Inoue Tatsuya, Obana Masahiro, Yamamoto Tomonori
Department of Cardiovascular Surgery, Tokyo Rinkai Hospital, Tokyo, Japan.
Kyobu Geka. 2013 Sep;66(10):934-7.
The patient was a 45-year-old female, who was emergently hospitalized with presyncope. Brain magnetic resonance imaging (MRI) confirmed an infarct in the left middle cerebral artery area. Echocardiography revealed mobile vegetations on the mitral valve and aortic valve, and the patient was diagnosed as having infective endocarditis. She was treated conservatively by appropriate antibiotic therapy. Four days after hospitalization, the patient developed brain hemorrhage due to ruptured mycotic cerebral aneurysm, and craniotomy for removal of the hematoma and brain aneurysm clipping were performed on the same day. As 3-dimensional computed tomography (3D-CT) obtained 2 weeks after the surgery suggested the existence of other brain aneurysms, it was determined that continued conservative management of the infection might not be feasible, and mitral valve and aortic valve replacements were performed 3 weeks after the craniotomy. The postoperative clinical course was satisfactory, without the complications of bleeding, aggravation of the cranial nerve disorders or recurrence of the infection. Ruptured mycotic cerebral aneurysms are usually associated with a poor prognosis. There are no specific guidelines for the treatment of infective endocarditis with brain complications like in this case, and it is important to select therapies tailored to individual cases.
该患者为一名45岁女性，因前驱晕厥紧急入院。脑部磁共振成像（MRI）证实左侧大脑中动脉区域梗死。超声心动图显示二尖瓣和主动脉瓣有活动赘生物，该患者被诊断为感染性心内膜炎。给予适当的抗生素治疗进行保守治疗。住院4天后，患者因霉菌性脑动脉瘤破裂发生脑出血，并于同日进行开颅血肿清除术和脑动脉瘤夹闭术。由于术后2周获得的三维计算机断层扫描（3D-CT）提示存在其他脑动脉瘤，因此确定继续对感染进行保守治疗可能不可行，于是在开颅术后3周进行了二尖瓣和主动脉瓣置换术。术后临床过程顺利，无出血、颅神经障碍加重或感染复发等并发症。霉菌性脑动脉瘤破裂通常预后较差。对于本例这种伴有脑部并发症的感染性心内膜炎，目前尚无具体的治疗指南，根据个体情况选择合适的治疗方法很重要。
