an intracranial or spinal subarachnoid hemorrhage ( sah ) can result from the rupture of an aneurysm in the anterior , posterior , radicular , or radiculomedullary cervical spinal arteries .
hemodynamic stress caused by arteriovenous malformation and coarctation of the aorta are well - known etiologic factors in formation and rupture of a spinal artery aneurysm.3)4)6)7)12)16 ) however , occurrence of an sah due to the rupture of an isolated aneurysm in the cervical anterior spinal artery is very rare .
we report on a case of an sah that resulted from the rupture of an aneurysm in the branch of the anterior spinal artery in a patient with end - stage common bile duct cancer .
a 47-year - old male was transferred to our emergency room in a semicomatose state .
initially , he presented with posterior neck pain that gradually became more aggravated during the transfer .
brain computerized tomography scans showed subarachnoid and intraventricular hemorrhages that were denser in the cisterns around the pons and medulla than in the basal and anterior interhemispheric cisterns ( fig .
we found an aneurysm in the anterior communicating artery and performed embolization of the aneurysm using detachable coils ( fig .
we did not notice a small aneurysm in the branch of the anterior spinal artery until the following day during a review of the angiograms ( fig .
we expected spontaneous occlusion of the aneurysm ; therefore , we decided to follow this aneurysm with cerebral angiography .
we took this course of action because the family did not want the aneurysm to be clipped .
in addition , we believed that endovascular treatment carried the risks of both parent artery occlusion and additional hemorrhaging . on the sixth day of hospitalization ,
follow - up cerebral angiography showed that the aneurysm was still present in the anterior spinal artery branch with a small filling defect in the aneurysm sac ( fig .
therefore , we decided to continue to follow the aneurysm with cerebral angiography . due to progression of the patient 's end - stage common bile duct cancer , his condition slowly worsened .
the angiograms showed no significant interval change in the aneurysm from previous examinations ( fig .
he returned to his hometown where he died of the cancer on the 103rd day after the sah .
both arteriovenous malformations of the spinal arteries and coarctation of the aorta are known to cause hemodynamic stress on the arteries and formation and rupture of aneurysms.3)4)6)7)12)16 ) however , rupture of an isolated aneurysm in the anterior spinal artery has rarely been reported . to the best of our knowledge ,
only eight cases of sahs resulting from the rupture of an isolated aneurysm in the cervical anterior spinal artery have been reported.8)9)14)15)17)18 - 20 ) in our case , the aneurysm was located in the branch of the cervical anterior spinal artery in a patient with common bile duct cancer . to the best of our knowledge ,
this is the first case in which an sah resulted from the rupture of an aneurysm that was located in the branch of the anterior spinal artery in a patient with common bile duct cancer .
the strategy for treatment of spinal artery aneurysms remains controversial . among the eight reported cases of ruptured anterior spinal artery aneurysms , two cases were treated conservatively,8)20 ) and
one of these two cases resulted in death.8 ) a review of the literature identified three cases of aneurysms located in the cervical radicular,5)11)21 ) radiculomedullary , or posterior spinal artery , which resulted in death among five conservatively treated cases.1)5)10)11)21 ) in contrast , all patients who were treated with embolization , surgical resection , or aneurysm clipping recovered completely or with some sequelae .
thus , we agree with the opinion that surgical or endovascular intervention is the ideal treatment of choice for a ruptured cervical anterior spinal artery aneurysm.8 ) however , conservative medical treatment has been successful in some cases . in the case of a patient with a small , ruptured aneurysm measuring approximately 2.5  1.3 mm in size and located in the anterior spinal artery at the first cervical vertebra level , the aneurysm disappeared from the angiograms after 108 days of conservative management .
the authors chose conservative treatment because they thought that obliteration of the aneurysm would be difficult without disrupting the blood flow of the parent artery .
due to its spontaneous disappearance , the authors assumed that the aneurysm was a dissecting aneurysm.8 ) in a second case , a ruptured aneurysm measuring approximately 3  2 mm in size and located at the c5 - 6 radiculomedullary artery was found in a patient with behet 's disease ; a follow - up angiography one month later showed no aneurysm following high - dose methyl - prednisolone therapy , which was initiated on the day of admission.1 ) another case report described a ruptured aneurysm in a patient with sjgren 's syndrome .
the small saccular aneurysm , which was located in a radiculomedullary branch of the right vertebral artery at the c3 level , had a diameter of approximately 2 mm .
the authors presumed that the aneurysm had formed due to the immunological vasculitis that is associated with sjgren 's syndrome and treated the patient with glucocorticoids , cyclophosphamide and azathioprine .
the aneurysm was not detected during digital subtraction angiography one year after the sah.10 ) in addition , longatti et al .
considered the mass effect of aneurysms or blood clots as the only indication for surgical treatment.13 ) therefore , conservative medical treatment can be another management strategy when the aneurysm is associated with dissection or immunological vasculitis , as in behet 's disease and sjgren 's syndrome
. this may be particularly true if the parent artery can not be preserved , the patient 's condition is not suitable for surgical treatment , or endovascular treatment poses more hazards than benefits .
spontaneous disappearance of an aneurysm between one month and one year after the sah has been reported .
thus , waiting at least one year for spontaneous occlusion of the aneurysm to occur is possible.1)2 ) we could not confirm the disappearance of the anterior spinal artery aneurysm , however , the aneurysm did not re - rupture during the 103 days after the sah . in addition , the caliber of the parent artery of the aneurysm can be considered too small to make a true saccular aneurysm .
thus , the author believes that the aneurysm in this case may have been a dissecting aneurysm .
an aneurysm rupture at the cervical spinal level results in development of intracranial hemorrhages as well as spinal sahs .
recurrent hemorrhage has been the cause of death in all patients who have received conservative treatment , and rebleeding occurred from the day of admission to the 17th hospital day.11)21 ) thus , an operative intervention should be performed immediately , if indicated , as in cases of intracranial aneurysm rupture .
an patient with end - stage cancer with an sah due to the rupture of an aneurysm in the branch of the anterior spinal artery received conservative management .
this expectative strategy was chosen because his family did not want open surgical management and endovascular treatment might carry the risk of parent artery occlusion and injury .
the patient survived for 103 days after the sah without a re - rupture of the aneurysm .
a conservative management strategy is a viable option for patients with conditions that are unsuitable for surgical or endovascular management .
 incidence of aneurysm of the anterior spinal artery is known to be very low and the standard treatment strategy has not yet been established . 
 the author experienced a case of subarachnoid hemorrhage ( sah ) caused by the rupture of an aneurysm in the branch of the cervical anterior spinal artery , which was managed conservatively . 
 the patient had end - stage common bile duct cancer and survived for 103 days after onset of the sah without a re - rupture of the aneurysm . 
INTRODUCTION
CASE REPORT
DISCUSSION
CONCLUSION