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Case Reports
. 2021 Nov 8:12:555.
doi: 10.25259/SNI_843_2021. eCollection 2021.

Surgical treatment of ruptured right middle cerebral artery mycotic aneurysm and central nervous system aspergillosis: Clinical case and literature review

Anton Konovalov  1 , Oleg Sharipov  2 , Oleg Shekhtman  1 , Vadim Gadzhiagaev  1 , Pavel Kalinin  2
Affiliations
Case Reports

Surgical treatment of ruptured right middle cerebral artery mycotic aneurysm and central nervous system aspergillosis: Clinical case and literature review

Anton Konovalov et al. Surg Neurol Int. .

Abstract

Background: Central nervous system (CNS) aspergillosis is more often met in patients with expressed immune suppression. Still, in 50% of cases of meningitis caused by Aspergillus spp., it is observed in patients without expressed immune suppression. The prognosis of CNS aspergillosis is unfavorable with the general rate of lethality around 70%.

Case description: Clinical case of a 58-year-old man who developed an Aspergillus abscess in the chiasmosellar region and an associated mycotic aneurysm of the right middle cerebral artery (MCA) and intracerebral hemorrhage. Microsurgical clipping of the fusiform-ectatic aneurysm of the right MCA in the conditions of rupture was performed. An extra-intracranial micro anastomosis was formed on the right. An open biopsy of the neoplasm in the chiasmosellar region was made. The neoplasm was yellow and destroyed the bone plate of the skull base. Biopsy results: Mycotic lesion (aspergillosis). The analysis of surgical treatment for mycotic aneurysms in the acute period of hemorrhage in patients with aspergillosis revealed a high rate of lethality. The issue of the feasibility and effectiveness of complicated revascularization interventions in the patients with hemorrhage and aspergillosis remains unsolved.

Conclusion: The lack of generally accepted tactics of the treatment of this pathology requires further studies and systemic analysis. A high risk of the lethal outcome in patients with invasive mycotic infection and rupture of mycotic aneurysm highlight the importance of timely diagnostics and the beginning of antimycotic therapy. WThe issue of the evaluation of the revascularization methods effectiveness in patients after surgical treatment of a mycotic aneurysm associated with cerebral aspergillosis remains poor.

Keywords: Aspergillosis; Bypass; Ruptured aneurysm.

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Conflict of interest statement

There are no conflicts of interest.

Figures

Figure 1:
Figure 1:
(a-c) Axial, sagittal, and frontal magnetic resonance imaging projection of the brain T1 + contrasting agent: the picture of the area of pathologic contrasting of the chiasmosellar region (red arrow) with elevated parameters of the perfusion. Probably, the picture of inflammatory (infectious?) alterations. Tumor presence is unlikely.
Figure 2:
Figure 2:
(a-c) Axial, sagittal, and frontal computed tomography angiography projection of the head: Fusiform, partially thrombosed aneurysm of the right middle cerebral artery (MCA) (red arrow). A 3D reconstruction showed a contrasting part of the aneurysm in the area of M2 of the right MCA in the form of two bulgings with a wide neck.
Figure 3:
Figure 3:
The scheme of the surgical intervention: Trapping-clipping of the aneurysm, extra-intracranial microanastomosis of the superficial temporal artery, and the M3 branch of the right middle cerebral artery. The location of the aspergilloma in the chiasmosellar region. The microscopic study of the biological material revealed the fragments of the connective tissue with chronic granulomatous inflammation and branching hyphae of the fungus (red arrow).
Figure 4:
Figure 4:
(a) Magnetic resonance angiography of the head on the 2nd day after the surgery. Extra-intracranial microanastomosis on the right functions (red arrow). (b) Arterial spin labeling magnetic resonance perfusion: Signs of ischemic events in the right frontal lobe (white arrow).
Figure 5:
Figure 5:
(a and b) computed tomography (CT) of the head on the 3rd day after the surgery. Hemispheric ischemic impairments on the right, expressed edema and dislocation of the brain. (c and d) CT of the head after decompressive trepanation. Expressed brain prolapse into the trepanation defect. Cisterna ambiens is visualized.
Figure 6:
Figure 6:
(a) Magnetic resonance imaging of the head with contrasting: Signs of expressed leptomeningitis with the formation of epidural empyema in the right frontal region. (b) Diffusion-weighted imaging: Vast foci of cerebrovascular accident are visualized in the basins of the middle cerebral artery from both sides. The internal carotid artery is occluded on the left.
See this image and copyright information in PMC

References

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