Mechanical Angioplasty with Comaneci for the Treatment Refractory Vasospasm Secondary to Coccidioidal Meningits
Objective:
We present a patient with refractory diffuse intracranial vasospasm secondary to coccidioidal meningitis treated with the Comaneci 17 device.
Background:
Coccidioides immitis is a fungus whose CNS manifestations include meningoencephalitis, parenchymal abscess, vasculitis, hydrocephalus, and intra or extramedullary spinal cord lesions. Intracranial vasospasm in coccidioidal meningitis is rare and may be attributable to vasculitis or surrounding meningeal inflammation. Common treatments for vasospasm includes induced hypertension and intra-arterial spasmolytics or balloon angioplasty. The Comaneci device is an adjustable radio-opaque mesh that allows for incremental control of device radius.
Results:
A 33 year-old-man with a history of recently diagnosed coccidioidomycosis on fluconazole presented to the hospital with a severe headache and shortly thereafter was intubated for decreased level of consciousness. CT brain was concerning for subarachnoid hemorrhage in the basilar cisterns and cerebral angiography showed diffuse vasculopathy involving large and medium sized blood vessels. Over 48 hours, the patient developed decerebrate posturing. MRI brain with contrast revealed evidence of basilar meningitis and ischemic infarcts in the right basal ganglia, left periaqueductal gray area, and bilateral midbrains. The patient was taken for cerebral angiography and intra-arterial verapamil administration. Despite intra-arterial therapy the patient developed deconjugate gaze and generalized stimulus induced myoclonus the next day. For the second treatment, angioplasty with the Comaneci 17 device was performed with slow expansion over four minutes of the device in the left internal carotid, left anterior cerebral, basilar, bilateral middle cerebral, and bilateral posterior cerebral arteries. Follow up angiographic results showed significant improvement in vasospasm. Despite continued treatment, the patient did not improve clinically and further invasive procedures were halted.
Conclusions:
Mechanical angioplasty with the Comaneci 17 device may be a safe treatment for refractory vasopasm induced by coccidioidal meningitis. Further studies are warranted.