· 70 y/o female.· Sudden onset of amaurosis of the left eye with weakness of the left lower limbs one year ago.· NE: (-).· 女性，70岁。· 一年前突发左眼黑矇及左下肢无力。· 神经系统查体阴性。
1
Pre-operative
Figure 1. MRI DWI showed no acute infarction. MRI DWI未见急性梗塞灶。
Figure 2. Angiography revealed severe stenosis of the inferior segment of the right MCA and the A1 segment of left ACA. The right A1 was not well-developed.造影示右侧大脑中动脉下干及左侧大脑前动脉A1段重度狭窄。右侧A1段发育不良。
2
Treatment Strategy
· Both left A1 and right M2 severe stenosis could be responsible for transient weakness of the left lower limb.· Strategy: Stenting of left A1 and right M2.· 右侧大脑中动脉下干及左侧大脑前动脉A1段重度狭窄均可能是患者左侧肢体乏力的责任病灶。· 治疗策略：左侧A1段及右侧大脑中动脉下干支架置入术。
3
Operation
Figure 3. Measurement of right MCA stenosis.右侧大脑中动脉狭窄测量。
Video 1. Transend 205 microwire penetrated the inferior segment of the right MCA while guiding Gateway 2.5mm*15cm balloon. Transend 205 微导丝引导Gateway 2.5mm*15cm球囊时刺破右侧大脑中动脉下干。
Video 2. Angiography showed contrast extravasation indicating hemorrhage. 造影示造影剂明显外渗。
4
Emergency treatment
· Step 1: Withdraw the balloon at the M1 segment and then inflate it for 120s.· Step 2: Use the coil to press the penetrated artery· Medication: mannitol, PAMBA, furosemidum· 回撤球囊置于M1段，充盈球囊压迫120秒。· 使用球囊压迫受损部位血管。· 紧急用药：甘露醇脱水，PAMBA止血，速尿。
Figure 4. Emergency treatment step 1. Inflating Gateway balloon in M1 for 120s. Afterward angiography showed bleeding was not stopped. 紧急处理1. 于M1段充盈球囊压迫120秒后造影示出血未停止。
Figure 5. Emergency treatment step 2. The microwire in the balloon was withdrawn. The attempt to insert Hypersoft 3mm*8cm to the rupture site via the balloon microcatheter was failed. After successfully inserted and kept undetached for about one minute in the ruptured branch,Hydrosoft 1.5mm*4cm coil was retrieved.紧急处理2. 撤出球囊导丝，试图通过球囊导管将Hypersoft 3mm*8cm置于破裂处失败。更换Hydrosoft 1.5mm*4cm置于破裂处并压迫约1分钟。
Figure 6. Superselective angiography showed no sign of bleeding. 超选造影示出血停止。
Figure 7. Dyna CT showed large volume of SAH.Dyna CT示大量蛛网膜下腔出血。
Video 3. Angiography after one hour waiting showed no more bleeding. Nimodipine 3ml was given via guiding catheter. 等待一小时后复查造影未见出血征象。经导引导管给予尼莫地平3ml。
5
Post-operative
· Lumbar puncture: red CSF 20ml, pressure 85mm H2O· 术后腰穿血性脑脊液，压力85mmH2O，放脑脊液20ml。
Figure 9. Post-operative CT (6 days) showed absorption of SAH without infarction.术后6天CT示出血大部吸收，未见明显梗塞灶。
6
Treatment for IPR
· Emergency treatment after observing the rupture: 术中处理1.Inflate the balloon in the ruptured artery2.Insert a small and soft coil close to the rupture point to stop the bleeding3.Angiographic confirmation of non-bleeding before finishing the operation4.Emergency medication: Mannitol, PAMBA, Nimodipine· Treatment after the operation:术后处理1.Lumbar puncture腰穿2.Continue giving medication继续药物治疗
7
Lessons and Experience
· There is an around 5mm invisible tip before the distal mark of the Gateway balloon.Gateway球囊远端标记前有约5mm长不可见的头端。· General heparinization should not be given until the angioplasty. 全身肝素化应等到球囊扩张结束后再使用。
