• 神经查体:-。
Figure 1. Local hospital MRI displayed the right cerebellum chronic infarctions.图 1. 当地医院MRI提示右侧小脑陈旧性脑梗死。
Figure 2 GIF. DSA confirmed an irregular dissecting aneurysm in the inferior segment of basilar artery, and right anterior-posterior inferior cerebellar artery arose from the proximal aneurysm sac. Anterior spinal artery arose from left V4.
图 2 GIF. DSA证实基底动脉下段不规则夹层动脉瘤,右侧小脑前下-后下动脉发自近端囊腔。脊髓前动脉发自左侧V4段。
Figure 3. Right posterior communicating artery was well-developed and left posterior communicating artery under-developed.
图 3. 右侧后交通动脉发育良好,左侧后交通动脉发育不佳。
1.Indications: The irregular basilar artery dissecting aneurysm, especially the daughter sac, harboured a high rupture risk, which was suggested treatment.
2.The distal daughter sac should be embolized to prevent rupture risk. Proximal dissection with slight ectasia was not embolized due to right anterior-posterior inferior cerebellar artery(AICA/PICA) originated from this. Solitaire stent with a satisfactory remolding effect for the significant tortuous parent artery was selected to reduce the recurrence rate. If recurrence occurred, flow diverter stent can be chosen in the second stage.
3.Anterior spinal artery arose from left V4 segment. Right vertebrate artery was chosen for the routine in order to not affect the anterior spinal artery.
4.Difficulties:
a.AICA/PICA originated from the proximal slight ectasia should be preserved. Therefore, the proximal slight ectasia was not embolized. Solitaire stenting was adopted to reduce the recurrence rate.
b.Daughter sac should be packed densely to lower the rupture risk.
1.指征:基底动脉不规则夹层动脉瘤伴远端子瘤,破裂风险高,建议治疗。
2.远端子瘤应该栓塞降低破裂风险。由于粗大小脑前下-后下动脉发自近端轻度扩张的夹层,不建议栓塞近端夹层避免缺血事件。夹层伴载瘤动脉瘤迂曲成角,建议采用Solitaire支架的血管成角重塑作用,降低复发风险。若随访夹层动脉瘤复发,二期可采用血流导向装置。
3.脊髓前动脉发自左侧椎动脉V4段,采用右侧椎动脉入路,可避免影响脊髓前动脉。
4.难点:
a.右侧小脑前下-后下动脉发自动脉瘤腔,栓塞近端夹层动脉瘤的同时保护小脑前下-后下动脉较困难。不栓塞近端轻度扩张的囊腔,可保证右侧小脑前下-后下动脉的通畅。采用Solitaire支架重塑来进行治疗。
Figure 4. An size 4.27*3.56mm, proximal parent artery diameter 1.53mm and distal 1.77mm. General heparization was conducted. 6F 105cm Tonbridge catheter was placed at right V4 segment. XT-27 microcatheter was navigated in the distal part of basilar artery via a microwire and an acute-curved Echelon-10 microcatheter was advanced into the sac. Solitaire 4*20mm stent was deployed from basilar artery to right vertebrate artery. Inserted 4 coils (target 360 4mm*10cm, 3mm*6cm, 2mm*3cm (*2)) in sequence.
图 4. 动脉瘤大小4.27*3.56mm,近端载瘤动脉直径1.53mm,远端载瘤动脉直径1.77mm。行全身肝素化。将中间导管6F 105cm Tonbridge置于右侧椎动脉V4段。XT-27微导管在微导丝导引下置于基底动脉远端,Echelon-10微导管塑急弯后置于瘤腔。Solitaire 4*20mm支架于基底动脉至右侧椎动脉释放覆盖瘤颈。经栓塞微导管依次填入4枚弹簧圈(target 360 4mm*10cm, 3mm*6cm,
2mm*3cm (*2))。
Figure 5 GIF. The daughter sac was densely satisfactorily and parent artery as well as right anterior-posterior inferior cerebellar artery patent.图 5 GIF. 复查造影夹层动脉瘤远端子瘤栓塞满意,载瘤动脉及右侧小脑前下-后下动脉通畅。
Figure 6. Parent artery was straightened significantly after stent deployment.图 6. 载瘤动脉动脉拉直明显。
Figure 7 GIF. Dyna-CT did not demonstrate any hemorrhage.
图 7 GIF. Dyna-CT未见出血。
•NE: GCS 15, bilateral eye movement normal, bilateral muscle strength normal, no swallowing difficulty nor facial paralysis.
•Medication:
Aspirin and Clopidogrel were prescribed for 7 days before operation.AA 92.1%, ADP 84.9%, CYP2C19 NM.Continue Aspirin and Clopidogrel after operation.
•神经查体:患者GCS 15,双侧眼球运动正常,四肢肌力正常,无饮水呛口及面瘫。
血栓弹力图:阿司匹林抑制率92.1%,氯吡格雷抑制率84.9,氯吡格雷基因代谢正常,酶活性正常。Figure 8 GIF. No new infarctions were detected from post-operative MRI.
图 8 GIF. 术后复查磁共振未见新发脑梗死。
Video 1. Right anterior-posterior inferior cerebellar artery patent and the distal aneurysm without recurrence by 6 month follow up.
视频 1. 6个月随访右侧小脑前下-后下动脉通畅,远端子瘤未见复发。
Video 2. No intra-stent stenosis occurred and vascular wall repaired by 6 month follow up.
视频 2. 6个月随访支架内未见狭窄,近端扩张囊腔缩小。
Video 3. Proximal ectasia and vascular wall repaired by 6 month follow up.
视频 3. 6个月随访近端扩张囊腔及管壁较前修复。
Figure 9. Parent artery was straightened significantly after stent deployment.
图 9. 载瘤动脉拉直明显。
1.Indications: The irregular basilar artery dissecting aneurysm, especially the daughter sac, harboured a high rupture risk, which was suggested treatment.
2.Right anterior-posterior inferior cerebellar artery originated from the proximal aneurysm sac, which should be preserved. Therefore, the proximal sac was not embolized. Solitaire stent with a satisfactory remolding effect for the significant tortuous parent artery was selected to reduce the recurrence rate. If recurrence occurred, flow diverter stent can be chosen in the second stage. The distal daughter sac should be packed densely to lower the rupture risk.
3.Solitaire stent with a satisfactory remolding effect was selected. The dissecting was recovered by 6 month follow up.
4.Long term follow up was necessary.