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For Medical Professionals Only For large and giant aneurysms, the advent of flow diverting devices has opened up new ways of treating large and giant aneurysms
.
The safety of endovascular treatment of large and giant intracranial aneurysms has been clinically affirmed, but the high recurrence rate is an important problem that is difficult to overcome at present
.
The application of stent-assisted coils has improved the recurrence rate of these diseases to a certain extent, but are there better treatment techniques? Recently, in the activity of "Three Walks in Urgency: Focusing on Skills", Professor Gao Guoyi of the First People's Hospital Affiliated to Shanghai Jiaotong University, Professor Zhang Bo of the First Affiliated Hospital of Southern University of Science and Technology, and Professor Cai Heng of Shengjing Hospital Affiliated to China Medical University Let's discuss the impact of the application of new ideas, new technologies and new materials on the treatment effect of intracranial aneurysms, let us review together
.
The first case shared by Professor Cai Heng in the treatment of large aneurysm with blood flow diversion device is the case of a 68-year-old female
.
The patient was given aspirin 100 mg qd + clopidogrel 75 mg qd to inhibit platelets before operation, and the monitoring results after 10 days of medication showed that the platelet inhibition rate reached the target
.
The preoperative 3D reconstruction image showed that the patient had a large aneurysm in the ophthalmic artery segment of the right internal carotid artery, and there was an unruptured small aneurysm at the distal end of the known aneurysm and the right middle cerebral artery.
distance, it was determined that one flow diverter could not cover both lesions
.
After discussing with the family, it was decided that the large internal carotid artery aneurysm should be treated first, and then the small unruptured right middle cerebral artery aneurysm should be treated after 6 weeks
.
Fig.
1 Preoperative imaging examination of the patient When selecting a blood flow guide device before surgery, a 3.
5 mm diameter stent was selected according to the proximal and distal diameter of the parent artery
.
Because the parent artery is tortuous and the aneurysm neck is wide, in order to ensure that the stent is anchored in the relatively straight part of the parent artery and completely covers the lesion, a 30 mm length stent was selected.
.
In addition, considering the three-dimensional relationship between the aneurysm neck angle and the parent artery, the surgical plan uses coils to loosely pack the patient's aneurysm to reduce the blood flow rate in the aneurysm to accelerate the healing process of the aneurysm
.
During the operation, it is estimated that the femoral artery can be cannulated first, and then according to the passage of the microcatheter, it is determined whether to use an intermediate catheter, and then the aneurysm is partially filled with a coil, and finally the blood flow guide device stent is released
.
After the intraoperative microcatheter was in place, three coils were released to embolize the aneurysm.
Immediate angiography results showed that the blood flow into the aneurysm was significantly reduced
.
After the third coil was released, the microcatheter was delivered to the distal normal vessel, and the guide wire was exchanged to the distal end of the upper trunk of the ipsilateral middle cerebral artery to ensure sufficient support for the stent catheter in place
.
Once the stent guide is in place, the stent is released
.
The patient was given aspirin 300 mg qd + clopidogrel 75 mg qd within 6 weeks after operation, and was instructed to return to the hospital for follow-up angiography after 6 weeks to treat the unruptured small aneurysm of the right middle cerebral artery
.
Professor Cai Heng pointed out that the recurrence of aneurysm cannot be avoided after stent-assisted embolization of large aneurysms and early reconstruction of the aneurysm neck
.
The reasons for the high recurrence rate of simple coil embolization include: wide aneurysm neck, easy to protrude into parent artery during coil packing; huge tumor body, coil partition is easy to occur during embolization; the water hammer effect of blood flow shock causes coil compression etc.
_
The role of stents in the treatment of large wide-necked aneurysms includes: providing a mechanical barrier to prevent the coil from protruding into the parent artery and maintaining the patency of the parent artery; improving the degree of dense embolization, preventing long-term recurrence and rebleeding as much as possible, and changing the protruding load.
Aneurysmal artery curvature and hemodynamics, reconstructed blood flow and parent artery
.
The dense mesh stent of the blood flow diverting device can also reduce blood flow inside the artery, providing support to endothelialize the neck of the aneurysm and permanently block blood flow
.
Histopathology in animal models confirmed that, in addition to reducing blood flow into the aneurysm, the flow diverter provided support such that the aneurysm neck was covered with neointima
.
However, Professor Cai Heng also emphasized that the blood flow guide devices commonly used in clinical practice can isolate aneurysm and circulating blood flow through high metal coverage, but their radial force is weaker than that of conventional stents, and the release process is more difficult, except for some types of stents.
, most of the other devices still lack sufficient clinical evidence and need further research
.
Various types of devices have different technical characteristics and are suitable for different indications.
More research is needed to compare and confirm the optimal use of blood flow diversion devices
.
It should be noted that in order to reduce the risk of postoperative bleeding in patients, attention should also be paid to the management of postoperative blood pressure and the rational use of antihypertensive drugs
.
At present, the most commonly used intravenous antihypertensive drug in neurosurgery is nicardipine, which takes effect immediately after administration, reaches the peak concentration in 1 minute, and reaches the peak effect in 2~3 minutes, which can achieve the purpose of rapid, safe and controllable blood pressure reduction.
Recommendations from relevant guidelines have also been obtained
.
Immediately afterwards, Professor Gao Guoyi reviewed the "history of conquering aneurysm" by Chinese neurosurgery experts and said: "As early as the 1950s, one of the pioneers and founders of neurosurgery in China, the Neurosurgery Department of Huashan Hospital Affiliated to Fudan University.
The founder, Professor Shi Yuquan, started the surgical resection of arteriovenous malformations, and performed the first aneurysm resection in China
.
Treatment of aneurysms by methods such as tamponade
.
In recent years, the application of blood flow diversion devices has given us more time to treat aneurysms, but during its application, care should be taken to protect the patient's intracranial perforating arteries.
In addition, it is necessary to Accumulate more data and experience to benefit more patients
.
"Professor Zhang Bo believes that interventional therapy to "conquer" intracranial aneurysms is a hot spot in the field of neurosurgery in recent years, and the application of blood flow guiding devices is also a hot spot in the field of intervention.
Such devices make interventional operations for aneurysms simpler and faster.
For
patients with giant aneurysms, some costs can also be saved
.
However, it should be noted that different brands of blood flow diverting devices have different characteristics, and also have differences in the healing rate, stent adherence, and bleeding risk, requiring individualized application.
In
addition, based on the risk of thrombosis, patients should be fully prepared for dual antiplatelet before surgery
.
Summarizing the new equipment and technologies represented by blood flow diverting devices, the clinic has a better ability to deal with large/giant aneurysms There are many effective means
.
However, due to the short clinical application time of such devices, more research is needed to accumulate more experience
.
In addition, in postoperative management, attention should be paid to the important role of blood pressure control in reducing the risk of bleeding in patients, and reasonable application Nicardi and other intravenous antihypertensive drugs, in order to maximize the prognosis of patients
.
Copyright notice: This information is intended to help medical and health professionals better understand the latest developments in the field of related diseases
.
If copyright issues are involved, please contact us.
We will deal with it as soon as possible
.
For informational use only by healthcare professionals
.
Such information is not intended to replace professional medical advice in any way, nor should it be considered medical advice
.
If such information is used for purposes other than informational , this site and the author do not take any responsibility
.
.
The safety of endovascular treatment of large and giant intracranial aneurysms has been clinically affirmed, but the high recurrence rate is an important problem that is difficult to overcome at present
.
The application of stent-assisted coils has improved the recurrence rate of these diseases to a certain extent, but are there better treatment techniques? Recently, in the activity of "Three Walks in Urgency: Focusing on Skills", Professor Gao Guoyi of the First People's Hospital Affiliated to Shanghai Jiaotong University, Professor Zhang Bo of the First Affiliated Hospital of Southern University of Science and Technology, and Professor Cai Heng of Shengjing Hospital Affiliated to China Medical University Let's discuss the impact of the application of new ideas, new technologies and new materials on the treatment effect of intracranial aneurysms, let us review together
.
The first case shared by Professor Cai Heng in the treatment of large aneurysm with blood flow diversion device is the case of a 68-year-old female
.
The patient was given aspirin 100 mg qd + clopidogrel 75 mg qd to inhibit platelets before operation, and the monitoring results after 10 days of medication showed that the platelet inhibition rate reached the target
.
The preoperative 3D reconstruction image showed that the patient had a large aneurysm in the ophthalmic artery segment of the right internal carotid artery, and there was an unruptured small aneurysm at the distal end of the known aneurysm and the right middle cerebral artery.
distance, it was determined that one flow diverter could not cover both lesions
.
After discussing with the family, it was decided that the large internal carotid artery aneurysm should be treated first, and then the small unruptured right middle cerebral artery aneurysm should be treated after 6 weeks
.
Fig.
1 Preoperative imaging examination of the patient When selecting a blood flow guide device before surgery, a 3.
5 mm diameter stent was selected according to the proximal and distal diameter of the parent artery
.
Because the parent artery is tortuous and the aneurysm neck is wide, in order to ensure that the stent is anchored in the relatively straight part of the parent artery and completely covers the lesion, a 30 mm length stent was selected.
.
In addition, considering the three-dimensional relationship between the aneurysm neck angle and the parent artery, the surgical plan uses coils to loosely pack the patient's aneurysm to reduce the blood flow rate in the aneurysm to accelerate the healing process of the aneurysm
.
During the operation, it is estimated that the femoral artery can be cannulated first, and then according to the passage of the microcatheter, it is determined whether to use an intermediate catheter, and then the aneurysm is partially filled with a coil, and finally the blood flow guide device stent is released
.
After the intraoperative microcatheter was in place, three coils were released to embolize the aneurysm.
Immediate angiography results showed that the blood flow into the aneurysm was significantly reduced
.
After the third coil was released, the microcatheter was delivered to the distal normal vessel, and the guide wire was exchanged to the distal end of the upper trunk of the ipsilateral middle cerebral artery to ensure sufficient support for the stent catheter in place
.
Once the stent guide is in place, the stent is released
.
The patient was given aspirin 300 mg qd + clopidogrel 75 mg qd within 6 weeks after operation, and was instructed to return to the hospital for follow-up angiography after 6 weeks to treat the unruptured small aneurysm of the right middle cerebral artery
.
Professor Cai Heng pointed out that the recurrence of aneurysm cannot be avoided after stent-assisted embolization of large aneurysms and early reconstruction of the aneurysm neck
.
The reasons for the high recurrence rate of simple coil embolization include: wide aneurysm neck, easy to protrude into parent artery during coil packing; huge tumor body, coil partition is easy to occur during embolization; the water hammer effect of blood flow shock causes coil compression etc.
_
The role of stents in the treatment of large wide-necked aneurysms includes: providing a mechanical barrier to prevent the coil from protruding into the parent artery and maintaining the patency of the parent artery; improving the degree of dense embolization, preventing long-term recurrence and rebleeding as much as possible, and changing the protruding load.
Aneurysmal artery curvature and hemodynamics, reconstructed blood flow and parent artery
.
The dense mesh stent of the blood flow diverting device can also reduce blood flow inside the artery, providing support to endothelialize the neck of the aneurysm and permanently block blood flow
.
Histopathology in animal models confirmed that, in addition to reducing blood flow into the aneurysm, the flow diverter provided support such that the aneurysm neck was covered with neointima
.
However, Professor Cai Heng also emphasized that the blood flow guide devices commonly used in clinical practice can isolate aneurysm and circulating blood flow through high metal coverage, but their radial force is weaker than that of conventional stents, and the release process is more difficult, except for some types of stents.
, most of the other devices still lack sufficient clinical evidence and need further research
.
Various types of devices have different technical characteristics and are suitable for different indications.
More research is needed to compare and confirm the optimal use of blood flow diversion devices
.
It should be noted that in order to reduce the risk of postoperative bleeding in patients, attention should also be paid to the management of postoperative blood pressure and the rational use of antihypertensive drugs
.
At present, the most commonly used intravenous antihypertensive drug in neurosurgery is nicardipine, which takes effect immediately after administration, reaches the peak concentration in 1 minute, and reaches the peak effect in 2~3 minutes, which can achieve the purpose of rapid, safe and controllable blood pressure reduction.
Recommendations from relevant guidelines have also been obtained
.
Immediately afterwards, Professor Gao Guoyi reviewed the "history of conquering aneurysm" by Chinese neurosurgery experts and said: "As early as the 1950s, one of the pioneers and founders of neurosurgery in China, the Neurosurgery Department of Huashan Hospital Affiliated to Fudan University.
The founder, Professor Shi Yuquan, started the surgical resection of arteriovenous malformations, and performed the first aneurysm resection in China
.
Treatment of aneurysms by methods such as tamponade
.
In recent years, the application of blood flow diversion devices has given us more time to treat aneurysms, but during its application, care should be taken to protect the patient's intracranial perforating arteries.
In addition, it is necessary to Accumulate more data and experience to benefit more patients
.
"Professor Zhang Bo believes that interventional therapy to "conquer" intracranial aneurysms is a hot spot in the field of neurosurgery in recent years, and the application of blood flow guiding devices is also a hot spot in the field of intervention.
Such devices make interventional operations for aneurysms simpler and faster.
For
patients with giant aneurysms, some costs can also be saved
.
However, it should be noted that different brands of blood flow diverting devices have different characteristics, and also have differences in the healing rate, stent adherence, and bleeding risk, requiring individualized application.
In
addition, based on the risk of thrombosis, patients should be fully prepared for dual antiplatelet before surgery
.
Summarizing the new equipment and technologies represented by blood flow diverting devices, the clinic has a better ability to deal with large/giant aneurysms There are many effective means
.
However, due to the short clinical application time of such devices, more research is needed to accumulate more experience
.
In addition, in postoperative management, attention should be paid to the important role of blood pressure control in reducing the risk of bleeding in patients, and reasonable application Nicardi and other intravenous antihypertensive drugs, in order to maximize the prognosis of patients
.
Copyright notice: This information is intended to help medical and health professionals better understand the latest developments in the field of related diseases
.
If copyright issues are involved, please contact us.
We will deal with it as soon as possible
.
For informational use only by healthcare professionals
.
Such information is not intended to replace professional medical advice in any way, nor should it be considered medical advice
.
If such information is used for purposes other than informational , this site and the author do not take any responsibility
.
