Review
History
• Past medical history: HTN; alcohol consumption for 40 years.
• PE: (-)
• 体检发现左侧颈内动脉瘤一年半。
• 既往史：高血压；吸烟40余年。
• 体格检查：-。
图 1 GIF. 造影示左侧脉络膜前动脉瘤伴子瘤，左侧脉络膜前动脉自动脉瘤颈部发出。
1
Strategy
1.Left anterior choroidal artery aneurysm with daughter sacs indicating a high rupture risk, was suggested treatment.
2.The anterior choroidal artery originated from the aneurysm neck, which should be preserved.
3.Stent-assisted coiling was preferred for the wide-necked aneurysm. Relatively large and long coils can be inserted to preserve left anterior choroidal artery and decrease the recurrence rate.
4.Flower divertor was an alternative choice.
2.脉络膜前动脉自动脉瘤颈部发出，术中需要保护。
3.宽颈脉络膜前动脉动脉瘤，拟采用大圈辅助支架整体栓塞策略，保护脉络膜前动脉，降低复发风险。
4.该动脉瘤也可以采用血流导向装置。
2
Operation
Figure 2. General anesthesia and general heparinization were performed. Aneurysm size 3.79*4.12mm, neck 2.7mm, proximal parent artery 3.47mm, distal parent artery 3.72mm. 6F Envoy DA was placed into the left cavernous segment via a 125cm MP. Nimodipine 1ml was administered. XT-27 microcatheter was navigated into the left M2 segment and spiral-curved Echelon-10 microcatheter into the sac. Deployed a Neuroform EZ 3.5*15mm.
图 2. 全麻成功后，行全身肝素化。动脉瘤大小3.79*4.12mm，瘤颈2.7mm，近端载瘤动脉直径3.47mm，远端载瘤动脉直径3.72mm。将6F Envoy DA导引导管在125cmMP导管支撑下置于左侧颈内动脉海绵窦段。经导引导管给予尼莫地平1ml。XT-27微导管在微导丝导引下置于左侧大脑中动脉M2段，Echelon-10微导管塑内螺旋形置于瘤腔。Neuroform EZ 3.5*15mm支架于瘤颈部释放。
Figure 3. Inserted 5 coils in sequence (Target-helical 4mm*8cm, Target-360 4mm*8cm (x3) and Target-360 4mm*8cm (cut 2cm)).
图 3. 依次填入5枚弹簧圈(Target-helical 4mm*8cm, 4枚Target-360 4mm*8cm，最后一枚Target-360 4mm*8cm头端减去 2cm)。
Figure 4 GIF. The aneurysm was packed satisfactorily. Tirofiban 8ml & nimodipine 0.5ml were administered.
图 4 GIF. 复查造影，动脉瘤栓塞满意。经导引导管予替罗非班8ml尼莫地平0.5ml。
图 5 GIF. 复查造影左侧脉络膜前动脉通畅，颅内血管完好。
图 6 GIF. 术后Dyna-CT未见出血。
3
Post-Operation
•Immediately post-operative neurologic examination:
GCS 15, bilateral pupils movement and light reflux normal, bilateral muscle strength V, sensation normal, bilateral Babinski negative.
•Medication:
Aspirin and Clopidogrel were administered 3 days before operation.
Maintained Tirofiban 6ml/h.
•Teg:
AA 80.3%, ADP 100%
CYP2C19 IM.
•2 hours after operation:
NE: GCS 15, bilateral pupils movement and light reflux normal, right-sided central facial palsy, right upper limb III, right lower limb III, left muscle strength V, sensation normal, right Babinski positive.
•Emergent treatments:
a.Emergency cranial CT: negative.
b.Half dose of heparization.
c.Tirofiban increased to 10ml/h.
NE: GCS 15, bilateral pupils movement and light reflux normal, bilateral muscle strength V, sensation normal, bilateral Babinski negative.
Medication: Tirofiban 10ml/h maintained for 24 hours, then decreased to 6ml/h for 24 hours.
•术后即刻查体：
GCS 15, 双侧瞳孔运动正常，对光反射灵敏，双侧肌力正常，双侧感觉对称，双侧Babinski阴性。
•药物：
术前3天已给予口服阿司匹林及氯吡格雷。
替罗非班6ml/h维持。
•血栓弹力图：
阿司匹林抑制率80.3%, 氯吡格雷抑制率 100%
氯吡格雷基因代谢慢代谢，酶活性偏低。
•术后2小时查体:
NE: GCS 15,双侧瞳孔运动正常，对光反射灵敏，右侧中枢性面瘫，右侧肌力III，左侧肌力正常，双侧感觉对称，右侧Babinski阳性。
•紧急处理措施：
a.复查急诊头颅CT平扫：未见出血。
b.予半量肝素化。
c.替罗非班加量至 10ml/h维持。
NE: GCS 15, 神经查体恢复正常，双侧瞳孔运动正常，对光反射灵敏，双侧肌力正常，双侧感觉对称，双侧Babinski阴性。
药物：替罗非班10ml/h维持24小时, 减量至6ml/h继续维持24小时。
图 7. 术后第一天DWI提示左侧侧脑室旁急性脑梗死。右侧肌力恢复正常，视野未见缺损，感觉正常，查体未见神经功能缺损。
4
7M-FU
Video 1. The aneurysm was not relapsed and left anterior choroidal artery patent by 7 month follow up.
视频 1. 7个月复查脑血管造影动脉瘤未见复发，左侧脉络膜前动脉通畅。
Video 2. No intra-stent stenosis occurred and intracranial vessels intact by 7 month follow up.
视频 2. 7个月随访支架内无狭窄，颅内血管完好。
5
Summary
1.Left anterior choroidal artery aneurysm with daughter sacs indicating a high rupture risk, was suggested treatment.
a. Coiling microcatheter shaping and stability.
b. Preserve the anterior choroidal artery.
a. Intraoperative aneurysm ruptured.
b. Intraoperative and postoperative thrombosis. Therefore, drugs should be used immediately for intraoperative thrombus formed, CT examination should be performed as soon as possible when postoperative symptoms appear, DSA examination also could be performed if necessary and heparinization and tirofiban should be administrated in time.
a. Emergency cranial CT to exclude hemorrhage.
b. Half dose of heparization.
c. Tirofiban maintained.
7.The aneurysm was no recurrence and the choroidal artery was patent by 7 month follow up. Stop aspirin and continue Atorvastatin. Long-term follow-up is still needed.
1.左侧脉络膜前动脉伴子瘤，破裂风险高，建议治疗。
a. 栓塞微导管的塑形和稳定。
b. 脉络膜前动脉自动脉瘤颈部发出，术中需要保护。
3.危险点：
a. 术中动脉瘤破裂。
b. 术中术后血栓形成。所以术中血栓形成应即刻使用药物，术后出现症状时及时复查CT和必要时行DSA检查，同时及时肝素化及应用替罗非班。
4.宽颈脉络膜前动脉动脉瘤，采用大圈辅助支架整体栓塞策略(均选择直径4mm的弹簧圈)，当栓塞微导管稳定的情况下，可保护脉络膜前动脉，降低复发风险。
5.该动脉瘤也可以采用血流导向装置。
a. 急查头颅CT平扫排除出血。
b. 半量肝素化。
c. 替罗非班维持。
7.术后7个月随访脉前动脉瘤未见复发，脉络膜前动脉血流通畅。暂停阿司匹林，继续口服阿托伐他汀。仍需长期随访。
张晓龙
复旦大学附属华山医院
复旦大学附属华山医院放射科主任医师，博士、教授、博士生导师;
斯坦福大学医学院客座临床教授;
主持国家自然科学基金3项，第一作者或通讯作者发表国内外权威期刊文章50余篇;
中华医学会、放射学会、卫生部医政司等组织中担任副主任委员、组长等职务.《中国名医百强榜》神经介入专业中国十强（2012年度、2013年度、2014年度、2015-16年度、2017-18年度）;
擅长复杂和疑难脑血管疾病的介入治疗，如复杂脑动脉瘤的栓塞，硬脑膜动静脉瘘栓塞，脑动静脉畸形栓塞，脑梗死的支架，脊髓血管畸形治疗;
自1995年开始从事脑血管疾病介入诊治工作和研究，师从黄祥龙教授、沈天真教授和凌锋教授，是我国最早从事神经介入的专家之一。2010年9月至今连续介入治疗颅内动脉瘤1500余例,无操作致死。
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