Mysteries Around Ruxolitinib Which Amazed Us All

Most previously reported mycotic ICA aneurysms did not specify the causative agent. In fact, we found 15 previously reported cases of intrapetrous ICA aneurysms and pseudoaneurysms arising from infection of adjacent tissues, but these cases do not delineate the pathogens in any instance.1�C7 Thus, it is conceivable that Pseudomonas infections might have been among them, but might not have been recognised. Crizotinib supplier Related reports highlight the extraordinary degree of carotid arterial damage that can be caused by Pseudomonas, including basilar skull infection and mastoiditis resulting in adjacent ICA pseudoaneurysms.5 7 The absence of blood culture data in these reports makes it unclear if the ICA pseudoaneurysms described were infective or primarily arose adjacent to inflamed tissue. In our patient, the infective aneurysm not only arose adjacent to infected mastoid tissue, but also the subsequent high-grade bacteraemia, that persisted despite antibiotics, as well as septic embolic phenomena within the distribution of the infected artery, provide strong confirmatory evidence for this diagnosis. Aneurysms of ICA can develop secondary to congenital abnormalities, trauma or inflammation although they generally arise from the extracranial ICA within the cervical segment.2 Aneurysms of the intrapetrous portion of the internal carotid are rare, but are reported sequelae of chronic otitis media or mastoiditis, as illustrated in this case. Although most infected aneurysms arise by haematogenous seeding, direct invasion of the adventitia of the artery from surrounding infection such as mastoiditis is a more likely cause in intrapetrous internal carotid aneurysms, due to proximity to the middle ear.8 Pharyngeal infections and cholesteatomas have also been implicated as causes of intrapetrous-infected aneurysms.8 As with all mycotic aneurysms, intrapetrous internal carotid mycotic aneurysms should be treated with effective long-term antibiotic therapy. The role of additional intervention for these rare infections is unclear. For cases with diminished flow, enlarging or ruptured aneurysm, surgical or intravascular intervention may be necessary. Surgical resection and primary anastomosis have been used in the past; however, balloon occlusion is now favoured due to lower ischaemic complications and subsequent haemorrhages.2 5 7 9 For idiopathic or traumatic intrapetrous carotid aneurysms, coil embolisation or stent placement has been used successfully.10 Coil procedure has also been used in previously reported cases with surrounding infections,2 5 but is controversial as it involves leaving foreign material in the infected vessel. In fact, recently reported cases advise against revascularisation procedures that involve use of foreign material.3 Owing to high-grade bacteraemia and mastoiditis, coil embolisation was deferred in our patient.