Dynamic Angiographic Nature of Cerebral Mycotic Aneurysms in Patients With Infective Endocarditis.

A 41-year-old male with nonischemic cardiomyopathy and left ventricular assist device on coumadin presented with constitutional symptoms for 1 week. Blood cultures were drawn. The next day, he developed severe headache (Hunt–Hess grade II), and noncontrast head computed tomography (CT) showed Fisher grade II subarachnoid hemorrhage over bilateral frontal convexities. International Normalized Ratio was 9. The blood cultures grew methicillin-resistant Staphylococcus aureus within a day. He was diagnosed with an infected left ventricular assist device and started on intravenous vancomycin. Brain CT angiography was negative for any vessel abnormality. Cerebral angiography on post bleed day 1 showed areas of subocclusive emboli in the left M3 segment of the middle cerebral artery (MCA) and left pericallosal artery, but did not reveal any identifiable source for subarachnoid hemorrhage. On post bleed day 2, the patient developed left frontal seizures that eventually progressed to status epilepticus. Repeat CT head showed a new intraparenchymal hemorrhage within the left frontal operculum, measuring 1.8 cm in diameter. Repeat cerebral angiography on post bleed day 2 revealed a new left M3 fusiform mycotic aneurysm (MA) in the exact location of the previously seen left M3 segment embolus. The pericallosal branch embolus had progressed to near vessel occlusion rather than aneurysm formation. The patient’s family withdrew care because of his poor cardiac and neurological status (Figure 1). Figure 1. Initial cerebral angiogram ( A ) showing subocclusive filling defects in the left pericallosal (black arrows) and M3 middle cerebral artery branch (white arrow) arteries. Follow-up angiography shows near occlusion of the left pericallosal branch ( B ), and fusiform mycotic aneurysmal dilatation of the previous left M3 lesion ( C and D ). A 31-year-old female with history of Tetrology of Fallot that had been repaired when she was a child, and previous infective endocarditis secondary to intravenous drug abuse requiring aortic valve replacement, …