RETURN TO ABSTRACT LISTING


Background
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 and abundant fragile collaterals provide conditions for spinal artery aneurysm formation, growth and rupture.

Educational Goals / Teaching Points
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. 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 microspirals.

Key Anatomic/Physiologic Issues and Imaging Findings/Techniques
A 67-year-old woman presented to the emergency room with bilateral lower extremity paresis accompanied by mildly altered mental status. The patient’s history was significant 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 with an irregularly shaped lobulated aneurysm (11 x 7mm) on its course was detected. 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 vertebral artery and advanced to the branching point of the radicular artery with the aneurysm. Functional test was performed upon balloon inflation with no neurological deterioration observed. The radicular artery feeding the aneurysm was accessed with a microcatheter. Embolization was performed and microspirals 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 branches off.

Conclusion
As our case demonstrates, spinal artery aneurysms induced by aortic coarctation are complex entities and pose a unique surgical and medical challenge. Treating the aneurysm should be prioritized specifically in cases of subarachnoid hemorrhage. Transradial approach for interventional procedures can avoid anatomic restrictions posed by coarctation.