Ruptured intracranial mycotic aneurysm in infective endocarditis: radiological and clinical findings.

showed a branch occlusion of the right middle cerebral artery at the site of the hemorrhage, but no evidence of mycotic aneurysms [Figures A-C]. The working diagnosis of cerebral infarct with unknown etiology led to subsequent investigations, which did not reveal any associated coagulopathies and the panel of autoimmune markers was within normal limits. Lumbar puncture showed pleocytosis with 330 polymorpho-nuclear cells, normal lactate and protein, and 37 mg/dl glucose (92 mg/dl blood glucose). Empiric intravenous ampicillin, ceftriaxone and acyclovir were started. After negative polymerase chain reaction for herpes simplex virus in a sample of spinal fluid, acyclovir was stopped and gentamicin was added. Transesophageal echocardiogram revealed moderate regurgitation associated with large mobile vegetations on the aortic and mitral valves [Figures D and E]. Blood cultures were positive for Enterococcus faecalis and a diagnosis of infective endocarditis was thus established. On day 6 of admission, the patient developed signs of pulmonary hyperten-sion and right congestive heart failure. Urgent cardiac operation disclosed perforation of the leaflets of the bicuspid aortic valve and of the anterior leaflets of the mitral valve, with multiple vegetations on the valve leaflets. The vegetations on all leaflets of both valves were shaved off. A biological prosthesis for the aortic valve was implanted, while for the mitral valve the rim of perforation was excised and commissuroplasty was performed obviating the need for prosthesis. Cultures of the vegetations yielded Enterococcus faecalis. t he management of patients with infective endocarditis complicated by intracranial mycotic aneurysm can be medical or surgical. However, it is unclear which modality is the most effective for these aneurysms. Endovascular treatment for intracranial mycotic aneurysms was recently developed, improving treatment outcome. We report a case of successful intracranial endovascular embolization in a patient with infective endocarditis who presented with acute stroke and subarach-noid hemorrhage secondary to intracranial mycotic aneurysm. Patient desCriPtion A 23 year old woman was admitted to our institution with a 1 month history of progressive behavioral changes, apathy, low grade fever, headache and fatigue. Physical examination revealed mild left facial paralysis, mild left hemiparesis, left upper quadranopsia and fever of 39 o C. Computed tomography and subsequent magnetic resonance imaging of the head showed subacute stroke in the right temporo-parieto-occipital lobe. A focus of subarachnoid hemorrhage in the right Sylvian fissure was noted. CT angiography Postoperative echocardiography revealed a functional mitral valve without evidence of recurrent endocarditis. Due to the subarachnoid hemorrhage …