LVIS stent-assisted spring coil embolism to treat a case of pseudo-aneurysm after arterial stent forming in the brain

Female patient, 44 years oldThe main victim was admitted to hospital on 14 September 2018 after suffering a two-week increase due to numbness and inability to do so on his left limb for about 3 yearsPatients about 3 years ago without obvious causes of left limb numbness, weakness, then in November 24, 2015 to my hospital, outpatient MRI and MRA examination tips right half-egg circle center softening stove, the right side of the brain artery artery artery limitation severe stenosis; Regular aspirin 100mg/d combined with clopidogrel 75mg/d double antiplatelet therapy after 21 days to aspirin 100mg/d oral, while long-term taking atolvastatin 20mg/d lipid stabilization and stabilization of plaque, symptoms gradually alleviated2 weeks ago there was no obvious cause to re-emerge the numbness of the left limb, weakness and the symptoms of sexual aggravationIn order to seek further diagnosis and treatment, again to my hospital for review, to "ischemic stroke, the right side of the brain artery severe stenosis" hospitalSince the onset of the disease, the spirit of general, sleep, diet is OK, there is no abnormality in size, no significant change in weightPrevious history of hypertension 3 years, long-term use of 80mg/d, blood pressure control in generalThere is no special personal history or family historyfirst admission diagnosis and treatment after a physical examination: clear mind, language is not clear, the spirit is general, high-level intelligent activity is normal; There are no obvious anomalies in the laboratory inspection indicatorsThere were no obvious abnormalities in the head MRI; CTA showed severe stenosis of the far end of the arterial M1 section of the right brain (Figure 1a) ;D SA visible severe stenosis of the arterial M1 segment in the right side of the brain, with a stenositis rate of 80% (Figure 1b), length of about 10mm, narrow near end and far-end tube cavity diameter of about 2.50mm, improved cerebral infarction fluid blood flow classification (mTICI) 2bAccording to the patient's clinical symptoms and signs, auxiliary examination results, the clinical diagnosis is severe arterial stenosis, ischemic stroke, hypertension (level 1)After the hospital, aspirin 100mg/d, clopidogrel 75mg/d and atolvastatin 20mg/d and other drugs are taken orallyOn September 21, 2018, at the end of general anaesthetic down the right side of the brain arterial stentforming, under DSA surveillance, 6F Envoy catheter (Cordis USA) was placed in the right-field artery C2 segment, 0.014in x 200cm Synchro micro-conduction (Stryker, USA) slowly through the arterial stenosis section of the right brain and stabilized in the M2 to M3 segment; After precise positioning, the U.SAbbott company with 810.60kPa pressure expansion, DSA showed a narrow section of blood flow perfusion significantly improved, residual narrowness rate of about 30% (Figure 1c) immediately after the NOVA balloon expansion bracket (2.25mm x 2.00mm, Sanofi Usai) positioning and 810.60Pa pressure continued to expand the balloon for 3 seconds, with a full opening for releaseDuring the operation DSA found that the stent implant area contrast agent penetration (Figure 1d), with low pressure filling ball sac blocking blood flow and closed blood vessels with the ball sac (Figure le), fish essence protein 15mg and heparin, etc., 30 minutes later dSA again dSA visible no contrast agent penetration, stent wall is good, residual stenosis rate 10% (Figure 1f), and narrow far end filletblood significantly improved, mTIClgradedImmediately after surgery, lumbar puncture cerebrospinal fluid examination visible blood cerebrospinal fluid outflow, pressure is about 150mmH2O (1mm H2O x 9.81 x 10-3kPa, 80-180mm H2O), to Nimodipine 5ml/h preventive vascular mculm, compound glycol 250 ml/secondary (3 times/dehydrated) reduced intracranial pressure The following day of surgery, the head CT was reviewed, showing multiple cerebral grooves, high density shadow in the brain cell, prompting the subcavity of the cobweb symcom hemorrhage, continuous release of blood cerebrospinal fluid through lumbar puncture, to the 5th day after surgery (September 25, 2018) CT showed that intracranial hemorrhage basic absorber stopped treatment The patient was hospitalized for a total of 12 days, when discharged from the left limb numbness, weakness symptoms improved, and no other conscious symptoms and signs re-admission diagnosis and treatment 2 months after the patient was discharged from the hospital (November 14, 2018) re-admission review, head DSA shows the right side of the brain arterial stent forming after surgery changes, the vascular cavity outside the visible bag-like puffing out, size of about 7.40mm x 3.60mm, internal visible contrast ingresss, drainage delay (Figure 2a), considering the formation of pseudo-artertic aneurysm To prevent the rupture of a false aneurysm, an intracranial aneurysm embolism is performed under general anaesthetic on 19 November 2018 Patients lying on their backs, using the 6F EnvoyDA guide tube (Medos, Germany) pushed to the right neck artery C2 section, again confirmed by dSA false aneurysm form and position, and then select edgy-10 microcatheter (Us Stryker) shaped with Transend micro-guide (Us Stryker Company) pushed to the right side of the brain, the micro-guide dystostic Way21 microcatheter (Ternumo Corporation, USA) to the far end of the artery in the right brain, via The Connection-10 microcatheter in turn using 4mm x 80mm, 2mm x 60mm and 2mm x 60mm spring rings to fill the aneurysm cavity, and implanted by Headway21 microcatheter 3.50mm x 15.00mm LV self-puffed dense mesh stent (Terumo Corporation, USA) to the atom lysate injection aneurysmal injection ;D SA shows an euratom filling satisfied (Figure 2b), releasing the stent and removing the microcatheter The patient was admitted to hospital for 9 days, taking aspirin 100mg/d and clopidogrel 75mg/d after surgery, and after 21 days of treatment changed to aspirin 100mg/d and atoflavatin 20mg/d for long-term oral use 6 months after surgery, the head CT did not see intracranial infarction lesions, recovered well (Figure 2c) discuss Intracranial atherosclerosis stenosis is not only the main cause of ischemic cerebrovascular disease (30%-40%), but also the predictor of death, up to 51% of ischemic cerebrovascular disease in China is caused by intracranial artery stenosis With the increase of vascular stenosis, the recurrence rate of stroke also increased, and the rate of stenosis waschemic cerebrovascular disease in patients with a rate of 70% within 1 year waschemic cerebrovascular disease recurrence rate of 20% Clinical trial results published in recent years suggest that the 30-day recurrence rate of intravascular treatment of stroke through rigorous screening of surgical adaptation certificates was only 4.3%, significantly lower than the stentforming and intensive drug therapy to prevent stroke recurrence in patients with intracranial arterial stenosis (SAMMPRISE) and Visse stent therapy ischemic stroke (VISSIT) In patients with severe intracranial artery stenosis with low perfusion, intravascular stentforming can significantly reduce the recurrence rate of stroke 14 days after the onset of ischemic stroke In this case, before treatment, there were symptoms of partial limb weakness, and by DSA confirmed that suffering from side blood flow perfusion decline and long-term drug treatment is not effective, so the right side of the brain arterial stent forming surgery, postoperative clinical symptoms significantly improved, indicating that surgical treatment is effective Blood vessel rupture caused by balloon dilation or stent release process is a serious complication of stent forming, which can lead to serious consequences if hemorrhage is not stopped in time In this case, the rupture of arterial artines in the brain after the release of the stent is mainly related to the anatomy of the intracranial artery, the pathological properties of the selected balloon dilating stent with too large diameter or narrow blood vessels The intracranial artery wall is thinner than other organs, and the membrane smooth muscle and the outer membrane elastic fiber is relatively small, when the blood vessel struck, its blood vessel wall loses elasticity and brittleness increases, the diameter of the arterial tube cavity in the right side of the brain of the patient is about 2.50mm, the selected balloon dilation stent specification is 2.25mm, in the stent release process, due to excessive pull caused by the blood wall tear bleeding In addition, the patients in this paper are middle-aged women, the cause of intracranial vascular stenosis is not very clear, may be non-atherosclerosis changes caused by increased wall brittleness, bleeding, the use of the cystic partial compression to stop hemorrhage and success, thus preventing the occurrence of catastrophic consequences However, during a 2-month review of the patient after surgery, DSA found that a false aneurysm was formed in the ruptured heeofory in the right brain, a special type of intracranial aneurysm, and the risk of ruptured bleeding was extremely high because it did not have complete vascular wall structures such as elastic fibroblasts or smooth muscle cells Angiovastomy is one of the main methods for treating intracranial pseudo-aneurysms, which gradually atrophy by isolating the passage between the pseudo-aneurysm and the normal vascular cavity, while maintaining the smooth flow of the blood vessels of the carrier tumor The use of spring ring dense filling tumor cavity, combined with stent reconstruction of blood vessel walls can minimize recurrence, improve the cure rate In this paper, the formation of false aneurysm is related to surgical trauma, in the second operation, we use LVIS self-puffed tight mesh stent to assist with aneurysm dense filling, effectively realized the damage to blood vessels in the tube cavity reconstruction and did not affect the blood flow of other blood vessels, and achieved better treatment results stentforming is one of the important methods to treat severe stenosis of the symptomatic intracranial atherosclerosis, the rupture of blood vessels caused by surgery can be remedied by the ball bag closure, and the false aneurysm caused by surgical trauma is treated with spring ring dense filling