• CC: Suffering from right blepharoptosis with double vision and headache for 1 month.• NE: Right ptosis and partial paralysis of right superior rectus. Width of palpebral fissure: R: 4mm, L: 6mm. Bilateral eye movement and light reflex normal.Bilateral pupils normal (2mm).• Med history: Left breast cancer; left lung carcinoma in situ. Meningioma in the parietal region. No HTN or DM.• 查体：右眼睑下垂，右眼上直肌不全麻痹；眼裂：右侧4mm，左侧6mm；双眼球运动可、大小2mm，对光反射灵敏。• 病史：左乳腺癌；左肺原位癌；左顶部脑膜瘤。无高血压、糖尿病。Figure 1. High resolution MRI show a large right ICA aneurysm with significant circumferential aneurysm wall enhancement. 高分辨率MRI提示右侧颈内动脉巨大动脉瘤，瘤壁明显环形强化。
Video 1. Angiography confirms a large right cavernous sinus aneurysm. 脑血管造影证实右侧海绵窦巨大动脉瘤。
Figure 2. Underdeveloped left A1 segment. 左侧A1段发育不佳。
1. Due to a high rupture risk and mass effect, such a large aneurysm requires treatment. 2. As the left A1 segment was underdeveloped, the dominant right ICA must be spanserved.3. Pipeline was inadvisable in this case because:• Pipeline implantation may still require coiling, which could induce mass effect.
• More than one Pipeline may be needed to control the flow jet.
• Furthermore, Pipeline has a high risk of long term intra-stent stenosis or occlusion.
4. For a large CS aneurysm, stent assisted or simple coiling technique is the spanferred treatment.1. 这个大动脉瘤破裂风险高、有占位效应，建议治疗。2. 由于左侧A1段发育不良，右侧优势颈内动脉必须保留。3. 该病例不推荐Pipeline治疗，原因如下：• Pipeline治疗后可能仍需要弹簧圈填塞，占位效应不能解除。
• 该病例可能需要多枚Pipeline才能控制射流。
• 此外，Pipeline长期支架内狭窄及闭塞风险高。
4. 对于海绵窦段巨大动脉瘤，优先选择支架辅助或单纯弹簧圈栓塞治疗。
Figure 3. Measurements. 测量。
Video 2. General heparinization. Prowler Plus and “C” curve Echelon-10 microcatheters were navigated into the sac. 全身肝素化。微导管Prowler Plus 及Echelon-10超选入动脉瘤内。
Video 3. 16 coils were deployed sequentially via Prowler-plus. 经Prowler-plus微导管填入16枚弹簧圈。
Figure 4A. MicroPlex-18 20mm*50cm (4), 18mm*44cm (7), 16mm*39cm (3), 11mm*28cm (2) coils. 依次填入弹簧圈MicroPlex-18 20mm*50cm (4), 18mm*44cm (7), 16mm*39cm (3), 11mm*28cm (2) 。
Figure 4B. MicroPlex-18 20mm*50cm (4), 18mm*44cm (7), 16mm*39cm (3), 11mm*28cm (2) coils. 依次填入弹簧圈 MicroPlex-18 20mm*50cm (4), 18mm*44cm (7), 16mm*39cm (3), 11mm*28cm (2) 。
Figure 5 GIF. Angiography shows parent artery patent and the intact of intracranial vessels. 血管造影显示载瘤动脉通畅，右侧颈内动脉完好。
Figure 6. Inserting MicroPlex-10 10mm*30cm (4) coils via Echelon-10. 经Echelon-10填入4枚MicroPlex-10 10mm*30cm弹簧圈。
Figure 7 GIF. Angiography shows densely packing of the aneurysm with parent artery patent and intact intracranial vessels. Tirofiban 6ml and Nimodipine 1ml were administrated via the guiding catheter. 血管造影显示动脉瘤致密填塞，载瘤动脉通畅。经导引导管予替罗非班6ml、尼莫地平1ml。
Post operation complication
• 24 hours later, right eye paralysis aggravated. Severe headache with nausea and vomiting.• PE: Right eye ptosis worsen with impaired adduction. Right pupil enlarged to 3-4mm and had no light reflex.• Medication: Mannitol 250ml q6h, Methylspandnisolone 120mg, 80mg, 40mg (dosage decreasing over three days), Mecobalamin 0.5mg tid• 24h后，患者右眼睑下垂加重，伴剧烈头痛、恶心呕吐。• 查体：右侧眼睑下垂加重，伴内收受限。右侧瞳孔3-4mm，对光反射消失。• 药物处理：甘露醇 250ml q6h，甲强龙120mg、80mg、40mg (3天内逐渐减量)，甲钴胺 0.5mg tid。• Four days later, the symptoms and signs improved. Still with left right eye pain and ptosis. Discharge was permitted.• PE: left pupil 2mm with normal light reflex, right pupil 3mm with impaired light reflex. Right eye ptosis with restricted abduction.• Medication: Aspirin 100mg qd po.• 4天后患者症状改善，仍残留右眼疼痛、右眼睑下垂，予以办理出院。• 查体：左侧瞳孔2mm、对光反射灵敏；右侧瞳孔3mm，对光反射消失，右眼睑下垂伴内收受限。• CC: Improved right eye ptosis.• Med history: Meningioma in the parietal region remained untreated and continue clinical follow up.• Medicine: Aspirin for one month then stopped.• PE: Right blepharoptosis. Width of palpebral fissure: R: 4mm, L: 6mm. Right eye adduction resisted without light reflex. Right pupil:3.5mm, Left pupil:2mm.• 查体：右眼睑下垂。右侧眼裂4mm，左侧眼裂6mm。右眼内收受限伴对光反射消失。右侧瞳孔3.5mm，左侧瞳孔2mm。
Figure 8. Improved right eye ptosis. 右眼睑下垂改善。
Figure 9 GIF. Follow-up angiography shows no relapse of the aneurysm. Next DSA follow up is scheduled in 3 years. 复查造影未见动脉瘤复发。建议3年后DSA随访。
1. Due to a high rupture risk and mass effect, such a large aneurysm requires treatment. 2. With the left A1 segment underdeveloped, spanservation of the right ICA is paramount.3. Pipeline was inadvisable in this case because:• Pipeline implantation may still require coiling, which could induce mass effect.
• More than one Pipeline may be needed to control the flow jet.
• Furthermore, Pipeline has a high risk of long term intra-stent stenosis or occlusion. For a large CS aneurysm, stent assisted coiling or coiling technique is the primary treatment.
4. Prowler Plus, a stiff micro-catheter, was selected to insert large and stiff coils. （18 系）5. Large coiling technique should reduce the recurrence rate, however mass effect may occur.Mass effect caused by large coil technique will be relieved gradually during long-term follow up. 6. Thrombus formation is the main cause of mass effect.7. FD stenting could be used at the second stage if recanalization occurs, though post-operative stenosis is a concern.1. 破裂风险高、占位效应明显的大动脉瘤，建议治疗。2. 左侧A1段发育不良，右侧优势颈内动脉必须保留。3. 该病例不推荐Pipeline治疗，原因如下：• Pipeline治疗后可能仍需要弹簧圈填塞，占位效应不能解除。
• 该病例可能需要多枚Pipeline才能控制射流。
• 此外，Pipeline长期支架内狭窄及闭塞风险高。海绵窦段巨大动脉瘤，优先选择支架辅助或单纯弹簧圈栓塞治疗。
4. 通过Prowler Plus微导管填入18系大圈。5. 大圈技术能降低复发率，但可能引起占位效应，大圈填塞导致的占位效应随着时间推移可以减轻。7. 如果动脉瘤复发，二期治疗可使用血流导向装置，但术后支架内狭窄是主要问题。
