Middle Cerebral Artery (M3) Aneurysm: Two “Mycotic” Aneurysms of the Middle Cerebral Artery due to Bacterial Endocarditis; Endovascular Treatment of One Aneurysm with Glue (nBCA) Injection During Adenosine-Induced Asystole; Spontaneous Resolution of the Second Aneurysm

  • Alexander Sirakov
  • Hosni Abu Elhasan
  • Marta Aguilar Pérez
  • Carmen Serna Candel
  • Hansjörg Bäzner
  • Hans HenkesEmail author
Living reference work entry


A 58-year-old male patient presented with phonemic paraphasia, pyrexia of 39.5 °C, chronic fatigue, and exhaustion. The patient reported experiencing mild but persistent left flank pain, weight loss of 14 kg, and excessive sweating during sleep for the past 6 months. Echocardiography revealed mobile vegetation on the mitral valve, and his blood culture was positive for Enterococcus faecalis. He was diagnosed as having infective endocarditis (IE), and intravenous antibiotic medication was started. He was also given oral anticoagulation agents due to an elevated serum D-dimer level. Initial abdominal and cranial MRI examinations revealed the presence of a previous splenic infarct and a left frontoparietal hemorrhagic infarction accompanied by time-of-flight (TOF) magnetic resonance angiography (MRA) signal abnormality among the changes. The cerebral infarction was suspected of being associated with a “mycotic” (inflammatory) aneurysm of the left middle cerebral artery (MCA) secondary to the IE. A digital subtraction angiography (DSA) examination was performed and confirmed the presence of two left-hand distally located MCA infectious intracranial aneurysms (IIA). The larger of the two aneurysms was successfully occluded by selective intrasaccular injection of nBCA/Lipiodol under adenosine-induced asystole to prevent hazardous migration of the embolic material during the embolization. The smaller and distally located aneurysm (2 mm fundus diameter) resolved spontaneously. The aneurysm treatment was well tolerated. Under continuous IV antibiotic infusion and with the complete resolution of the somatic symptoms, echocardiography revealed no mitral valve vegetation, suggesting the IE was under control. Long-term follow-up confirmed persistent aneurysm occlusion and the permanent clinical improvement of the patient. The management of IIA by parent vessel occlusion using glue injection under adenosine-induced asystole is the main topic of this chapter.


Middle cerebral artery Mycotic aneurysm Infectious intracranial aneurysm Parent vessel occlusion Adenosine Induced asystole nBCA Lipiodol 


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© Springer Nature Switzerland AG 2020

Authors and Affiliations

  • Alexander Sirakov
    • 1
  • Hosni Abu Elhasan
    • 2
  • Marta Aguilar Pérez
    • 1
  • Carmen Serna Candel
    • 1
  • Hansjörg Bäzner
    • 3
  • Hans Henkes
    • 1
    Email author
  1. 1.Neuroradiologische Klinik, NeurozentrumKlinikum StuttgartStuttgartGermany
  2. 2.Department of NeurosurgeryHadassah Medical CenterJerusalemIsrael
  3. 3.Neurologische Klinik, NeurozentrumKlinikum StuttgartStuttgartGermany

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