Isolated spinal aneurysms with spontaneous regression

Abstract

Purpose: To share our clinical experience with conservative management of isolated spinal arterial aneurysms (ISAs) and to identify clinical scenarios where conservative management may be appropriate, in the context of a literature review.

Methods: We performed a retrospective review of spinal angiograms from two German neuroradiology centers and conducted a systematic literature review of reported ISA cases. We analyzed demographics, clinical presentation, imaging findings, treatments, and outcomes.

Results: We identified seven patients (mean age 48; 4 women) with nine ISAs, eight of which were managed conservatively. Five of them had excellent short-term outcomes, and spontaneous regression was documented in four cases. With our cases, 208 ISAs have been reported in the literature in 164 patients (mean age 51; 52% female). They most commonly present with subarachnoid hemorrhage (90%) and back pain (69%). Most are located in the thoracic (51%) or cervical spine (40%) and involve the anterior spinal circulation (63%). They may be treated by surgical intervention (47%) or conservatively (37%), less commonly by endovascular therapy (16%). 78% of patients have favorable outcomes (mRS 0-3), similar across all treatment approaches. In 52% of conservatively managed cases, spontaneous regression was documented by imaging. Clinical deterioration was primarily associated with respiratory complications and spinal cord infarction, with a documented rebleeding rate of 8% and a mortality rate of 12%.

Conclusions: ISAs are a rare and potentially underrecognized cause of cerebral and spinal subarachnoid hemorrhage. In select cases, particularly small ISAs of the anterior spinal or a radiculomedullary artery and with transient neurological symptoms, conservative management appears to be a reasonable approach, supported by increasing evidence of the possibility of spontaneous regression.

Keywords: Spinal aneurysm; Spinal angiography; Spinal hemorrhage; Subarachnoid hemorrhage.

Fig. 1

Representative case (Patient 1). A) Head CT showed minimal basal SAH. B-F) Spinal MRI showed extensive cervical and intracranial SAH as seen on sagittal T2 (B) and axial T2 (D) weighted images, as well as an intradural cystic mass ventral to the cervical myelon as seen on sagittal (C) and axial (E) contrast-T1 weighted images. Extensive spinal cord infarction is seen on sagittal T2 (F). A fusiform aneurysm of a cervical RMA at C7 level was found on DSA, with supply from the left inferior thyroid artery and the cervical ascendent artery (G)

Fig. 2

Representative case (Patient 4). On cranial MRI, cerebral SAH is seen on FLAIR (A) and T2* (B) images. On spinal MRI, spinal SAH is seen in the thecal sac (C and D), and a small cystic lesion with flow void in the ventral dural sac at T11 level (E and F). DSA shows a fusiform aneurysm of the ASA at T12 level (G)

Fig. 3

Proposed management algorithm for isolated spinal aneurysms