Abstract
Infectious intracranial aneurysms are rare and most commonly associated with infective endocarditis. When infective endocarditis is not evident, and patients have common vascular risk factors such as hypertension, lobar hemorrhage may be misclassified as primary hypertensive intracerebral hemorrhage, and infectious intracranial aneurysms may be overlooked. We report a case in which a perihematomal isodense lesion on computed tomography prompted vascular evaluation and led to the diagnosis of a ruptured distal cortical presumed infectious aneurysm during treatment for pyogenic spondylodiscitis.
A 77-year-old woman with hypertension was hospitalized under orthopedic care for severe low back pain and treated with intravenous antibiotics. Lumbar imaging confirmed spondylodiscitis at L3/4. On hospital day 37, computed tomography revealed a left parietal subcortical hemorrhage with an approximately 12-mm isodense perihematomal lesion that was partially enhanced on contrast-enhanced computed tomography, prompting transfer to the neurosurgery department. She was neurologically intact except for higher cortical dysfunction. Cerebral angiography demonstrated a small aneurysm in a distal cortical branch. Craniotomy with aneurysm resection and hematoma evacuation was performed. Histopathology showed inflammatory cell infiltration consistent with infectious vasculitis; cultures were negative, likely due to prior antibiotic exposure. Transthoracic echocardiography showed no valvular vegetation.
This case highlights that a subtle perihematomal computed tomography lesion should prompt vascular imaging to exclude treatable secondary causes such as infectious intracranial aneurysm, even in patients with hypertension without evidence of infective endocarditis.
