J Neurol Surg A Cent Eur Neurosurg 2021; 82(05): 500-504
DOI: 10.1055/s-0040-1720988
Case Report

The Use of Real-Time 3D Intraoperative Ultrasound “Angiography” in Localization and Occlusion Control of a Ruptured Mycotic Aneurysm: A Case Report

Ntenis Nerntengian
1   Department of Neurosurgery, School of Health Sciences, Democritus University of Thrace, Alexandroupolis, Greece
2   Department of Neurosurgery, Universitätsmedizin Göttingen, Goettingen, Germany
,
Grigorios Gkasdaris
1   Department of Neurosurgery, School of Health Sciences, Democritus University of Thrace, Alexandroupolis, Greece
3   Department of Clinical Neurosciences, Service of Neurosurgery, Lausanne University Hospital, Lausanne, Switzerland
,
Nikolaos Barettas
1   Department of Neurosurgery, School of Health Sciences, Democritus University of Thrace, Alexandroupolis, Greece
,
Efthymia Theodoropoulou
1   Department of Neurosurgery, School of Health Sciences, Democritus University of Thrace, Alexandroupolis, Greece
,
Theodosios Birbilis
1   Department of Neurosurgery, School of Health Sciences, Democritus University of Thrace, Alexandroupolis, Greece
› Author Affiliations

Abstract

Background Infectious (mycotic) aneurysms are rare with high mortality and are most commonly found at the distal branches of the middle cerebral artery (MCA). Because aneurysms of the distal MCA are located deep in the Sylvian fissure and are small in size, intraoperative identification and safe clip occlusion of these aneurysms are challenging. Thus, the use of intraoperative imaging and navigation can be beneficial. We describe the use of intraoperative real-time 3D ultrasound “angiography” (3D-iUS) in localizing and occlusion control of a ruptured MCA M3 segment mycotic aneurysm. To our knowledge, its application in the surgery of a ruptured mycotic distal MCA aneurysm is not yet reported.

Clinical Presentation A 54-year-old woman with a history of septic thrombophlebitis treated with long-term antibiotic therapy presented with sudden onset of headaches, dysphasia, and seizures. Computed tomography (CT) revealed subarachnoid hemorrhage in the distal portion of the left Sylvian fissure. Digital subtraction angiography (DSA) showed an aneurysm at the peripheral branch of the M3 segment of the MCA with characteristics of an infectious aneurysm. A microsurgical treatment was decided. 3D-iUS scan showed an aneurysm within the Sylvian fissure at a depth of 5 cm. The aneurysm was clipped and a repeated 3D-iUS scan showed total occlusion of the aneurysm and patency of the parent artery. The intraoperative findings were confirmed with a postoperative DSA.

Conclusion Our case report shows that real-time 3D-iUS, despite its limitations, is an important tool to locate and ascertain the successful clip occlusion of an aneurysm, especially when intraoperative angiography (IA) and indocyanine green (ICG) videoangiography are not available due to low-income settings.



Publication History

Received: 31 May 2020

Accepted: 13 August 2020

Article published online:
05 December 2020

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