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Ruptured Distal Mycotic Middle Cerebral Artery Aneurysm with Cortical Haemorrhagic Stroke Treated with NBCA Embolization: Case Report

Aminur Rahman, Sirintara Pongpech, Pakorn Jiarakongmun, Ekachat Chanthanaphak, Wittawat Takong, Kittiphop Somboonnithiphol and Thanaboon Wongkitthamrongchai

Mycotic aneurysms are a rare cause of intracranial aneurysms that develop in the presence of infections such as infective endocarditis. They account for a small percentage of all intracranial aneurysms and carry a high mortality rate when ruptured. A 48-year-old male patient was admitted to our hospital with a severe headache and right-sided weakness. Computed tomography scan (CT scan) of the brain and Magnetic Resonance Imaging (MRI) revealed cortical hemorrhagic stroke with perilesional oedema in the left parietal lobe in left middle cerebral artery (MCA) territory and Magnetic Resonance Angiography (MRA) showed an aneurysm located at the distal subcortical mycotic aneurysm in the left MCA. A cerebral angiogram revealed 2 aneurysms; one pseudoaneurysm (approx. 2×2 mm) located at the left M4 distal MCA and the other false aneurysm in right basal ganglia. Findings of echocardiography were mitral valve myxomatous change and prolapse posterior mitral leaflet with oscillating vegetation with moderate mitral regurgitation (MR). Laboratory studies showed Streptococcus viridians positive blood culture of 3 specimens, anaemia, leucocytosis, and elevated inflammatory factors. The patient was treated with appropriate antibiotics therapy for 4 weeks and improved clinically. The follow-up MRA showed an unchanged mycotic aneurysm. We planned for another cerebral angiography and found an increased size of pseudoaneurysm (5×5 mm) and successful embolization with NBCA concentration 1:1 without any complication. Control angiography showed that the mycotic aneurysm was completely resolved. The patient was nearly free of symptoms.