Review
History
• 45 y/o male.
• Suffered from sudden onset of severe headache and consciousness loss six years ago.
• SAH was confirmed from the CT scan, and a right MCA bifurcation aneurysm was detected (images were unavailable). Simple coiling of the aneurysm was performed.The aneurysm recurrence was revealed in the local hospital after a 6-year follow-up.
• Aspirin and clopidogrel were taken orally 3 days before surgery.
• Past medical history: HTN for ten years, well-controlled
• PE: (-)
• 45岁，男性。
• 6年前突发剧烈头痛、意识不清。
• 当地医院头颅CT平扫提示蛛网膜下腔出血。检查发现右侧大脑中分叉部动脉瘤（影像学片子未见）。外院予急诊行动脉瘤弹簧圈单纯栓塞。经过6年随访动脉瘤被证实复发。
• 术前3天已口服阿司匹林及氯吡格雷双抗。
• 既往史：高血压10年，血压控制良好。
• 体格检查：-。
图 1. MRA提示右侧大脑中动脉动脉瘤复发，形态不规则，累及大脑中动脉下干。高分辨率磁共振提示动脉瘤瘤壁部分增厚伴强化。
Figure 2 GIF. DSA confirmed the right MCA bifurcation aneurysm neck recurrence involved the inferior trunk.
图 2 GIF. DSA证实右侧大脑中分叉部动脉瘤颈部复发，复发动脉瘤累及大脑中动脉下干。
1
Indication and Strategy
Indications:
•The recurrent MCA bifurcation aneurysm with an irregular shape and wall enhancement has a high re-rupture risk, which should be treated.
•The aneurysm, characterized by its broad neck, significantly impacts the inferior trunk. Stent-assisted coiling is preferred.
•A Solitaire stent is recommended to straighten the inferior trunk acute angle to decrease the recurrence risk due to its excellent bending stiffness, ease of delivery, and low thrombogenic potential.
•Following stent deployment, rotational angiography is required to select the optimal working projection for embolization due to the deformation of the parent artery. Additionally, nimodipine is used to alleviate vasospasm.
•After the stent is deployed, the Meshing technique is preferred for embolizing irregularly shaped small aneurysms, minimizing the rupture risk in the Jailing technique.
•Relatively larger caliber coil selection reduces the recurrence risk while protecting the inferior trunk.
Challenges and Risks:
2.The significant involvement of the aneurysm sac with the inferior trunk raises the risk of excessive embolization affecting the inferior trunk. The stent and relatively larger coils can protect the inferior trunk.
适应症：
•大脑中动脉分叉部复发动脉瘤，形态不规则，高分辨率磁共振提示瘤壁部分强化，破裂风险高，建议治疗。
•复发大脑中动脉分叉部动脉瘤，动脉瘤累及大脑中动脉下干起始部，瘤颈部较宽累及载瘤动脉明显，首选支架辅助栓塞，保护下干。
•选择Solitaire可以矫正下干起始部成角，降低复发风险。选择Solitaire支架，因为Solitaire支架具有良好的弯曲硬度，容易输送到位，同时不易形成血栓。
•首先释放支架矫正下干起始部成角后，选用Meshing技术栓塞瘤腔，针对不规则小动脉瘤可以降低Jailing技术释放支架时刺破动脉瘤风险。
•支架释放后，由于载瘤动脉形变，需行旋转造影重新选择动脉瘤栓塞工作角度，同时需使用尼莫地平缓解血管痉挛。
•选择相对大尺寸弹簧圈降低复发风险的同时保护下干起始部受到影响。
难点及危险点：
2.动脉瘤腔累及下干明显，有过度栓塞影响下干风险，解决方案：支架及大圈保护下干。
2
Operation
Figure 3. General heparization was performed. 6F Envoy DA guiding catheter was placed into right cavernous segment. Nimodipine 0.5ml was administered. A curve-tipped Prowler plus microcatheter was navigated into inferior trunk.
图 3. 行全身肝素化。将6F Envoy DA导引导管置于右侧颈内动脉海绵窦段。经导引导管给予尼莫地平0.5ml。Prowler plus微导管头端塑C弯后超选至右侧大脑中动脉下干主干内。
Figure 4 GIF. Deployed a Solitaire 4*20mm stent. Angiograms did not detect any bleeding.
图 4 GIF. 于瘤颈部释放Solitaire 4*20mm支架。复查造影颅内血管未见出血。
图 5. 重新选择工作角度。将Echelon-10-45微导管超选入动脉瘤腔内。经微导管填入共计6枚弹簧圈（ Target-360 5mm*15cm (2), 4mm*15cm, 4mm*8cm (2), 2.5mm*6cm）。
图 6 GIF. 两个工作角度复查造影，动脉瘤栓塞满意。
图 7 GIF. 复查造影颅内血管完好，右侧大脑中动脉下干通畅。经导引导管给予替罗非班9ml、尼莫地平0.5ml。
图 8 GIF. 术后Dyna-CT未见出血。
3
Post-Operation
•Medication:
Tirofiban 5ml/h maintained for 24 hours.
TEG: ADP 97%.
•药物：
替罗非班5ml/h维持24h。
继续阿司匹林和氯吡格雷（术前3天已口服双抗）。
图 9 GIF. 术后第3天DWI提示右侧颞叶少许点状无症状急性脑梗死。患者术后双抗3月后，改阿司匹林单抗，半年至一年住院复查脑血管造影。
4
9M-FU
Video 1. The aneurysm was not relapsed by 9 month follow up.
视频 1. 9个月随访动脉瘤未见残余或复发。
Figure 10. The parent artery straightened further.
图 10. 载瘤动脉进一步拉直。
Video 2. Parent artery was patent and the intracranial vessels were intact by 9 month follow up.
视频 2. 9个月复查载瘤动脉通畅，颅内血管完好。
5
Summary
Angioarchitecture and Strategy:
•The aneurysm, characterized by its broad neck, significantly impacts the inferior trunk. Stent-assisted coiling was performed.
•The Solitaire stent is recommended to straighten the inferior trunk acute angle to decrease the recurrence risk, which is attributed to its excellent bending stiffness, ease of delivery, and low thrombogenic potential.
•Following stent deployment, rotational angiography is required to select the optimal working projection for embolization due to the deformation of the parent artery. Additionally, nimodipine is used to alleviate vasospasm.
•After the stent is deployed, the Meshing technique is preferred for embolizing irregularly shaped small aneurysms, minimizing the rupture risk compared with the Jailing technique.
•Relatively larger caliber coil selection reduces the recurrence risk while protecting the inferior trunk.
Challenges and Risks:
•The significant involvement of the aneurysm sac with the inferior trunk raises the risk of excessive embolization affecting the inferior trunk. The stent and relatively larger coils can protect the inferior trunk.
适应症：
•大脑中动脉分叉部复发动脉瘤，形态不规则，高分辨率磁共振提示瘤壁部分强化，破裂风险高，建议治疗。
•复发大脑中动脉分叉部动脉瘤，动脉瘤累及大脑中动脉下干起始部，瘤颈部较宽累及载瘤动脉明显，首选支架辅助栓塞，保护下干。
•选择Solitaire可以矫正下干起始部成角，降低复发风险。选择Solitaire支架，因为Solitaire支架具有良好的弯曲硬度，容易输送到位，同时不易形成血栓。
•首先释放支架矫正下干起始部成角后，选用Meshing技术栓塞瘤腔，针对不规则小动脉瘤可以降低Jailing技术释放支架时刺破动脉瘤风险。
•支架释放后，由于载瘤动脉形变，需行旋转造影重新选择动脉瘤栓塞工作角度，同时需使用尼莫地平缓解血管痉挛。
•选择相对大尺寸弹簧圈降低复发风险的同时保护下干起始部受到影响。
难点及危险点：
•动脉瘤腔累及下干明显，有过度栓塞影响下干风险，解决方案：支架及大圈保护下干。
参考：
Krischek O, Miloslavski E, Fischer S, Shrivastava S, Henkes H. A comparison of functional and physical properties of self-expanding intracranial stents [Neuroform3, Wingspan, Solitaire, Leo+, Enterprise]. Minim Invasive Neurosurg. 2011 Feb;54(1):21-8. doi: 10.1055/s-0031-1271681. Epub 2011 Apr 19. PMID: 21506064.
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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