Microsurgical Trapping and Excision of Ruptured Mycotic Aneurysms in a Patient with Mitral Valve Endocarditis: A Surgical Technique.

This case Video 1 demonstrates a microsurgical technique for trapping and excision of 2 ruptured mycotic aneurysms. The patient was a 64-year-old man with severe mitral regurgitation and valvular vegetations suggestive of endocarditis. On examination, the patient presented with speech difficulty. Preoperative imaging showed a large left temporoparietal intracerebral hemorrhage and associated sulcal subarachnoid hemorrhage from 2 distal aneurysms of the left middle cerebral artery. In the presence of ruptured aneurysms in a patient who requires anticoagulation for valve replacement, endovascular options are limited. For aneurysms located in an eloquent area in the left hemisphere, microsurgical treatment with small corridors can facilitate excision and minimize damage to the surrounding tissue. As such, the patient was treated with microsurgical trapping and excision of the aneurysms followed by evacuation of intraparenchymal hemorrhage using stereotactic navigation. Intraoperative neurophysiologic monitoring was used to prepare for a potential bypass in the event of inadequate collaterals or changes in neurophysiologic potentials. Postoperatively, the patient remained symmetric in his motor strength and had improved speech deficits, indicative of an uneventful recovery. The patient was cleared for full anticoagulation and valve replacement on postoperative day 10. The patient underwent intravenous antibiotic therapy with ceftriaxone before undergoing mitral valve replacement by cardiac surgery.