- Department of Neurosurgery, Hospital do Servidor Público Estadual de São Paulo, IAMSPE, São Paulo, Brazil
Matheus Fernandes de Oliveira
Department of Neurosurgery, Hospital do Servidor Público Estadual de São Paulo, IAMSPE, São Paulo, Brazil
DOI:10.4103/2152-7806.141776Copyright: © 2014 Pahl FH. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
How to cite this article: Pahl FH, de Oliveira MF, Cavalcanti Rotta MA, Soares Dias GM, André Luiz Rezende, José Marcus Rotta. Spontaneous resolution of an isolated cervical anterior spinal artery aneurysm after subarachnoid hemorrhage. Surg Neurol Int 25-Sep-2014;5:139
How to cite this URL: Pahl FH, de Oliveira MF, Cavalcanti Rotta MA, Soares Dias GM, André Luiz Rezende, José Marcus Rotta. Spontaneous resolution of an isolated cervical anterior spinal artery aneurysm after subarachnoid hemorrhage. Surg Neurol Int 25-Sep-2014;5:139. Available from: http://sni.wpengine.com/surgicalint_articles/spontaneous-resolution-of-an-isolated-cervical-anterior-spinal-artery-aneurysm-after-subarachnoid-hemorrhage/
Background:Isolated cervical anterior spinal artery aneurysms are extremely rare. Subarachnoid hemorrhage (SAH) secondary to such lesions have been described only in six cases to the best of our knowledge.
Case Description:We describe an unusual clinical picture of SAH due to rupture of anterior spinal artery aneurysm in a patient with previous normal angiogram. Due to the location of the aneurysm and clinical status of the patient, conservative management was proposed, and she was discharged to further follow-up. Monthly routine angiograms revealed resolution of the aneurysm 90 days after bleeding, which was highly suggestive of vascular dissection.
Conclusion:We highlight the need to consider these aneurysms in the differential diagnosis of SAH, especially when occurring in the posterior fossa and when angiography findings are inconclusive.
Keywords: Diagnosis, intracranial aneurysm, treatment
Isolated cervical anterior spinal artery (ASA) aneurysms are extremely rare.[
We report an unusual clinical picture of SAH due to rupture of ASA aneurysm in a patient with a previously normal angiogram, and highlight the need to consider this entity in the differential diagnosis of SAH of unknown etiology.
A 43-year-old female presented at an outside hospital with acute suboccipital headache and vomiting, which rapidly progressed to decreased level of consciousness and coma 12 h after headache onset. She was a regular smoker, but denied any preexisting medical conditions, such as hypertension, drug abuse, or vasculopathy. A complete laboratory profile was within normal limits.
She underwent a computed tomography (CT) scan of the head, which revealed SAH, intraventricular hemorrhage, and hydrocephalus [
Skull CT revealing SAH in basal cisterns, hydrocephalus and hemoventricle in posterior fossa; brain MR disclosing laminar hemorrhage in T1 sagittal and axial images, just ahead of cervicomedullary junction; cerebral angiogram: In A, anteroposterior view of posterior circulation with no abnormalities. In B, lateral view. In C, a small aneurysm in ASA is noted, which is better exposed in D
The patient remained under sedation and endotracheal intubation for 10 days. Her course was complicated by development of ventilator-associated pneumonia. After broad-spectrum antibiotic therapy, sedation was withdrawn and she was extubated, maintaining a GCS of 15.
A control angiogram performed 10 days after bleeding revealed no abnormalities. Magnetic resonance imaging (MRI) of the neck revealed a laminar bleed at the right anterior cervicomedullary junction [
Due to the location of the aneurysm and clinical status of the patient, conservative management was proposed, and she was discharged to further follow-up. Monthly routine angiograms revealed resolution of the aneurysm 90 days after bleeding (angiograms at 1- and 2-month follow-up were quite similar), which was highly suggestive of vascular dissection [
Spinal artery aneurysms are rare findings.[
These aneurysms are found mainly in the upper cervical segment of the ASA and in the upper portion of the artery of Adamkiewicz. Mean age at presentation is approximately 52 years, and there is no evident gender predominance.[
Radiological investigation is essential, and a complete radiological workup should include CT and brain/cervical MRI to exclude angiomas and vascular malformations. Some advocate a full spinal angiogram and, at the very least, an upper spinal angiogram when blood is seen on cervical MRI. Angiography provides detailed information on aneurysm shape, size, direction, and location.[
Although controversy persists, the current experience suggests that surgical or endovascular treatment are the preferred strategies.[
As a general rule, patients in good clinical status may be candidates for surgical/endovascular treatment, whereas patients in worse condition should avoid interventional procedures. In the latter case, control angiograms are necessary to assess progression.[
Our patient had an isolated cervical ASA aneurysm. This is only the seventh report of this finding in the literature[
However, one must remember that following a ruptured aneurysm with serial angiograms does not represent general standard of care. The fact that a favorable outcome was achieved illustrates how unusual and interesting this case was, but does not mean that this is the proper way to manage all similar cases.
Finally, individual evaluation of each case and its particularities is essential for definition of the optimal treatment strategy, as the cases published thus far do not provide enough evidence to support one modality over another.[
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