Ruptured anterior spinal artery aneurysm associated with coarctation of aorta. Case report and literature review

Abstract

A 39-year-old man presented with acute headache and neck pain, followed by quadriparesis and quadriparesthesia, accompanied by urinary and bowel incontinence. Lumbar puncture showed subarachnoid haemorrhage. Angiogram via a right axillary approach revealed severe coarctation of the aorta, between the left common carotid artery and left subclavian artery. Multiple collateral circulation including an enlarged anterior spinal arterial axis bridging the stenosed arch provided collateral circulation to the abdominal aorta. A small lobulated aneurysm was seen at the radiculomedullary-anterior spinal artery junction from the right ascending cervical artery. This patient underwent successful surgical clipping of the aneurysm. Pathogenesis of the spinal arterial aneurysm associated with coarctation of the aorta is likely to result from the haemodynamic stress from collateral circulation through the anterior spinal axis rather than segmental arterial disease or angiodysplastic disease. Aneurysms of the spinal artery are rare but can be unusually found in association with SCAVMs, coarctation of aorta, Klippel-Trenaunay syndrome or more rarely with aortic arch interruption.

Figure 1

Plain chest film showed rib notching due to collateral circulation through intercostal arteries.

Figure 2

Sagittal PD and T2W of the thoracic spine show heterogeneous small flow void structures ventral to the spinal cord, suggestive of partially thrombosed anterior spinal aneurysm.

Figure 3

Aortogram from femoral arterial approach shows obstruction of the distal aortic arch.

Figure 4

Arch aortogram done from a transaxillary approach shows severe aortic arch coarctation between the left common carotid artery and left subclavian artery with complex collateral flow through an enlarged right internal mammary artery and anterior spinal axis with aneurysm.

Figure 5

Superselective right vertebral angiogram shows collateral flow to the left vertebral artery, left thyrocervical trunk and left subclavian artery subsequently, through the dilated muscular branches.

Figure 6

Superselective angiogram of the right ascending cervical artery shows a dilated radiculomedullary artery which contributes to the cervical anterior spinal artery;it clearly shows the saccular aneurysm at the junction between the radiculomedullary artery and the anterior spinal artery.

Figure 7

Superselective angiogram of the right ascending cervical artery shows a dilated anterior spinal axis contributing to collateral circulation through lower radiculomedullary artery at left T6, supplying the lower descending aorta below the coarctation.