Double-barrel STA-MCA bypass and partial trapping of a ruptured mycotic MCA aneurysm with flash fluorescence technique

Mycotic brain aneurysms are rare and unusual cerebrovascular lesions arising from septic emboli that degrade the elastic lamina and vessel wall of intracranial arteries, which results in pathologic dilatation. Mycotic aneurysms are nonsaccular lesions that are not often suitable for clipping and instead require bypass, trapping, and flow reversal. This case demonstrates the use of indocyanine green “flash fluorescence” to identify the cortical distribution supplied by an aneurysm’s outflow, facilitating safe treatment with a double-barrel extracranial-intracranial bypass and partial trapping and conversion of a deep bypass to a superficial one. The video can be found here: https://stream.cadmore.media/r10.3171/2021.10.FOCVID21163

Sudden Cardiac Death Caused by a Septic Coronary Artery Embolism as the First Clinical Presentation of Infective Endocarditis

This report describes an uncommon and fatal case of myocardial infarction due to coronary embolus arising from vegetation in the aortic valve with a background of infective endocarditis (IE). There are various causes of fatal IE. Myocardial infarction due to septic emboli is rare. We report a case of sudden death in a 69-year-old woman with hyperlipidemia and no known cardiac disease. She had severe general weakness and was hospitalized for colonoscopy. The patient unexpectedly presented with cardiac arrest and died. The autopsy showed total occlusion of the left anterior descending artery by an embolus, which originated from the septic vegetation of the aortic valve. Myocardial infarction from septic emboli associated with IE can be fatal and manifested as the first presentation. In autopsy practice of deceased patients with IE, careful examination of the coronary arteries is required.

679. Infective Endocarditis and Septic Emboli-Related Complications; Epidemiology and Impacts on Hospital Outcomes

Background Infectious endocarditis (IE) remains a disease of high mortality, complications and a severe burden to the healthcare system despite advances in diagnostic techniques and treatments. There are several investigations of IE using a nation-based population cohort, however, with limited focus on septic emboli-related complications. Figure 1. Flowchart of the study cohort. IE=Infective Endocarditis Methods We used the 2016 to 2018 National Readmission Database (NRD) to identify a primary diagnosis of admissions among adults (Age≥18) with IE. International Statistical Classification (ICD-10) codes were used to identify patients with a primary diagnosis of IE who experienced in-hospital septic emboli-related complications. Primary outcomes were mortality, length of stay, total cost and 30-day all-cause readmission. Uni- and Multivariate Linear, Logistic and Cox regression were used to assess statistical significance and a two-sided p-value less than 0.05 was considered significant. Results A total of 30,870 patients were admitted with a primary diagnosis of IE from 2016 to 2018 (December admissions were omitted). After excluding the patients with omitted information, 30,289 patients went into analysis. Baseline characteristics are shown in Table 1. Septic emboli-related complications were seen in 42.6% of the patients; about 10% had central nervous system (CNS) complications, 7% had cardiac complications and 20.2% had respiratory complications. Embolic complications of any kind were associated with higher mortality (Odds Ratio = 2.11 [1.74 – 2.54]), a longer length of stay (5.72 days [5.17 – 6.27]) and higher total costs (21,812 dollars [19,856 – 23,769]) while adjusted for baseline characteristics. Multivariate Cox regression to assess the risk of 30-day readmission was not statistically significant. Predictors of 30-day all-cause readmission among baseline characteristics and subgroups of embolic complications are shown in table 4 and table 5, respectively. Conclusion The prevalence of septic emboli-related complications was up to 42.6% of patients admitted with the primary diagnosis of IE. These complications significantly impact hospital outcomes; including mortality, length of stay and total cost. Further studies are required to clarify the relationship between 30-day all-cause readmissions and embolic complications. Disclosures All Authors: No reported disclosures

Complete manuscript title: Neurological complications from sinugenic orbital cellulitis

Introduction: This study was undertaken with an aim to identify any common factors or trends among patients of orbital cellulitis that developed neurological complications. Methods: A 24-month retrospective review of patients was undertaken to include those showing clinical deterioration and neurological complications on radiological imaging, after being treated for orbital cellulitis at Manchester Royal Eye Hospital. The study specifically looked at the site of orbital collection, sinus involvement, types of neurological complications and whether these were detected at initial presentation, surgical input and microbiology findings. Results: Nine patients (9/26) developed associated neurological complications during the study period. (February 2018 and January 2020) This included subdural empyema in six patients; leptomeningeal enhancement in two and septic emboli in one patient. All the patients had associated significant pan-sinusitis at initial presentation. Neurological complications were detected in three patients at the time of admission and after clinical deterioration and further investigations in the rest. Conclusion: A superior orbital abscess and Streptococcus mileri infection had higher risk of neurological complications. It is worth debating whether patients with chronic sinusitis who develop orbital cellulitis need earlier surgical input rather than a conservative treatment. Patients who fail to improve clinically need to be re-imaged to look for possible neurological complications.

Unusual presentation of infective endocarditis in ICU

Bacterial endocarditis remains a challenging condition to manage owing to its variety of different presentations. This report describes a 55-year-old woman with endocarditis who presented confused with shoulder and back pain. Initial diagnosis was made difficult by a negative echocardiogram but aided by striking peripheral stigmata. She was treated for infective endocarditis as she met all five Duke’s minor criteria for infective endocarditis. Gallium scan was a useful investigation in identifying lumbar spine and acromioclavicular joint septic foci. This case highlights the challenges of diagnosing endocarditis. It also describes how gallium scans can be useful in identifying occult septic emboli in these patients.

Lemierre’s syndrome with cavernous sinus thrombosis caused by dental infection

Lemierre’s syndrome is a rare multisystemic infection beginning in oropharynx commonly caused by oral anaerobic organisms and leading to internal jugular vein thrombosis with septic emboli. Here, we describe a 45-year-old woman with hypertension and unrecognised type 2 diabetes who presented to a community hospital with fever, double vision and septic shock. Examination showed neck pain aggravated by neck flexion, limited ocular movement of right lateral rectus, left medial rectus and left superior oblique and incomplete ptosis of the left eye. These symptoms were suggestive of bilateral cavernous sinus syndrome. CT of the brain showed bilateral proximal internal jugular vein and cavernous sinus thrombosis. CT angiography revealed septic emboli at both upper lungs. The patient had good improvement of neurological symptoms after dental extraction, intravenous antibiotic and anticoagulant.