MRI:13 Nov 2008- showed extensive cord changes and a tortuous flow void in the anterior thecl sac with a globular void at top of the serpentine vessel.

MRI:20 Dec 2008: clearly shows presence of severe hematomyelia. A diagnosis of spinal arterio-venous malformation was kept.

DSA: 2nd March 2009:

The aarch aortogram revealed a bunch of tortuous vessels aat root of neck bilaterally as well as amidline tortuous vessel (the anterior spinal artery) with an aneurysm. But what was surprising was that some of these vessels opened in the aorta lower down.

Suprised a thoracic aortogram was done which rrevealed a coarctation!

And, a review of the MR image donw earlier showed the finding very well.

The chest x ray reviewed now revealed ell-tale signs-large heart and rib notching!

and no one had read it well.

The problems in this case were:

1. Femoral pulses were palpable and equal on both sides

2. Radial pulses not compared with femoral pulses initially

3. Patient was non-hypertensive

4. No evidence of limb ischaemia

5. During angiogram the catheter and guidewire used to pass up straight due to the low coarctation hence could not be made out.

Trans-coarctation gradient of 30 mm Hg was recorded at angiography

Two Embolisation Attempts: 12 March and 16th March 2009

Failed as the feeding artery located within the mesh of tortuous vessels could not be catheterized

Patient was sent to the surgeons who attempted to operate -ligated some of the vessels entering the Cervical canal from the right side at C6 level in the hopw that the feeding artery could be excluded from circulation.

Post surgery MRI: 2nd April 2009 (POD2)

Discussion

Etiology of Spinal artery aneurysm (Rengachary et al)

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