1naresh2naresh
Array
(
    [urn:ac.highwire.org:guest:identity] => Array
        (
            [runtime-id] => urn:ac.highwire.org:guest:identity
            [type] => guest
            [service-id] => ajnr-ac.highwire.org
            [access-type] => Controlled
            [privilege] => Array
                (
                    [urn:ac.highwire.org:guest:privilege] => Array
                        (
                            [runtime-id] => urn:ac.highwire.org:guest:privilege
                            [type] => privilege-set
                            [privilege-set] => GUEST
                        )

                )

            [credentials] => Array
                (
                    [method] => guest
                )

        )

    [8031c012-b61b-4723-ade4-9232ab5b671b] => Array
        (
            [runtime-id] => 8031c012-b61b-4723-ade4-9232ab5b671b
            [type] => toll-free-key
            [service-id] => ajnr-ac.highwire.org
            [access-type] => Controlled
            [privilege] => Array
                (
                    [7d0d9d2f-2e3a-45f2-8513-51035f8def84] => Array
                        (
                            [runtime-id] => 7d0d9d2f-2e3a-45f2-8513-51035f8def84
                            [type] => toll-free-key
                        )

                )

            [credentials] => Array
                (
                    [method] => toll-free-key
                    [value] => tf_ipsecsha;a70c17e8df81d69cfe0d7c2a3c0552d31d6aac63
                )

        )

)
1naresh2naresh
Array
(
    [urn:ac.highwire.org:guest:identity] => Array
        (
            [runtime-id] => urn:ac.highwire.org:guest:identity
            [type] => guest
            [service-id] => ajnr-ac.highwire.org
            [access-type] => FreeToRead
            [privilege] => Array
                (
                    [urn:ac.highwire.org:guest:privilege] => Array
                        (
                            [runtime-id] => urn:ac.highwire.org:guest:privilege
                            [type] => privilege-set
                            [privilege-set] => GUEST
                        )

                )

            [credentials] => Array
                (
                    [method] => guest
                )

        )

    [cc338cdb-afcb-45f1-9cfb-148bc71fc0e3] => Array
        (
            [runtime-id] => cc338cdb-afcb-45f1-9cfb-148bc71fc0e3
            [type] => toll-free-key
            [service-id] => ajnr-ac.highwire.org
            [access-type] => FreeToRead
            [privilege] => Array
                (
                    [5763df5a-d9c6-4dc5-9b7a-74951a4ca58f] => Array
                        (
                            [runtime-id] => 5763df5a-d9c6-4dc5-9b7a-74951a4ca58f
                            [type] => toll-free-key
                        )

                )

            [credentials] => Array
                (
                    [method] => toll-free-key
                    [value] => tf_ipsecsha;a70c17e8df81d69cfe0d7c2a3c0552d31d6aac63
                )

        )

)
1naresh2naresh
Array
(
    [urn:ac.highwire.org:guest:identity] => Array
        (
            [runtime-id] => urn:ac.highwire.org:guest:identity
            [type] => guest
            [service-id] => ajnr-ac.highwire.org
            [access-type] => FreeToRead
            [privilege] => Array
                (
                    [urn:ac.highwire.org:guest:privilege] => Array
                        (
                            [runtime-id] => urn:ac.highwire.org:guest:privilege
                            [type] => privilege-set
                            [privilege-set] => GUEST
                        )

                )

            [credentials] => Array
                (
                    [method] => guest
                )

        )

    [53ddce98-9b77-43d5-b138-e218991f2b9d] => Array
        (
            [runtime-id] => 53ddce98-9b77-43d5-b138-e218991f2b9d
            [type] => toll-free-key
            [service-id] => ajnr-ac.highwire.org
            [access-type] => FreeToRead
            [privilege] => Array
                (
                    [d365251d-b380-457b-9718-0620ef9ed995] => Array
                        (
                            [runtime-id] => d365251d-b380-457b-9718-0620ef9ed995
                            [type] => toll-free-key
                        )

                )

            [credentials] => Array
                (
                    [method] => toll-free-key
                    [value] => tf_ipsecsha;a70c17e8df81d69cfe0d7c2a3c0552d31d6aac63
                )

        )

)
1naresh2naresh
Array
(
    [urn:ac.highwire.org:guest:identity] => Array
        (
            [runtime-id] => urn:ac.highwire.org:guest:identity
            [type] => guest
            [service-id] => ajnr-ac.highwire.org
            [access-type] => Controlled
            [privilege] => Array
                (
                    [urn:ac.highwire.org:guest:privilege] => Array
                        (
                            [runtime-id] => urn:ac.highwire.org:guest:privilege
                            [type] => privilege-set
                            [privilege-set] => GUEST
                        )

                )

            [credentials] => Array
                (
                    [method] => guest
                )

        )

    [8031c012-b61b-4723-ade4-9232ab5b671b] => Array
        (
            [runtime-id] => 8031c012-b61b-4723-ade4-9232ab5b671b
            [type] => toll-free-key
            [service-id] => ajnr-ac.highwire.org
            [access-type] => Controlled
            [privilege] => Array
                (
                    [7d0d9d2f-2e3a-45f2-8513-51035f8def84] => Array
                        (
                            [runtime-id] => 7d0d9d2f-2e3a-45f2-8513-51035f8def84
                            [type] => toll-free-key
                        )

                )

            [credentials] => Array
                (
                    [method] => toll-free-key
                    [value] => tf_ipsecsha;a70c17e8df81d69cfe0d7c2a3c0552d31d6aac63
                )

        )

)
1naresh2naresh
Array
(
    [urn:ac.highwire.org:guest:identity] => Array
        (
            [runtime-id] => urn:ac.highwire.org:guest:identity
            [type] => guest
            [service-id] => ajnr-ac.highwire.org
            [access-type] => Controlled
            [privilege] => Array
                (
                    [urn:ac.highwire.org:guest:privilege] => Array
                        (
                            [runtime-id] => urn:ac.highwire.org:guest:privilege
                            [type] => privilege-set
                            [privilege-set] => GUEST
                        )

                )

            [credentials] => Array
                (
                    [method] => guest
                )

        )

    [8031c012-b61b-4723-ade4-9232ab5b671b] => Array
        (
            [runtime-id] => 8031c012-b61b-4723-ade4-9232ab5b671b
            [type] => toll-free-key
            [service-id] => ajnr-ac.highwire.org
            [access-type] => Controlled
            [privilege] => Array
                (
                    [7d0d9d2f-2e3a-45f2-8513-51035f8def84] => Array
                        (
                            [runtime-id] => 7d0d9d2f-2e3a-45f2-8513-51035f8def84
                            [type] => toll-free-key
                        )

                )

            [credentials] => Array
                (
                    [method] => toll-free-key
                    [value] => tf_ipsecsha;a70c17e8df81d69cfe0d7c2a3c0552d31d6aac63
                )

        )

)
1naresh2naresh
Array
(
    [urn:ac.highwire.org:guest:identity] => Array
        (
            [runtime-id] => urn:ac.highwire.org:guest:identity
            [type] => guest
            [service-id] => ajnr-ac.highwire.org
            [access-type] => Controlled
            [privilege] => Array
                (
                    [urn:ac.highwire.org:guest:privilege] => Array
                        (
                            [runtime-id] => urn:ac.highwire.org:guest:privilege
                            [type] => privilege-set
                            [privilege-set] => GUEST
                        )

                )

            [credentials] => Array
                (
                    [method] => guest
                )

        )

    [8031c012-b61b-4723-ade4-9232ab5b671b] => Array
        (
            [runtime-id] => 8031c012-b61b-4723-ade4-9232ab5b671b
            [type] => toll-free-key
            [service-id] => ajnr-ac.highwire.org
            [access-type] => Controlled
            [privilege] => Array
                (
                    [7d0d9d2f-2e3a-45f2-8513-51035f8def84] => Array
                        (
                            [runtime-id] => 7d0d9d2f-2e3a-45f2-8513-51035f8def84
                            [type] => toll-free-key
                        )

                )

            [credentials] => Array
                (
                    [method] => toll-free-key
                    [value] => tf_ipsecsha;a70c17e8df81d69cfe0d7c2a3c0552d31d6aac63
                )

        )

)
1naresh2naresh
Array
(
    [urn:ac.highwire.org:guest:identity] => Array
        (
            [runtime-id] => urn:ac.highwire.org:guest:identity
            [type] => guest
            [service-id] => ajnr-ac.highwire.org
            [access-type] => Controlled
            [privilege] => Array
                (
                    [urn:ac.highwire.org:guest:privilege] => Array
                        (
                            [runtime-id] => urn:ac.highwire.org:guest:privilege
                            [type] => privilege-set
                            [privilege-set] => GUEST
                        )

                )

            [credentials] => Array
                (
                    [method] => guest
                )

        )

    [8031c012-b61b-4723-ade4-9232ab5b671b] => Array
        (
            [runtime-id] => 8031c012-b61b-4723-ade4-9232ab5b671b
            [type] => toll-free-key
            [service-id] => ajnr-ac.highwire.org
            [access-type] => Controlled
            [privilege] => Array
                (
                    [7d0d9d2f-2e3a-45f2-8513-51035f8def84] => Array
                        (
                            [runtime-id] => 7d0d9d2f-2e3a-45f2-8513-51035f8def84
                            [type] => toll-free-key
                        )

                )

            [credentials] => Array
                (
                    [method] => toll-free-key
                    [value] => tf_ipsecsha;a70c17e8df81d69cfe0d7c2a3c0552d31d6aac63
                )

        )

)
1naresh2naresh
Array
(
    [urn:ac.highwire.org:guest:identity] => Array
        (
            [runtime-id] => urn:ac.highwire.org:guest:identity
            [type] => guest
            [service-id] => ajnr-ac.highwire.org
            [access-type] => FreeToRead
            [privilege] => Array
                (
                    [urn:ac.highwire.org:guest:privilege] => Array
                        (
                            [runtime-id] => urn:ac.highwire.org:guest:privilege
                            [type] => privilege-set
                            [privilege-set] => GUEST
                        )

                )

            [credentials] => Array
                (
                    [method] => guest
                )

        )

    [55721191-ef66-417c-9d17-b4028a85d8d4] => Array
        (
            [runtime-id] => 55721191-ef66-417c-9d17-b4028a85d8d4
            [type] => toll-free-key
            [service-id] => ajnr-ac.highwire.org
            [access-type] => FreeToRead
            [privilege] => Array
                (
                    [85fe2d4f-20f2-489f-bd13-aee4560ac970] => Array
                        (
                            [runtime-id] => 85fe2d4f-20f2-489f-bd13-aee4560ac970
                            [type] => toll-free-key
                        )

                )

            [credentials] => Array
                (
                    [method] => toll-free-key
                    [value] => tf_ipsecsha;a70c17e8df81d69cfe0d7c2a3c0552d31d6aac63
                )

        )

)


  
    






























































    Subarachnoid Hemorrhage Due To Isolated Spinal Arteries: Rare Cases ith Controversy About the Treatment Strategy | American Journal of Neuroradiology  
    



















    































    
  
  




    
    

  

      


    

      

  
  
  

    

  

    

  

                
    

      

  

    

  
      
  
  

    


Advertisement



  



  


  
  



  



    

  


  


  


  
  
  
  
  
  

  	      


    
      

    
  
    
        
    

  

    
                        

  

                
    

      

	  

		
		

			

			  

  
      
  
  

    

  
  
      
LetterLetter

  
      

  
      
Subarachnoid Hemorrhage Due To Isolated Spinal Arteries: Rare Cases ith Controversy About the Treatment Strategy
  
    	
Ansgar Berlis and Martin Schumacher

  
    	
American Journal of Neuroradiology April 2006,  27 (4) 726-727; 

  
  
  



  


  
  



			

		

	
	
 	
	  
  

		
		

			

			  

  
      
  
  

    
  


  
  



  
      
  
  

    

  

    

  
      
  
  

    
Recently, Massand et al1 reported 4 more patients with ruptured isolated spinal artery aneurysms successfully treated by surgery. Subarachnoid hemorrhage (SAH) due to isolated spinal aneurysms without associated arteriovenous malformation (AVM) or other entities such as aortic coarctation or vasculitides is very rare. Only approximately 20 cases of spinal SAH due to rupture of isolated spinal aneurysms have been reported until now. The clinical hallmarks of spinal SAH are back pain and, later, cranial and meningeal symptoms. The angiographic appearance of the spinal aneurysms tends to be fusiform along the course of the artery.1, 2 An inflammatory process, dissecting aneurysms, and no evident cause are discussed as the underlying etiology.
Perhaps spinal artery aneurysms are more frequent than we believe and should, accordingly, be diagnosed more often by MR imaging and MR angiography in cases of spinal SAH. Recently, we detected our fourth patient within 3 years with isolated spinal aneurysm at the descending anterior spinal artery at level T12. At the time of admission, our patient had paraplegia and symptomatic cerebral vasospasms, which had already induced large bilateral hemispheric infarcts. Therefore, the prognosis was judged unfavorable. There were no signs for rerupture of the aneurysm. Palliative treatment was performed until the death of the patient 23 days after admission due to a pneumogenic sepsis.
Histopathologic analysis showed no dissection and most notably did not show the anticipated inflammatory process.
There is still controversy about the treatment strategy. Whereas in the article of Massand et al1 all 4 patients were treated surgically, we preferred a wait and see strategy with conservative treatment. Spontaneous aneurysm occlusion occurred in all of our 3 published cases.2
Comparing the 2 groups, we found that all these patients showed favorable outcome with no or only minor neurologic deficits. The main reason for the fatal outcome of our last patient was the fact that spinal MR imaging was not performed and an SAH was not well recognized before admission. Because of the small number of case reports, there is no clear indication for treatment. At first, angiography is necessary to detect the source of the spinal SAH. A mass effect compressing the spinal cord seems to be perhaps the only indication for treatment. The mass effect can result from a blood clot or the aneurysm size, though most reported aneurysms were small. Transcranial Doppler sonography controls are also necessary to detect cerebral vasospasm, and CSF drainage might prevent arachnoiditis. Aneurysms involving the artery of Adamkiewicz as well as the anterior spinal artery have a risk of spinal infarct if the aneurysm is occluded.
References
  1. ↵
    Massand MG, Wallace RC, Gonzalez LF, et al. Subarachnoid hemorrhage due to isolated spinal artery aneurysm in four patients. AJNR Am J Neuroradiol 2005;26:2415–19
    Abstract/FREE Full Text
  2. ↵
    Berlis A, Scheufler KM, Schmahl C, et al. Solitary spinal artery aneurysms as a rare source of spinal subarachnoid hemorrhage: potential etiology and treatment strategy. AJNR Am J Neuroradiol 2005;26:405–10
    Abstract/FREE Full Text
Subarachnoid Hemorrhage Due To Isolated Spinal Arteries: Rare Cases ith Controversy About the Treatment Strategy: Reply

        Reply:
      
We appreciate the comments from Drs. Berlis and Schumacher regarding our article, “Subarachnoid Hemorrhage (SAH) due to Isolated Spinal Artery Aneurysms in Four Patients.”1
We agree with Berlis and Schumacher that spontaneous or idiopathic aneurysms of the spinal cord causing hematorrhachis (spinal SAH) are rare. We also agree that these aneurysms usually exhibit dissecting characteristics as shown by Gonzalez et al2 and previously described by others.
We presented 4 patients with isolated spinal artery aneurysms and no other underlying illnesses. In contrast, patient 2, reported by Berlis et al,3 had signs of systemic inflammation, such as fever, “elevated inflammatory laboratory parameters,” and elevated antigen levels of Candida organisms. This patient was treated with fluoconazole, with a stable course for 6 months, and then presented with new a neurologic decline and an area of “stroke” within the spinal cord. It is possible that this stroke was the end result of fungal vasculitis and local ischemia. We do not believe that this patient should be included within the category of idiopathic or spontaneous aneurysms of the spinal cord.
As Berlis and Schumacher point out, only approximately 20 cases of spinal SAH due to rupture of isolated spinal artery aneurysms have been previously reported. With so little experience available, we think it is worrisome to “wait and see” if the aneurysm will spontaneously thrombose. In addition, a definitive diagnosis of spinal aneurysm may be difficult to make on the basis of imaging studies alone.
The treatment paradigm we use depends on whether there is angiographic evidence of flow distal to the aneurysm: If there is distal flow, the aneurysm can be wrapped or it can be resected with primary reconstruction of the parent vessel; on the other hand, if the distal flow is absent, the aneurysm is resected and the parent vessel is occluded.2 In cases in which the diagnosis is clear and there is an absence of distal flow, endovascular occlusion of the parent vessel may be possible. Endovascular technologies are rapidly evolving; smaller more flexible catheters will facilitate the endovascular management of these lesions. The idea of doing a Wada test3 during selective spinal angiography is very appealing and may reduce the risks of occluding the parent vessel in these cases.
Finally, we apologize for the involuntarily exclusion of the article by Berlis et al3 from our reference list; our manuscript was submitted before theirs was published.
References
  1. ↵
    Massand MG, Wallace RC, Gonzalez LF, et al. Subarachnoid hemorrhage due to isolated spinal artery aneurysm in four patients. AJNR Am J Neuroradiol 2005;26:2415–19
    Abstract/FREE Full Text
  2. ↵
    Gonzalez LF, Zabramski JM, Tabrizi P, et al. Spontaneous spinal subarachnoid hemorrhage secondary to spinal aneurysms: diagnosis and treatment paradigm. Neurosurgery 2005;57:1127–31
    PubMed
  3. ↵
    Berlis A, Scheufler KM, Schmahl C, et al. Solitary spinal artery aneurysms as a rare source of spinal subarachnoid hemorrhage: potential etiology and treatment strategy. AJNR Am J Neuroradiol 2005;26:405–10
    Abstract/FREE Full Text
  


  
  



  
      
  
  

    
  


  
  



  




  


  
  



  
      
  
  

    
  


  
  



  
      
  
  

     Back to top  


  
  



			

		

		
		

			

			  

  
        
In this issue

    
  
  

    
  


  
  



  
      
  
  

    

  

    

  
      
  
  

    


Advertisement



  



  


  
  



  



  


  
  



  
      
  
  

    

	  
  

		

          

            

  
      
  
  

     Print  


  
  



  
      
  
  

     Download PDF  


  
  



  
      
  
  

    
 Email Article
  


  
  



  
      
  
  

    
 Citation Tools
  


  
  



          

        

        
        

          

            



  
      
  
  

    

  

    

  
      
  
  

    

  
  
  
  
      
Subarachnoid Hemorrhage Due To Isolated Spinal Arteries: Rare Cases ith Controversy About the Treatment Strategy
  
    	
Ansgar Berlis, Martin Schumacher

  
    	
American Journal of Neuroradiology Apr 2006, 27 (4) 726-727; 

  
  
  



  


  
  



  
      
  
  

    

  
    
  
  
    
  
  
    
  


  


  
  



  
      
  
  

    
del.icio.us logo Twitter logo Facebook logo Mendeley logo
  


  
  



  



  


  
  



  
      
  
  

    
  


  
  



          

        

	
 	
	
	


  


  
  



  
        
Jump to section

    
  
  

    
  


  
  



  
      
  
  

    

  

    
 Related Articles
  • No related articles found.
 Cited By...
  • No citing articles found.
 More in this TOC Section
 Similar Articles

  



  


  
  



			

		

	
	
 	
	
	


    

  



  

                
    

      

  

    

  
      
  
  

    


Advertisement