特殊类型动脉瘤的介入治疗课件.ppt
特殊类型动脉瘤的介入治疗特殊类型动脉瘤 特殊部位 颈动脉前壁动脉瘤 脉络膜前动脉动脉瘤 大脑后动脉动脉瘤 远端动脉瘤 穿支血管动脉瘤 特殊类型 合并假性成分的动脉瘤 夹层动脉瘤 外伤性动脉瘤 蛇形动脉瘤脉络膜前动脉动脉瘤脉络膜前动脉动脉瘤（Anterior Choroidal Artery Aneurysm,AChAN）占所有颅内动脉瘤的2-5%AChA 颈内动脉的终末分支，其穿支供应了视束、大脑脚、外侧膝状体、苍白球、内囊后肢等重要的结构。AChA 发自瘤颈，术后缺血并发症发生率23.8%（5/21）AchA 与动脉瘤无关，无缺血并发症（0/17）KimBMetal.Neuroradiology(2008)50:251脉络膜前动脉动脉瘤Case 151-Y-O-F10min later 术后即刻言语含糊，对侧上肢肌力1级，下肢3级，对侧Babinski征阳性 1个月后对侧肢体轻偏瘫 Subtotal Embo.Case 247-Y-O-FSAHFinalStent+coilCase 356-Y-O-FSAHMESH technique15m FU建议术前3-D重建仔细分析AchA与An的关系术中注意AchA通畅性累及AchA的An，宁愿次全栓塞或瘤颈残留支架有利于AchA的保护和动脉瘤愈合大脑后动脉动脉瘤 占全部颅内动脉瘤的0.7-2.3%多发于P1、P2段 发病平均年龄38岁 大或巨大动脉瘤常见 Drake,42%ofgiantaneurysms Yasargil,50%ofgiantaneurysms Ciceri,24%ofgiantaneurysms 分类 囊性动脉瘤 夹层动脉瘤大脑后动脉分段ZealAA,RhotonALJr.JNeurosurg,1978,48(4):534CiceriEF,etal.AJNRAmJNeuroradiol,2001,22:27治疗方法手术 technical difficulties and high risks介入 囊性动脉瘤：动脉瘤弹簧圈栓塞 夹层动脉瘤：载瘤动脉闭塞（parentvesselocclusion，PVO）riskofinfarctionfromperforatorsand/ordistalbranchocclusion 支架辅助栓塞囊性动脉瘤Case 9男，47岁突发头痛SAH无再出血，无神经功能缺损囊性动脉瘤2mFU囊性动脉瘤 PCA-An血流动力学相关的多为囊性动脉瘤AJNR Am J Neuroradiol 22:2734,January2001夹层动脉瘤 P2P段Case 1045-Y-O-FSAH&IVHCase 11男，26岁头痛，神经系统（-）夹层动脉瘤夹层动脉瘤 P2PP2P段段术前R-ICA术后R-ICA术后左侧视野缺损术后3 月改善 术后3 月 Itisimpossibletobecertainwhetherornotaparentarteryocclusionwillbetolerated.Ingeneral,however,weavoidparentarteryocclusionattheP1orP2segmentsgiventherichvascularsupplytothebrainstemthatoriginatesfromtheseanatomiclocationsandthepossibleneurologicdeficitsthatmayoccurasaresultofsuchtreatment.CiceriEFetal.AJNRAmJNeuroradiol2001,22:2734夹层动脉瘤 P2A段Case 1258-year-old maleincidental foundEnterprise4.5/2211MFU11MFUAfter 2 Enterprise stentsA BD C PVO TheincidenceofsymptomaticinfarctionafterPAocclusionwas16.3%intheliteraturereview.BOT 无效，不常用 Stent assisted coiling Inliteraturereview,themorbidityandmortalityofstentforPCAaneurysmswas7.9%intotal.Noinfarctionwasreported.Therewerethree(13%)recurrences,butonlyone(4.3%)causedrebleeding.HuangQ,etal.ClinNeuroradiol.2013建议囊性动脉瘤应单纯栓塞动脉瘤夹层动脉瘤可能需要闭塞载瘤动脉 P1、P2段动脉瘤闭塞载瘤动脉可能导致穿支闭塞，尽可能保留载瘤动脉定期随访幕下远端动脉瘤 Distalaneurysmsofcerebellararteriesarerarelesionsaccountingfor0.6%ofalltreatedaneurysms 夹层、假性动脉瘤常见 一般需要闭塞载瘤动脉PelusoJPP,etal.AJNRAmJNeuroradiol.2007,28:1573TokimuraH,etal.NeurosurgRev.2012,35:497Distal PICA AnCase 1358-Y-O-FSAH&IVH in 4th ventricleCase14Distal AICA AnMarathonsuperselectiveangio.Onyx-34ControlangiographyafterembolizationMRI4daysafterembolization注意事项Onyx-34 intraprocedual leakage术前术后评价闭塞动脉瘤及载瘤动脉原位闭塞注意术中破裂风险F,52Yrs,Suddenonsetofheadache&nauseaRebleeding20dayslater,HHgradeII2010-10-292010-11-182010-11-22合并假性成分的AnCase15Onyx0.2mln n Endovascular Endovascular coiling&Onyx injection.coiling&Onyx injection.Hydrosoft2/6 SuccessfulsealtestHyperform4/7Final control6M Follow-upCase16Intralumenonyx评价利：栓塞率高、栓塞效果好不利：操作复杂、占位效应、经验较少建议：特殊病例应用，注意并发症椎动脉夹层动脉瘤椎动脉夹层动脉瘤 出血性夹层 再出血24%71.4%70%发生在首次出血后24 小时内，80%发生在一周内 缺血性夹层 无症状治疗手术 近端夹闭 动脉瘤孤立 颅神经麻痹介入 夹层动脉瘤孤立 夹层近端闭塞 血管重建Case21SAHVA-V4 出血性夹层Case2058yFemale,acuteSAH,bilateralVAdissectioninganeurysm.VA-V4 出血性夹层R-VAdissectionworkingprojection,doublemicrocatheterinpositionSemi-deploythestentandintroducecoilsFourcoilsintroducedandfullydeploythefirstEnterpriseAfterdeploying3stents,decreasedcontrastinthedissectioninganeurysmwasoberserved.L-VAocclusion50minafterdeployingthe3rdstent,R-VAreconstructed,R-PICApatentCase22非出血性夹层4Enterprisestents8mFU三维模拟速度场 壁面切应力 压力场支架孔率对血流动力学的效应关系汇聚变发散完全抑制强度变弱金属覆盖率金属覆盖率30%-40%30%-40%支架和弹簧圈对于分支血流的影响 收缩末期经过分支截面的血流速度。A 为治疗前；B-D 为植入1-3 枚支架，随着支架数量的增加，血流速度无明显变化；E-H 为植入1 枚支架和不同栓塞密度的弹簧圈，弹簧圈密度分别为2.5%，4.7%，8.5%和14.9%，随着弹簧圈的增加，血流速度进行性下降，当栓塞密度达到14.9%时，血流方向发生改变。I-L 为0-3 枚支架结合4.7%栓塞密度的弹簧圈,在弹簧圈数量固定的情况下增加支架数量，分支血流速度无明显变化。Tubridge 46根镍钛丝（40u）2根Pt显影芯（80u）金属覆盖率 35%脉瘤颈处30%50%其它位置12%20%6mFU外伤性假性动脉瘤87M38,4weeksafterheadtraumawithskullbasefracture,lefteyeblindness,pseudo-aneurysmofophthalmicsegmentofleftICA88M38,4weeksafterheadtraumawithskullbasefracture,lefteyeblindness,pseudo-aneurysmofophthalmicsegmentofleftICA89Enterprisestentinposition,firsthydrocoil4/10,followbythree3/10barecoils,twoAxium1.5/2coils90Last3/4coil,partialloopsatruptureholeandpartialintheparentvessel,wishingtocovertheruptureholeafterstentdeployment91Finalresult92ImmediatelyafterOp1weekFU93ImmediatelyafterOp4mFU94ImmediatelyafterOp4mFU Non-intracranial covered stents:Jostent(AbbottVascular)Symbiot(BostonScientific)CarotidWallstent(BostonScientific)Autologousvein-coveredstent Intracranial covered stentWillis(MicroPort,Shanghai,China)Jostent6m follow up SAH Calcification in PcomA area蛇形动脉瘤DSA3D-DSAMCAICAAchAP2PcomAP1DynaCTP2PcomAP1P2ICAAchAPcomADSA L-CCA Slim ICA,distal ICA filled by collateral branches of MMA via retrograde flow through OA,MCA thus filledICADSA R-ICAA1DynaCTCarotidCanalCarotidCanalPreoperative CTPStrategy Step 1STA-MCABypss Step 2BOTinBA Step 3OcclusionofPcomA&AnPosterative CTPrCBVrCBFTTP-MTT-ComparedwithpreoperativeCTP10 days later Angio.&BOT via L-CCA3D DSACBV based on 8sDSA Pre-BOTBOT in BAPCABOT in BAICACBV when BOT in BA No significant difference with previous CTPEmbolization of PcomA&AnPost-embolizationPost-embolizationPost-embolizationPost-embolizationCoilsContrastinPcomA
