American Journal of Neuroradiology 23:697-699, April 2002
© 2002 American Society of Neuroradiology
Case Report
INTERVENTIONAL
Brain Abscess after Endovascular Coiling of a Saccular Aneurysm: Case Report
Riyadh AL-Okailia and
Sunil J. Patelb
a Departments of Radiology (R.A.-O.), Medical University of South Carolina, Charleston
b Departments of Neurological Surgery (S.J.P.), Medical University of South Carolina, Charleston
Address reprint requests to Riyadh AL-Okaili, MD, Department of Radiology, 171 Ashley Avenue, Charleston, SC 29425
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Abstract
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Summary: CNS infection occurring after therapeutic angiography
is rare. We present a case report of a brain abscess complicating
endovascular coiling of an intracranial aneurysm. We recommend
the use of prophylactic antibiotics, especially when performing
therapeutic CNS angiography.
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Introduction
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Endovascular coiling of intracranial aneurysms has been used
increasingly during the past few years. It provides an alternative
to surgical clipping, especially for patients who are poor surgical
candidates. Although less invasive than craniotomy, there have
been reports of complications, such as aneurysm rupture and
cerebral infarction. CNS infection is a rare complication of
intra-cranial endovascular procedures. A review of the literature
revealed only two reported cases occurring after embolization
of cerebral arteriovenous malformations (
1,
2). We report the
case of a patient who developed a peri-aneurysm abscess after
undergoing an uneventful aneurysm coiling procedure.
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Case Report
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The patient was a right-handed 70-year-old woman who was referred
to our institution with an incidentally diagnosed, unruptured
large right posterior communicating artery aneurysm measuring
2.2
x 2.2
x 2.7 cm. This was initially seen on a CT scan of
the brain that was obtained to evaluate a chronic frontotemporal
headache even though there appeared to be no indication by history
to suggest previous aneurysmal hemorrhage. The patient denied
any other associated neurologic symptoms. Her history was significant
for hypertension, diabetes mellitus, hypercholesteremia, and
several pack-years’ history of cigarette smoking. An examination
revealed no neurologic deficit. Because of the patient’s
age and medical condition, surgical clipping of the aneurysm
was not recommended. Instead, the patient was given the option
of endovascular coiling of the aneurysm.
The aneurysm was coiled with 51 Guglielmi detachable coils of variable configurations and dimensions during a single session. The procedure lasted approximately 12 hours, and no prophylactic antibiotic was administered. Immediately after the procedure, the patient suffered a focal neurologic deficit that was likely ischemic in nature, expressed as a transient mild left-sided pronator drift that resolved after 24 hours. The patient was discharged 2 days after the procedure.
One month after discharge, the patient was rehospitalized for acute alteration in her sensorium. She had developed gradually worsening left-sided body and facial weakness and several episodes of falling during a 2-week period. During that time, she had also complained of occasional headaches, double vision, swallowing difficulties, and speech problems. An examination revealed no fever, but the patient was lethargic and aroused only with painful stimuli. She had mild left hemiparesis, withdrawing that side in response to pain only, and inconsistently followed commands. She also displayed a partial right cranial nerve III palsy with left facial weakness sparing the frontalis muscle (central). She had no nuchal rigidity. Peripheral WBC count was 14,100/mm3, and CSF studies showed the following: yellow and hazy appearance; RBC count, 155/mm3; WBC count, 445/mm3 (56% neutrophils, 32% lymphocytes); glucose, 49 mg/dL (serum glucose level, 248 mg/dL); and protein, 241 mg/dL. Findings from gram stains and cultures of the peripheral blood and CSF were negative, but a urinary tract infection was present. A CT scan of the brain, even though it had significant artifact from the coils, showed edema involving the right caudate and thalamus, causing some mass effect on the adjacent lateral ventricle. Further evaluation with MR imaging and MR angiography revealed prominent ring-enhancing areas adjacent to the aneurysm and extending into the right side of the pons, midbrain, and basal ganglia with surrounding edema (Fig 1). MR angiography showed that the aneurysm was nearly totally thrombosed. These imaging findings and the CSF results were thought to be consistent with an abscess. Because of the high risks of aspirating such an abscess (deep and hemorrhage potential), it was elected to treat this empirically without having cultures to confirm infection and help identify the bacterial species.
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FIG 1. MR images of the brain of a 70-year-old woman show a thrombosed aneurysm after endovascular coiling, with adjacent ring-enhancing lesion representing an abscess involving the brainstem and the right basal ganglia region.
A, Axial nonenhanced T1-weighted MR image (400/8/2 [TR/TE/NEX]), obtained through the pons, shows a focal low-intensity area.
B, Axial contrast-enhanced T1-weighted MR image (500/8/2), obtained through the pons, shows a ring-enhancing lesion.
C, Axial contrast-enhanced T1-weighted MR image (500/8/2), obtained through the midbrain, shows a ring-enhancing lesion adjacent to a thrombosed right posterior communicating artery aneurysm.
D, Coronal contrast-enhanced T1-weighted MR image (400/8/2), obtained through the brainstem, shows an oblong curved ring-enhancing lesion wrapping over a thrombosed right posterior communicating artery aneurysm.
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The patient was treated with broad spectrum IV administered antibiotics (cefotaxime, 2 g every 6 hours; vancomycin, 1 g every 6 hours; metronidazole, 500 mg every 6 hours; and fluconazole, 400 mg daily) for 6 weeks. Follow-up MR imaging was performed approximately 2 weeks after completion of the antibiotic course. This revealed near total resolution of the ring-enhancing lesion and edema (Fig 2).
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FIG 2. MR images of the brain, obtained approximately 2 weeks after completion of the 6-week antibiotic course, show interval near total resolution of edema and enhancement.
A, Axial nonenhanced T1-weighted MR image (500/11/2), obtained through the pons, shows no focal low-intensity area.
B, Axial contrast-enhanced T1-weighted MR image (500/11/2), obtained through the pons, shows that the ring-enhancing lesion has resolved.
C, Axial contrast-enhanced T1-weighted MR image (500/11/2), obtained through the midbrain, shows resolution of the ring-enhancing lesion adjacent to a thrombosed right posterior communicating artery aneurysm.
D, Coronal contrast-enhanced T1-weighted MR image (450/11/2), obtained through the brainstem, shows resolution of the ring-enhancing lesion adjacent to a thrombosed right posterior communicating artery aneurysm.
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Discussion
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Bacteremia and even septicemia have been well documented to
occur after diagnostic and therapeutic angiography (
3,
4). One
study reported a bacteremia occurrence rate of 32% after therapeutic
angiography procedures lasting >2 hours (
5). Pyogenic abscesses
after therapeutic angiography have been reported to occur in
the liver, spleen, lungs, retroperitoneal space, and perineum.
Infective aortitis has also been reported (
6–
12). Two
cases of CNS abscesses have been reported previously after endovascular
treatment of arteriovenous malformations (
1,
2).
The cause of infection and source of contamination are unclear. In our case, infection was likely caused by improper handling of the catheters; this has been reported to be the source in 83% of postoperative infections (13). The large number of coils used in our case certainly increased the chances of infection with repeated handling of the catheters. Another factor is the length of the procedure, as has been shown in surgical procedures. The presence of a urinary tract infection at presentation adds to the uncertainty of the source of infection; a source unrelated to the procedure is still possible.
In the normal brain, an optimally functioning blood-brain barrier provides resistance to infection (14). Cases of brain abscesses have been described after damage to this barrier, as in postischemic abscesses (15, 16). With a high incidence of bacteremia during therapeutic angiography, the risk of infection is heightened if the procedure causes any ischemia (14–16). This possibility exists in our case, in which the patient suffered a transient neurologic deficit. Whether the deficit resulted solely from the mass effect of having placed so many coils into the aneurysm or from a transient ischemic event is difficult to prove.
In this case, antibiotics were not used during the procedure, and this raises the interesting question regarding the routine use of antibiotic prophylaxis with all endovascular procedures. Perhaps this should be considered, especially if foreign materials are being placed and/or the procedures carry high risk for ischemic complications.
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Received May 21, 2001;
accepted after revision December 10, 2001.
TOP
Abstract
Introduction