Ruptured venous aneurysm of cervicomedullary junction
A 52-year-old male with no known previous comorbidities presented with sudden onset headache, vomiting, and transient loss of consciousness. Patient was conscious but disoriented with no focal motor/sensory deficit. Computed tomography (CT) head revealed subarachnoid hemorrhage (SAH) with intraventricular hemorrhage (IVH) [].\nComputerized tomography angiography (CTA) [Figure –] and digital substraction angiography (DSA) [Figure and ] revealed a saccular contrast filling pouch in the left lateral aspect of CMJ. The filling was seen in early venous phase on DSA. No arterial feeder could be demonstrated. There was no AVM in the vicinity of the lesion suggesting a diagnosis of solitary alone venous aneurysm.\nPatient was operated through a midline suboccipital craniectomy with excision of posterior arch of atlas. Dura was opened in Y shape. There was no apparent dural AVM. There was evidence of old subarachnoid blood with presence of thick subarachnoid adhesions. A saccular pliable structure approx. 1.5 × 1cm was found in the subarachnoid space. Its color was indicative of venous blood. Careful dissection revealed the attachment/neck of the aneurysm with a vein. There were no arterial feeders, or evidence of surrounding AVM or dilated perimedullary vein. This aneurysm was clipped and excised [Figure –]. Gross examination revealed a thin walled vascular structure with no arterial ostia. There was a thrombus present. HPR revealed a single layer of fibromuscular tissue lined [] by a flat endothelium. There were no signs of sclerosis or inflammation. There was no muscle layer [Figure and ]. Patient was discharged on 5th postoperative day. Postoperative DSA did not show any aneurysm/AVM. On the last follow up at 5 months after surgery, the patient has no focal deficits and has joined work.