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


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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  • References

  • 1 Joo SP, Kim TS, Choi JW. et al. Characteristics and management of ruptured distal middle cerebral artery aneurysms. Acta Neurochir (Wien) 2007; 149 (07) 661-667
  • 2 Samson DS, Batjer HH, White J, Trammell JT, Eddleman CS. Intracranial Aneurysm Surgery: Basic Principles and Techniques. 1st ed. New York, NY: Thieme; 2012: 65-67
  • 3 Tandon PN, Ramamurthi R. Ramamurthi and Tandon's Textbook of Neurosurgery. 3rd ed. New Delhi: Jaypee Brothers Medical Publishers (P) Ltd; 2012. 993. 1032-1033
  • 4 Payer M, Kaku Y, Bernays R, Yonekawa Y. Intraoperative color-coded duplex sonography for localization of a distal middle cerebral artery aneurysm: technical case report. Neurosurgery 1998; 42 (04) 941-942 , discussion 942–943
  • 5 Greenberg MS. Handbook of Neurosurgery. 9th ed. New York, NY: Thieme; 2020: 1289
  • 6 Tambuzzi S, Boracchi M, Maciocco F, Tonello C, Gentile G, Zoja R. Fungal aneurism of the right posterior inferior cerebellar artery (PICA). Med Mycol Case Rep 2019; 26: 25-27
  • 7 Nonaka S, Oishi H, Tsutsumi S. et al. Endovascular therapy for infectious intracranial aneurysm: a report of four cases. J Stroke Cerebrovasc Dis 2016; 25 (03) e33-e37
  • 8 Phuong LK, Link M, Wijdicks E. Management of intracranial infectious aneurysms: a series of 16 cases. Neurosurgery 2002; 51 (05) 1145-1151 , discussion 1151–1152
  • 9 Nakahara I, Taha MM, Higashi T. et al. Different modalities of treatment of intracranial mycotic aneurysms: report of 4 cases. Surg Neurol 2006; 66 (04) 405-409 , discussion 409–410
  • 10 Chun JY, Smith W, Halbach VV, Higashida RT, Wilson CB, Lawton MT. Current multimodality management of infectious intracranial aneurysms. Neurosurgery 2001; 48 (06) 1203-1213 , discussion 1213–1214
  • 11 Frizzell RT, Vitek JJ, Hill DL, Fisher III WS. Treatment of a bacterial (mycotic) intracranial aneurysm using an endovascular approach. Neurosurgery 1993; 32 (05) 852-854
  • 12 Dashti R, Hernesniemi J, Niemelä M. et al. Microneurosurgical management of distal middle cerebral artery aneurysms. Surg Neurol 2007; 67 (06) 553-563
  • 13 Reinges MH, Nguyen HH, Krings T, Hütter BO, Rohde V, Gilsbach JM. Course of brain shift during microsurgical resection of supratentorial cerebral lesions: limits of conventional neuronavigation. Acta Neurochir (Wien) 2004; 146 (04) 369-377 , discussion 377
  • 14 Nimsky C, Ganslandt O, Hastreiter P, Fahlbusch R. Intraoperative compensation for brain shift. Surg Neurol 2001; 56 (06) 357-364 , discussion 364–365
  • 15 Policicchio D, Doda A, Sgaramella E, Ticca S, Veneziani Santonio F, Boccaletti R. Ultrasound-guided brain surgery: echographic visibility of different pathologies and surgical applications in neurosurgical routine. Acta Neurochir (Wien) 2018; 160 (06) 1175-1185
  • 16 Altieri R, Melcarne A, Di Perna G. et al. Intra-operative ultrasound: tips and tricks for making the most in neurosurgery. Surg Technol Int 2018; 33: 353-360
  • 17 Podlesek D, Meyer T, Morgenstern U, Schackert G, Kirsch M. Improved visualization of intracranial vessels with intraoperative coregistration of rotational digital subtraction angiography and intraoperative 3D ultrasound. PLoS One 2015; 10 (03) e0121345
  • 18 Yasuda K, Nakajima S, Wakayama A, Oshino S, Kubo S, Yoshimine T. Intraoperative three-dimensional reconstruction of power Doppler vascular images. Minim Invasive Neurosurg 2003; 46 (06) 323-326
  • 19 Marbacher S, Mendelowitsch I, Grüter BE, Diepers M, Remonda L, Fandino J. Comparison of 3D intraoperative digital subtraction angiography and intraoperative indocyanine green video angiography during intracranial aneurysm surgery. J Neurosurg 2018; 131 (01) 64-71
  • 20 Turner CL, Kirkpatrick PJ. Detection of intracranial aneurysms with unenhanced and echo contrast enhanced transcranial power Doppler. J Neurol Neurosurg Psychiatry 2000; 68 (04) 489-495