Simultaneous spontaneous thrombosis of multiple true mycotic intracranial aneurysms in a patient with rhinocerebral mucormycosis
EANS Academy. Carvalho V. 09/25/19; 275879; EP01016
Dr. Vasco Carvalho
Dr. Vasco Carvalho

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Introduction: Rhinocerebral mucormycosis remains a rare and challenging entity with a daunting prognosis. True intracranial mycotic aneurysms may develop and its rupture have been associated almost inevitably with death.
Case report: The authors present a 14-year old male patient with T-cell Lymphoblastic Lymphoma, which underwent specific treatment protocol and entered remission within one month.
Five months after, he developed left facial numbness rapidly progressing to complete ipsilateral ophthalmoplegia, ptosis and a full left visual deficit. Head CT-scan revealed extensive paranasal sinuses infection infiltrating the left orbital apex and thrombosed cavernous sinus. He was started on anticoagulants, antibacterial, antifungal drugs and an endoscopic transnasal biopsy was performed, confirming Rhizopus sp. as the causal agent. Cerebral MRI showed intracranial progression within days with extensive skull base invasion, a frontotemporal abscess and sylvian fissure diffuse enhancement. Carotid artery flow was present but irregularly diminished. A combined multidisciplinary procedure was undertaken and further treatment was escalated to two antifungal drugs and referral for hyperbaric therapy.
Five weeks later, multiple large mycotic aneurysms on middle cerebral artery (MCA) bifurcation and petrous/cavernous segments of left internal carotid artery (ICA) were identified on a control MRI (Angio). While under evaluation, the patient suffered a massive nasal/orbital hemorrhage with associated hemodynamic changes that stopped spontaneously. An urgent CT-scan displayed new hyperdensities within the aforementioned aneurysms and subsequent angiogram confirmed complete lack of ICA flow distal to the cervical segment and also along the M1 segment of the MCA. The previously reported aneurysms were not identifiable.
The patient fared well on the following months and control MRIs confirmed the mycotic aneurysms as thrombosed and regressing.
Conclusion: The authors report on a very unusual development under a particularly challenging clinical setup, highlighting the need to maintain a critical perspective on its prognosis and also supporting the need for aggressive treatment.
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