**1. Introduction**

326 Aneurysm

Umeoka K, Kominami S, Mizunari T, Murai Y, Kobayashi S, Teramoto A (2011). Cerebral artery restenosis following transluminal balloon angioplasty for vasospasm after

Wasay M, Bakshi R, Kojan S, Bobustuc G, Dubey N, Unwin DH (2001). Nonrandomized comparison of local urokinase thrombolysis versus systemic heparin anticoagulation for

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subarachnoid hemorrhage. Surg Neurol Int :2:43.

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Intracranial mycotic pseudoaneurysms are rare and generally lethal. The infectious pseudoaneurysms occur more frequently in the anterior circulation and may be multiple. Haemorrhage is rare but is associated with poor neurological outcome. The outcome in children is comparable, or slightly better, than in adults. Mortality reaches up to 80% in some studies. Cerebral mycotic or infectious aneurysms are a complication of infectious diseases (Cloud et al.,2003). Recently, infectious aneurysms occur more frequently in patients with a history of drug abuse (cocaine, heroine, pervitine, etc.), or in patients with Human Immunodeficiency Syndrome (HIV)**.**

Presenting symptoms are typically headache, focal neurological deficit and/or haemorrhage. Headache is the most common presenting complaint in infectious and dissecting aneurysms.

Treatment of mycotic aneurysms is often difficult; they are managed conservatively with a prolonged course of antibiotics. In case of haemorrhage, surgical or endovascular treatment is used. Although surgery has been a traditional treatment of ruptured infectious pseudoaneurysms, it is associated with a higher rate of mortality (up to 80%). Endovascular treatment seems to be more safe. Parent artery occlusion (PAO) with coil embolisation or droplet of glue has become an attractive alternative treatment due to its low rate of morbidity and mortality. Vasospasm associated with haemorrhage is usually well tolerated in young patients.

© 2012 Procházka et al., licensee InTech. This is an open access chapter distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. © 2012 The Author(s). Licensee InTech. This chapter is distributed under the terms of the Creative Commons Attribution License http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

#### **2. Selective cases**

#### **2.1. Case No. 1**

A 17-year-old girl, with the history of desoxyephedrine abuse for the last 2 years, was admitted into the hospital due to severe attack of headache, accompanied with a left-sided hemiparesis. The girl was anorectic, with vaginal discharge. Initial CT/CTA scan showed a large right hemisphere intracerebral haematoma (Fig. 1). The presence of pseudoaneurysm was suspected and confirmed by angiography, located in the right M3-MCA segment (Fig. 2). All vessels in the surrounding area were narrowed, with vessel wall irregularities. Due to the rebleeding risk and marked clinical deterioration at the time of the emergency angiography, parent artery occlusion of M3 MCA segmental branch was performed (Fig. 3).

**A,** CT scan: large intracerebral haematoma in the right hemisphere with midline shift. **B,** CTA sagital view: large depo of contrast media in area of M3 segment of right MCA.

#### **Figure 1.** Initial CT/CTA scan

Immediately after the embolisation procedure, neurosurgeon evacuated the residual intracerebral haematoma and a decompressive craniectomy was completed (Fig. 4). The blood analysis confirmed latent infectious stage with a high white blood cell count of 17,9 x 109/l, CRP 146mg/l and a higher level of fibrinogen 5,252 g/l, with no subsequent shift in coagulation. HIV test was negative.

In addition to the endovascular procedure, intravenous administration of an antibiotic therapy (Claforan, Lek, SLO) was implemented. After a two-month period, the girl was doing quite well, Rankin scale-1, with small residual left-side hemiparesis and completely selfsufficient. All blood tests were normalized. Second control cerebral angiography confirmed a total occlusion of the pseudoaneurysm (Fig.5). At one-year follow-up, digital subtraction angiography was unremarkable, without pseudoaneurysm perfusion and vessel wall inflammation. Surrounding vessels were regular. The girl was back at school and doing well.

**2. Selective cases** 

**Figure 1.** Initial CT/CTA scan

coagulation. HIV test was negative.

A 17-year-old girl, with the history of desoxyephedrine abuse for the last 2 years, was admitted into the hospital due to severe attack of headache, accompanied with a left-sided hemiparesis. The girl was anorectic, with vaginal discharge. Initial CT/CTA scan showed a large right hemisphere intracerebral haematoma (Fig. 1). The presence of pseudoaneurysm was suspected and confirmed by angiography, located in the right M3-MCA segment (Fig. 2). All vessels in the surrounding area were narrowed, with vessel wall irregularities. Due to the rebleeding risk and marked clinical deterioration at the time of the emergency angiography, parent artery occlusion of M3 MCA segmental branch was performed (Fig. 3).

**A,** CT scan: large intracerebral haematoma in the right hemisphere with midline shift. **B,** CTA sagital view: large depo of contrast media in area of M3 segment of right MCA.

Immediately after the embolisation procedure, neurosurgeon evacuated the residual intracerebral haematoma and a decompressive craniectomy was completed (Fig. 4). The blood analysis confirmed latent infectious stage with a high white blood cell count of 17,9 x 109/l, CRP 146mg/l and a higher level of fibrinogen 5,252 g/l, with no subsequent shift in

**A B**

In addition to the endovascular procedure, intravenous administration of an antibiotic therapy (Claforan, Lek, SLO) was implemented. After a two-month period, the girl was doing quite well, Rankin scale-1, with small residual left-side hemiparesis and completely selfsufficient. All blood tests were normalized. Second control cerebral angiography confirmed a total occlusion of the pseudoaneurysm (Fig.5). At one-year follow-up, digital subtraction angiography was unremarkable, without pseudoaneurysm perfusion and vessel wall inflammation. Surrounding vessels were regular. The girl was back at school and doing well.

**2.1. Case No. 1** 

**C**

**A,** Angiography frontal view: M2-3 segment of MCA artery; we see a large pseudoaneurysm, the supplying vessel has irregular shape.

**B,** Lateral view angiogram with large pseudoaneurysm in the M2-3 segment of the right MCA artery.

**C,** 3D-XRA reconstruction of the right MCA artery pseudoaneurysm

**Figure 2.** Digital subtraction angiography with 3D-XRA reconstruction

**A,** Microcatheter in the parent artery. Control angiography confirmed the correct position of microcatheter just below the aneurysm.

**B,** Frontal view angiogram confirming pseudoaneurysm occlusion.

**Figure 3.** Embolisation procedure

**A,** One-year follow-up angiography in the AP and lateral view **B,** shoving no contrast filling of the pseudoaneurysm, normal shape of the vessels in the region of right MCA artery.

**Figure 5.** Follow-up angiogram

#### **2.2. Case No. 2**

330 Aneurysm

the aneurysm.

craniectomy.

**Figure 3.** Embolisation procedure

**A,** Microcatheter in the parent artery. Control angiography confirmed the correct position of microcatheter just below

**A B**

**Figure 4.** CT scan after neurosurgical removal of large intracerebral haematoma and decompressive

**B,** Frontal view angiogram confirming pseudoaneurysm occlusion.

A 12-year-old boy, with the history of premature delivery due to the placenta release, (30th week of gestation, having 1300g of body weight and 38cm of height at birth), spent 8 weeks in the incubator on ventilation support and phototherapy due to severe icterus. At 10 months of age, he was admitted into the hospital because of severe pneumonia and was put on assisted ventilation. He also suffered from severe focal seizures, headache, anxiety and impaired locomotion. However, due to the headache deterioration, MRI examination was performed and showed a small area of bleeding in the left opercular insular segment (Fig. 6) suggesting a presence of pseudoaneurysm in the left MCA branch. Peripheral blood counts and CRP levels were in physiological range. Subsequent angiography revealed a mycotic pseudoaneurysm in the left MCA opercular segment (Fig.7) with a straightened supplying artery, while the surrounding vessels were narrowed. Due to the high risk of pseudoaneurysm rupture, the endovascular PAO was directly performed, using coil embolisation. Immediately after the embolization, a weak bradylalia developed due to the Brockas´ area MCA supplying territory perfusion, but the condition rapidly disappeared (Fig.8). Seizure attacks following embolisation stopped, and one-month follow-up MRI confirmed pseudoaneurysm thrombosis (Fig.9).

**C**

**A,B** MRI + MRA: Pd T2, MRA axial plane confirmed little area of haemorrhage in the left opercular area, deposits of methemoglobine

**C,** Based on MRA scan, suspicion of pseudoaneurysm in the region of M2,3 segment of the left MCA was confirmed.

**Figure 6.** MRI/MRA diagnostic scan for seizure and headache.

**A,B,** Large pseudoaneurysm in the area of the left MCA artery M3 segment in AP and lateral view, normal size and shape of surrounding vessels.

**Figure 7.** Digital subtraction angiography of the left intracranial circulation

Six-month follow-up MRA showing no contrast filling of the pseudoaneurysm, and regular shape of the surrounding vessels.
