To evaluate the comparative outcomes of surgical versus non-surgical interventions from a comprehensive meta-analysis and literature review.

Ruptured cervical anterior spinal artery aneurysm (CASAA) in the absence of associated arteriovenous malformation is a rare, yet, potentially devastating cause of intracranial and spinal SAH. There are no established guidelines on the optimal management of ruptured CASAAs. 

We present three cases of spinal SAH secondary to ruptured CASAA, diagnosed with CTA on day one of their presentations. All cases were managed conservatively, one with attempted and failed endovascular treatment. Two of them with < 3 mm CASAA recovered from hemorrhage with complete occlusion of the aneurysm. The third with 9 mm aneurysm, presented with severely elevated posterior fossa ICP and died 36 hours after a failed intervention.

A comprehensive meta-analysis was performed focusing on presenting symptoms/clinical grade, rates of spontaneous regression and comparative outcomes of surgical vs non-surgical interventions.

All patients presented with occult SAH, with only 30% cases found to have CASAA on the day of the presentation. 85% had an aneurysm in the upper cervical region and 80% had feeders from ASA. Twelve patients (60%) were treated with conservative management, out of which ten had a complete recovery, one had a residual neurological deficit and one expired. Amongst eight patients treated with surgical intervention, five recovered fully, two had residual deficits and one expired.

Ruptured CASAAs are difficult to diagnose due to their small size and occult radiographical presentation. Our meta-analysis suggests that the conservative approach with aggressive blood pressure management and short-term interval imaging is reasonable with good clinical outcomes and low rates of re-rupture.