Selective endovascular techniques in the treatment of cerebral mycotic aneurysms

Report of three cases

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✓ The aim of this study was to evaluate the role of endovascular treatment for intracranial mycotic aneurysms. The clinical and angiographic features of three patients with endocarditic vegetation (two with Streptococcus viridans and one with Staphylococcus) were reviewed retrospectively. Patients were selected for this treatment according to the clinical setting and aneurysm location. In two cases, selective catheterization of a distal middle cerebral and posterior cerebral artery branch with a microcatheter followed by superselective amobarbital testing of the parent vessel was preliminary to the occlusion of that vessel with autologous clot or glue. The third patient was treated by selective occlusion of the aneurysm by intra-aneurysmal placement of platinum minicoils. Two patients presented with intracranial hemorrhage and in one the lesion was found on computerized tomography. All three aneurysms had been excluded from the circulation at the 6-month follow-up review. The only complication from the procedure, despite the septic nature and distal localization, was balloon deflation in one patient, who was successfully retreated with coils. Endovascular embolization is indicated in patients who are at risk of hemorrhage and cannot undergo the standard procedure. The superselective amobarbital test allows selection of patients who will tolerate distal vessel occlusion. This endovascular procedure represents a safe and effective treatment for these lesions.

Article Information

Address for Dr. Khayata: Division of Neurological Surgery, Barrow Neurological Institute, Phoenix, Arizona.Address for Dr. Woimant: Neurology Department, Lariboisière Hospital, Paris, France.Address reprint requests to: Jean Jacques Merland, M.D., Interventional Neuroangiography, Lariboisière Hospital, Paris University, 2 Rue Ambroise Pare, 75010 Paris, France.

© AANS, except where prohibited by US copyright law.

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    Case 1. A: Computerized tomography scan following vertebral injection of contrast material showing a posterior cerebral artery aneurysm. B: Selective catheterization with a flow-guided catheter demonstrating filling of the aneurysm and the calcarine artery (Amytal test was positive). C: Superselective catheterization with a torque-controlled system filling only the aneurysm and the parent vessel (Amytal test was negative), which was embolized with N-butyl-cyanoacryiate glue. D: Follow-up arteriogram showing complete obliteration of the aneurysm. The patient's neurological examination remained normal. E: Magnetic resonance image obtained 6 months after the procedure revealing minimal changes related to the earlier hemorrhage.

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    Case 2. Left: Internal carotid arteriogram, lateral view, showing the aneurysm on a rolandic branch of the middle cerebral artery (arrow). The branch was catheterized selectively and tested functionally with the catheter in a flow-control position. Test occlusion of the branch was well tolerated clinically and showed ample collateral circulation on angiography. Amytal injection was also well tolerated. The branch and the aneurysm were then embolized. Right: Repeat arteriogram demonstrating complete elimination of the aneurysm. The patient returned to his full activities.

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    Case 3. Angiography showed two aneurysms: a right middle cerebral artery (MCA) aneurysm that hemorrhaged and an asymptomatic small posterior cerebral artery aneurysm. Left: Lateral internal carotid arteriogram showing the MCA aneurysm, which was treated endovascularly with a balloon. Center: The balloon deflated and the aneurysm refilled. Right: The aneurysm was then successfully obliterated with minicoils.

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