Management and outcomes for thoracic anterior spinal artery aneurysms: illustrative case

Abstract

Background: Anterior spinal artery (ASA) aneurysms are uncommon and difficult to diagnose due to their variable presentation and limited visibility with traditional imaging. They often present with severe back pain from rupture and spinal subarachnoid hemorrhage (SAH). There are few published studies and no established treatment recommendations. This study reports a ruptured thoracic ASA aneurysm treated with clip reconstruction and reviews the literature.

Observations: A man in his late 40s presented with sudden, intense interscapular pain that progressed to paraplegia and sensory loss below T5. He regained neurological function within 6 hours, with residual back pain. Imaging showed SAH and an aneurysm from the left ASA at T5. After a left T4 costotransversectomy, the aneurysm was clipped, and postoperative angiography confirmed ASA patency and aneurysm occlusion. A review of 31 patients (mean [SD] age 43.4 [17.8] years) showed varied treatments: microsurgery (n = 13, 42%), endovascular embolization (n = 3, 10%), conservative management (n = 13, 42%), and surgical exploration followed by conservative management (n = 1, 3%). Complete symptom resolution occurred in 45% (n = 14) of cases.

Lessons: Thoracic ASA aneurysms present diagnostic and treatment challenges. This case illustrates that open microsurgical treatment can successfully decompress the spinal cord and occlude the aneurysm while preserving parent artery flow. https://thejns.org/doi/10.3171/CASE24649.

Keywords: aneurysm; anterior spinal artery; costotransversectomy; microsurgery; spine; subarachnoid hemorrhage; thoracic.

FIG. 1.

Summary of the literature search strategy. Data added to the PRISMA template (from Page MJ, McKenzie JE, Bossuyt PM, Boutron I, Hoffmann TC, Mulrow CD, et al. The PRISMA 2020 statement: an updated guideline for reporting systematic reviews. BMJ. 2021;372:n71) under the terms of the Creative Commons Attribution (CC BY 4.0) License (https://creativecommons.org/licenses/by/4.0/).

FIG. 2.

Preoperative imaging in a patient with a ruptured thoracic ASA aneurysm. A: Sagittal (left) and axial (right) views of T2-weighted MR images showing a well-circumscribed clot in the subarachnoid space, ventral to the spinal cord at the T4 level. B: Coronal (left), sagittal (center), and axial (right) views of CT angiograms showing a prominent spot at the superior portion of the T4 level, suggestive of a dolichoectatic aneurysm. C: Digital subtraction angiograms showing the aneurysm origin from the left ASA at the T5 level as it ascends to its characteristic hairpin turn in original magnification (left) and high magnification (center), as well as the presence of a diminutive artery of Adamkiewicz at the right T9 level (right). Arrows indicate the ASA aneurysm.

FIG. 3.

Microsurgical clip reconstruction of a ruptured thoracic ASA aneurysm. A: Intraoperative photograph showing the dolichoectatic aneurysm morphology with a clear rupture site and intraluminal clot. B: Intraoperative photograph showing the final clip reconstruction of the aneurysm. C: Intraoperative indocyanine green videoangiogram confirming the patency of the ASA and adequate aneurysm occlusion.

FIG. 4.

Postoperative imaging in a patient with a ruptured thoracic ASA aneurysm treated with clip reconstruction. A: Digital subtraction angiogram showing the surgical construct and location of the clip reconstruction (white arrow). B: Digital subtraction angiogram showing preservation of the ASA and occlusion of the aneurysm (white arrow).