Endovascular Therapy for Mycotic Aneurysms in Patients with High Comorbidities

Introduction Mycotic intracranial aneurysms (MIAs) are infrequent but potentially life‐threatening lesions, primarily due to their tendency to rupture. Endovascular therapy is frequently required as a primary treatment strategy when afflicted patients have many systemic comorbidities. Early detection and treatment of mycotic aneurysms are essential due to the significant risks of morbidity and mortality. Endovascular therapy presents several advantages over surgical intervention in the management of MIA . These include reduced anesthesia‐related risk, particularly in patients with valvular dysfunction with faster initiation of anticoagulation, and a significantly shortened interval between aneurysm treatment and subsequent cardiac surgery. Purpose To present a case of MIA managed with coiling and multi disciplinary collaboration. Material and Method Patient was identified in routine clincal practice Result 58 years female with hypertension, chronic kidney disease, hyperlipidemia, SLE presented after a fall . Her CT head was unremarkable. She was febrile (102°F) with positive blood cultures for Actinomyces odontolyticus. Overnight, she developed acute severe dysarthria with right hemiparesis . Repeat CT head demonstrated subarachnoid hemorrhage and left parietal ischemic infarct with hemorrhagic transformation. Echocardiogram revealed a large (0.5 × 2.5 cm) mobile vegetation on cusp of the aortic valve. MRI brain showed left posterior frontal intraparenchymal hemorrhage with a 4 mm enhancing nodular focus overlying an enhancing vessel . Digital subtraction angiography revealed distal parietal branch MCA vascular irregularities adjacent to the hemorrhage. Given the high rupture risk and ongoing septic embolic source, urgent endovascular treatment was performed. Super‐selective microcatheterization of the M4 branch was achieved, and the aneurysm was embolized with preservation of flow to uninvolved cortical branches. She subsequently underwent successful aortic valve replacement. At follow‐up, no further intracranial hemorrhage occurred, and neurological deficits partially improved with rehabilitation. Conclusion Most patients with MIA are critically ill with multiple comorbidities, making endovascular treatment more appropriate option. Antimicrobial therapy alongside valve replacement surgery is often recommended. Although no direct randomized controlled trials compare endovascular and open surgical approaches, endovascular treatment is the preferred method for managing MIA's. Surgical clipping may be challenging in distal fragile vessels and septic environments. Patient outcomes largely depend on timely diagnosis and early, aggressive intervention. Endovascular approaches, including coil embolization, Onyx, or NBCA, permit rapid exclusion of the aneurysm with reduced surgical trauma and faster stabilization for systemic infection control. Literature suggests that prompt endovascular treatment in ruptured distal mycotic aneurysms significantly reduces morbidity, mortality, and delays in definitive infective endocarditis management.