Spontaneous Subarachnoid Haemorrhage Due to Coarctation of Aorta and Intraspinal Collaterals: A Rare Presentation
A 40 year old hypertensive male presented with sudden onset of severe neck pain, mild giddiness and numbness of bilateralupper extremities that improved spontaneously within two hours. There were no motor deficits, bladder or bowel disturbances. General examination revealed a differential blood pressure (BP) measurement with upper extremity BP of 150/90 mmHg and lower extremity BP of 130/80 mmHg. Cardiovascular examination revealed prominent brachiofemoral pulse delay, and a continuous systolic murmur in the interscapular area. Other systems were unremarkable. Routine laboratory investigations were normal. Chest radiograph revealed inferior rib notching of bilateral lower ribs. Electrocardiogram revealed left ventricular hypertrophy. Echocardiogram showed normal chambers, bicuspid aortic valve, trivial aortic regurgitation without aortic stenosis, and normal ejection fraction. The patient underwent a Magnetic Resonance Imaging (MRI) examination of brain and cervical spine, which revealed subarachnoid hemorrhage (SAH) in the prepontine cistern () and prominent flow voids in the cervicothoracic subarachnoid space (Fig & ). Narrowing of the thoracic aorta just distal to origin of left subclavian artery (aortic isthmus) was suspected in visualized aortic segment in the sagittal images of cervical spine.\nA Computerized Tomographic (CT) aortogram was performed to evaluate further, that revealed a prominent intraspinal extramedullary collateral arising from the left subclavian artery, coursing through the spinal canal ventral to the lower cervical and upper thoracic spinal cord from C5 to D5 vertebral level and terminates in the left 3rd intercostal artery (Fig & ) anda short segment severe aortic stenosis with extensive collaterals between the pre-stenotic and post stenotic aortic segments along the anterior, posterior aspects of the chest and the abdominal walls (Fig &). Left vertebral artery was seen separately. CT cerebral angiogram revealed no intracranial aneurysms. He was managed conservatively during which his pain subsided and was subsequently discharged with a planned coarctation of aorta (CoA) repair.