Introduction: Spinal subarachnoid hemorrhage (SAH) is called hematorrhachis, the incidence is lower than 1% of all the SAH reported in the literature. The most common etiology of a spinal SAH is a spinal-cord arteriovenous malformation (AVM) and bleeding complication of intraspinal neoplasms (predominantly neurinomas and ependymomas). Spinal aneurysms are an extremely rare entity that is usually associated with certain conditions such as AVM, arteriovenous fistulas, polyarteritis nodosa and aortic coartaction. An isolated spinal aneurysm is so rare that in a series of 3,000 spinal angiograms only one was found.

Case report: A 67-year-old, right-handed female presented with a 5-day progress of sudden severe dorsalgia and moderate headache and 2-day gait alteration, bladder disturbance and drowsiness, 4/5 symmetric weakness of lower limbs. The initial MRI shows an anterior spinal hemorrhage. A selective spinal angiogram evidenced a D4 level Anterior Spinal Artery (ASA) aneurysm and a diffuse mild to moderate cerebral vasospasm in both Anterior and Medial cerebral arteries as well as the basilar artery in the cerebral angiogram. In view of the clinical and radiological findings, surgery was excluded, and a conservative approach was preferred. The patient experienced an improvement of pain, level of consciousness, urinary continence and gait.

Discussion: An isolated aneurysm as a cause for a spontaneous spinal subarachnoid hemorrhage is very rare. The diagnosis may be delayed due to absence of neurological deficits. Our treatment approach can be compared to 4 cases described by Berlis et al. and Longatti et al. in reports of 2005, 2006 and 2008. Controversy may arise from literature reporting an endovascular or surgical resolution for this pathology as mentioned by González et al. and Lavoie et al. However, in a patient with no neurological deficits there is more to lose. A close follow-up was conducted with radiological resolution of the SAH.