Abstract
Severe spontaneous subarachnoid hemorrhage (SAH) is predominantly caused by aneurysm rupture, with non-aneurysmal vascular lesions representing only a minority of possible causes. We present the case of a 58-year old lady with a coincidental posterior communicating artery (PCom) aneurysm and a high cervical spine arterio-venous fistula associated with a small ruptured aneurysm. After the emergency clipping of the PCom aneurysm, additional diagnostic procedures—repeated digital subtraction angiography and spinal magnetic resonance imaging, revealed the actual cause of the SAH, a type-A ventral intradural fistula at cervical level C2/3. The fistula was treated micro surgically via a ventral approach using C3 somatectomy and C2-4 stabilization after the initial failure of endovascular therapy. Furthermore, the patient was treated for complications associated with severe SAH, including acute hydrocephalus and meningitis. In cases where the SAH pattern and perioperative findings do not suggest an intracranial aneurysm as the source of SAH, further diagnostic investigation is warranted to discover the real cause. Patients with severe non-aneurysmal SAH require a similar algorithm in diagnosing the cause of the hemorrhage as well as complex conditions such as ruptured aneurysms.
Highlights
Spontaneous subarachnoid hemorrhage (SAH) is caused by an intracranial aneurysm rupture in85% of cases [1]
Non-aneurysmal SAH can be divided into perimesencephalic SAH (PMSAH) and non-perimesencephalic SAH
Spinal arterio-venous fistulas (AVFs) are rare lesions, which usually present with pain, paralysis, or paresthesias, about 9% may present with SAH [4]
Summary
Spontaneous subarachnoid hemorrhage (SAH) is caused by an intracranial aneurysm rupture in. There has been an increasing incidence of patients with non-aneurysmal. While patients with PMSAH, in general, seem to have good outcomes with a minimal chance of an undisclosed lesion diagnosis on initial digital subtraction angiography (DSA), about 12% of patients with non-PMSAH have a cranial or spinal lesion responsible for the SAH [3]. Spinal arterio-venous fistulas (AVFs) are rare lesions, which usually present with pain, paralysis, or paresthesias, about 9% may present with SAH [4]. We present the case of a patient who suffered severe SAH and harbored a ruptured ventral intradural cervical. We demonstrate our diagnostic approach and treatment of the lesion itself as well as the complications associated with SAH in such a rare case
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