Abstract
A rare case of mycotic (Aspergillus) aneurysms which were newly formed near the clip after surgery for an aneursysm of the middle cerebral artery is reported in this paper.
A 47-year-old man was admitted to our hospital after suddenly developing severe headache and vomiting. A computed tomography (CT) scan revealed a moderate amount of subarachnoid blood in the right Sylvian fissure. Four-vessel angiography demonstrated a saccular aneurysm of the trifurcation of the right middle cerebral artery. The neck of the aneurysm was successfuly clipped without the use of induced hypotension. There was no obvious bleeding during the operation and no other aneurysm was present. The postoperative course was smooth and uneventful. A cerebral angiography which was done on the 10th day after operation revealed the complete disappearance of the aneurysm. Twelve days after operation the patient complained of headache and 17 days after operation fever occurred. Headache and fever continued, but no meningeal irritation signs were detected. However, a Lumbar tap revealed cerebrospinal fluid with marked pleocytosis. No bacteria was found. Thirty-one days after operation the patient deteriorated suddenly, and next day became comatose with decerebrate posture. A CT scan revealed a right parietotemporal hematoma with ventricular hemorrhage and midline shift to the left side. A repeat cerebral angiography demonstrated two newly formed aneurysms near the clip. The hematoma was evacuated and the aneurysms were excised after clipping. These aneurysms originated from the arterial wall which was touched by the clip previously applied on the middle cerebral artery aneurysm. The vessels were fragile and control of bleeding was very difficult. The patient died five days after the second operation. Microscopic examination showed that the aneurysms were mycotic in nature; the numerous hyphae were identified as Aspergillus.
Mycotic aneurysms of fungal origin are very rare. Only 17 cases have been reported in the literature. Four of these 17 cases developed aneurysms after neurosurgical procedure. Our case is the first that followed clipping of an aneurysm. From analysis of the reported cases. The authors suggest that 1) in five cases which developed aneurysms after neurosugical procedure, damage of the arterial wall during the operation played a very important role in development of fungal aneurysms, 2) in patients who develop fungal meningitis after neurosurgical procedure, cerebral angiography is neccessary in order to detect aneurysms, 3) direct surgical treatment in the acute stage should be avoid because manipulation of the inflamed friable wall may result in its gragmentation, and the necessity to occlude the parent artery. 4) prognosis of fungal aneurysms is very poor: there is no report of survival.
