【AN】Right MCA AN【SAC/Intraprocedure rupture】

Our case

History

· 56 y/o male.

· The patient had three aneurysms. Two aneurysms （L-ICA&L-MCA）were embolized in another hospital on 17/04/2019.  The R-MCA aneurysm was left untreated.

· NE: (-)

· 患者，男，59岁。

· 该患者有三个颅内动脉瘤。外院已栓塞两枚（LICA和LMCA动脉瘤）。右侧大脑中动脉动脉瘤未治疗。

· 神经系统查体：阴性。

1

Pre-operative

Figure 1. Brain CT showing metallic coils and infarction on the left parietal lobe. 头颅CT示弹簧圈金属影及左侧顶叶软化灶。

Figure 2. 3D reconstruction of DSA showing stenosis of right M1 segment, the aneurysmal dilatation involving both superior trunk and inferior trunk of right MCA, and the formation of daughter sac. 三维重建示梭形动脉瘤，近端M1狭窄，MCA上下干梭形扩张和瘤样扩张，瘤体上子瘤形成。

Figure 3. Working projection was chosen for better showing the daughter sac (blue arrow) and the parent artery (red line).显示子瘤（蓝箭）和载瘤动脉（红线）最佳的工作角度。

2

Strategy

· M1-2段狭窄扩张并动脉瘤形成、子瘤形成，提示节段性发育不良，治疗策略按夹层动脉瘤制定。

· The M1-2 stenosis and dilatation, the aneurysmal dilatation and the formation of daughter sac suggest segmental dysplasia.  The treatment strategy should be similar to that of the dissecting aneurysm. 

· 弹簧圈辅助支架局部动脉瘤及载瘤动脉（上干）加固重建，同时用大圈技术保护下干。

· Remodeling the aneurysmal dilated vessel including the superior MCA trunk by stenting assisted with coiling. Large coil technique for protecting the inferior trunk. 

· 手术危险点：意外刺破小子瘤或夹层动脉瘤。

· Risk: the intraoperative rupture of aneurysm or daughter sac 

· 术中出血后救治预案：压颈动脉、麻醉师降压、不可回拉弹簧圈，微导管减张力的过程中继续填圈，即使部分可能填塞到蛛网膜下腔，同时准备另一个微导管到动脉瘤内致密填塞动脉瘤，止血确切后再抗聚药物应用。

· Emergency plan for intraprocedure rupture: Compress CCA. Control BP by anesthesiologist. No withdrawal of the coil. Continue coiling even protruding to subarachnoid space. Preparing another micro-catheter for densely packing the aneurysm. Administrating anti-platelet drugs after the confirmation of no bleeding.

3

Operation

Figure 4. Headway-21 was navigated to the superior trunk of right MCA . Headway-21微导管置于右侧大脑中动脉上干。

Figure 5. Measurement. Dome: 3.15*3.09mm. Neck: 3.74mm. 测量。

Figure 6. Headway-17 microcatheter with C curved tip was placed into the aneurysm sac. 头端‘C’塑形的Headway-17微导管置于瘤腔。

Figure 7. Basket coil Hypersoft 3mm*6cm was inserted to the aneurysm sac. Hyersoft 3mm*6cm 填入瘤腔内成篮。

Figure 8. Solitaire 4*20mm was deployed across the aneurysm neck. 释放Solitaire支架保护瘤颈。

Figure 9. Two Hypersoft 2mm*4cm coils were inserted. 将2枚Hypersoft弹簧圈填入瘤腔。

Video 1. A coil loop was out of aneurysm contour when inserting a Hypersoft 2mm*4cm. 在填入一枚HyperHypersoft 2mm*4cm时，弹簧圈突出动脉瘤轮廓。

Figure 10. The framing coil loop (red arrow). 突出的弹簧圈襻（红色箭头）。

Video 2. Angiography showing contrast extravasation adjacent from the aneurysm sac. 造影示造影剂渗出。

4

Emergency treatment

· Compress ipsilateral CCA

· Control BP to 90/60mmHg

· Continue coiling

· 压迫同侧颈总动脉

· 控制血压到90/60mmHg

· 继续填塞动脉瘤

5

Operation

Figure 11. The protruded coil was failed to be inserted as a whole. A small segment of coil was left in the microcatheter, undetached (red arrow). An Echelon-10 microcatheter with straight tip was navigated to the aneurysm sac through the stent mesh.  拉回突出的弹簧圈重新填塞，一小段圈无法填入，不解脱。将另一根直头Echelon-10微导管穿过支架网孔置于瘤腔内。

Figure 12. Hypersoft 1.5mm*4cm and Hypersoft 1.5mm*3cm were inserted. 先后填入Hypersoft 1.5mm*4cm 和 Hypersoft 1.5mm*3cm。

Figure 13. Detaching the coil in the Headway-17 microcatheter which was withdrawn later. A part of coil was left between the vessel wall and the stent. 解脱Headway-17微导管内的弹簧圈，回收微导管。未填入的弹簧圈贴于支架和血管壁支架。

Figure 14. Parent artery thrombosis (red arrow). The superior trunk of MCA was occluded (blue arrows). 载瘤动脉内血栓形成（红箭）。右侧大脑中动脉中上干闭塞（蓝箭）。

Figure 15. Pial compensation. 软膜代偿。

Figure 16. Dyna CT showing subarachnoid hemorrhage. CT示蛛网膜下腔出血。

Figure 17. General heparinization and Tirofiban 12ml were administrated via guiding catheter. Angiography showing partial recanalization of the superior trunk of MCA. 通过导引导管给予全身肝素化，替罗非班12ml。造影示部分再通。

Figure 18. After mechanical fragmentation, blood flow of the superior trunk of MCA improved with thrombus volume decreasing. 机械碎栓后，载瘤动脉血栓量减少，血流较前通畅。

Video 3. Tirofiban 3+3+3+3ml, Nimodipne 1+1+1+1ml given by microcatheter within 1 hour. Angiography showing densely packing of the aneurysm and the superior trunk recanalization with mild distal flow retention. 一小时内分次给予Tirofiban和Nimodipine。造影显示动脉瘤致密栓塞，右侧大脑中动脉上干再通，远端血流少许滞留。

Figure 19. Dyna CT showing no increase of bleeding volume. CT显示出血量未明显增多。

Figure 20. Post-operative CT(48hrs)：The hemorrhage was totally absorbed and no infarction was found on right hemisphere.术后48小时CT:右侧半球蛛血完全吸收，未见梗死灶。

6

Summary

· The treatment strategy of MCA fusiform aneurysm should be similar to that of the dissecting aneurysm. (Large coils with stent-assisted coiling)

· 大脑中动脉梭形动脉瘤采用与夹层动脉瘤相同的治疗方法。（大圈保护技术和支架辅助栓塞）

· The maneuver of microcatheter across the aneurysm neck should be cautious due to the fragile daughter sac.

· 子瘤容易破裂出血，因此微导管过瘤颈时操作必须非常小心。

· After the placement of microcatheter for stenting, the parent artery angle will change.  Then rotation DSA should be re-performed to select a better working projection.

· 支架微导管置入后载瘤动脉的角度会改变，因此需要重新做旋转DSA选择更好的工作角度。

· When bleeding occurs during the procedure, do not retrieve the coil and micro-catheter. Compress the ipsilateral CCA, decrease BP to 90/60mmHg and try to insert coils. Then navigate another micro-catheter with optimal tip and densely pack the aneurysm with small and soft coils quickly.

· 术中出血时，无需回收微导管和弹簧圈。压迫同侧颈总动脉，降压，继续填塞弹簧圈。同时使用另一根微导管快速地向动脉瘤内填塞小软圈。

· Thrombosis within the stent: First, assure the densely embolization of the aneurysm and confirm no more bleeding. Then, mechanical fragmentation and medications such as Tirofiban and Nimodipine could be used to resolve the fresh thrombus.

· 处理支架内血栓：首先，确保动脉瘤致密栓塞和无新发出血。可以使用机械碎栓活或药物如替罗非班和尼莫地平溶解新鲜血栓。