-29. In view of the serious prognosis in all cases A. B. (July, 1960): “Mycotic aneurysm comof ruptured mycotic aneurysm, bilateral carotid ‘King,plicated by subdural haemorrhage.” 1. Neurology, angiography should be performed in all patients VOI. 17, 788-91. with bacterial endocarditis who develop signs of ‘Kirkes, W. S. (1852): “Principal effects resulting from detachment of fibrinous deposits from interior of cerebral embolism. By this means, mycotic the heart.” M e d . Chir. Tr.. 35,281. aneurysm can be detected early and excised “Molinani, Gaetano F., Smith, Lewis, Goldstein. Marbefore rupture occurs.
SUMMARY A case of ruptured intracranial mycotic aneurysm in a patient with bacterial endocarditis is reported. A brief account of intracranial mycotic aneurysms and their pathogenesis is given. The distal location of intracranial my-
vis, N., and Richard, S. (April, 1973): “Pathogenesis of cerebral mycotic aneurysm.” Neurology, Vol. 23, No. 4. ‘Nakata, Y., Shionoya, S., Kamiya (1968): “Pathogenesis of rnycotic aneurysm.” Atrgiologg, 19, 593-601. ‘Roach, M. R., and Drake, C. G. (1965): “Ruptured, cerebral aneurysms caused by micro-organism. N. EngIartd I . Med.. 273, 240.
Australasian Radiology, Yol. XZX. N o . 3 , September, 1975
257
Ruptured Mycotic I n t r a c d Aneurysm K. K. Nc,M.B.B.S. (SPORE),D.M.R.D. (ENG.),F.F.R.(LONDON) W. K. WONG,M.B.B.S. (SPORE),D.M.R.D. (ENG.) and F.F.R. HILIARY SKENE-SMITH, M.R.C.P. (LONDON), Department of Radiology, Faculty ofMedicine, University ofMalaya INTRODUCTION The causes of non-traumatic intracranial haemorrhage are numerous. A ruptured mycotic aneurysm is rare and it can bleed into the subarachnoid space, into the brain substance and even into the subdural space ( ~ i ~ 1960). & we wish to report a case of a ruptured intracranial mycotic aneurysm in a patient with a ventricular septal defect. Case History A 15-year-old Chinese female presented with a five-month history of intermittent fever. She had twice been admitted to another hospital, where the diagnosis of subacute bacterial endocarditis complicating an asymptomatic ventricular septal defect had been made. She had been vigorously treated with antibiotics and on her discharge was afebrile. On her admission to University Hospital she was again pyrexial with a temperature of 100.4"F. Examination revealed no embolic phenomenon and the only abnormal finding was a grade 3/6 pansystolic murmur, maximal in the 3rd and 4th left intercostal spaces. Laboratory examination revealed a haemoglobin of 9.1 G%, a normal white cell count and a raised ESR of 141 nim/hr. Urinalysis was normal. Repeated blood cultures failed to grow any anaerobic or aerobic organisms. A clinical diagnosis of subacute bacterial endocarditis was made and she was treated with intravenous penicillin and became afebrile. She was well on this treatment until three weeks after admission, when she suddenly developed a severe headache and slumng of speech immediately followed by generalised fits. She rapidly deteriorated and started to decerebrate. Physical examination demonstrated fight facial nerYe of upper neuron type and right hemiparesis. Her left Pupil was dilated and showed sluggish response A usfralasian Radiology, Vol. XIX,No. 3, September,
to light. There were haemorrhagic spots on the inferior temporal part Of the right fundus. A left carotid angogram and 2, revealed a Nptured aneurysm in a peripheral branch Of the left middle cerebra' artery with intracerebral haematoma in the left parietotemprd region* A large intracerebd 'lot in the parieto-temporal re@on Of the left hemisphere, partly organised and partly fresh, with surrounding necrotic brain tissue, was evacuated via a left parietal craniotomy. She failed to improve and died two days later. Consent for autopsy Was refused.
FIGURE 1-Antero-post*or view of left carotid mogram. Note: (1) Displacement of the left anterior cerebral artery across midline. (2) The distal location of the left middle cerebral artery aneurysm indicated by arrow. I975
255
RUPTURED MYCOTIC INTRACRANIAL ANEURYSM
FIGURE2-Lateral view of left caroiid angiogram. Nole: ( 1) Aneurysm in a peripheral branch of left middle cerebral artery indicated by arrow. (2) Elevation of the middle cerebral artery. and (3) Widely spread and stretched peripheral branches of the middle cerebral artery.
COMMENT The diagnosis of bacterial endocarditis in this patient was made because of a pre-existing congenital heart lesion associated with five months’ intermittent fever and a raised blood sedimentation rate. The repeatedly negative blood cultures were du:: most probably to previous antibiotic therapy. The development of right hemiparesis and right facial nerve palsv of upper motor neuron type associated with rapid deterioration following headache and a fit was due to the intracerebral clot in the parieto-temporal region of the left cerebral 256
hemisphere, from the ruptured mycotic aneurysm of the peripheral branch of the left middle cerebral artery.
DISCUSSION Rupture of an intracranial mycotic aneurysm is a well-recognised complication of bacterial endocarditis (Kirkes 1852, Church 1870). The pathogenesis of an intracranial mycotic aneurysm has now been well established (Nakata Y.et al., 1968; Gaetano et at., 1970). Septic emboli, invariably from the heart, become lodged in a peripheral branch of a cerebral
Australasian Radiology, Vol. X I X , N o . 3, September, 1975
K. K. NGAND W. K. WONG artery, especially the middle cerebral, with re- cotic aneurysms is stressed. The importance of sulting short-segment occlusion. Infection of the bilateral carotid angiography in all patients arterial wall occurs via the vasa vasorum. In- with bacterial endocarditis who exhibit signs tense inflammation starting in the adventitia of cerebral embolism is emphasised. spreads inwards to the tunica media causing weakness of the vessel wall with aneurysm ACKNOWLEDGEMENT formation. The inflammation can even invade to express our thanks to Assoc. We wish the elastic membrane, resulting in rupture of the mycotic aneurysm and hence intracranial Prof. Wong Hee Ong for allowing us access to case note of her patient, and to Mrs. Pearly haemorrhage. Tho0 for typing the manuscript. Cerebral mycotic aneurysms occur most frequently in the distal branches of the middle REFERENCES cerebral artery, though occasionally they may occur in the distal branches of the anterior ‘Chrrch, W. S. (1870): On the “Formation of aneurysms and especially of intracranial aneurysms i i cerebral artery. They tend to increase rapidly early life.” Sr. Barrhoiowrnew’s Hospital Rep., 6 , in size and rupture while under observation, re99. sulting in intracerebral haematoma and sub- ’Hampson, J. R., and Harrison, M. I. G. (1967): arachnoid haemorrhage. Associated occlusion “Sterile blood culture in bacterial endocarditis.” of distal branches of the affected cerebral Quart. J . M e d . , 36, 167. artery may occur, with resulting cerebral in- Houriha-e, J. Brian (March, 1970) : “Ruptured Mycotic lctracranial Aneurysm.” Vascular Surgery, farction. Vol. 4, 21-29. In view of the serious prognosis in all cases A. B. (July, 1960): “Mycotic aneurysm comof ruptured mycotic aneurysm, bilateral carotid ‘King,plicated by subdural haemorrhage.” 1. Neurology, angiography should be performed in all patients VOI. 17, 788-91. with bacterial endocarditis who develop signs of ‘Kirkes, W. S. (1852): “Principal effects resulting from detachment of fibrinous deposits from interior of cerebral embolism. By this means, mycotic the heart.” M e d . Chir. Tr.. 35,281. aneurysm can be detected early and excised “Molinani, Gaetano F., Smith, Lewis, Goldstein. Marbefore rupture occurs.
SUMMARY A case of ruptured intracranial mycotic aneurysm in a patient with bacterial endocarditis is reported. A brief account of intracranial mycotic aneurysms and their pathogenesis is given. The distal location of intracranial my-
vis, N., and Richard, S. (April, 1973): “Pathogenesis of cerebral mycotic aneurysm.” Neurology, Vol. 23, No. 4. ‘Nakata, Y., Shionoya, S., Kamiya (1968): “Pathogenesis of rnycotic aneurysm.” Atrgiologg, 19, 593-601. ‘Roach, M. R., and Drake, C. G. (1965): “Ruptured, cerebral aneurysms caused by micro-organism. N. EngIartd I . Med.. 273, 240.
Australasian Radiology, Yol. XZX. N o . 3 , September, 1975
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