Our case
History
· Male, 62 years old, headache and dizziness for two weeks.
· PE: left face and left fingers numbness, Romberg sign (+),no diplopia, muscle strength normal.
· 62岁，男性，头痛头晕2周。
· 神经系统查体：左面部及左手指麻木，Romberg征（+），无复视，肌力正常。
01
Pre-operative
Figure 1. MRI DWI shows left medulla infarction (left). DSA shows left vertebral dissecting aneurysm (right).左侧延髓梗塞，左侧椎动脉夹层动脉瘤。
Video 1. Measurement of the aneurysm.左侧椎动脉夹层动脉瘤测量。
02
Treatment Strategy
· Indication: vertebral dissecting aneurysm with related region infarction.
· Treatment: Large-coil embolization assisted double stents implantation.
· 椎动脉夹层动脉瘤，缺血改变，有治疗指征。
· 方案：大圈辅助双支架技术。
03
Operation
Figure 2. Headway-21 microcatheter was advanced to LVA distal to the dissection. Insert Hypersoft 4*8 to the dissecting site via another microcatheter Headway-17.将支架微导管Headway-21跨过夹层部位置入椎动脉，再通过栓塞微导管Headway-17将Hypersoft 4*8填入夹层部位。
Figure 3. Insert Hypersoft 3*8, 3*8 and 3*6.先后置入Hypersoft 3*8两枚，3*6一枚。
Video 2. LVIS 3.5*15 was deployed, which spanssed coils to the vessel wall.释放LVIS 3.5*15支架使弹簧圈贴壁。
Figure 4. Microwire was used to ‘massage’ the stent.微导丝‘massage’支架。
Figure 5. Headway-21 microcatheter was navigated through the stent. Then the Solitaire 4*20 was implanted.Headway-21微导管通过支架内，再置入Solitaire 4*20。
Video 3. LVA rotation showed the embolization of the aneurysm with the patent of LVA.左侧椎动脉旋转造影：动脉瘤栓塞，左侧椎动脉通畅。
Figure 6. Axial view of post-op 3D reconstruction showed patent parent artery with coils around, which was similar to the effect of flow divert.
术后轴位三维重建：载瘤动脉通畅，周围绕以弹簧圈，起到血流导向装置的作用。
04
Summary
· Multiple stents implantation without coil embolization could also be considered for this case. However, we spanfer multiple-stent assisted coiling for its reliability.
· The maneuver of Pipeline is easier but due to its off label use in posterior circulation and huge expenses, we spanfer multiple-stent assisted coil embolization.
· 该病例亦可采用单纯多支架，但是我们认为同时使用弹簧圈治疗效果更可靠。
· Pipeline虽然操作相对简单，但是在后循环属于off label使用，而且费用昂贵，因此我们使用弹簧圈辅助双支架技术替代血流导向装置。
