PMC2946581_01
MRI of brain on presentation: (a) sagital view showing acute right side frontal lobe infarct marked by arrow. (b) Axial view with same right side frontal lobe infarct marked by arrow. (c) Diffusion-Weighted Image of ischemic stroke in the right centrum semiovale.
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The MRI was significant for a small acute nonhemorrhagic infarct in the right frontal periventricular white matter as well as scattered punctate areas of chronic blood products (Figure 1).
Four chamber view echocardiogram showing large vegetation on the MVL marked by arrow. LV-left ventricle, LA-left atrium, RV-right ventricle, RA-right atrium, TV-tricuspid valve, MVL-mitral valve leaflet.
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The echocardiogram visualized large mobile vegetations on the mitral valve (Figure 2). 6 of 6 blood cultures were positive for Streptococcus viridans.
Progression of the ruptured Mycotic Aneurysm: (a) initial subarachnoid hemorrhage after 6 days IV antibiotics. Note interhemispheric hemorrhage. (b) Repeat noncontrast CT Brain 12 hours later, intraparenchymal hemorrhage is marked by arrow. Note prominent basal ganglia calcifications.
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A noncontrast CT head was repeated and showed acute subarachnoid hemorrhage (Figure 3).
CT Cerebral angiogram showing a large fusiform aneurysm at the distal anterior cerebral artery (ACA). (a) Shaded Surface Display CT coronal view showing a large fusiform aneurysm at the distal segment of the ACA marked by the large arrow. Proximal ACA segments are marked by the smaller arrows. RIC: right internal carotid artery, LIC: left internal carotid artery, RMCA: right middle cerebral artery, LMCA-left middle cerebral artery, RACA and LACA are right and left anterior cerebral arteries, respectively. (b) Close-up coronal view of ACA mycotic aneurysm. (c) Additional sagital view of mycotic aneurysm. (d) CT Angiogram axial view, an arrow marks the location of the ruptured aneurysm adjacent to a large hemorrhagic lesion. (e) CT Angiogram sagital view demonstrating areas of intracerebral hemorrhage.
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Angiogram established a multilobulated cerebral aneurysm at the A3 segment of the right distal anterior cerebral artery measuring 13 mm by 8.7 mm at the coronal plane, as well as interval development of intraventricular and intraparenchymal hemorrhage (Figure 4). After the placement of a ventriculostomy catheter, the patient was emergently taken to the operating room to undergo aneurysm clipping and ligation.