Ruptured Spinal Artery Aneurysm Associated with Coarctation of the Aorta Salah G. Aoun 1 , Tarek Y. El Ahmadieh 1 , Maryam Soltanolkotabi 2 , Sameer A. Ansari 2 , Franklin A. Marden 3 , H. Hunt Batjer 1 , Bernard R. Bendok 1,2 INTRODUCTION Spinal artery aneurysms (SAA) (22) are rare (4, 12, 20). They often develop secondary to lesions disturbing normal cerebral blood flow such as arteriovenous malformations and fistulae. Their epidemiology and nat- ural history are poorly understood due to the paucity of reported cases (15). Although SAA may regress after the causal vascular anomaly has been treated (15), definitive cure often requires direct surgical inter- vention (15). Although aortic coarctation is a recognized risk factor for spinal artery aneurysm formation, to our knowledge, only eight cases of SAA associated with aortic coarctation have been reported in the literature (7, 11, 15, 17). This combination poses unique diagnostic, follow-up, and therapeutic challenges, due in part to the significant hemodynamic disturbances resulting from the collateral circulation. In addition, the physical obstacle posed by the coarctation prevents the use of conven- tional endovascular access routes. We report here the case of a 59-year-old woman who presented with an intracranial sub- arachnoid hemorrhage (SAH) from a ruptured 7-mm, wide-necked, saccular, anterior SAA The aneurysm was associated with a previously undiagnosed aortic coarctation and was treated by coiling. The patient subsequently underwent repair of her aortic coarctation with placement of an interposition graft. CASE REPORT A 59-year-old woman with a long-standing history of hypertension was awakened in the morning by a severe posterior neck pain accompanied by a moderate headache. An initial head computed tomography scan done at an outside hospital revealed sub- arachnoid and intraventricular hemorrhage (Figure 1), with presence of blood in the cisterna magna that extended to the C1 level, and enlargement of the temporal horns. She was intubated and a frontal ventriculostomy drain was placed. An angiogram revealed a previously undiagnosed coarctation of the aorta, with a very large supreme intercostal artery aneurysm arising from the postductal descending aorta (Figure 2). This was confirmed by a chest computed tomography angiography that showed a narrow 4-mm (80%) juxtaductal coarctation (Figure 3) with an extensive network of collaterals. She was then transferred to our institution for treat- ment and follow-up. On arrival the patient was unconscious, intubated, but stable. Her systolic blood pressure on admission was 150 mm Hg in the arms, but her lower extremities were pulseless. Her chest radiograph showed a prominent heart, widened mediastinum with a “figure of 3” sign, and prominent inferior rib notching (Figure 4). An admis- sion chest computed tomography angio- gram and spinal magnetic resonance - BACKGROUND: Spinal artery aneurysms associated with aortic coarctation are exceptionally rare, with only eight cases reported in the literature that we are aware of, and treatment of the aneurysm described only in one of them. Aortic coarctation often results in an aberrant collateral circulation with hyperdynamic flow and potential spinal artery aneurysm formation, growth, and rupture. Microsurgical, interventional, and medical management of these lesions can be challenging and has rarely been reported. Complication avoidance re- quires thorough knowledge of the clinical presentation of the disease, the he- modynamic factors involved, and the therapeutic tools available. - CASE DESCRIPTION: A 59-year-old woman with a previously undiagnosed isthmic coarctation of the aorta presented with subarachnoid hemorrhage. A 7- mm wide-necked, saccular spinal artery aneurysm was identified as the source of the hemorrhage and was subsequently successfully coiled through a trans- brachial access route. After rehabilitation, the patient returned to her asymp- tomatic neurologic baseline, and underwent successful surgical repair of the aortic coarctation with placement of an interposition graft. - CONCLUSIONS: Spinal artery aneurysms induced by aortic coarctation are rare and complex entities. They pose unique surgical and medical challenges. Securing the aneurysm should be prioritized specifically in cases of sub- arachnoid hemorrhage. Blood pressure should be closely monitored and balanced to reduce the risk of rehemorrhage and at the same time allow for sufficient end-organ perfusion. Key words - Aortic coarctation - Coiling - Management - Spinal artery aneurysm - Spinal subarachnoid hemorrhage Abbreviations and Acronyms SAA: Spinal artery aneurysm SAH: Subarachnoid hemorrhage From the Departments of 1 Neurological Surgeryand 2 Radiology, Feinberg School of Medicine and McGaw Medical Center, Northwestern University, Chicago, Illinois; and 3 Department of Interventional Radiology, Alexian Brothers Medical Center, Elk Grove Village, Illinois, USA To whom correspondence should be addressed: Bernard R. Bendok, M.D. [E-mail: bbendok@nmff.org] Citation: World Neurosurg. (2014) 81, 2:441.e17-441.e22. http://dx.doi.org/10.1016/j.wneu.2012.07.027 Journal homepage: www.WORLDNEUROSURGERY.org Available online: www.sciencedirect.com 1878-8750/$ - see front matter ª 2014 Elsevier Inc. All rights reserved. WORLD NEUROSURGERY 81 [2]: 441.e17-441.e22, FEBRUARY 2014 www.WORLDNEUROSURGERY.org 441.E17 Peer-Review Short Reports