Long-term clinical and radiographic stability after clip reconstruction of a midbasilar dissecting mycotic aneurysm.
OBJECTIVE
Mycotic aneurysm rupture has been described as a rare, universally fatal complication of central nervous system Coccidioides immitis meningitis. Recently, however, we reported the successful surgical management of a midbasilar dissecting mycotic aneurysm related to C. immitis meningitis in a 24-year-old pregnant woman with acquired immune deficiency syndrome.


METHODS
A 24-year-old pregnant woman with known acquired immune deficiency syndrome and a history of C. immitis meningitis presented to our institution with subarachnoid and intraventricular hemorrhage. Diagnostic cerebral angiography revealed a dissecting, midbasilar aneurysm involving the right anterior inferior cerebellar artery and causing stenosis of the proximal basilar artery. Through a retrosigmoid craniotomy, clip reconstruction of the basilar artery under hypothermic circulatory arrest was performed. The patient was neurologically intact at discharge (postoperative day 19) with the exception of mild disconjugate gaze and headache.


RESULTS
At her 53-month follow-up, the patient was neurologically intact with only mild disconjugate gaze on upgaze. There was no evidence of local aneurysm recurrence or regional aneurysm formation, and the basilar artery was patent. Her C. immitis meningitis was well controlled. The patient is maintained on oral highly active antiretroviral therapy and an antifungal regimen.


CONCLUSIONS
Our patient represents the only survivor of a C. immitis mycotic aneurysm rupture. In her case, long-term clinical and radiographic stability were achieved through a vigilant multidisciplinary approach.
Division of Neurological Surgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA.
David J
DJ
Fusco
Walter J
WJ
Jermakowicz
Giacomo D
GD
Consiglieri
Robert F
RF
Spetzler
D017088:AIDS-Related Opportunistic Infections / Q000000981:diagnostic imaging* / Q000601:surgery*; D000328:Adult; D000784:Aortic Dissection / Q000000981:diagnostic imaging* / Q000601:surgery*; D000785:Aneurysm, Infected / Q000000981:diagnostic imaging* / Q000601:surgery*; D017542:Aneurysm, Ruptured / Q000000981:diagnostic imaging* / Q000601:surgery*; D002531:Cerebellum / Q000098:blood supply*; D002533:Cerebral Angiography; D050792:Circulatory Arrest, Deep Hypothermia Induced; D003045:Coccidioides; D003047:Coccidioidomycosis / Q000000981:diagnostic imaging* / Q000601:surgery*; D003399:Craniotomy; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D007090:Image Interpretation, Computer-Assisted; D021621:Imaging, Three-Dimensional; D002532:Intracranial Aneurysm / Q000000981:diagnostic imaging* / Q000601:surgery*; D016921:Meningitis, Fungal / Q000000981:diagnostic imaging* / Q000601:surgery*; D011183:Postoperative Complications / Q000000981:diagnostic imaging*; D011247:Pregnancy; D013525:Surgical Instruments; D014715:Vertebrobasilar Insufficiency / Q000000981:diagnostic imaging* / Q000601:surgery*