Endovascular occlusion of ruptured isolated aneurysm of anterior spinal artery

Abstract

Abstract. Aneurysms arising from spinal arteries are extremely rare and could be congenital but are typically related to lesions that induce an increase in blood flow through the arteries which results in haemodynamic stress aneurysm formation along the parent arteries. Occur in such as spinal cord arteriovenous malformations, arteriovenous fistulas, coarctation of the aorta (J. Nakhla et al., 2016), bilateral vertebral artery occlusion or moyamoya disease; systemic diseases as syphilis, connective tissue abnormalities or when spinal arteries are used as a route for collateral blood supply or because of underlying vasculopathies. The manifestation of the rupture of a spinal aneurysm is acute with sudden back pain and/or radicular pain syndrome, irritation of the meningeal membranes, which leads to a stiff neck and a positive reaction. Mostly they are small in diameter <3 mm, may have thrombus inside and are fusiform without the neck. Spinal aneurysms of anterior spinal artery more often occur than aneurysms of posterior spinal arteries and Adamkiewicz artery. Spinal aneurysms occurs most frequently in the upper cervical and thoracolumbar region. For the treatment of patients with this pathology, microsurgical, endovascular and conservative methods are used, taking into account the advantages and risks of each of the treatment options. It was performed a review of existing publications to examine efficacy and safety different tactics in the treatment of spinal aneurysms. It were published rare cases of endovascular treatment of aneurysm of anterior spinal artery, a case of successful obliteration of aneurysm of anterior spinal artery, related to aorta coarctation. The treatment strategy of anterior spinal artery aneurysm remains controversial. Surgical trapping and resection, endovascular occlusion, and conservative management (wait-and-see) have been used during last more thаn two decades, depending on the case and the set of advantages and risks for each of this management options. Because of the location and the eloquence of the tissue supplied by such arteries, technical difficulties and of significant risk an ideal management paradigm has not been established. The position of the aneurysm with respect to the spinal cord is a key determinant of the surgical approach. Microsurgical clipping and/or resection is possible, especially when they are located dorsally or dorsolaterally. Endovascular method applicable to dorsally and ventrally located spinal aneurysms. A combined approach to ruptured spinal artery aneuryms, using an endovascular approach for securing the aneurysm and a laminectomy for decompression, can be considered. As most spinal aneurysms are fusiform in morphology, super selective endovascular access with microcatheters may prove, especially difficult as the small caliber of these vessels makes them susceptible to vasospasm, thrombosis, and even dissection. We used the endovascular method for occlusion of the radiculomedullary artery aneurysm. Also highlighted a group of patients who received conservative treatment according to the strategy observation. This strategy gave positive clinical results. It was described the successful endovascular treatment of an isolated ruptured aneurysm of the radiculopial feeding artery of anterior spinal artery. Informed consent was obtained from each patient (parent or guardian) enrolled in the study and the study protocol conforms to the ethical guidelines of the Declaration of Helsinki as reflected in a priori approval by the Institutional Ethical Review Board (Institution's Human Research Committee). A 45-year-old previously healthy man presented with acute onset an acute headache, severe pain in the thoracolumbar region and lower limb motor weakness. Neurological disturbances were: lower limbs weakness IV/V, paresthesia, thoracalgia, positive meningeal signs. Cranial Angiography was performed, any evidence of vascular pathology was found. Cerebral CT reveal subarachnoid hemorrhage. Spinal MR imaging and MR angiography revealed subarachnoid hemorrhage and a contrast-enhancing intradural saccular lesion (5 × 7 mm) at the level of T5. Spinal angiography revealed fusiform aneurysm occurs immediately before the radiculomedullary artery reaches the longitudinal anterior axis supplying the anterior spinal artery. Embolization was accomplished using microcoils (ED Coil) to reach and obliterate the left segmental T6 artery and proximal portion of the ascending anterior spinal radiculopial branch leading to the aneurysm at the level of T5 vertebra and to anterior spinal artery. No neurological worsening after endovascular obliteration was observed. Any periprocedural complications were observed. The patient remained neurologically stable during the course of hospital stay. The patient was successfully treated using endovascular coiling with an independent functional outcome. We described our endovascular method to treat the anterior spinal artery aneurysm to emphasize technical possibility to occlude the aneurysm in case of its proximal location close to spinal artery originating. Such active tactic on this level of spinal cord allow not to wait for severe rebleeding, to occlude the aneurysm without high risk of spinal cord blood supply disturbance. Conclusions. The pathogenesis, clinical presentation, and treatment strategies of isolated spinal artery aneurysms are poorly established. With subarachnoid hemorrhage, when the cerebral nature is denied, the possibility of pathology of spinal vessels should be taken into account, as a rare cause of this clinical condition. The use of coiling to exclude a spinal artery aneurysm is an effective and safe method of treating this condition.

Keywords

• aneurysm of anterior spinal artery; radiculomedullar artery; subarachnoid hemorrhage; coil occlusion; spinal artery.