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      Posterior Spinal Artery Aneurysm Presenting with Leukocytoclastic Vasculitis

      case-report

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          Abstract

          Rupture of isolated posterior spinal artery (PSA) aneurysms is a rare cause of subarachnoid hemorrhage (SAH) that presents unique diagnostic challenges owing to a nuanced clinical presentation. Here, we report on the diagnosis and management of the first known case of an isolated PSA aneurysm in the context of leukocytoclastic vasculitis. A 53-year-old male presented to an outside institution with acute bilateral lower extremity paralysis 9 days after admission for recurrent cellulitis. Early magnetic resonance imaging was read as negative and repeat imaging 15 days after presentation revealed SAH and a compressive spinal subdural hematoma. Angiography identified a PSA aneurysm at T9, as well as other areas suspicious for inflammatory or post-hemorrhagic reactive changes. The patient underwent a multilevel laminectomy for clot evacuation and aneurysm resection to prevent future hemorrhage and to establish a diagnosis. The postoperative course was complicated by medical issues and led to the diagnosis of leukocytoclastic vasculitis that may have predisposed the patient to aneurysm development. Literature review reveals greater mortality for cervical lesions than thoracolumbar lesions and that the presence of meningitic symptoms portents better functional outcome than symptoms of cord compression. The outcome obtained in this case is consistent with outcomes reported in the literature.

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          Most cited references19

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          Unruptured intracranial aneurysms: a review.

          B Weir (2001)
          In this article, pathological, radiological, and clinical information regarding unruptured intracranial aneurysms is reviewed. Treatment decisions require that surgeons and interventionists take into account information obtained in pathological, radiological, and clinical studies of unruptured aneurysms. The author has performed a detailed review of the literature and has compared, contrasted, and summarized his findings. Unruptured aneurysms may be classified as truly incidental, part of a multiple aneurysm constellation, or symptomatic by virtue of their mass, irritative, or embolic effects. Unruptured aneurysms with clinical pathological profiles resembling those of ruptured lesions should be considered for treatment at a smaller size than unruptured lesions with profiles typical of intact aneurysms, as has been determined at autopsy in patients who have died of other causes. The track record of the surgeon or interventionist and the institution in which treatment is to be performed should be considered while debating treatment options. In cases in which treatment is not performed immediately, ongoing periodic radiological assessment may be wise. Radiological investigations to detect unruptured aneurysms in asymptomatic patients should be restricted to high-prevalence groups such as adults with a strong family history of aneurysms or patients with autosomal dominant polycystic kidney disease. All patients with intact lesions should be strongly advised to discontinue cigarette smoking if they are addicted. The current state of knowledge about unruptured aneurysms does not support the use of the largest diameter of the lesion as the sole criterion on which to base treatment decisions, although it is of undoubted importance.
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            Solitary spinal artery aneurysms as a rare source of spinal subarachnoid hemorrhage: potential etiology and treatment strategy.

            Solitary aneurysms of spinal arteries lacking associated vascular malformations are rare. We report three patients with spinal subarachnoid hemorrhage (SAH) due to rupture of such aneurysms, which regressed spontaneously, as confirmed on conventional angiography. One patient had spinal SAH with presumed spontaneous dissection of a segmental artery. In the other two, SAH resulted from ruptured fusiform aneurysms of the artery of Adamkiewicz immediately proximal to the anterior spinal artery. Solitary aneurysms of the spinal arteries appear to be etiopathologic entities completely different from intracranial aneurysms. Spontaneous occlusion seems to be common, justifying a wait-and-see strategy rather than urgent treatment.
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              Cerebral vasculopathy with aneurysm formation in HIV-infected young adults.

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                Author and article information

                Journal
                J Cerebrovasc Endovasc Neurosurg
                J Cerebrovasc Endovasc Neurosurg
                JCEN
                Journal of Cerebrovascular and Endovascular Neurosurgery
                Korean Society of Cerebrovascular Surgeons; Society of Korean Endovascular Neurosurgeons
                2234-8565
                2287-3139
                March 2016
                31 March 2016
                : 18
                : 1
                : 42-47
                Affiliations
                [1 ]New York University School of Medicine, New York, NY, USA.
                [2 ]Department of Neurosurgery, New York University School of Medicine, New York, NY, USA.
                [3 ]Department of Pathology, New York University School of Medicine, New York, NY, USA.
                [4 ]Department of Radiology, New York University School of Medicine, New York, NY, USA.
                [5 ]Department of Neurosurgery, Naval Medical Center Portsmouth, Portsmouth, VA, USA.
                Author notes
                Correspondence to Paul P. Huang. Bellevue Hospital Center 462 First Ave, Room 7S4 New York, NY 10016, USA. Tel: 1-212-263-6414, Fax: 1-212-263-8225, paul.huang@ 123456nyumc.org
                Author information
                http://orcid.org/0000-0002-7995-9315
                Article
                10.7461/jcen.2016.18.1.42
                4842908
                27114966
                b8a6ce7c-2fd8-4b1f-84f8-c47fa0cf2aad
                © 2016 Journal of Cerebrovascular and Endovascular Neurosurgery

                This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License ( http://creativecommons.org/licenses/by-nc/3.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

                History
                : 16 December 2014
                : 27 June 2015
                : 05 July 2015
                Categories
                Case Report

                Surgery
                aneurysm,subarachnoid hemorrhage,leukocytoclastic vasculitis,hypersensitivity vasculitis,posterior spinal artery syndrome,spinal cord vascular diseases

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