Clip Reconstruction of a Ruptured Thoracic Anterior Spinal Artery Aneurysm Utilizing a Costotransversectomy Approach: 2-Dimensional Operative Video

Abstract

Anterior spinal artery (ASA) aneurysms are exceptionally rare and challenging to diagnose. They typically manifest with severe back pain due to rupture and spinal subarachnoid hemorrhage, a condition referred to as "le coup de poignard rachidien." [1][2][3][4][5] We report a case in a man in his late 40s who presented after experiencing sudden, intense interscapular electric shock-like pain that progressed to paraplegia and complete sensory loss below the T5 level. Within 6 hours, the patient regained intact neurological function. Spinal magnetic resonance imaging revealed subarachnoid hemorrhage at the T4 level. Diagnostic digital subtraction angiography pinpointed a dolichoectatic aneurysm originating from the left ASA at the T5 level. The patient consented to surgical hematoma evacuation for spinal decompression and aneurysm clip reconstruction. The patient required a T4 costotransversectomy with T3-5 fusion to access the ventral spinal canal. Hematoma evacuation aided in exposing the ASA and facilitated proximal and distal control of the aneurysm. The ASA aneurysm was clip-reconstructed using a curved clip, with a second, curved miniclip placed on the opposite side to reconstruct the ASA lumen. Intraoperative indocyanine green videoangiography confirmed patency of the ASA and adequate aneurysm occlusion, with postoperative digital subtraction angiography validating these findings. The patient remained neurologically intact after the operation. This video demonstrates surgical clip reconstruction of a dolichoectatic ASA aneurysm using a costotransversectomy with fusion, highlighting the distinctive clinical and radiographic characteristics of ASA aneurysms and presenting contemporary management strategies for this rare condition.