, Volume 181, Issue 5–6, pp 425–433 | Cite as

Fungal Mycotic Aneurysm of the Internal Carotid Artery Associated with Sphenoid Sinusitis in an Immunocompromised Patient: A Case Report and Review of the Literature

  • Marwan M. Azar
  • Roland Assi
  • Natalie Patel
  • Maricar F. Malinis


In immunocompromised patients, invasive molds such as Aspergillus and Mucor can lead to locally aggressive angioinvasive infections that are often life-threatening. A particularly devastating complication is the development of a fungal mycotic aneurysm resulting from invasion of the arterial wall. Due to anatomic contiguity, the sphenoid sinus provides potential access for these fungi, which often colonize the respiratory sinuses, into the cavernous sinus and internal carotid artery (ICA), thus leading to the formation of ICA aneurysms. The ideal treatment of fungal ICA aneurysms includes a combination of surgical debridement and long-term effective antifungal therapy, but the role of endoscopic resection and the duration of antimicrobials are poorly defined. Here, we present the case of a 71-year-old immunocompromised patient who developed an ICA mycotic aneurysm, associated with a proven invasive fungal infection (presumptively Mucorales) of the sphenoid sinuses, as defined by EORTC/MSG criteria, and who survived after undergoing coil embolization with parent vessel sacrifice of the aneurysm in combination with liposomal amphotericin B. We also review the literature for published cases of invasive fungal sphenoid sinusitis associated with mycotic aneurysms of the ICA and provide a comparative analysis .


Mycotic aneurysm Fungal Mucormycosis Sphenoid sinusitis 


Author Contributions

MA collected and analyzed the data, reviewed all relevant literature, and wrote the first draft of the manuscript. RA, NP, and MM edited and revised the manuscript. All authors have seen and approved the final version for submission. All authors contributed significantly to this work.

Compliance with Ethical Standards

Conflict of interest

The authors have no conflicts of interest.


  1. 1.
    Anderson CB, Butcher HR Jr, Ballinger WF. Mycotic aneurysms. Arch Surg. 1974;109(5):712–7.CrossRefPubMedGoogle Scholar
  2. 2.
    Budu V, Mogoanta CA, Fanuta B, Bulescu I. The anatomical relations of the sphenoid sinus and their implications in sphenoid endoscopic surgery. Rom J Morphol Embryol. 2013;54(1):13–6.PubMedGoogle Scholar
  3. 3.
    Okudaira M, Kurata H, Sakabe F. Studies on the fungal flora in the lung of human necropsy cases. A critical survey in connection with the pathogenesis of opportunistic fungus infections. Mycopathologia. 1977;61(1):3–18.CrossRefPubMedGoogle Scholar
  4. 4.
    Espinel-Ingroff A, Oakley LA, Kerkering TM. Opportunistic zygomycotic infections. A literature review. Mycopathologia. 1987;97(1):33–41.CrossRefPubMedGoogle Scholar
  5. 5.
    Patterson TF, Kirkpatrick WR, White M, Hiemenz JW, Wingard JR, Dupont B, et al. Invasive aspergillosis. Disease spectrum, treatment practices, and outcomes. I3 Aspergillus Study Group. Medicine. 2000;79(4):250–60.CrossRefPubMedGoogle Scholar
  6. 6.
    Roden MM, Zaoutis TE, Buchanan WL, Knudsen TA, Sarkisova TA, Schaufele RL, et al. Epidemiology and outcome of zygomycosis: a review of 929 reported cases. Clin Infect Dis. 2005;41(5):634–53.CrossRefPubMedGoogle Scholar
  7. 7.
    Hot A, Mazighi M, Lecuit M, Poiree S, Viard JP, Loulergue P, et al. Fungal internal carotid artery aneurysms: successful embolization of an Aspergillus-associated case and review. Clin Infect Dis. 2007;45(12):e156–61.CrossRefPubMedGoogle Scholar
  8. 8.
    Ahuja GK, Jain N, Vijayaraghavan M, Roy S. Cerebral mycotic aneurysm of fungal origin. Case report. J Neurosurg. 1978;49(1):107–10.CrossRefPubMedGoogle Scholar
  9. 9.
    Hurst RW, Judkins A, Bolger W, Chu A, Loevner LA. Mycotic aneurysm and cerebral infarction resulting from fungal sinusitis: imaging and pathologic correlation. AJNR Am J Neuroradiol. 2001;22(5):858–63.PubMedGoogle Scholar
  10. 10.
    Iihara K, Makita Y, Nabeshima S, Tei T, Keyaki A, Nioka H. Aspergillosis of the central nervous system causing subarachnoid hemorrhage from mycotic aneurysm of the basilar artery—case report. Neurol Med Chir. 1990;30(8):618–23.CrossRefGoogle Scholar
  11. 11.
    Komatsu Y, Narushima K, Kobayashi E, Tomono Y, Nose T. Aspergillus mycotic aneurysm—case report. Neurol Med Chir. 1991;31(6):346–50.CrossRefGoogle Scholar
  12. 12.
    Morriss FH Jr, Spock A. Intracranial aneurysm secondary to mycotic orbital and sinus infection. Report of a case implicating penicillium as an opportunistic fungus. Am J Dis Child. 1970;119(4):357–62.CrossRefPubMedGoogle Scholar
  13. 13.
    Thajeb P, Thajeb T, Dai D. Fatal strokes in patients with rhino-orbito-cerebral mucormycosis and associated vasculopathy. Scand J Infect Dis. 2004;36(9):643–8.CrossRefPubMedGoogle Scholar
  14. 14.
    Dusart A, Duprez T, Van Snick S, Godfraind C, Sindic C. Fatal rhinocerebral mucormycosis with intracavernous carotid aneurysm and thrombosis: a late complication of transsphenoidal surgery? Acta Neurol Belg. 2013;113(2):179–84.CrossRefPubMedGoogle Scholar
  15. 15.
    Jao SY, Weng HH, Wong HF, Wang WH, Tsai YH. Successful endovascular treatment of intractable epistaxis due to ruptured internal carotid artery pseudoaneurysm secondary to invasive fungal sinusitis. Head Neck. 2011;33(3):437–40.PubMedGoogle Scholar
  16. 16.
    Lee DH, Yoon TM, Lee JK, Joo YE, Park KH, Lim SC. Invasive fungal sinusitis of the sphenoid sinus. Clin Exp Otorhinolaryngol. 2014;7(3):181–7.CrossRefPubMedPubMedCentralGoogle Scholar
  17. 17.
    Nenoff P, Kellermann S, Horn LC, Keiner S, Bootz F, Schneider S, et al. Case report. Mycotic arteritis due to Aspergillus fumigatus in a diabetic with retrobulbar aspergillosis and mycotic meningitis. Mycoses. 2001;44(9–10):407–14.CrossRefPubMedGoogle Scholar
  18. 18.
    Wang H, Rammos S, Fraser K, Elwood P. Successful endovascular treatment of a ruptured mycotic intracavernous carotid artery aneurysm in an AIDS patient. Neurocrit Care. 2007;7(2):156–9.CrossRefPubMedGoogle Scholar
  19. 19.
    Wilson WR, Hawrych A, Olan W. Rapid development of bilateral internal carotid artery aneurysm from sphenoid sinus aspergillosis. Skull Base Surg. 1998;8(4):211–4.CrossRefPubMedPubMedCentralGoogle Scholar
  20. 20.
    Brust JC, Dickinson PC, Hughes JE, Holtzman RN. The diagnosis and treatment of cerebral mycotic aneurysms. Ann Neurol. 1990;27(3):238–46.CrossRefPubMedGoogle Scholar
  21. 21.
    Ducruet AF, Hickman ZL, Zacharia BE, Narula R, Grobelny BT, Gorski J, et al. Intracranial infectious aneurysms: a comprehensive review. Neurosurg Rev. 2010;33(1):37–46.CrossRefPubMedGoogle Scholar
  22. 22.
    Kannoth S, Thomas SV. Intracranial microbial aneurysm (infectious aneurysm): current options for diagnosis and management. Neurocrit Care. 2009;11(1):120–9.CrossRefPubMedGoogle Scholar
  23. 23.
    Kannoth S, Iyer R, Thomas SV, Furtado SV, Rajesh BJ, Kesavadas C, et al. Intracranial infectious aneurysm: presentation, management and outcome. J Neurol Sci. 2007;256(1–2):3–9.CrossRefPubMedGoogle Scholar
  24. 24.
    Fey SG, Lindholm E. Systolic blood pressure and heart rate changes during three sessions involving biofeedback or no feedback. Psychophysiology. 1975;12(5):513–9.CrossRefPubMedGoogle Scholar
  25. 25.
    van der Schaaf IC, Brilstra EH, Buskens E, Rinkel GJ. Endovascular treatment of aneurysms in the cavernous sinus: a systematic review on balloon occlusion of the parent vessel and embolization with coils. Stroke. 2002;33(1):313–8.CrossRefPubMedGoogle Scholar
  26. 26.
    Moret J, Cognard C, Weill A, Castaings L, Rey A. Reconstruction technic in the treatment of wide-neck intracranial aneurysms. Long-term angiographic and clinical results. Apropos of 56 cases. J Neuroradiol. 1997;24(1):30–44.PubMedGoogle Scholar
  27. 27.
    Cottier JP, Pasco A, Gallas S, Gabrillargues J, Cognard C, Drouineau J, et al. Utility of balloon-assisted Guglielmi detachable coiling in the treatment of 49 cerebral aneurysms: a retrospective, multicenter study. AJNR Am J Neuroradiol. 2001;22(2):345–51.PubMedGoogle Scholar
  28. 28.
    Phatouros CC, Sasaki TY, Higashida RT, Malek AM, Meyers PM, Dowd CF, et al. Stent-supported coil embolization: the treatment of fusiform and wide-neck aneurysms and pseudoaneurysms. Neurosurgery. 2000;47(1):107–13 (discussion 13–5).PubMedGoogle Scholar
  29. 29.
    Mericle RA, Lanzino G, Wakhloo AK, Guterman LR, Hopkins LN. Stenting and secondary coiling of intracranial internal carotid artery aneurysm: technical case report. Neurosurgery. 1998;43(5):1229–34.CrossRefPubMedGoogle Scholar
  30. 30.
    Ghali MG, Ghali EZ. Intracavernous internal carotid artery mycotic aneurysms: comprehensive review and evaluation of the role of endovascular treatment. Clin Neurol Neurosurg. 2013;115(10):1927–42.CrossRefPubMedGoogle Scholar
  31. 31.
    Yen PS, Teo BT, Chen SC, Chiu TL. Endovascular treatment for bilateral mycotic intracavernous carotid aneurysms. Case report and review of the literature. J Neurosurg. 2007;107(4):868–72.CrossRefPubMedGoogle Scholar
  32. 32.
    Chapot R, Houdart E, Saint-Maurice JP, Aymard A, Mounayer C, Lot G, et al. Endovascular treatment of cerebral mycotic aneurysms. Radiology. 2002;222(2):389–96.CrossRefPubMedGoogle Scholar
  33. 33.
    Kan CD, Lee HL, Yang YJ. Outcome after endovascular stent graft treatment for mycotic aortic aneurysm: a systematic review. J Vasc Surg. 2007;46(5):906–12.CrossRefPubMedGoogle Scholar
  34. 34.
    Allen LM, Fowler AM, Walker C, Derdeyn CP, Nguyen BV, Hasso AN, et al. Retrospective review of cerebral mycotic aneurysms in 26 patients: focus on treatment in strongly immunocompromised patients with a brief literature review. AJNR Am J Neuroradiol. 2013;34(4):823–7.CrossRefPubMedGoogle Scholar

Copyright information

© Springer Science+Business Media Dordrecht 2015

Authors and Affiliations

  1. 1.Section of Infectious Diseases, Department of Internal MedicineYale School of MedicineNew HavenUSA
  2. 2.Department of SurgeryYale University School of MedicineNew HavenUSA
  3. 3.Department of PathologyYale University School of MedicineNew HavenUSA

Personalised recommendations