Introduction: Mycotic aneurysms are a serious complication of infective endocarditis with increased risk of intracranial hemorrhage. Patients undergoing open heart surgery for valve repair or replacement are exposed to anticoagulants, increasing the risk of aneurysm bleeding. These patients may require endovascular or surgical aneurysm treatment prior to heart surgery, but data on this approach are scarce. Methods: Retrospective review of consecutive patients with infectious endocarditis and mycotic aneurysms treated endovascularly with Trufill n-butyl cyanoacrylate (n-BCA) at the Cleveland Clinic between January 2013 and December 2015. Results: Nine patients underwent endovascular treatment of mycotic aneurysms with n-BCA (mean age of 39 years). On imaging, 4 patients had intracerebral hemorrhage, 2 had multiple embolic infarcts, and the rest had no imaging findings. Twelve mycotic aneurysms were detected (3 patients with 2 aneurysms). Seven aneurysms were in the M4 middle cerebral artery segment, 4 in the posterior cerebral artery distribution, and 1 in the callosomarginal branch. n-BCA was diluted in ethiodized oil (1:1 to 1:2). Embolization was achieved in a single rapid injection with immediate microcatheter removal. Complete aneurysm exclusion was achieved in all cases without complications. All patients underwent open heart surgery and endovascular embolization within a short interval, 2 with both procedures on the same day. There were no new hemorrhages after aneurysm embolization. Conclusions: Endovascular embolization of infectious intracranial aneurysms with liquid embolics can be performed successfully in critically ill patients requiring immediate open heart surgery and anticoagulation. Early embolization prior to and within a short interval from open heart surgery is feasible.

Keywords:
Endovascular embolization, Intracranial infectious aneurysm, Open heart surgery, n-Butyl cyanoacrylate
1.
Ducruet AF, Hickman ZL, Zacharia BE, Narula R, Grobelny BT, Gorski J, Connolly ES Jr: Intracranial infectious aneurysms: a comprehensive review. Neurosurg Rev 2010;33:37-46.
2.
Kannoth S, Iyer R, Thomas SV, Furtado SV, Rajesh BJ, Kesavadas C, Radhakrishnan VV, Sarma PS: Intracranial infectious aneurysm: presentation, management and outcome. J Neurol Sci 2007;256:3-9.
3.
Kannoth S, Thomas SV: Intracranial microbial aneurysm (infectious aneurysm): current options for diagnosis and management. Neurocrit Care 2009;11:120-129.
4.
Venkatesh SK, Phadke RV, Kalode RR, Kumar S, Jain VK: Intracranial infective aneurysms presenting with haemorrhage: an analysis of angiographic findings, management and outcome. Clin Radiol 2000;55:946-953.
5.
Peters PJ, Harrison T, Lennox JL: A dangerous dilemma: management of infectious intracranial aneurysms complicating endocarditis. Lancet Infect Dis 2006;6:742-748.
6.
Hui FK, Bain M, Obuchowski NA, Gordon S, Spiotta AM, Moskowitz S, Toth G, Hussain S: Mycotic aneurysm detection rates with cerebral angiography in patients with infective endocarditis. J Neurointerv Surg 2015;7:449-452.
7.
Grandhi R, Zwagerman NT, Linares G, Monaco EA 3rd, Jovin T, Horowitz M, Jankowitz BT: Onyx embolization of infectious intracranial aneurysms. J Neurointerv Surg 2014;6:353-356.
8.
Jadhav AP, Pryor J, Nogueira RG: Onyx embolization for the endovascular treatment of infectious and traumatic aneurysms involving the cranial and cerebral vasculature. J Neurointerv Surg 2013;5:562-565.
9.
Chalouhi N, Tjoumakaris S, Gonzalez LF, Hasan D, Alkhalili K, Dumont AS, Rosenwasser R, Jabbour P: Endovascular treatment of distal intracranial aneurysms with Onyx 18/34. Clin Neurol Neurosurg 2013;115:2528-2532.
10.
Rosen RJ, Contractor S: The use of cyanoacrylate adhesives in the management of congenital vascular malformations. Semin Intervent Radiol 2004;21:59-66.
11.
Elsenousi A, Aletich VA, Alaraj A: Neurological outcomes and cure rates of embolization of brain arteriovenous malformations with n-butyl cyanoacrylate or Onyx: a metaanalysis. J Neurointerv Surg 2016;8:265-272.
12.
Singla A, Fargen K, Blackburn S, Neal D, Martin TD, Hess PJ, Beaver TM, Klodell CT, Hoh B: National treatment practices in the management of infectious intracranial aneurysms and infective endocarditis. J Neurointerv Surg 2016;8:741-746.
© 2017 S. Karger AG, Basel
2017
Copyright / Drug Dosage / Disclaimer
Copyright: All rights reserved. No part of this publication may be translated into other languages, reproduced or utilized in any form or by any means, electronic or mechanical, including photocopying, recording, microcopying, or by any information storage and retrieval system, without permission in writing from the publisher.
Drug Dosage: The authors and the publisher have exerted every effort to ensure that drug selection and dosage set forth in this text are in accord with current recommendations and practice at the time of publication. However, in view of ongoing research, changes in government regulations, and the constant flow of information relating to drug therapy and drug reactions, the reader is urged to check the package insert for each drug for any changes in indications and dosage and for added warnings and precautions. This is particularly important when the recommended agent is a new and/or infrequently employed drug.
Disclaimer: The statements, opinions and data contained in this publication are solely those of the individual authors and contributors and not of the publishers and the editor(s). The appearance of advertisements or/and product references in the publication is not a warranty, endorsement, or approval of the products or services advertised or of their effectiveness, quality or safety. The publisher and the editor(s) disclaim responsibility for any injury to persons or property resulting from any ideas, methods, instructions or products referred to in the content or advertisements.
You do not currently have access to this content.