Stent Assisted Coiling of Left V4 Segment Dissecting Aneurysm - 脑医汇 - 神外资讯

Review

History

• 58 y/o, male.

• Suffered from vertigo for 20 days.

• Medical history: HTN for 6 years, controlled well; smoking cigarettes for 39 years, 1.5 pack/d, no quitting.

• Medication: Aspirin, Irbesartan and Atorvastatin. Clopidogrel was added 2 days before operation.

• NE: (-)

• 58岁，男性。

• 头晕伴视物旋转20天。

• 既往史：高血压6年，血压控制良好；吸烟39年，平均1.5包/天，未戒烟。

• 药物：阿司匹林，厄贝沙坦，阿托伐他汀。术前2天加用氯吡格雷。

• 神经查体：-。

Figure 1. Cervical CTA revealed a left V4 segment dissecting aneurysm.

图 1. 颈部CTA提示左侧椎动脉V4段夹层动脉瘤。

Figure 2 GIF. HR-MRI depicted a left V4 segment dissecting aneurysm with wall enhancement and thrombosis formation.

图 2 GIF. HR-MRI提示左侧椎动脉V4段夹层动脉瘤伴血栓形成，动脉瘤瘤壁明显强化。

Figure 3 GIF. DSA confirmed a left V4 segment dissecting aneurysm.

图 3 GIF. DSA证实左侧椎动脉V4段夹层动脉瘤。

Strategy

1、A V4 segment dissecting aneurysm harboured a potential rupture or ischemic risk which should be treated.

2、ASA should be protected to prevent ischemic event.

3、Stent assisted large coiling technique was adopted to lower recurrence, and larger coils can avoid protruding into parent artery through stent mesh.

4、Flow divertor can be another choice.

1、V4段夹层动脉瘤有破裂出血及脑梗风险，建议治疗。

2、脊髓前动脉需要保护。

3、计划采用支架辅助大圈栓塞技术，降低术后复发风险。同时大圈栓塞能防止弹簧圈经支架网孔向载瘤动脉突出。

4、该夹层动脉瘤也可以采用血流导向装置。

Operation

Figure 4. General heparinization was performed. 6F 105cm Tonbridge was placed into left VA initial segment via a 125cm MP and 0.035 wire. Nimodipine 1ml was administered. Then 125cm MP was advanced into left V4 segment. XT-27 microcatheter was advanced into basilar artery and C-curved Echelon-10 into aneurysm sac. Target 360 ultra 5mm*20cm coil failed to frame satisfactorily, therefore Neuroform EZ 3.5*20mm was deployed first. The following coils (Target 360 ultra 5mm*20cm, 5mm*15cm (2), Perdenser 3d 5mm*15cm (2), 4mm*15cm (2) and 4mm*10cm) were inserted in sequence.

图 4. 行全身肝素化。将6F 105cm Tonbridge中间导管在125cm MP和0.035导丝支撑下置于左侧椎动脉起始部，予尼莫地平1ml。再将125cm MP导引导管置于左侧椎动脉V4段。选用XT-27微导管置于基底动脉近端，Echelon-10微导管头端塑“C”弯后超选入动脉瘤腔内。尝试填入Target 360 ultra 5mm*20cm弹簧圈，成篮不满意。遂先释放Neuroform EZ 3.5*20mm支架。然后依次填入8枚(Target 360 ultra 5mm*20cm, 5mm*15cm (2), Perdenser 3dmm*15cm (2), 4mm*15cm (2) and 4mm*10cm)弹簧圈。

Figure 5 GIF. Angiograms showed the dissecting aneurysm invisible and ASA patent. Tirofiban 8ml was administered.

图 5 GIF. 复查造影示夹层动脉瘤不显影，脊髓前动脉显影良好。经导引导管予替罗非班8ml。

Figure 6 GIF. Intracranial vessels were intact.

图 6 GIF. 复查造影示颅内血管显影良好。

Figure 7. Post-operative dyna-CT did not demonstrate any hemorrhage.

图 7. 术后dyna-CT未见出血。

Post-Operation

•NE: GCS 15, bilateral pupils movement and light reflux normal, bilateral muscle strength V, normal swallowing, bilateral Babinski negative.

•Medication: Tirofiban 5ml/h maintained for 24 hours. Continue Aspirin and Clopidogrel. TEG: ADP 94.8%，AA 77.4%.

•神经查体：GCS 15, 双侧瞳孔运动正常，对光反射灵敏，双侧肌力正常，吞吐正常，双侧Babinski阴性。

•药物：替罗非班5ml/h维持24h。继续阿司匹林和氯吡格雷。血栓弹力图：氯吡格雷抑制率97%，阿司匹林抑制率77.4%。

Figure 8 GIF. No acute infarctions were detected from DWI.

图 8 GIF. DWI 未见急性脑梗死。

Video 1. Angiograms depicted the dissecting aneurysm without recurrence and parent artery patent by 9 month follow up.

视频 1. 术后9月复查造影，夹层动脉瘤未见复发，载瘤动脉通畅。

Video 2. The dissecting aneurysm was no relapsed by 9 month follow up

视频 2. 术后9月复查造影夹层动脉瘤无残留。

Summary

1、A V4 segment dissecting aneurysm harboured a potential rupture or ischemic risk which should be treated.

2、Stent assisted large coiling technique was adopted to lower recurrence. During the procedure, a stent was deployed first because of unfavorable basket.

3、Coiling microcatheter location should be adjusted according to the sac remnant space. The last 3 coils inserted into the bottom of the aneurysm.

4、The large coil technique, which functions as an intra-saccular flow diverter, can not only protect anterior spinal artery but also reduce the recurrence rate. Flower diverters can be another choice for the dissecting aneurysm. While the anterior spinal artery originated nearby, it may be affected by flower diverters.

5、Long-term follow up was still needed.

1、V4段夹层动脉瘤有破裂出血及脑梗风险，建议治疗。

2、本病例采用了支架辅助大圈栓塞技术，降低术后复发风险。术中由于反复尝试首枚弹簧圈成篮不满意，故先释放了支架。

3、栓塞时应根据残余瘤腔调整栓塞微导管的位置。最后3枚弹簧圈主要栓塞了夹层动脉瘤底部残余瘤腔。

4、大圈技术起到了腔内密网的作用，既保护了脊髓供血动脉，也可以降低复发率。当然该夹层动脉瘤也可以采用血流导向装置，但脊髓前动脉距离夹层动脉瘤较近，可能受到FD支架影响。

5、本病例仍需要长期随访。

声明：脑医汇旗下神外资讯、神介资讯、脑医咨询、Ai Brain 所发表内容之知识产权为脑医汇及主办方、原作者等相关权利人所有。

投稿邮箱：NAOYIHUI@163.com

未经许可，禁止进行转载、摘编、复制、裁切、录制等。经许可授权使用，亦须注明来源。欢迎转发、分享。

投稿/会议发布，请联系400-888-2526转3。