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Table of Contents    
NEUROIMAGES
Year : 2016  |  Volume : 64  |  Issue : 5  |  Page : 1089-1091

Aspergillus arteritis of the right internal carotid artery resulting in massive stroke


1 Department of Histopathology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
2 Department of Neurosurgery, Postgraduate Institute of Medical Education and Research, Chandigarh, India

Date of Web Publication12-Sep-2016

Correspondence Address:
Bishan D Radotra
Department of Histopathology, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0028-3886.190233

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How to cite this article:
Chatterjee D, Radotra BD, Mukherjee KK. Aspergillus arteritis of the right internal carotid artery resulting in massive stroke. Neurol India 2016;64:1089-91

How to cite this URL:
Chatterjee D, Radotra BD, Mukherjee KK. Aspergillus arteritis of the right internal carotid artery resulting in massive stroke. Neurol India [serial online] 2016 [cited 2018 Aug 19];64:1089-91. Available from: http://www.neurologyindia.com/text.asp?2016/64/5/1089/190233




A 20-year-old female patient, with a history of stillbirth 7months ago, presented with headache and left-sided visual impairment for the last 3 months. Magnetic resonance imaging (MRI) of the brain and paranasal sinuses showed a T1 iso-/T2 hypointense soft tissue lesion in the floor of anterior cranial fossa and left sphenoid and posterior ethmoidal sinuses extending into the suprasellar region and in close proximity to bilateral internal carotid artery (ICA). The lesion was pushing the pituitary gland inferiorly [Figure 1]a and [Figure 1]b. One month later, she presented to the emergency department with decreased movement of the left side of the body with impaired consciousness for the last 3 days. On examination, she was in Glasgow Coma scale E2V1M5 status and there was left-sided hemiplegia. The patient was started on amphotericin B in view of the suspected fungal etiology. A repeat non-contrast computed tomography showed the right internal carotid artery (ICA) territorial infarct [Figure 1]c. The patient gradually deteriorated and ultimately succumbed to her illness after 4 days of hospital stay.
Figure 1: (a) Magnetic resonance imaging showing soft tissue mass-like lesion in the floor of anterior cranial fossa, more on the left side, left sphenoid, and posterior ethmoid sinuses extending into the suprasellar region. (b) There is no evidence of infarction. (c) Subsequent non-contrast computed tomography of the brain showing massive infarction in the right internal carotid artery territory

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At autopsy, the brain weighed 1180 g and was extremely soft. The optic nerve and chiasma were covered with gray-white exudate. A well-circumscribed, yellowish-white, firm mass measuring 2.5 × 2 × 1.5 cm was seen in the suprasellar region obscuring the optic nerves. The first part of right ICA was firm and occluded. The left ICA was normal. The cerebral cortex in the right anterior cerebral artery (ACA) and middle cerebral artery (MCA) territory was infarcted. On microscopic examination, fungal granulomas were seen in the suprasellar region with numerous fungal profiles showing slender, septate hyphae with acute angle branching conforming to the morphology of Aspergillus. The intracranial portion of the right ICA revealed necrotizing arteritis, thrombosis, and occlusion [Figure 2]a,[Figure 2]b,[Figure 2]c. Fungal profiles were identified within the thrombus and infiltrating the wall of the ICA [Figure 2]d.
Figure 2: (a) Photomicrograph showing complete occlusion of the internal carotid artery with fibrin thrombus (Hematoxylin and Eosin (H and E, ×40). (b) There is necrotizing inflammation of the arterial wall with disruption of the internal elastic lamina (arrow) (H and E, ×200). (c) Elastic van Giessen stain highlighting disruption of the elastic lamina (arrow) (×200). (d) Periodic acid Schiff stain showing numerous septate fungal profiles in the vessel wall (×400)

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Cerebral aspergillosis is one of the most common forms of central nervous system (CNS) fungal infection, which may be a part of disseminated aspergillosis or may be localized rhinocerebral aspergillosis.[1] CNS infection by Aspergillus may occur following its hematogenous spread, with lung being the most common primary site of infection, or it may be due to direct extension from contiguous structures such as the paranasal sinuses. The most common forms of CNS aspergillosis are intracerebral aspergillomas which are intracerebral, solid, and firm lesions, and are histologically characterized by granulomatous inflammation with varying degree of fibrosis.[1] This type of lesion mainly involves the base of the brain, basifrontal, and temporal regions and radiologically mimics a meningioma or a tuberculoma. These are usually long-standing lesions and do not invade the blood vessels. The second form of cerebral aspergillosis is an aspergillus abscess. This is histologically characterized by central necrosis containing Aspergillus hyphae, surrounded by acute inflammatory infiltrate, with or without giant cells. This type of lesion is usually due to hematogenous spread and is seen commonly in immunocompromised patients. The third variety is acute necrotizing disseminated aspergillosis, which is generally seen in immunocompromised states due to a variety of conditions. Pathologically, it manifests as areas of hemorrhagic necrosis with suppuration. The rarest form is cerebrovascular aspergillosis that results from direct vascular invasion by the fungi, resulting in infarction or hemorrhage without suppuration. There are only a few reported cases of cerebrovascular aspergillosis which may occur from a septic embolus or direct inoculation of a large vessel during surgery.[2],[3] Infectious fungal etiology is an uncommon cause of cerebral infarction; however, infections such as tuberculous meningitis are well-known causes of cerebral infarction in young patients in developing countries because of widespread vascular involvement.[4] Vascular invasion by Aspergillus is a common manifestation, but involvement of major arteries i.e. aorta and its branches is uncommon. However, it may be seen due to elastase production. Two south Indian studies have reported three cases of cerebral aspergillosis causing invasion and thrombosis of the basilar artery, ICA, and MCA, and one case of isolated basilar artery thrombosis causing a massive infarction.[5],[6] Vascular invasion by Aspergillus may give rise to fatal subarachnoid hemorrhage, which may not be detectable by angiography. The present case is unusual in that this patient had rhinocerebral aspergillosis which affected the main right ICA, resulting in a massive occlusive stroke. The affected segment neither formed an aneurysm nor ruptured to give rise to a massive hemorrhage. The factors contributing to preserving the structural integrity of the vessel wall and formation of the occlusive thrombus are not clear. An early diagnosis and treatment with amphotericin B and other antifungal agents are essential; however, the prognosis of intracerebral aspergillosis remains poor.

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  References Top

1.
Shankar SK, Mahadevan A, Sundaram C, Sarkar C, Chacko G, Lanjewar DN, et al. Pathobiology of fungal infections of the central nervous system with special reference to the Indian scenario. Neurol India 2007;55:198-215.  Back to cited text no. 1
[PUBMED]  Medknow Journal  
2.
Ueki Y, Kazuta T, Naitou E, Hayashi M, Tanaka K, Mizutani T, et al. A case of CNS aspergillosis developing orbital apex syndrome and causing mycotic aneurysm and the subsequent cerebral infarction. Rinsho Shinkeigaku 2002;42:761-5.  Back to cited text no. 2
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3.
Sugiyama T, Kuroda S, Nakayama N, Houkin K. Invasive paranasal sinus fungal infection developing orbital apex syndrome and causing internal carotid artery infiltration: Reports of 3 cases. No Shinkei Geka 2011;39:155-61.  Back to cited text no. 3
[PUBMED]    
4.
Chatterjee D, Radotra BD, Vasishta RK, Sharma K. Vascular complications of tuberculous meningitis: An autopsy study. Neurol India 2015;63:926-32.  Back to cited text no. 4
[PUBMED]  Medknow Journal  
5.
Murthy JM, Sundaram C, Prasad VS, Purohit AK, Rammurti S, Laxmi V. Aspergillosis of central nervous system: A study of 21 patients seen in a university hospital in south India. J Assoc Physicians India 2000;48:677-81.  Back to cited text no. 5
[PUBMED]    
6.
Uppin MS, Challa S, Uppin SG, Alladi S, Yarlagadda JR. Cerebral Aspergillus arteritis with bland infarcts: A report of two patients with poor outcome. Neurol India 2007;55:298-300.  Back to cited text no. 6
[PUBMED]  Medknow Journal  


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This article has been cited by
1 Invasive Aspergillosis Complicated by Occlusion of Internal Carotid Artery and Cerebral Infarction
Eungseok Lee,Sangwon Lee,Hae-In Park,Woochang Chun,Hee-Kwon Park
Journal of the Korean Neurological Association. 2017; 35(4): 203
[Pubmed] | [DOI]



 

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