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Large ophthalmic AN with LVIS-assisted large-coil embolization

2022-07-04 张晓龙教授团队

0

Review

History

• 73 y/o, female.

• CC: Suffered from blurred vision for a month. Local hospital MRI revealed a left ophthalmic aneurysm ( not available) .

• NE: Identify finger count from 15cm, left temporal visual field defect ( without specialized eye exams). 

• Past medical history: Congenital deafness in the left ear; Cholecystectomy 7 years ago; Duodenal ulcer.

• Medication: (-)
• 73岁,女性。
• 主诉:视物模糊1月。当地医院MRI提示左侧颈眼动脉瘤。

• 查体:15cm可识指数,粗测左眼颞侧视野缺损 (未行眼科检查)。

• 既往史:先天性左侧耳聋;7年前行胆囊切除术;十二指肠溃疡。

• 药物:(-)。

Figure 1 GIF. DSA reveals a large ophthalmic aneurysm with a daughter sac located in the upper-medial ICA wall. 
图 1 GIF. DSA证实左颈内动脉前壁大颈眼动脉瘤伴子瘤。


1

Treatment Strategy

• Irregular left large upper-medial ophthalmic aneurysm with mass effect should be treated. 

• Pipeline was unavailable at that time. So, the stent-assisted large coil technique was preferred to decrease the recurrence. 
• Block by Block embolization was the strategy for the case. And coil selection should be carefully considered– large coils for aneurysm sac to provide strong support and small coils with LVIS-stent assistance for aneurysm neck embolization to decrease neck relapse.

• 颈内动脉上内侧壁不规则大颈眼动脉瘤,患者出现视物模糊,该动脉瘤建议治疗。

• 当时无Pipeline可供选择;为降低复发率,首选大圈辅助支架栓塞。

• 该病例采用分区栓塞,同时弹簧圈的选择十分重要。动脉瘤腔内选用大圈栓塞以提供足够的支撑力,小圈技术LVIS支架辅助致密填塞瘤颈部以降低复发风险。


2

Operation

Figure 2 GIF.  Measurements. Large aneurysm with wide neck and daughter sac. Aneurysm sac: 16.9*15.5mm; daughter sac: 7.9mm; neck: 4.9mm. 

图 2 GIF.  测量。宽颈大动脉瘤伴子瘤。动脉瘤腔:16.9*15.5mm;子瘤瘤腔:7.9mm;瘤颈:4.9mm。


Figure 3 GIF. Microcatheter for coiling is navigated to the aneurysmal sac. 

图 3 GIF.  栓塞微导管超选至动脉瘤瘤腔。


Video 1. Microplex18 Cosmos Complex 20mm*65cm was inserted into the aneurysmal sac for framing. 

视频 1. 将Microplex18 Cosmos Complex 20mm*65cm弹簧圈填入动脉瘤腔内成篮。


Figure 4 GIF. Insert the following coils to make the main sac densely packed: Three Microplex18 Cosmos Complex  16mm*52cm, Microplex18 Cosmos Complex 14mm*51cm. 

图 4 GIF. 填入以下弹簧圈将动脉瘤腔致密栓塞。填入弹簧圈为:3枚Microplex18 Cosmos Complex 16mm*52cm弹簧圈,Microplex18 Cosmos Complex 14mm*51cm弹簧圈1枚。


Video 2. Insert a Microplex18 Helical Regular 8mm*30cm coil.

视频 2. 填入1枚Microplex18 Helical Regular 8mm*30cm弹簧圈。


Video 3. Coils were inserted successively to pack the neck. During the coiling, repeated protrusion of the coil loop to the parent artery made it difficult to densely pack the neck.

视频 3. 将以下弹簧圈(弹簧圈Microplex18 Helical Regular 7mm*30cm2枚,Microplex10 Cosmos Complex 5mm*15cm和Microplex10 Cosmos Complex 5mm*22cm各1枚,Microplex10 Cosmos Complex 5mm*15cm2枚 )依次填入栓塞瘤颈部。填圈时弹簧圈袢反复突出至载瘤动脉,很难将瘤颈部致密栓塞。


Figure 5 GIF. LVIS 3.5mm*20cm were deployed covering the aneurysmal sac. 

图 5 GIF. 于瘤颈部释放LVIS 3.5mm*20cm支架。


Figure 6 GIF. A Microplex10 Hypersoft Helical 3mm*8cm coil was inserted into the aneurysmal sac successfully without protrusion.

图 6 GIF. 将Microplex10 Hypersoft Helical 3mm*8cm弹簧圈成功填入动脉瘤腔,弹簧圈袢未突出。


Figure 7 GIF. Then the coils inserted for dense packing of the neck were as followed: Microplex10 Hypersoft Helical 3mm*8cm, two; Microplex10 Hypersoft Helical 2mm*4cm, three; Microplex10 Hypersoft Helical 1.5mm*3cm, one; Microplex10 Hypersoft Helical 1mm*3cm, two.

图 7 GIF. 将以下弹簧圈填入瘤颈部,将瘤颈致密栓塞。填入弹簧圈为2枚Microplex10 Hypersoft Helical 3mm*8cm;3枚Microplex10 Hypersoft Helical 2mm*4cm;1枚Microplex10 Hypersoft Helical 1.5mm*3cm及2枚Microplex10 Hypersoft Helical 1mm*3cm。


Figure 8 GIF. The aneurysm was densely packed with parent artery patent.

图 8 GIF. 动脉瘤致密栓塞,载瘤动脉通畅。


Figure 9 GIF. Intracranial vessels are intact. No evident hemorrhage or thrombus.
图 9 GIF. 颅内血管完好,无出血及栓塞。


3

Post Operation

• GCS 15, left temporal visual field defect and blurred vision, no new neurological defect. 

• TEG: ADP 10.7%. 

• Medication: Suggest dual antiplatelets at least 3 months. However the patient stopped antiplatelets 2 months after operation.

• 患者GCS 15分,左眼颞侧视野缺损、视物模糊,无新发神经功能缺损。 

• 血栓弹力图:氯吡格雷抑制率10.7%。 

• 药物:建议双抗至少3个月,但术后2个月患者自行停药。


4

Follow-up (4-month, 38-month)

• The patient still suffered from blurred vision and eye exams showed bilateral eye field defect. 

• Four-month and 38-month DSA revealed no residue or recurrence. 
• Next follow up is scheduled in 5 years.

• 患者仍诉视物模糊,眼科会诊提示双眼视野缺损。

• 4个月和38个月DSA随访动脉瘤无残留及复发。

• 建议5年后再次随访。


Figure 10 GIF. Follow-up angiography shows no relapse of the aneurysm. 

图 10 GIF.  DSA随访未见动脉瘤复发。


Figure 11 GIF. Rotational DSA comparison among post-operation and twice follow up DSA shows complete occlusion of the aneurysm. 
图 11 GIF.  对比术后及两次随访的DSA旋转造影证实动脉瘤完全栓塞。


6

Summary

  • Left large upper-medial ophthalmic aneurysm with mass effect should be treated. 

  • This case adopted the stent-assisted large coiling technique. Block by Block embolization was performed to pack the sac with large coils and embolize the neck with small coils, which can decrease the recurrence rate while the mass effect may remain existed.
  • Large coils for aneurysm sac provided strong support and LVIS assisted small coils for aneurysm neck embolization to decrease neck relapse. Large coiling technique could lower recurrence rate while mass effect may remain existed. 
  • A pipeline could be chosen to alleviate mass effect for this case. 
  • Coil selection is significant in this case. Though the first two coils did not provide a satisfied frame, the stable basket involving the neck was achieved by the third coil framing.
  • The right ophthalmic aneurysm is regular and small, indicating the low risk of rupture. It coud be follow-up.
  • 颈内动脉上内侧壁大的颈眼动脉瘤,患者出现视物模糊,该动脉瘤建议治疗。
  • 该病例采用支架辅助大圈技术分区栓塞。大圈栓塞动脉瘤腔,LVIS支架辅助小弹簧圈栓塞动脉瘤颈,降低动脉瘤颈复发风险。

  • 大圈技术能降低复发率但占位效应可能不能缓解。

  • Pipeline 可能能改善占位效应。

  • 弹簧圈的选择在该病例中十分重要。尽管前两枚弹簧圈并没有在瘤颈中成篮,第三枚弹簧圈包裹瘤颈并稳定成篮。

  • 右侧颈内动脉眼段规则小动脉瘤随访,提示小的规则的颈眼动脉瘤一般比较稳定。

END

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