Abstract Number ‐ 124: Spinal hemorrhage due to ruptured radicular artery aneurysm in patient with coarctation of the aorta

Abstract

Introduction Spinal artery aneurysms associated with previously undiagnosed coarctation of the aorta in adults are exceptionally rare. Aortic coarctation often results in aberrant collateral circulation with hyperdynamic flow. Abundant and fragile collaterals provide favourable conditions for spinal artery aneurysm formation, growth and rupture. There are very few reports of spinal artery aneurysms associated with coarctation of the aorta in the literature, with even less describing current endovascular methods of their treatment. Management of such lesions is especially challenging due to aberrant anatomy and the presence of collaterals. We describe a case of a 67‐year old woman with a previously unrecognized coarctation of the aorta who presented a ruptured radicular artery aneurysm. The patient was treated with endovascular embolization using microcoils. Methods Case report. Results A 67‐year old female presented to the emergency room with severe bilateral lower extremity paresis. Patient’s history was significant of hypertension, ischemic heart disease, atrial fibrillation and a previous subarachnoid hemorrhage of an unknown cause. An initial computed tomography scan done at an outside hospital showed a spinal canal hemorrhage at the cervical level and was suspicious for vascular malformation of cervical spine. Diagnostic angiogram via radial approach revealed a previously undiagnosed coarctation of the aorta. The examination showed an extensive network of collaterals between both subclavian arteries and thoracic aorta. A spinal artery aneurysm was identified as the source of the hemorrhage. At the C7/Th1 level on the left side a dilated radicular artery providing collateral blood flow to the left subclavian artery was detected, with an irregularly shaped lobulated aneurysm (11×7 mm) on its course. The following day endovascular embolization of the aneurysm was performed. Both radial arteries were punctured. On the left side, a pigtail catheter was placed in the left subclavian artery, and on the right side, a 5F guiding catheter was placed in the left vertebral artery. A balloon catheter was introduced to the left vertebral artery and advanced to the branching point of the radicular artery with the aneurysm on its course. Functional test was performed and upon balloon inflation no neurological deterioration was observed. The radicular artery feeding the aneurysm was accessed with a microcatheter. Embolisation was performed and microcoils were deployed in the radicular artery proximal to the aneurysm site. A control angiogram via left subclavian showed retrograde inflow into radicular artery from which the anterior spinal artery branched off. Conclusions As our case demonstrates, spinal and radicular artery aneurysms induced by aortic coarctation are complex entities and pose a unique surgical and medical challenge. Treating the aneurysm should be prioritized in cases of subarachnoid hemorrhage. Transradial approach for interventional procedures can avoid anatomic restrictions posed by coarctation.