Bacterial intracranial aneurysms

Full access

✓ The treatment of 13 patients with bacterial intracranial aneurysms is reported. The incidence of bacterial intracranial aneurysms was 4% of all patients admitted with intracranial aneurysms and 3% of all patients admitted with bacterial endocarditis. Each patient had neurological signs or symptoms suggestive of intracranial disease prior to the diagnosis of an aneurysm. Alpha Streptococcus was the most common infecting organism. All patients were treated with specific, high-dose antibiotics, and five patients underwent surgery as well. There were no surgical deaths. Six of eight nonsurgically treated patients died. A review of the literature confirms a high mortality for patients treated with only antibiotics, and a low mortality for elective surgery. The authors conclude that 1) patients with bacterial endocarditis, who develop sudden severe headache, focal neurological signs or symptoms, or seizures, should undergo serial cerebral angiography every 7 to 10 days throughout their hospitalization; 2) if an aneurysm is identified it should be excised whenever possible; and 3) patients with proximal or multiple aneurysms should be considered for surgery.

Bacterial intracranial aneurysms are uncommon, but life-threatening, lesions. Controversy has recently arisen over the appropriate management of these lesions and has motivated this review. This paper reports the experience at a single hospital with bacterial intracranial aneurysms, and includes 13 patients. Drawing from this experience and the literature, we propose to examine the following questions: 1) Are there warning signs or symptoms that suggest the diagnosis of bacterial intracranial aneurysm prior to a hemorrhage? 2) Which patients with bacterial endocarditis should have cerebral angiography? 3) What is the role of serial angiography in following patients with bacterial endocarditis? 4) If an aneurysm has been documented, is medical therapy alone adequate? 5) Is there a recommended surgical management, and is it modified by the presence of proximal or multiple aneurysms?

The records were reviewed for all patients with a diagnosis of bacterial or mycotic intracranial aneurysm seen at the UCLA Center for the Health Sciences from June, 1955, to April, 1978. The diagnosis of bacterial aneurysm was established by pathological examination of surgical and autopsy specimens or by the finding of an aneurysm in the cerebral circulation of patients whose history, physical examination, and blood cultures led to a diagnosis of bacterial endocarditis.

Illustrative Case Reports
Case 1

This 20-year-old white woman was known to have congenital subaortic stenosis. The patient was well until March 31, 1978, when she had an attack of bronchitis. Treatment consisted of oral ampicillin. Over the next 12 days, she developed neck stiffness, nonpruritic, erythematous, raised lesions on her legs, swollen, sore fingers, splinter hemorrhages, and fever elevations to 40°C. The patient was admitted to UCLA when she was found to be difficult to arouse.

Examination revealed a temperature of 37.4°C, hemorrhagic lesions on fingers, toes, palms, and soles, a small hemorrhage in the right retina, and a Grade III/VI aortic murmur. The patient was lethargic and had a nonfluent aphasia. The eyes were deviated to the left, the right side was paretic, and the neck was slightly stiff. The admitting diagnosis was bacterial endocarditis with a left frontal hemorrhage. The patient was started on intravenous penicillin, oxacillin, and gentamicin. All of 12 blood cultures grew Staphylococcus aureus. Computerized tomography (CT) on the day of admission showed a left frontoparietal hemorrhage, and arteriography showed an embolic filling defects at the parieto-occipital branch of the posterior cerebral artery and at the bifurcation of the pericallosal artery, and narrowing of the left opercular branches (Fig. 1 left).

Fig. 1.
Fig. 1.

Case 1. Left internal carotid artery angiograms. Left: On admission, embolic filling defects are seen at the bifurcation of the pericallosal artery and the parieto-occipital branch of the posterior cerebral artery (double arrows). An anterior operculum branch is narrowed (single arrow). Right: Eleven days later, aneurysms are revealed at the locations of the previously demonstrated emboli or narrowing.

Two weeks after admission, the patient had a generalized seizure and became unresponsive, with bilateral decerebrate posturing. A CT scan showed hemorrhage into the left temporal lobe and basal ganglia. Angiography showed aneurysms of the distal, left middle cerebral, left posterior cerebral, and the pericallosal arteries (Fig. 1 right). The hematoma was evacuated, and what was thought to be an aneurysm was clipped.

Angiography 2 weeks after operation showed enlargement of the left middle cerebral aneurysm to twice the original size, with no change in the other aneurysms. The enlarging aneurysm was excised 3 days later. Angiography was repeated 10 days after the second surgery and showed no middle cerebral artery aneurysm, no change in the remaining two aneurysms, and no further emboli. The patient was treated with antibiotics for 6 weeks. Her neurological examination at discharge showed a moderate nonfluent aphasia, and a right hemiparesis. Five months later she had a mild nonfluent aphasia and Grade 4 strength on the right. Soon after this examination the patient developed refractory heart failure and died.

Case 2

This 47-year-old white man had a history of a heart murmur but was previously in excellent health. He was admitted to UCLA Center for the Health Sciences three times in 1 month complaining of a persistent fever. On his third admission the physical examination was normal except for a temperature of 39.4°C, mental confusion, and a moderate nonfluent aphasia. Lumbar puncture showed an opening pressure of 220 mm H2O, 729 white blood cells/cu cm (75% polymorphonuclear cells), 220 red blood cells/cu cm, a protein of 92 mg%, and a glucose of 58 mg% with a blood glucose of 122 mg%. Gram and acid-fast stains, india ink preparation, and cultures were all negative. The patient was admitted with a diagnosis of either meningitis or cerebral abscess, and was started on intravenous penicillin, intramuscular streptomycin, and triple antituberculous therapy. The day following admission, a Grade II/VI systolic murmur and an Osler's node on the ball of the left foot were noted. Bacterial endocarditis was diagnosed, and a cerebral angiogram was recommended to rule out a bacterial aneurysm.

Angiography confirmed a left ascending parietal branch aneurysm (Fig. 2), which was excised 2 days later. The pathological diagnosis was a bacterial cerebral aneurysm. Postoperatively, the patient was neurologically normal. Angiography was repeated 3½ weeks after operation, and showed no new aneurysm and no filling of the previous aneurysm. The patient was discharged in good health after 6 weeks of antibiotic therapy.

Fig. 2.
Fig. 2.

Case 2. Preoperative left internal carotid artery injection showing an ascending parietal branch aneurysm (arrows).

Summary of Cases
Patient Population

During the period of this study, there were 459 patients admitted with bacterial endocarditis and 296 patients with cerebral aneurysms. Thirteen patients fulfilled the requirements for bacterial intracranial aneurysm. Seven were female and six were male. Their ages ranged from 20 to 70 years, with an average age of 40 years (Table 1).

TABLE 1

Patient population*

Case No.Age (yrs), SexSAHUnderlying Heart DiseasePossible Predisposing FactorsPeriod E to SAH (days)
120, Fyessubaortic stenosisbronchitis12
247, Myesmitral regurgitation0
332, Fnoprolonged laborunruptured
429, Fnoteeth cleanedunruptured
525, Myesmitral regurgitationteeth extraction8
670, Myesurological surgery23
752, Myes0
828, Myesmitral regurgitation35
958, Myesdental work35
1039, Fyesteeth cleaned, IV drugs used5
1137, Fyesmitral regurgitationcarious teeth28
1229, Fyesteeth cleaned24
1352, Fyes6

SAH = subarachnoid hemorrhage; BE = bacterial endocarditis; IV = intravenous.

The number of days from the diagnosis of bacterial endocarditis to the diagnosis of subarachnoid hemorrhage.

Cases previously reported by Takahashi, et al.42

Five of thirteen patients had a past history of heart disease. Nine patients had possible predisposing conditions. Examples included dental work, bronchitis, carious teeth, prolonged labor, and urological surgery (Table 1).

Clinical Presentation

The diagnosis of bacterial endocarditis was made in all patients within 2 days of admission. This diagnosis preceded that of bacterial intracranial aneurysm in all but one case. The time from diagnosis of bacterial endocarditis to subarachnoid hemorrhage (SAH) ranged from 0 to 35 days, with an average of 18 days. Two patients with an aneurysm had not suffered an SAH. The diagnosis of bacterial intracranial aneurysm was made following the sudden onset of coma in six patients, after the onset of focal neurological findings in six patients, and after the sudden onset of severe headache in one patient.

Bacteriological Studies

Twelve of 13 patients had positive cultures, 11 from blood and one from an autopsy specimen (Table 2). A single organism was found in all 12 instances. The remaining patient (Case 2), who had not recently been treated with antibiotics, failed to grow organisms in spite of multiple cultures for aerobes, anaerobes, and fungi. The diagnosis of bacterial intracranial aneurysm was established in this case by pathological examination of the excised aneurysm. The most common organism was alpha Streptococcus.

TABLE 2

Bacteriological findings in 12 patients

Organism CulturedNo. of Cases
alpha hemolytic Streptococcus5
gamma Streptococcus3
Staphylococcus aureus2
beta hemolytic Streptococcus1
Peptostreptococcus1

Computerized Tomography

Computerized tomographic scans were obtained in six patients (Table 3). One was normal, one was performed 1 month after a diagnostic angiogram, and four were completed on the day of angiography. The latter four each demonstrated hematomas. The CT scan was positive for a hematoma in one patient who had no angiographically demonstrated aneurysm. The aneurysm was discovered at operation in this patient.

TABLE 3

Radiographic results

Radiographic ProcedureTotal CasesPositive Results
computerized tomography65
angiography1211

Angiography

Twelve patients underwent cerebral angiography, and at least one clearly defined aneurysm was seen in 11 (Table 3). A total of 19 aneurysms were found. The diagnosis of bacterial aneurysm was made at operation or autopsy in the two patients without angiographic evidence of an aneurysm. Serial angiograms were obtained in six patients. An aneurysm clearly enlarged in two cases, resolved in one case, and a new aneurysm appeared in one case (Table 4). There were three patients with multiple aneurysms. The locations included 15 middle cerebral, two anterior cerebral, and two on the posterior cerebral arteries (Table 5). All aneurysms were beyond the first major bifurcation of the involved vessel and were thus labelled as “distal.”

TABLE 4

Results of serial angiography in six patients

ResultNo. of Cases
enlargement of aneurysm2
complete resolution of aneurysm1
aneurysm absent after excision2
new aneurysm at a new site1
TABLE 5

Location of 19 aneurysms*

Location of AneurysmsNo. of Aneurysms
middle cerebral artery15
anterior cerebral artery2
posterior cerebral artery2

All aneurysms were beyond the first division of each individual vessel. Three patients had multiple aneurysms.

Treatment

Twelve of 13 patients received a 6-week course of appropriate, high-dose, intravenous antibiotic therapy, beginning with the day of admission (Table 6). The 13th patient's treatment was started 2 days after admission, when the results of blood cultures were obtained. Craniotomy was performed in five patients. Eight patients received only antibiotic therapy. No patient received antihypertensive or antifibrinolytic therapy. Six of eight patients treated only with antibiotics died as a direct result of aneurysm rupture. The remaining two patients were neurologically normal at discharge. Of the five patients treated surgically, four were operated on after an SAH. Surgical treatment consisted of complete excision of four aneurysms and muscle-wrapping of one. There were no operative deaths and, at discharge, two patients were neurologically normal, one had a very mild monoparesis, and two remained hemiplegic as a result of their original hemorrhages.

TABLE 6

Treatment and outcome in 13 patients

TherapyOutcomeTotal Cases
NormalDisabledDead  
antibiotics alone2068
antibiotics & operation2305

Pathological Findings

Pathological analysis of the bacterial aneurysm was obtained in eight of 13 cases. All cases were described as showing enlarged or ruptured vessels with prominent inflammation and marked attenuation of the vessel wall with wall necrosis.

Discussion

Bohmfalk, et al.,5 summarized 85 cases of bacterial intracranial aneurysm reported between 1954 and 1978. We have reviewed these cases from the literature1–7,9–14,16–23,26–29,31–38,40–44 and have compared the results with our own.

Patient Population

The age, sex, incidence of bacterial intracranial aneurysm in all patients with intracranial aneurysm, and the incidence of bacterial intracranial aneurysm in patients with bacterial endocarditis in our series were similar to others.4–6,8,15,17,35,37,39 The incidence in our patients of underlying heart disease, predisposing conditions, and the spectrum of these conditions was also similar to the literature.8,35

Pathogenesis

In 1968, Nakata, et al.,30 published experimental results showing that after the introduction of bacteria into the dog aorta, which had been isolated by temporary clamps just above the renal arteries and the aortic bifurcation, vascular wall destruction began in the layers adjacent to the vasa vasorum. They concluded that stasis and sepsis in the vasa vasorum were the necessary initiating events for the formation of a bacterial aneurysm.

Molinari, et al.,24,25 pointed out that, although the original site of infection might be the vasa vasorum, this was rarely present in the cerebral vessels, particularly in distal branches where bacterial aneurysms were most likely to occur. From their own experimental model of bacterial emboli introduced into the cerebral circulation, they were able to conclude that aneurysms consistently appeared at the site of an infected embolus and that the earliest changes in the vessel wall occurred in the adventitial layer and spread to involve the media. They proposed that “in the absence of the vasa vasorum, bacteria could escape through occluded origins of the thin-walled penetrating vessels to the Virchow-Robin space and then to the adventitia of the parent vessel.”25 They explained that the aneurysmal enlargement was produced by pulsations against the necrotic wall of an occluded vessel or by those same pulsations against a weakened wall of a recanalized vessel. This latter process might explain the late appearance of an aneurysm during antibiotic treatment, as occurred in Case 1. Molinari24 stressed the short time period (1 to 3 days) between lodging of an infected embolus in a cerebral vessel and aneurysm formation in dogs not treated with antibiotics, or infected with virulent organisms. However, Molinari and his co-workers25 also noted that, if dogs were partially treated with an appropriate antibiotic, aneurysm rupture no longer regularly occurred in 1 to 3 days, but aneurysms were present when the dogs were sacrificed 7 or 8 days after embolization. These results would suggest that an aneurysm may develop in a patient with bacterial endocarditis who is appropriately treated, in as short a time as 1 week.

Clinical Presentation and Angiography

The neurological signs and symptoms of patients who develop bacterial intracranial aneurysms are variable,17 but are often secondary to one of three processes: 1) septic embolization; 2) meningitis; and 3) SAH. The first two produce signs and symptoms before aneurysm formation, and are infectious processes that may go on to aneurysm formation, as noted by Molinari, et al.,24,25 and Suwanwela, et al.40 The third is a direct result of aneurysm rupture, and is frequently associated with disastrous results. Most authors have expressed concern that there are no early warning signs to herald aneurysm formation except SAH, and, thus, unless all patients with bacterial endocarditis undergo serial angiograms, the mortality rate cannot be reduced.

A review of our patients suggests otherwise. Each of our cases was accompanied by premonitory signs or symptoms suggestive of intracranial disease (Table 7). In six patients who survived, these events initiated angiography. Case 2 is an example. One other patient who survived had early signs and symptoms, but angiography was not done until she suddenly became hemiplegic. The six patients who died as a direct result of an intracranial hemorrhage also had warning signs or symptoms. In two patients (Table 8), these symptoms occurred only a few hours before a catastrophic event. It is doubtful whether early diagnostic procedures would have changed their clinical course. However, the remaining four patients had signs or symptoms days before a catastrophic event, which, if correctly interpreted, could have led to early angiography and definitive treatment. Our results suggest that those patients who develop a sudden severe headache, focal neurological deficits, or seizures, should be selected for angiography. It is recognized that 28% to 39% of patients with bacterial endocarditis may present with neurological signs or symptoms.17,35 However, only 19% have been reported with the above signs or symptoms,17 and one could expect that at least 25% to 33% of these patients (4% to 6% of all bacterial endocarditis patients) would have a cerebral bacterial aneurysm.

TABLE 7

Signs and symptoms prior to hemorrhage

Symptoms or SignsNo. of Cases
sudden severe headache6
focal deficits
 aphasia3
 hemiparesis4
 facial weakness1
 facial numbness1
seizures1
TABLE 8

Relationship of signs and symptoms to the diagnosis of an aneurysm

Case No.Signs or SymptomsDelay* (days)Discharge Status
1hemiparesis, decreased mental status12disabled
2nonfluent aphasia, decreased mental status13normal
3sudden severe headache, hemiparesis13disabled
4sudden severe headache5normal
5sudden severe headachedead
6seizures, decreased mental status4dead
7sudden severe headache¼dead
8facial weakness, personality change6dead
9hemiparesis35dead
10sudden severe headache1normal
11nonfluent aphasia, personality change1normal
12sudden severe headache29dead
13nonfluent aphasia8disabled

Number of days from onset of warning signs or symptoms to catastrophic hemorrhage or angiographic diagnosis of an aneurysm.

Serial Angiography

Several points should be noted from our cases and the literature: 1) rupture of a bacterial intracranial aneurysm may occur at any point in the course of appropriate antibiotic therapy; 2) a new aneurysm may appear in subsequent angiograms even though previous angiograms were negative; and 3) new aneurysms may appear after excision of a solitary aneurysm.4,5,17–19,23,37,44 These facts emphasize the need for serial angiography throughout hospitalization. The experimental literature indicated that aneurysms are present 7 days after a septic embolus to the brain.25 Our own experience demonstrates that there is an average of 10 days from the onset of warning signs or symptoms to a catastrophic hemorrhage or to the angiographic demonstration of a cerebral aneurysm (Table 8). Therefore, three-vessel cerebral angiography at the onset of these signs or symptoms and repeated every 7 to 10 days during 6 weeks of antibiotic therapy, even after surgical excision of one aneurysm, would seem to be the method and frequency that would be most reliable for detecting bacterial cerebral aneurysms.

Computerized tomography has not been helpful in establishing a diagnosis of bacterial intracranial aneurysm, and it seems unlikely that in the near future it can do little more than establish the presence of a hemorrhage, abscess, or infarct in these patients. Importantly, a 6-week course of antibiotic therapy does not insure the prevention of further aneurysm formation,2 but, as demonstrated by our data (Table 1), most episodes of SAH occurred within 35 days of the diagnosis of bacterial endocarditis, and thus before completion of antibiotic therapy.

Treatment: Surgical or Nonsurgical

Bingham,4 in a review of 45 patients with bacterial intracranial aneurysms, emphasized that 11 of 21 patients followed with serial angiography had complete resolution of their aneurysms, and an additional six patients of this group had a decrease in aneurysm size. This led him to suggest serial angiography for all patients with a documented aneurysm. He recommended an operation only if the aneurysm enlarged, or did not change in size after 6 weeks of antibiotic therapy. He reported that three of 20 patients, who received only antibiotic therapy, died, and six of 25 patients, who received combined antibiotic and surgical treatment, died. He noted that the higher mortality rate associated with operation was not a true reflection of surgical mortality, which he estimated to be quite low.

Bohmfalk, et al.,5 reviewed 85 patients, including the patients in Bingham's series. They noted that an aneurysm resolved completely in 10 of 25 patients treated with antibiotics alone, and followed with serial angiography. This group of patients, as with Bingham's series, was a selected population and excluded the majority of patients (60 of 85 and 24 of 45, respectively) who were not followed by serial angiography. We emphasize that, although bacterial cerebral aneurysms resolve or decrease in size in some patients, the mortality of antibiotic therapy alone is high. Bohmfalk and colleagues reported that 20 of 38 patients in this group died. There were, however, no deaths for elective surgical procedures. Eight of 13 patients who required emergency operations died, but a careful examination of these eight patients confirms Bingham's earlier opinion that in most instances the deaths were not a result of surgery, but secondary to the already moribund state of the patient, rupture of a second aneurysm after the first had been successfully treated, or from unrelated causes. Our results underscore the high mortality associated with conservative therapy alone (six of eight patients) and the low mortality for craniotomy plus antibiotics (0 of five patients) (Table 9). These data suggest that therapy should consist of excision of the aneurysm as well as antibiotic treatment whenever possible.

TABLE 9

Bacterial intracranial aneurysms: treatment and mortality in three series

Authors & YearAntibiotics OnlyAntibiotics & Surgery
Total CasesDeadTotal CasesDead 
Bingham, 1977203256
Bohmfalk, et al., 19783820308
Frazee, et al., 19808650

Proximal and Multiple Aneurysms

The most recent comprehensive review5 suggests nonsurgical treatment for proximal and multiple aneurysms unless the latter show enlargement. A review of the treatment and outcome of the 13 cases of proximal aneurysm reported in the literature,2,4,6,18,28,33,36,37,41,44 excluding cavernous sinus aneurysms, shows one surgical death in three patients with operation; six of 10 patients died when treated with antibiotics alone (Table 10). The outcome is unknown for one patient in this latter group. The surgical group is too small to allow us to draw conclusions, but the high mortality associated with nonoperative treatment (two–thirds of the cases) should lead one to carefully consider an operation in each case. The concern for cerebral infarction as a complication of excision of a proximal aneurysm is obvious, but several alternative approaches should be examined before relying upon antibiotic treatment alone. These would include clipping of the aneurysm, excision with a superficial temporal artery to middle cerebral artery bypass, trapping of the aneurysm with or without a bypass, and wrapping of the aneurysm with muscle. We have had no experience with bypass surgery in these cases.

TABLE 10

Treatment and mortality in previously reported cases*

TreatmentTotal CasesDead
proximal aneurysms*
 operation31
 nonsurgical96
multiple aneurysms
 operation40
 nonsurgical110

Treatment and outcome is unknown for one patient.

No surgically treated patient died as a result of operation.

The results of treatment for two patients are unknown.

Interestingly, two of the previously reported “proximal” aneurysms were described as “berry” aneurysms, not bacterial,36 while a third occurred approximately 2 years after endocarditis.2 Thus, these aneurysms may have been preexisting saccular aneurysms that became secondarily infected.

Finally, we must consider the appropriate therapy for multiple aneurysms. A review of 15 such cases reported previously3–5,7,10,13,14,17,23,34,37,40 shows that four patients died, and 11 recovered. Four patients were treated surgically and 11 nonsurgically (Table 10). No patient died as a direct result of treatment. It is unclear why the mortality was unusually low in the nonsurgically treated group. However, as noted before, mortality for nonsurgically treated patients in general is approximately 50%, and this fact should be kept in mind when selecting the most appropriate therapy.

We believe that most patients with multiple aneurysms are surgical candidates. If multiple aneurysms are unilateral, they should be excised at one operation whenever possible. If they are bilateral, the largest aneurysm or the one presumed to have bled should be excised first. An appropriate recovery period should be allowed and angiography repeated before excision of the remaining aneurysm.

Conclusions

In view of the serious consequences of a ruptured bacterial intracranial aneurysm, the high morbidity of nonsurgical therapy, the low elective surgical mortality, and the rapid appearance of new aneurysms in some patients, we would recommend aggressive management for patients with bacterial endocarditis. Specifically, we suggest that 1) those patients with the diagnosis of bacterial endocarditis, who develop sudden severe headache, focal neurological signs or symptoms, or seizures, should undergo serial cerebral angiography every 7 to 10 days throughout their hospitalization; 2) if an aneurysm is identified, it should be excised whenever possible; and 3) patients with proximal or multiple aneurysms should be considered for operation, but that therapy must be individualized.

Acknowledgment

We gratefully acknowledge the advice and assistance of Mrs. Elizabeth Kugler in preparing this manuscript.

References

  • 1.

    Agnoli ABettag W: Endokarditis und Subarachnoidalblutung. Z Neurol 199:2953051971Z Neurol 199:

  • 2.

    Alajouanine TCastaigne PLhermitte Fet al: Cerebral arteritis of bacterial endocarditis: its late complications. JAMA 170:18581959 (Abstract)JAMA 170:

  • 3.

    Bell WEButler C 2nd: Cerebral mycotic aneurysms in children. Two case reports. Neurology 18:81861968Neurology 18:

  • 4.

    Bingham WF: Treatment of mycotic intracranial aneurysms. J Neurosurg 46:4284371977Bingham WF: Treatment of mycotic intracranial aneurysms. J Neurosurg 46:

  • 5.

    Bohmfalk GLStory JLWissinger JPet al: Bacterial intracranial aneurysm. J Neurosurg 48:3693821978J Neurosurg 48:

  • 6.

    Cantu RCLeMay MWilkinson HA: The importance of repeated angiography in the treatment of mycoticembolic intracranial aneurysms. J Neurosurg 25:1891931966J Neurosurg 25:

  • 7.

    Castaigne PLaplane DRicou Pet al: [Multiple intracranial arterial aneurysm of mycotic appearance. Repeated vascular embolic accidents. Myxoma of the left ventricle]. Rev Neurol 131:3393461975 (Fr)Rev Neurol 131:

  • 8.

    Cates JEChristie RV: Subacute bacterial endocarditis. Q J Med 20:931301951Q J Med 20:

  • 9.

    Devadiga KVMathai KVChandy J: Spontaneous cure of intracavernous aneurysm of the internal carotid artery in a 14-month-old child. Case report. J Neurosurg 30:1651681969J Neurosurg 30:

  • 10.

    Gilroy JAndaya LThomas VJ: Intracranial mycotic aneurysms and subacute bacterial endocarditis in heroin addiction. Neurology 23:119311981973Neurology 23:

  • 11.

    Hannesson BSachs E Jr: Mycotic aneurysms following purulent meningitis. Report of a case with recovery and review of the literature. Acta Neurochir 24:3053131971Acta Neurochir 24:

  • 12.

    Harrison MJGHampton JR: Neurological presentation of bacterial endocarditis. Br Med J 2:1481511967Br Med J 2:

  • 13.

    Heidelberger KPLayton WM JrFisher RG: Multiple cerebral mycotic aneurysms complicating post-traumatic pseudomonas meningitis. Case report. J Neurosurg 29:6316351968J Neurosurg 29:

  • 14.

    Hourihane JB: Ruptured mycotic intracranial aneurysm. A report of three cases. Vase Surg 4:21291970Hourihane JB: Ruptured mycotic intracranial aneurysm. A report of three cases. Vase Surg 4:

  • 15.

    Housepian EMPool JL: A systematic analysis of intracranial aneurysms from the autopsy file of the Presbyterian Hospital, 1914 to 1956. J Neuropathol Exp Neurol 17:4094251958J Neuropathol Exp Neurol 17:

  • 16.

    Ishikawa MWaga SMoritake Ket al: Cerebral bacterial aneurysms: report of three cases. Surg Neurol 2:2572611974Surg Neurol 2:

  • 17.

    Jones RH JrSiekert RGGeraci JE: Neurologic manifestations of bacterial endocarditis. Ann Intern Med 71:21281969Ann Intern Med 71:

  • 18.

    Katz RIGoldberg HISelzer ME: Mycotic aneurysm. Case report with novel sequential angiographic findings. Arch Intern Med 134:9399421974Arch Intern Med 134:

  • 19.

    King AB: Successful surgical treatment of an intracranial mycotic aneurysm complicated by a subdural hematoma. J Neurosurg 17:7887911960King AB: Successful surgical treatment of an intracranial mycotic aneurysm complicated by a subdural hematoma. J Neurosurg 17:

  • 20.

    Laguna JDerby BMChase R: Cardiobacterium hominis endocarditis with cerebral mycotic aneurysm. Arch Neurol 32:6386391975Cardiobacterium hominis endocarditis with cerebral mycotic aneurysm. Arch Neurol 32:

  • 21.

    Lansky LLMaxwell JA: Mycotic aneurysm of the internal carotid artery in an unusual intra-cranial location. Dev Med Child Neurol 17:79881975Dev Med Child Neurol 17:

  • 22.

    Matson DD: Intracranial arterial aneurysms in childhood. J Neurosurg 23:5785831965Matson DD: Intracranial arterial aneurysms in childhood. J Neurosurg 23:

  • 23.

    McNeel DEvans RAOry EM: Angiography of cerebral mycotic aneurysms. Acta Radiol (Diagn) 9:4074121969Acta Radiol (Diagn) 9:

  • 24.

    Molinari GF: Septic cerebral embolism. Stroke 3:1171221972Molinari GF: Septic cerebral embolism. Stroke 3:

  • 25.

    Molinari GFSmith LGoldstein MNet al: Pathogenesis of cerebral mycotic aneurysms. Neurology 23:3253321973Neurology 23:

  • 26.

    Montrieul BTerrasse JAlix Bet al: [The relationship between intracerebral hematoma, mycotic aneurysm, Staphylococcal septicemia and endocarditis.] Sem Hop Paris 49:200920131973 (Fr)Staphylococcal septicemia and endocarditis.] Sem Hop Paris 49:

  • 27.

    Morgan WLBland EF: Bacterial endocarditis in the antibiotic era with special reference to the later complications. Circulation 19:7537651959Circulation 19:

  • 28.

    Morin MATalalla A: Angiography for mycotic aneurysm. N Engl J Med 281:124912501969 (Letter)N Engl J Med 281:

  • 29.

    Moskowitz MARosenbaum AETyler HR: Angiographically monitored resolution of cerebral mycotic aneurysms. Neurology 24:110311081974Neurology 24:

  • 30.

    Nakata YShionoya SKamiya K: Pathogenesis of mycotic aneurysm. Angiology 19:5936011968Angiology 19:

  • 31.

    Ng KKWong WKSkene-Smith H: Ruptured mycotic intracranial aneurysm. Australas Radiol 19:2552571975Australas Radiol 19:

  • 32.

    Noonan JAWilson CBSpencer FCet al: Cerebral and cardiac complications from bacterial endocarditis. A successfully managed case with unusual complications. Am J Dis Child 116:6666741968Am J Dis Child 116:

  • 33.

    North-Coombes DSchonland MM: Cerebral mycotic aneurysm. A case report. S Afr Med J 48:180818101974S Afr Med J 48:

  • 34.

    Ojemann RGNew PFJFleming TC: Intracranial aneurysms associated with bacterial meningitis. Neurology 16:122212261966Neurology 16:

  • 35.

    Pankey GA: Acute bacterial endocarditis at the University of Minnesota Hospitals, 1939–1959. Am Heart J 64:5835911962Am Heart J 64:

  • 36.

    Ray HWahal KM: Subarachnoid hemorrhage in subacute bacterial endocarditis. Neurology 7:2652691957Neurology 7:

  • 37.

    Roach MRDrake CG: Ruptured cerebral aneurysms caused by micro-organisms. N Engl J Med 273:2402441965N Engl J Med 273:

  • 38.

    Shibuya SIgarashi SAmo Tet al: Mycotic aneurysms of the internal carotid artery. Case report. J Neurosurg 44:1051081976J Neurosurg 44:

  • 39.

    Snow RMCobbs CG: Treatment of complications of infective endocarditisKaye D (ed): Infective Endocarditis. Baltimore: University Park Press1976213228Infective Endocarditis.

  • 40.

    Suwanwela CSuwanwela NCharuchinda Set al: Intracranial mycotic aneurysms of extravascular origin. J Neurosurg 36:5525591972J Neurosurg 36:

  • 41.

    Sypert GWYoung HF: Ruptured mycotic pericallosal aneurysm with meningitis due to Neisseria meningitidis infection. Case report. J Neurosurg 37:4674691972Neisseria meningitidis infection. Case report. J Neurosurg 37:

  • 42.

    Takahashi MKillefer FWilson G: Cerebral mycotic aneurysms. Nippon Acta Radiol 30:4894991970Nippon Acta Radiol 30:

  • 43.

    Yarnell PRStears J: Intracerebral hemorrhage and occult sepsis. Neurology 24:8708731974Neurology 24:

  • 44.

    Ziment IJohnson BL Jr: Angiography in the management of intracranial mycotic aneurysms. Arch Intern Med 122:3493521968Arch Intern Med 122:

Article Information

Address reprint requests to: John G. Frazee, M.D., Division of Neurosurgery, University of California-Los Angeles Medical Center, Los Angeles, Calfornia 90024.

© AANS, except where prohibited by US copyright law."

Headings

Figures

  • View in gallery

    Case 1. Left internal carotid artery angiograms. Left: On admission, embolic filling defects are seen at the bifurcation of the pericallosal artery and the parieto-occipital branch of the posterior cerebral artery (double arrows). An anterior operculum branch is narrowed (single arrow). Right: Eleven days later, aneurysms are revealed at the locations of the previously demonstrated emboli or narrowing.

  • View in gallery

    Case 2. Preoperative left internal carotid artery injection showing an ascending parietal branch aneurysm (arrows).

References

1.

Agnoli ABettag W: Endokarditis und Subarachnoidalblutung. Z Neurol 199:2953051971Z Neurol 199:

2.

Alajouanine TCastaigne PLhermitte Fet al: Cerebral arteritis of bacterial endocarditis: its late complications. JAMA 170:18581959 (Abstract)JAMA 170:

3.

Bell WEButler C 2nd: Cerebral mycotic aneurysms in children. Two case reports. Neurology 18:81861968Neurology 18:

4.

Bingham WF: Treatment of mycotic intracranial aneurysms. J Neurosurg 46:4284371977Bingham WF: Treatment of mycotic intracranial aneurysms. J Neurosurg 46:

5.

Bohmfalk GLStory JLWissinger JPet al: Bacterial intracranial aneurysm. J Neurosurg 48:3693821978J Neurosurg 48:

6.

Cantu RCLeMay MWilkinson HA: The importance of repeated angiography in the treatment of mycoticembolic intracranial aneurysms. J Neurosurg 25:1891931966J Neurosurg 25:

7.

Castaigne PLaplane DRicou Pet al: [Multiple intracranial arterial aneurysm of mycotic appearance. Repeated vascular embolic accidents. Myxoma of the left ventricle]. Rev Neurol 131:3393461975 (Fr)Rev Neurol 131:

8.

Cates JEChristie RV: Subacute bacterial endocarditis. Q J Med 20:931301951Q J Med 20:

9.

Devadiga KVMathai KVChandy J: Spontaneous cure of intracavernous aneurysm of the internal carotid artery in a 14-month-old child. Case report. J Neurosurg 30:1651681969J Neurosurg 30:

10.

Gilroy JAndaya LThomas VJ: Intracranial mycotic aneurysms and subacute bacterial endocarditis in heroin addiction. Neurology 23:119311981973Neurology 23:

11.

Hannesson BSachs E Jr: Mycotic aneurysms following purulent meningitis. Report of a case with recovery and review of the literature. Acta Neurochir 24:3053131971Acta Neurochir 24:

12.

Harrison MJGHampton JR: Neurological presentation of bacterial endocarditis. Br Med J 2:1481511967Br Med J 2:

13.

Heidelberger KPLayton WM JrFisher RG: Multiple cerebral mycotic aneurysms complicating post-traumatic pseudomonas meningitis. Case report. J Neurosurg 29:6316351968J Neurosurg 29:

14.

Hourihane JB: Ruptured mycotic intracranial aneurysm. A report of three cases. Vase Surg 4:21291970Hourihane JB: Ruptured mycotic intracranial aneurysm. A report of three cases. Vase Surg 4:

15.

Housepian EMPool JL: A systematic analysis of intracranial aneurysms from the autopsy file of the Presbyterian Hospital, 1914 to 1956. J Neuropathol Exp Neurol 17:4094251958J Neuropathol Exp Neurol 17:

16.

Ishikawa MWaga SMoritake Ket al: Cerebral bacterial aneurysms: report of three cases. Surg Neurol 2:2572611974Surg Neurol 2:

17.

Jones RH JrSiekert RGGeraci JE: Neurologic manifestations of bacterial endocarditis. Ann Intern Med 71:21281969Ann Intern Med 71:

18.

Katz RIGoldberg HISelzer ME: Mycotic aneurysm. Case report with novel sequential angiographic findings. Arch Intern Med 134:9399421974Arch Intern Med 134:

19.

King AB: Successful surgical treatment of an intracranial mycotic aneurysm complicated by a subdural hematoma. J Neurosurg 17:7887911960King AB: Successful surgical treatment of an intracranial mycotic aneurysm complicated by a subdural hematoma. J Neurosurg 17:

20.

Laguna JDerby BMChase R: Cardiobacterium hominis endocarditis with cerebral mycotic aneurysm. Arch Neurol 32:6386391975Cardiobacterium hominis endocarditis with cerebral mycotic aneurysm. Arch Neurol 32:

21.

Lansky LLMaxwell JA: Mycotic aneurysm of the internal carotid artery in an unusual intra-cranial location. Dev Med Child Neurol 17:79881975Dev Med Child Neurol 17:

22.

Matson DD: Intracranial arterial aneurysms in childhood. J Neurosurg 23:5785831965Matson DD: Intracranial arterial aneurysms in childhood. J Neurosurg 23:

23.

McNeel DEvans RAOry EM: Angiography of cerebral mycotic aneurysms. Acta Radiol (Diagn) 9:4074121969Acta Radiol (Diagn) 9:

24.

Molinari GF: Septic cerebral embolism. Stroke 3:1171221972Molinari GF: Septic cerebral embolism. Stroke 3:

25.

Molinari GFSmith LGoldstein MNet al: Pathogenesis of cerebral mycotic aneurysms. Neurology 23:3253321973Neurology 23:

26.

Montrieul BTerrasse JAlix Bet al: [The relationship between intracerebral hematoma, mycotic aneurysm, Staphylococcal septicemia and endocarditis.] Sem Hop Paris 49:200920131973 (Fr)Staphylococcal septicemia and endocarditis.] Sem Hop Paris 49:

27.

Morgan WLBland EF: Bacterial endocarditis in the antibiotic era with special reference to the later complications. Circulation 19:7537651959Circulation 19:

28.

Morin MATalalla A: Angiography for mycotic aneurysm. N Engl J Med 281:124912501969 (Letter)N Engl J Med 281:

29.

Moskowitz MARosenbaum AETyler HR: Angiographically monitored resolution of cerebral mycotic aneurysms. Neurology 24:110311081974Neurology 24:

30.

Nakata YShionoya SKamiya K: Pathogenesis of mycotic aneurysm. Angiology 19:5936011968Angiology 19:

31.

Ng KKWong WKSkene-Smith H: Ruptured mycotic intracranial aneurysm. Australas Radiol 19:2552571975Australas Radiol 19:

32.

Noonan JAWilson CBSpencer FCet al: Cerebral and cardiac complications from bacterial endocarditis. A successfully managed case with unusual complications. Am J Dis Child 116:6666741968Am J Dis Child 116:

33.

North-Coombes DSchonland MM: Cerebral mycotic aneurysm. A case report. S Afr Med J 48:180818101974S Afr Med J 48:

34.

Ojemann RGNew PFJFleming TC: Intracranial aneurysms associated with bacterial meningitis. Neurology 16:122212261966Neurology 16:

35.

Pankey GA: Acute bacterial endocarditis at the University of Minnesota Hospitals, 1939–1959. Am Heart J 64:5835911962Am Heart J 64:

36.

Ray HWahal KM: Subarachnoid hemorrhage in subacute bacterial endocarditis. Neurology 7:2652691957Neurology 7:

37.

Roach MRDrake CG: Ruptured cerebral aneurysms caused by micro-organisms. N Engl J Med 273:2402441965N Engl J Med 273:

38.

Shibuya SIgarashi SAmo Tet al: Mycotic aneurysms of the internal carotid artery. Case report. J Neurosurg 44:1051081976J Neurosurg 44:

39.

Snow RMCobbs CG: Treatment of complications of infective endocarditisKaye D (ed): Infective Endocarditis. Baltimore: University Park Press1976213228Infective Endocarditis.

40.

Suwanwela CSuwanwela NCharuchinda Set al: Intracranial mycotic aneurysms of extravascular origin. J Neurosurg 36:5525591972J Neurosurg 36:

41.

Sypert GWYoung HF: Ruptured mycotic pericallosal aneurysm with meningitis due to Neisseria meningitidis infection. Case report. J Neurosurg 37:4674691972Neisseria meningitidis infection. Case report. J Neurosurg 37:

42.

Takahashi MKillefer FWilson G: Cerebral mycotic aneurysms. Nippon Acta Radiol 30:4894991970Nippon Acta Radiol 30:

43.

Yarnell PRStears J: Intracerebral hemorrhage and occult sepsis. Neurology 24:8708731974Neurology 24:

44.

Ziment IJohnson BL Jr: Angiography in the management of intracranial mycotic aneurysms. Arch Intern Med 122:3493521968Arch Intern Med 122:

TrendMD

Cited By

Metrics

Metrics

All Time Past Year Past 30 Days
Abstract Views 0 0 0
Full Text Views 56 56 56
PDF Downloads 22 22 22
EPUB Downloads 0 0 0

PubMed

Google Scholar