Unexpected death for ruptured mycotic right Posterior Inferior Cerebellar Artery aneurysm after acoustic-neurinoma resection : a medico-legal case

Infective or mycotic intracranial aneurysms are infrequent cerebrovascular lesions (0,7-4,4% of all intracranial aneurysms) that were related (in the pre-antibiotic era) to bacterial endocarditis or to the intravenous use of drugs. Currently they occur asymptomatically and their finding is occasional during autopsies (5-10% of cases). In this case-report, the Authors show the case of a death due to an intracranial haemorrhage caused by a ruptured mycotic aneurysm of the Postero Inferior Cerebellar Arthery (PICA). It occured in a woman submitted to surgical excision of a right acoustic neurinoma; this case came to forensic observation for the suspect of clinical malpractice. The case A 38 years old woman underwent surgical resection of an 8th cranial nerve benign neoplasy showing asthenia and fever after discharge. For these reasons, she was hospitalized in the same structure for further clinical investigations. After ten days, however, she suddenly died. The Judicial Authority ordered the autopsy, in order to investigate possible medical malpractice occurred during surgery. Results The cadaver was in good conditions of preservation; scalp showed surgical sutured cut at the right fronto-parietal area, and a surgical scar of 12 cm at the retromastoid area. Head dissection demonstrated abundant emission of partially coagulated blood from a drill hole of 1 cm, at the right temporoparietal area of the skull. In the epidural area of the right portion of the posterior cranial fossa, hemostatic material and a surgical suture of the dura mater were found, with a massive hemorrhagic blood collection at the clivus. A cerebral hemorrhage with multifocal localization (leptomeningeal cerebellar, peribulbar, tetraventricular, and right pericisternal) was detected and considered as the cause of death. Histopathologic analysis showed a complete aneurysmatic dissection of the right PICA, at almost 0,2 cm from the origin; it was characterized by the presence of mycotic hyphae with a 45°angle pattern, typical of Aspergillus spp. Conclusions This report describes a case of sudden unexpected death due to a ruptured mycotic aneurysm of the PICA; it occurred in a 38 years old woman, previously submitted to a surgical excision of a neurinoma. It has to be considered a rare, occasional event, which is secondary to an aggressive mycotic infection related to invasive neurosurgical procedures. At Authors’ knowledge, it’s the first case involving VIII cranial nerve neurinoma resection.