Ruptured Spinal Aneurysms: Diagnosis and Management Paradigms

Isolated Cervical Ruptured Radiculomedullary Artery Aneurysm Predominantly Presenting as Supratentorial Subarachnoid Hemorrhage: Case Report and Review of the Literature

A spinal artery aneurysm originating from the branch of the extracranial vertebral artery is uncommon. Most of them were finally diagnosed due to the evidence of infratentorial or spinal subarachnoid hemorrhage (SAH). Herein, we report an extremely rare case of a ruptured spinal artery aneurysm which predominantly presented with supratentorial SAH. A 68-year-old woman was initially revealed cranial computed tomographic angiographically negative SAH with a Hunt-Hess grade of 3, while the digital subtraction angiography confirmed an isolated radiculomedullary aneurysm arising from the medial ascending branch of V2 segment at C2 level. The patient underwent surgery in a hybrid operating room. She was originally attempted with coil embolization, but successful clipping of the aneurysm was achieved through unilateral laminectomy at last. Regrettably, the current case suffered a poor clinical outcome due to the complications caused by progressive cerebral vasospasm. In summary, angiogram is of great value for this rare kind of aneurysmal definitive diagnosis. A hybrid operating room may be a feasible choice for the ruptured spinal artery aneurysm.

Role of the Cervical Anterior Spinal Artery in the Endovascular Treatment of Vascular Diseases: Bystander, Accomplice, Victim, or Friend?

The cervical anterior spinal artery (ASA) is a very important artery arising from the intracranial vertebral artery (VA). It can play different roles in endovascular treatment (EVT) of spinal vascular diseases. The current understanding of these roles is incomplete; therefore, we performed this review. We found that cervical ASA can be involved in many spinal vascular diseases, such as arteriovenous fistula (AVF), arteriovenous malformation (AVM), and aneurysm, and can serve as a collateral channel in proximal VA occlusion. In AVF and AVM, when the cervical ASA is involved, it often plays the role of an accomplice or victim because it acts as the feeder or as a bystander that does not provide blood flow to the AVF and AVM. In cervical ASA aneurysm, the ASA is a victim. During EVT of VA aneurysms or stenoses, the cervical ASA ostia can be covered or occluded, resulting in ASA ischemia. In this situation, the ASA is a victim. In VA occlusion or the subclavian steal phenomenon, the cervical ASA can serve as a collateral channel to provide blood flow to the posterior circulation. In this case, the ASA plays the role of a friend. According to the role of the cervical ASA in spinal vascular diseases, EVT should be determined “case by case.” Most importantly, when EVT is performed to treat these diseases, the cervical ASA axis must be preserved. Therefore, understanding the role of the cervical ASA in spinal vascular diseases is crucial.

Pregnancy as a Subgroup in the Pathophysiologic Classification of Spinal Aneurysms

BACKGROUND

Aneurysms of spinal arteries not associated with any known predisposing condition are referred to as isolated spinal aneurysms (SAs). In our series, an SA was found in 2 patients during the postpartum period. The goal of this study is to determine whether an occurrence of an SA may be related to puerperium.

METHODS

In a retrospective analysis of our consecutive series of 10 cases of SAs from 2008 to 2020, we identified 2 cases of SAs during puerperium. Patients' charts and imaging were reviewed, for potential predisposing factors.

RESULTS

In both cases, angiography showed fusiform aneurysms of the anterior SA with concomitant bilateral vertebral artery (VA) dissections. Serum vasculitis and inflammatory panel and genetic testing for collagen disorders were negative in both cases. Review of the literature showed that pregnancy is associated with an increased risk of arterial dissections in various locations and supports the hypothesis that hemodynamic and hormonal changes may play a role in the formation of SAs.

CONCLUSIONS

Pregnancy and peripartum state may be a distinct cause of the formation of SAs, possibly as a result of increased hemodynamic stress and hormonal changes that may alter the arterial wall. It would be appropriate to add pregnancy as a subgroup in the classification of SAs. In our series, both cases were associated with bilateral VA dissections; it is possible that the bilateral VA stenosis may have contributed to the formation of the SAs. It is important to recognize this possibility when considering the occlusion of a dissected VA.

Isolated aneurysms of the spinal circulation: a systematic review of the literature

Aneurysms arising in the spinal circulation are rare and underreported. The objective of this study was to systematically review the English literature on different aspects of isolated spinal aneurysms using the PubMed, Ovid MEDLINE, and Google Scholar databases. Eighty-two papers reporting 107 individual patient cases were included. Most isolated spinal aneurysms have a fusiform morphology, and are most commonly found in the anterior spinal artery at the thoracic or cervical levels. Subarachnoid hemorrhage is the most common form of presentation, and sudden onset back pain is the most common initial symptom. The diagnosis of spinal aneurysms requires a high degree of clinical suspicion. Because of their small size, they can be missed on CT/MR angiography and spinal angiogram may be employed. Treatment of spinal aneurysms should be individualized on a case-by-case basis. Conservative management can be a valid option in spinal aneurysms where the risk of treatment is high. Surgical or endovascular intervention may be indicated in cases of significant or progressive neurologic decline due aneurysmal mass effect, or progressive growth of the aneurysm despite conservative treatment.

Endovascular treatment for ruptured cervical anterior spinal artery aneurysm caused by occlusive disease of bilateral vertebral arteries: A case report and literature review

A cervical anterior spinal artery (ASA) aneurysm not concomitant with vascular malformations is extremely rare, and is treated by conservative management or direct surgery in most cases. The endovascular treatment approach for these lesions is not well-documented. We present a case of a ruptured flow-related cervical ASA aneurysm due to the occlusive disease of the bilateral vertebral arteries (VA) treated by endovascular therapy. A 77-year-old woman with acute onset of headache and right hemiparesis was transferred to our hospital. Computed tomography revealed subarachnoid hemorrhage thick in the posterior fossa. A cerebral angiogram showed tandem stenosis of the left VA and the occlusion of the right VA at the V4 segment, with an enlarged C4 radiculomedullary artery and a subsequent aneurysm on the ASA. VA angiography revealed retrograde flow through the lesion and ASA axis to posterior circulation, suggesting a flow-related etiology of the aneurysm. We embolized the aneurysm using a flow-directed microcatheter and coils, preserving the ASA axis. Then, we dilated the VA stenosis using stents to prevent aneurysm recurrence by reducing hemodynamic stress on the ASA.

Acute Myelopathy: Vascular and Infectious Diseases

Vascular and infectious causes are rare but important causes of spinal cord injury. High suspicion for these processes is necessary, as symptoms may progress over hours to days, resulting in delayed presentation and diagnosis and worse outcomes. History and clinical examination findings can assist with localization of the affected vascular territory and spinal level, which will assist with focusing spinal imaging. Open and/or endovascular surgical management depends on the associated vascular abnormality. Infectious myelopathy treatment consists of targeted antimicrobial therapy when possible, infectious source control, and again, close monitoring for systemic complications.