ACA A2-A3 dissecting AN Two stage embolization

Review

History

• 41 y/o male.

• CC: The patient suffered a headache, and CT scan showed subarachnoid hemorrhage in June 2017.

• PE: The clumsy right limb and left limb hypoesthesia.

• Past medical history: smoking 10+ years, half pack per day, quitting about 2 years.

• NE: Left limb hypoesthesia; Babinski (-).

• 41岁，男性。

• 主诉：2017年6月突发头痛，CT提示蛛网膜下腔出血。

• 查体：右侧肢体活动不灵活，左侧肢体感觉减退。

• 既往史：吸烟10余年，每天半包，戒烟2年。

• 神经查体：左侧肢体感觉减退，巴氏征(-)。

Figure 1 GIF. Callosum and intraventricular hemorrhage.

图 1 GIF. 胼胝体区出血并破入脑室。

Figure 2 GIF. Rotational DSA confirms a ruptured pericallosal aneurysm with irregular shape and daughter sacs.

图 2 GIF. 旋转DSA证实破裂胼周动脉瘤，形态不规则伴子瘤。

Treatment Strategy

• Ruptured pericallosal aneurysm with irregular shape and daughter sacs indicated high re-rupture risk, which should be treated as soon as possible.

• To avoid perioperative bleeding and antiplatelet drugs, simple coiling was adopted in the acute phase of aneurysmal hemorrhage. If the aneurysm recurred, stent-assisted coiling was used in the second stage.

• Both sacs of the aneurysm need to be packed densely with dual microcatheters.

• 破裂的胼周动脉动脉瘤，形态不规则伴有子囊，再次破裂风险高，一期治疗应行急诊治疗。

• 出血急性期动脉瘤，为避免术中出血及术后使用活血药物，可以考虑单纯栓塞治疗该动脉瘤，复发后二期支架辅助栓塞。

• 双囊动脉瘤，均应致密栓塞，栓塞时使用双微导管栓塞。

Operation

Video 1. The aneurysm with two daughter sacs was densely packed by the dual microcatheter technique.

视频 1. 双微导管双囊同时致密栓塞。

Video 2. Post-operative angiography shows the aneurysm neck is overpacked with the slow flow in the front branch of ACA

视频 2. 动脉瘤致密栓塞，瘤颈部稍过度栓塞，额前内侧支稍血流减慢。

Video 3. Six-month follow-up angiography shows mild relapse at the aneurysmal neck.

视频 3. 6个月随访动脉瘤瘤颈部轻度复发。

Figure 3 GIF. 18-month follow-up angiography demonstrates enlarged aneurysmal neck relapse.

图 3 GIF. 18个月造影随访提示复发动脉瘤颈部增大。

Second stage treatment strategy

• Though the aneurysm was densely packed, the aneurysm neck relapsed and enlarged on 6-month and 18-month follow-up respectively, which indicated the neck was unstable. Therefore the relapsed aneurysm should be treated.

• Direct blood flow impingement may lead to recurrence. Therefore, a stent-assisted coiling technique was adopted in the second stage to straighten the parent artery and remodel the hemodynamics to decrease recurrence risk.

• 尽管一期栓塞做到了轻度过度栓塞，半年复发瘤颈部轻度复发，18月复查瘤颈部明显扩大，该动脉瘤不稳定，建议二期治疗。

• 复发原因可能为血流直接冲击，二期采用支架辅助栓塞，改变血流动力学、减少血流直接冲击，降低动脉瘤复发风险。

Figure 4 GIF. Measurements. Residual sac: 2.08*1.44mm; parent arteries: 1.40-1.54mm.

图 4 GIF. 测量。残留瘤腔2.08*1.44mm；载瘤动脉1.4-1.54mm。

Figure 5 GIF. A headway-21 microcatheter with a preshaped tip was navigated to the right callosomarginal artery. An Echelon-10 microcatheter with a straight tip was sent to the residual aneurysmal sac.

图 5 GIF. headway-21微导管头端塑形后，超选至右侧胼缘动脉。直头Echelon-10 微导管超选入动脉瘤腔内。

Figure 6 GIF. A Solitaire 4mm*20mm stent was deployed via the Headway-21 microcatheter.

图 6 GIF. 经Headway-21微导管释放Solitaire 4mm*20mm支架。

Figure 7 GIF. A Hypesoft 2mm*3cm coil could not form a satisfied basket and protrude into the parent artery. It was retrieved.

图 7 GIF. Hypesoft 2mm*3cm弹簧圈成篮不满意，突入载瘤动脉，遂撤回该枚弹簧圈。

Figure 8 GIF. A Hypersoft 2mm*6cm coil was inserted into and densely packed the residual sac.

图 8 GIF. Hypersoft 2mm*6cm弹簧圈致密填塞复发残腔。

Figure 9 GIF. The aneurysm was densely packed with parent artery patent. Intact intracranial vessels are noted. Tirofiban 15ml was administrated via the guiding catheter.

图 9 GIF. 动脉瘤致密栓塞，载瘤动脉通畅。颅内血管完好。经导引导管给予替罗非班15ml。

Figure 10. Straightened parent artery angle is noted compared to the parent artery angle of the relapsed aneurysm.

图 10. 较复发再次治疗前，载瘤动脉被拉直。

Post Operation

NE: GCS 15, Left limb hypoesthesia, bilateral limb strength normal, Babinski (-).

Medication: Tirofiban 15ml/h sustained 48 hours.

TEG: AA 100%, ADP 64%.

At discharge:

• Clopidogrel 75mg for 3 months and Aspirin 100mg for long-term.

• Control and monitor the blood pressure.

• Follow up was scheduled in a year.

神经查体：GCS 15分，左侧肢体感觉减退，双侧肌力正常，巴氏征阴性。

药物：替罗非班15ml/h微泵48小时。

血栓弹力图：阿司匹林抑制率100%，氯吡格雷抑制率64%。

出院:

• 氯吡格雷每天75mg口服3月，阿司匹林每天100mg长期口服。

• 控制监测血压。

• 建议1年后随访。

29-month follow-up

• The patient felt left limb numbness and right limb clumsy

• Medication: Clopidogrel 50 mg qd for one year

• Follow up: 3-5 year DSA

• 患者诉左侧肢体麻木，右侧肢体活动笨拙。

• 药物：氯吡格雷50mg每天口服一年。

• 3-5年后DSA随访。

Figure 11 GIF. Eleven month after the stent assisted coiling for the residual sac at 18-month follow-up, the angiography shows no relapse and the parent artery patent.

图 11 GIF. 二期支架辅助栓塞11个月复查，未见动脉瘤残余及复发，载瘤动脉通畅。

Figure 12. Review of treatment stages and follow-up. After SAC, a significantly straightened parent artery is observed at post-stenting and follow-up angiography.

图 12. 对比不同期治疗及随访。支架辅助栓塞后及复查，造影提示载瘤动脉成角明显增大。

Summary

• Indication: Ruptured pericallosal aneurysm with irregular shape and daughter sacs indicated high re-rupture risk, which should be treated as soon as possible.

• Treatment strategy: To avoid perioperative hemorrhage and antiplatelet drugs, simple coiling was adopted in the acute phase of aneurysmal hemorrhage. If the aneurysm is recanalized, stent assisted coiling can be used at the second stage. In this case, the unstable aneurysm neck relapsed and enlarged in follow-up, SAC was performed.

• Techniques: Both sacs of the aneurysm need to be packed densely with dual microcatheters.

Advantage of SAC at the second stage:

• Direct blood flow impingement may lead to the recurrence. Therefore, stent assisted coiling technique was performed at the second stage for changing the hemodynamics to decrease recurrence risk.

• Stent-induced vessel straightening combined coil embolization has the best performance in hemodynamic modifications and may reduce the recurrence rate for intracranial bifurcation aneurysms1.

• Solitaire stent possessed low thrombogenicity. For intracranial bifurcation aneurysms, Solitaire stent-assisted coiling induced favorable parent artery angular remodeling and achieved a significantly low recurrence rate2.

• 破裂的胼周动脉动脉瘤，形态不规则伴有子囊，再次破裂风险高，一期治疗应行急诊治疗。

• 出血急性期动脉瘤，为避免术中再次出血及术后活血药物应用，可以考虑单纯栓塞治疗该动脉瘤，复发后二期支架辅助栓塞。

• 双囊动脉瘤，均应致密栓塞，栓塞时使用双微导管栓塞。

尽管一期栓塞做到了瘤颈部轻度过度栓塞，但是动脉瘤瘤颈部依旧复发、增长，动脉瘤颈不稳定建议栓塞治疗:

• 动脉瘤复发可能由于血流直接冲击导致，所以二期采用支架辅助栓塞，改变血流动力学，降低动脉瘤复发风险。

• 颅内分支动脉瘤支架辅助栓塞，支架具有拉直载瘤动脉作用，增大载瘤动脉角度，改变血流动力学，降低复发风险1。

• 对于颅内分叉部动脉瘤，Solitaire支架致栓性低，Solitaire支架辅助弹簧圈栓塞动脉瘤能矫正载瘤动脉角度，进行血流重塑，降低复发风险2.

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