Objective:

To present a rare case of ruptured right MCA mycotic aneurysm that was not present on initial DSA.

Background:

Mycotic aneurysms are rare, but life-threatening complications of infective endocarditis especially with fungal infections. These aneurysms can develop in peripheral cerebral vasculature and are prone to rupture. We describe a case of a fungal mycotic aneurysm in the middle cerebral artery (MCA) territory that was not identified on initial DSA, however, was diagnosed on repeat DSA following clinical deterioration.

Design/Methods:

This research was supported in whole or in part by HCA Healthcare and/or an HCA Healthcare affiliated entity. The views expressed in this publication represent those of the authors and do not necessarily represent the official views of HCA Healthcare or any of its affiliated entities.

Results:

A 50-year-old immunocompromised male with recently treated Candida parapsilosis and Streptococcus anginosus mitral valve endocarditis secondary to infected permacath (treated 4 months prior) presented to the emergency department following a syncopal episode. Initial non-contrast computed tomography (CT) of head revealed a right frontal intraparenchymal hemorrhage (IPH). A diagnostic subtraction angiogram (DSA) performed on day 3 did not reveal vascular malformations. However, blood cultures obtained on admission grew Candida parapsilosis by day 3, raising concerns for recurrent fungemia. Transesophageal echocardiogram (TEE) did not show evidence of active endocarditis. Shortly after TEE, the patient experienced acute neurological deterioration. Repeat DSA revealed a 6 mm right middle cerebral artery (MCA) mycotic pseudoaneurysm. The aneurysm was successfully embolized by interventional neuroradiology.

Conclusions:

Fungal mycotic aneurysms are rare but devastating complications of endocarditis, often eluding early detection. Clinicians should maintain vigilance in patients with history of fungal endocarditis who present with cerebrovascular events, even in the absence of initial imaging abnormalities. Early recognition and aggressive intervention are essential to mitigate morbidity and mortality, though prognosis remains guarded, particularly in patients with significant comorbidities.