Ruptured spinal artery aneurysms, <1% of SAH, pose challenges in understanding and management . In contrast to intracranial aneurysms, they often manifest with symptoms like back pain and possibly myelopathy.

 While morbidity and mortality seem low, limited data makes generalizations difficult. Fatalities have resulted from re-ruptures. Management options—surgical clipping, endovascular treatment, and conservative care—lack consensus. Surgical clipping appears to be most common, recommended for rebleeding prevention. However, some advocate conservative care due to spontaneous regression and low rebleeding risk.

Our study presents five cases of spinal SAH from posterior spinal artery aneurysms. Patients aged 58-81, with three males and two females, who underwent spinal angiography and a repeat angiogram in 1-9 days between 2018 and 2022 at two Denver institutions. 

Notably, our study is the largest single practice case series to date. All patients initially reported back pain, with three experiencing leg paresthesias. One patient had confusion and a seizure. Four of the five were hypertensive. Crucially, all five patients achieved resolution and aneurysm occlusion on repeat angiograms. Our findings highlight the potential of conservative care for ruptured spinal artery aneurysms, with spontaneous thrombosis demonstrated on short-term follow-up angiograms.

 Based on our results, we propose a "hybrid" approach: starting with conservative management and angiographic follow-up in 3 to 7 days, typically when most aneurysms occlude. Clinical deterioration or persistent/worsening angiographic features at one week would prompt endovascular or surgical intervention as needed.