Ruptured infectious intracranial aneurysm related to infective endocarditis: report of a successfully treated case

Intracranial infectious aneurysm (IIA) is a rare but highly dangerous complication of infective endocarditis (IE), associated with a significant risk of rupture, particularly when anticoagulation is involved. Managing IE patients with IIA poses a significant challenge for both cardiac surgeons and neurologists.

We report a complex case of IIA related to IE in a 9-year-old girl with a history of patent ductus arteriosus ligation and aortic valvuloplasty. The patient was admitted for recurrent fever over 3 months despite irregular antibiotic therapy. Transthoracic echocardiography identified IE with vegetations on the aortic valve, and cerebral magnetic resonance angiography revealed an IIA. The patient experienced a sudden intracranial haemorrhage while awaiting intervention, requiring emergency craniotomy with haematoma removal and aneurysm resection. After 4 weeks of neurological rehabilitation and antimicrobial therapy, she recovered well without major neurological impairment. However, a recurrent IIA with haemorrhage was detected at the previously operated site. Following a multidisciplinary discussion, a one-stage procedure combining transcatheter aneurysm embolization and mechanical aortic valve replacement was performed successfully. Three years post-discharge, the patient maintained good cardiac and neurological function.

Managing IIA in patients with IE poses significant challenges due to the limited availability of high-level evidence. Endovascular therapy presents a promising approach, given its minimally invasive nature and the ability to expedite the initiation of anticoagulation therapy. This strategy could facilitate earlier cardiac surgery and potentially improve outcomes in critically ill patients.