题目：

双血流导向装置串联植入联合弹簧圈辅助栓塞重塑椎动脉V4段巨大夹层动脉瘤

摘要：

53岁男性患者，因“突发呕吐10天”入院。诊断：右侧椎动脉V4段巨大夹层动脉瘤（改良Mizutani Ⅲ型）。予以双血流导向装置串联植入联合弹簧圈辅助栓塞重塑血流，载瘤动脉通畅，邻近的小脑后下动脉（PICA）保护良好。术后22个月随访，mRS 0，载瘤动脉通畅，病变未复发

ABSTRACT: A 53-year-old male patient was admitted to the hospital due to "sudden onset of vomiting for 10 days". Imaging examinations confirmed the diagnosis of a giant dissecting aneurysm in the V4 segment of the right vertebral artery, which was classified as modified Mizutani type Ⅲ.

After comprehensive preoperative evaluation and discussion, the patient underwent endovascular treatment with tandem implantation of dual flow-diverter stents combined with coil-assisted embolization to reconstruct the blood flow of the parent artery. During the operation, the patency of the parent artery was successfully maintained, and the adjacent posterior inferior cerebellar artery (PICA) was well protected without ischemic complications.

At the 22-month postoperative follow-up, the patient had a modified Rankin Scale (mRS) score of 0, indicating no neurological dysfunction. Imaging reexamination showed that the parent artery remained patent, and no recurrence of the aneurysm was observed.

前言

本例患者的治疗难点：

1、本例小脑后下动脉（PICA）从瘤囊远端发出。因此，需要采取保留载瘤动脉的手术策略，椎动脉闭塞及动脉瘤孤立术均存在导致严重缺血事件的风险。

2、椎动脉路径迂曲，夹层动脉瘤治疗相对风险高。据研究统计，支架重建术复发率高达5%-26%，缺血事件发生率为6.2%，破裂出血发生率为1.8%。

3、本例夹层动脉瘤形态不规则、累及长节段血管壁，为巨大夹层动脉瘤，难以为支架的锚定提供稳定支撑；支架尺寸的选择对术者经验提出了较高要求。

病例简介

患者：53岁男性。

主诉：突发呕吐10天。

现病史：10天前无明显诱因出现呕吐不适，呕出胃内容物，于外院完善头颅MRI示“延髓腹侧占位”，脑血管CTA示“右侧椎动脉V4段巨大动脉瘤伴血栓形成”。

既往史：既往体健，否认高血压、糖尿病等慢性病史。

术前影像学检查

诊断和鉴别诊断

治疗方案

专家点评：许奕教授

椎动脉巨大夹层动脉瘤毗邻脑干，累及多根重要穿支血管，治疗上要解决动脉瘤破裂、瘤内涡流及血栓脱落导致远端缺血事件以及巨大动脉瘤本身的占位效应，目前尚无标准化治疗方案，是显微神经外科与神经介入领域公认的治疗难题。本例紧扣病变特征制定个体化血管内治疗策略，以双血流导向装置套叠植入重建载瘤动脉、保护PICA，辅以弹簧圈疏松填塞，在防控破裂复发的同时有效缓解占位效应。22个月随访证实疗效稳定可靠，为同类复杂病变的临床治疗决策提供了宝贵参考。