Review
History
• 65 y/o female.
• Suffered from dizziness twice for 9 months. Local hospital CTA revealed right anterior communicating artery and anterior choroidal artery aneurysms.
• Med history: HTN, DM.
• Medication: Shakubaquvalsartan, Degumen Dongdi Insulin, Acarbose, Sigliptin.
• NE:(-).
• 9个月来头晕两次，当地医院CTA显示前交通动脉瘤及右侧脉络膜前动脉瘤。
• 既往史：高血压、糖尿病。
• 药物：沙库巴曲缬沙坦、德谷门冬胰岛素、阿卡波糖、西格列汀。
图 1. CTA显示前交通动脉瘤，右侧脉络膜前动脉瘤。左侧大脑前动脉A1段发育不良。手术路径迂曲。
图 2. DSA证实前交通动脉瘤，右侧脉络膜前交通动脉瘤，左侧大脑前动脉A1段发育不良。
Figure 3 GIF. DSA confirmed anterior communicating artery irregular aneurysm and right anterior choroidal aneurysm with a daughter sac. Right anterior choroidal artery originate from the neck of aneurysm.
图 3 GIF. DSA证实前交通不规则宽颈动脉动脉瘤主要累及同侧A2段与前交通动脉，右侧脉络膜前动脉瘤伴子瘤，右侧脉络膜前动脉自动脉瘤颈部发出。
1
Strategy
1.Anterior communicating artery aneurysm with irregular shape presents a high rupture risk which should be treated.
2.The anterior communicating artery aneurysm was mainly involved ipsilateral A2 segment. Solitaire stent should be deployed in the ipsilateral ACA.
3.Solitaire stent protects and straightens the parent artery, diminishing blood flow to reduce the aneurysm recurrence rate.
4.Solitaire stent proximal portion should be implanted A1 segment to avoid affecting ICA Neuroform EZ stent deployment.
5.Due to underdeveloped contralateral A1, the anterior communicating artery should be preserved via proper working projection and large coil technique.
6.Stenting microcatheter should be routinely shaped to increase trafficability.
7.Straight tip coiling microcatheter can be tried for stable coiling.
Stent microcatheter shaping and trafficability.
Preserving ipsilateral A2 segment and anterior communicating artery
Dangerous points:
Intraoperative aneurysm ruptured.
Occlusion of ipsilateral A2 segment and anterior communicating artery.
前交通动脉瘤治疗指征：
1.不规则前交通动脉瘤，破裂风险高，建议治疗。
2.前交通动脉瘤主要累及同侧A2段。应在同侧大脑前动脉内放置Solitaire支架。
3.Solitaire支架可以保护并拉直载瘤动脉，减少血流冲击，降低动脉瘤复发几率。
4.Solitaire 支架近端应当释放在A1段，避免影响近端Neuroform EZ支架的释放。
5.由于对侧A1发育不良，前交通动脉应通过大线圈技术保护。
6.支架微导管应常规塑形以增加其通过性。
7.栓塞前交通动脉瘤应选用直头微导管保证栓塞的稳定性。
支架微导管的形状和通过性。
保证同侧A2段和前交通动脉血流通畅。
危险点：
术中动脉瘤破裂。
同侧A2段与前交通动脉闭塞。
1.Right anterior choroidal artery aneurysm with a daughter sac presents high rupture risk which should be treated.
2.Stent-assisted coiling was preferred for the wide-necked aneurysm. Right anterior choroid artery originates from the aneurysm neck. Relatively large coils can be inserted to preserve right anterior choroidal artery and decrease the recurrence rate.
3.Meshing technique is preferred to decrease intraoperative rupture during stent deployment via Jailing technique.
4.Choroidal artery tiny aneurysm with low recurrence rate need not densely packed, avoiding anterior choroidal artery occlusion risk.
5.Flow diverter stent is an alternative for the anterior choroidal artery aneurysm.
Coiling microcatheter shaping and navigation.
Large coil technique preserving anterior choroidal artery.
Dangerous points:
Intraoperative aneurysm ruptured.
Occlusion of anterior choroidal artery.
右侧脉络膜前动脉瘤治疗指征：
1.右侧脉络膜前动脉瘤伴子瘤，破裂风险高，建议治疗。
2.右侧脉络膜前动脉自动脉瘤颈部发出，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。
3.采用穿网孔技术减少放置支架时栓塞导管刺破动脉瘤的风险。
4.脉络膜动脉瘤不追求致密栓塞，小动脉瘤复发风险低，以免脉络膜前动脉有闭塞的风险。
5.脉络膜前动脉瘤也可以采用血流导向支架。
栓塞微导管的成型和超选。
保证脉络膜前动脉通畅。
危险点：
术中动脉瘤破裂。
脉络膜前动脉闭塞。
2
Operation
图 4. 6F Envoy DA放置于右侧颈内动脉海绵段。给予尼莫地平1ml。在Synchro-2微丝导引下，将塑“C”型的Prowler plus支架微导管置入右侧大脑前动脉A2段。释放Solitaire 4*20mm支架。
图 5 GIF. 支架植入术后，载瘤动脉角度被拉直。重新三维旋转造影，寻找新的栓塞角度。
图 6. 动脉瘤大小3.76*3.61mm，瘤颈4.67mm。设置红色安全线是用来保护同侧的A2段及前交通动脉。直头Echelon-10微导管在Synchro-2微导丝导引下置于动脉瘤腔。
Figure 7. Inserted 2 Target helical 4*8 coils in sequence. Unfavorable location of target helical 3*10.
图 7. 依次填入2枚Target helical 4*8，Target helical 3*10填入位置欠满意。
Figure 8 GIF. Adjusting the last coil (target helical 3*10), suspected rupture sign from a coil loop protrude the outline of the aneurysm. Fluoroscopy showed no hemorrhage. Anterior communicating artery was patent. Retrieval of coiling microcatheter. Tirofiban 7ml was given.
图 8 GIF. 调整最后一枚弹簧圈 (target helical 3*10)，弹簧圈袢突出动脉瘤轮廓，怀疑出血可能。冒烟未见出血。再次造影证实前交通动脉通畅。撤出栓塞导管。灌注替罗非班7ml。
图 9. 动脉瘤大小2.34*2.04mm，瘤颈2.45mm，近端载瘤动脉直径2.66mm，远端载瘤动脉直径3.09mm。XT-27微导管在微导丝导引下置于右侧大脑中动脉M1段。Neuroform EZ 3.0*15mm支架于瘤颈部释放。
图 10. Echelon-10 45°微导管在Synchro-2微导丝导引下置于动脉瘤腔。依次填入Target 2*4及1.5*2。
Figure 11 GIF. Anterior communicating artery aneurysm and anterior choroidal artery aneurysm were packed satisfactorily. Anterior communicating artery and anterior choroidal artery patent and intracranial vessels intact. Tirofiban 7ml was given.
图 11 GIF. 复查造影前交通动脉瘤及脉络膜前动脉瘤栓塞满意。前交通动脉及脉络膜前动脉通畅，颅内血管显影完好。灌注7ml替罗非班。
图 12 GIF. Dyna-CT证实支架扩张满意，未见出血。术后MRI未见明显脑梗灶。
3
Post-Operation
Medication:
Aspirin and Clopidogrel were administered 3 days before operation.
Maintained Tirofiban 7ml/h for 24h.
Teg: AA 100%, ADP 93.7%.
CYP2C19 NM.
药物：
术前3天已给予口服阿司匹林及氯吡格雷。
替罗非班7ml/h维持24小时。
血栓弹力图：阿司匹林抑制率100%, 氯吡格雷抑制率 93.7%.
4
8M-FU
Figure 13 GIF. The anterior communicating artery aneurysm and anterior choroidal artery aneurysm were not relapsed, while anterior communicating artery and right anterior choroidal artery patent by 8 month follow up.
图 13 GIF. 8个月复查脑血管造影前交通动脉瘤及右侧脉络膜前动脉瘤未见复发，前交通动脉及右侧脉络膜前动脉通畅。
图 14 GIF. 8个月随访动脉瘤未见复发，支架内无狭窄，颅内血管完好。
5
Summary
1.Anterior communicating artery aneurysm with irregular shape presents a high rupture risk which should be treated.
2.The anterior communicating artery aneurysm was mainly involved ipsilateral A2 segment. Solitaire stent should be deployed in the ipsilateral ACA.
3.Solitaire stent protects and straightens the parent artery, diminishing blood flow to reduce the aneurysm recurrence rate.
4.Solitaire stent proximal portion should be implanted A1 segment to avoid affecting ICA Neuroform EZ stent deployment.
5.Due to underdeveloped contralateral A1, the anterior communicating artery should be preserved via proper working projection and large coil technique (SL-10 microcatheter or Atlas can be selected).
6.Stenting microcatheter should be routinely shaped to increase trafficability.
7.Straight tip coiling microcatheter can be tried for stable coiling.
Stent microcatheter shaping and trafficability.
Preserving ipsilateral A2 segment and anterior communicating artery.
Dangerous points:
Intraoperative aneurysm ruptured.
Occlusion of ipsilateral A2 segment and anterior communicating artery.
前交通动脉瘤治疗指征：
1.不规则前交通动脉瘤，破裂风险高，建议治疗。
2.前交通动脉瘤主要累及同侧A2段。应在同侧大脑前动脉内放置Solitaire支架。
3.Solitaire支架可以保护并拉直载瘤动脉，减少血流冲击，降低动脉瘤复发几率。
4.Solitaire 支架近端应当释放在A1段，避免影响近端Neuroform EZ支架的释放。
5.由于对侧A1发育不良，前交通动脉应通过合适的工作角度及大圈技术保护（可采用SL-10微导管或Atlas支架保护）。
6.支架微导管应常规塑形以增加其通过性。
7.栓塞前交通动脉瘤应选用直头微导管保证栓塞的稳定性。
支架微导管的形状和通过性。
保证同侧A2段和前交通动脉血流通畅。
危险点：
术中动脉瘤破裂。
同侧A2段与前交通动脉闭塞。
1.Right anterior choroidal artery aneurysm with a daughter sac presents high rupture risk which should be treated.
2.Stent-assisted coiling was preferred for the wide-necked aneurysm. Right anterior choroid artery originates from the aneurysm neck. Relatively large coils can be inserted to preserve right anterior choroidal artery and decrease the recurrence rate.
3.Meshing technique is preferred to decrease intraoperative rupture during stent deployment via Jailing technique.
4.Choroidal artery tiny aneurysm with low recurrence rate need not densely packed, avoiding anterior choroidal artery occlusion risk.
5.Flow diverter stent is an alternative for the anterior choroidal artery aneurysm.
Coiling microcatheter shaping and navigation.
Large coil technique preserving anterior choroidal artery.
Dangerous points:
Intraoperative aneurysm ruptured.
Occlusion of anterior choroidal artery.
脉络膜前动脉瘤治疗指征：
1.右侧脉络膜前动脉瘤伴子瘤，破裂风险高，建议治疗。
2.右侧脉络膜前动脉自动脉瘤颈部发出，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。
3.采用穿网孔技术减少放置支架时栓塞导管刺破动脉瘤的风险。
4.脉络膜动脉瘤不追求致密栓塞，小动脉瘤复发风险低，以免脉络膜前动脉有闭塞的风险。
5.脉络膜前动脉瘤也可以采用血流导向支架。
栓塞微导管的成型和超选。
大圈技术保证脉络膜前动脉通畅。
危险点：
术中动脉瘤破裂。
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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