【AN】Complex anterior communicating artery aneursym...

ryi

Our case

History

· 79 y/o female

· Suffering from dizziness and found intracranial aneurysm for 6 months

· NE: (-)

· 女，79岁

· 头晕，发现颅内动脉瘤6月

· 神经系统查体无殊

1

Pre-operative

Figure 1. Bilateral ICA angiography showed an anterior communicating artery aneurysm with daughter sac. Bilateral ACAs originated from the aneurysm neck. The A1 segment of right ACA was not developed with bilateral MCA stenosis.A small aneurysm of left M2 was also revealed. 前交通动脉瘤，瘤体见子瘤形成，双侧大脑前动脉发自瘤颈。右侧大脑前动脉A1段未发育，双侧大脑中动脉狭窄。左侧大脑中动脉M2段小动脉瘤。

Figure 2.Under a proper working projection showing the whole route of left A2, the aneurysm neck was not wide. Also considering the high risk of thrombosis due to the A2 stenosis and patient's elder age,  single stent assisted coiling was selected to protect the right ACA while large coil technique was chosen to preserve the left ACA!!!左侧大脑前动脉A2段在合适的工作角度下显示瘤颈不宽，同时A2段有狭窄，患者高龄，支架会增加血栓形成风险,所以采用单支架保护右侧大脑前，左侧用大圈技术保护！！！

2

Discussion

High risk of ischemic complication

1.The patient was an old female. Angiography showed bilateral MCA stenosis.

2.Bilateral anterior cerebral arteries originate from the aneurysm neck. The A1 segment of right anterior cerebral artery is not developed.

3.The vasculature architect of the aneurysm indicated long operation time and complex operation procedure.

Treatment:

1.The application of general heparinization at the beginning of the procedure.

2.Protecting the left ACA by operating under a proper working projection and with the helping of big coils instead of implanting a stent.

3.Preserving the right A2 by implanting a stent.

4.Y stents will increase the risk of thrombosis.

缺血性并发症危险因素

1.老年女性，双侧大脑中动脉狭窄。

2.双侧大脑前动脉发自瘤颈，右侧A1不发育，如右侧大脑前动脉血流受累，无法通过A1段代偿。

3.该动脉瘤血管构筑提示该病例操作复杂，手术时间预计较长。

策略：

1.术前全身肝素化。

2.栓塞时可通过选择合适的工作角度清楚显示左侧大脑前动脉路径保持该载瘤动脉的通畅性。

3.故本病例仅在右侧大脑前动脉置入支架，使用支架保护技术,左侧大脑前动脉采用大圈保护技术。

4.Y型支架更增加血栓事件可能，单支架简化操作，病人高龄，降低手术风险。

Risk factor of hemorrhagic complication：Anterior communication artery aneurysm with daughter sac.

Strategy:

1.Select large coils for stable framing.

2.Daughter sac was the priority, which was embolized by several small soft coils in the beginning of the procedure.

出血性并发症危险因素:前交通动脉瘤伴子瘤形成

策略：

1.使用大圈稳定成篮。

2.优先治疗子瘤，使用小圈填塞。

3

Operation

Figure 3. The first working projection was selected to better demonstrate the daughter sac and the relationship between aneurysm neck and the sharp turn of left A1-2 segment. 第一工作角度，清晰显示子瘤和左侧A1-2转弯处及瘤颈的关系。

Video 1. A microwire  was delivered to the right A2 segment through the curved Acom under the first working projection.在第一工作角度下，微导丝从左侧A1通过迂曲的前交通到达右侧A2段。

Video 2. Headway-21 micro catheter was navigated to the A3 segment of the right anterior cerebral artery under the second working projection.  在第二个工作角度下，将Headway-21微导管置于右侧大脑前动脉A3段。

Figure 4. Headway-17 microcatheter with C shaped tip was guided to the aneurysm sac by the microwire.将头端C型的Headway-17微导管在微导丝引导下置入瘤腔。

Figure 5. The frame coil was Microplex-10 7mm*30cm.选用Microplex-10 7mm*30cm弹簧圈成篮。

Figure 6. Solitarie 4*20mm stent was deployed by Headway-21 microcatheter, covering the aneurysm sac.将Solitarie 4*20mm支架通过Headway-21微导管释放，覆盖瘤颈。

Figure 7. The second Microplex-10 5mm*20cm coil was inserted to the aneurysm sac. 填入第二枚Microplex-10 5mm*20cm弹簧圈。

Figure 8. Two Hypersoft 3mm*8cm and one Hypersoft 2mm*6cm coils were then inserted for better embolizing the daughter sac. 填入Hypersoft 3mm*8cm两枚，2mm*6cm一枚，重点填塞子瘤。

Figure 9. Two Hypersoft 2mm*6cm and two Hypersoft 3mm*6cm coils were inserted.继续填入Hypersoft 2mm*6cm两枚，3mm*6cm两枚。

Figure 10. Working projection angiography shows no hemorrhage or thrombosis. Tirofiban 13ml was given via the guiding catheter.复查造影，未见出血或血栓形成征象。经导引导管给予替罗非班13ml。

Video 3. The microcatheter tip was adjusted.调整微导管头端位置。

Figure 11. Hypersoft 3mm*4cm coil was inserted.填入Hypersoft 3mm*4cm弹簧圈。

Figure 12. Working projection angiography shows complete obliteration of the aneurysm with patent of the parent artery. 工作角度造影示动脉瘤致密栓塞，载瘤动脉通畅。

Figure 13. Post-operative angiography shows intracranial vessels are intact without thrombosis. 复查正侧位造影，颅内血管未见血栓形成。

Figure 14. Pre-operative and post-operative comparison under the working projection. 栓塞前后工作角度对比。

Figure 15. Two hours after the operation, the patient had right limbs paralysis with left gaze. Emergency CT shows contrast medium retention with no hemorrhage or infarction. 术后两小时，患者出现右侧肢体乏力及左侧凝视。急诊CT示造影剂滞留，未见明显出血或梗塞征象。

Figure 16. Emergency DSA shows thrombosis of the A2 segment of left ACA and the M2 segment of left MCA (red arrows). 急诊DSA示左侧大脑前动脉A2段，左侧大脑中动脉M2段血栓形成（红箭）。

Figure 17. After giving Tirofiban 19ml in total via the guiding catheter within 1 hour, angiography shows thrombosis is partial resolved. 一小时内经导引导管分次给予替罗非班共19ml。复查造影，血栓部分溶解。

Figure 18. Transend 205 microwire and Echelon-10 microcatheter were used for mechanical fragmentation.使用Transend 205微导丝和Echelon-10微导管机械碎栓。

Figure 19. Angiography showed recanalization of thrombosis artery with only small thrombus left in the M2 segment of left MCA. The muscle strength of the right limbs was III to IV.复查造影，血栓大部溶解，左侧大脑中动脉M2段残留少许血栓。患者右侧肌力恢复至3-4级。

4

Post-operative

Figure 20. CT showed recanalization of thrombosis artery with only small thrombus left in the M2 segment of left MCA. The muscle strength of the right limbs was III to IV and no left gaze. The right-sided muscle strength recovered to V before the discharge.术后24小时CT示无出血及大面积脑梗塞,患者右侧肢体肌力4-5级，左侧凝视消失。出院前患者肌力恢复正常。

5

Summary

· Decision on strategy based on patient’s elder age, the vascular architecture of the aneurysm with relevant arteries including daughter sac, the undevelopement of contralateral A1 segment, the sharp turn of the left A1 and A2 segment of the parent artery. 

· The single stent-assisted coiling was selected to protect the right ACA. Large coil technique was chosen for a better occlusion of the aneurysm with the patent of the left ACA. The treatment strategy was simplified and minimize the risk of complications.

· For acute post-operative thrombosis, emergency angiography was a must-do. The application of general heparinization and Tirofiban are the keys for good prognosis.

· 本病例治疗决策基于患者高龄，动脉瘤及周边血管的构筑如子瘤，对侧A1段未发育，载瘤动脉A1-2间的急弯等。

· 选用单支架技术保护右侧大脑前动脉，弹簧圈大圈栓塞技术治疗动脉瘤并保护左侧大脑前动脉，简化操作，减少术中并发症的风险。

· 术后急性血栓形成后，复查造影，全身肝素化和经导引导管内注入替罗非班是良好预后的关键。