A case of parent artery occlusion with a coil for ruptured mycotic aneurysm before open-heart surgery

Abstract

A 57-year-old woman was hospitalized for fever and left hemiparesis. She was diagnosed with infective endocarditis by echocardiography, and with cerebral infarction and subarachnoid hemorrhage (SAH) by brain MRI. Antibiotic therapy was given for one week, but cardiac function worsened gradually due to complication of mitral regurgitation, and the patient was transferred to our hospital for open-heart surgery. Brain MRI at arrival showed new lesions of ischemic stroke and SAH, and hematoma in the left occipital lobe. Emergency angiography revealed a cerebral aneurysm of the distal segment of the left posterior cerebral artery (PCA). The patient was diagnosed with cerebral hemorrhage due to rupture of intracranial mycotic aneurysm (IMA). Early surgical intervention was necessary to prevent rerupture of the aneurysm before cardiac surgery because administration of a high dose of heparin was required during extracorporeal circulation. Given the general condition, parent artery occlusion of the distal left PCA with a platinum coil was chosen as minimally invasive surgery and was performed on the same day. The ruptured aneurysm was occluded completely, and cardiac surgery was then performed on the next day. Head CT after both surgeries revealed neither enlargement of the hematoma in the left occipital lobe nor new lesions in the other territory. After treatment with antibiotics for two months, the patient was discharged without neurological deficits. This case suggests that coil embolization could be a treatment option for a ruptured IMA in a serious case of infective endocarditis that requires open-heart surgery.