Cerebral Infarction and Subarachnoid Hemorrhage Caused by Central Nervous System Aspergillus Infection

The mortality rate of central nervous system (CNS) Aspergillus infection is >90%. Most cases with ruptured aneurysmal formation resulting from CNS aspergilloma invasion into the arterial wall are difficult to treat with surgical therapy, antifungal drugs, or steroid administration. There is no established therapy for ruptured Aspergillus aneurysms. Both a standardized examination for the diagnosis of CNS aspergillosis and effective treatment of ruptured Aspergillus aneurysms are needed.

A 56-year-old man developed prolonged fever and headache. Magnetic resonance imaging showed a mass lesion around the brainstem. No laboratory data were suspicious for inflammatory diseases or autoimmune diseases. Considering the invasiveness of a surgical approach, we initiated steroid pulse therapy to confirm whether the mass would shrink before biopsy or resection for definitive pathologic diagnosis. Cerebral infarction and subarachnoid hemorrhage occurred almost concurrently just after steroid therapy. We first performed decompression surgery to treat the elevated intracranial hypertension. The specimen taken from the mass lesion at the time of surgery showed CNS Aspergillus fungal forms. Endovascular treatment of the ruptured aneurysm was performed, and medical therapy with an antifungal drug was started. After the Aspergillus infection was well controlled, the patient was discharged. Glasgow Outcome Scale score at discharge was 3.

Although most patients with ruptured Aspergillus aneurysm have poor outcomes as reported in the literature, this patient's clinical course and outcome were good. Early recognition of CNS aspergillosis and timely surgical intervention to control the vascular event can improve the prognosis for these patients.