· 74 y/o female.· Suffering from dizziness for 3 years and found intracranial aneurysm for a month.· NE:(-).· 患者，女，74岁。· 头晕3年，发现颅内动脉瘤一月。· 神经系统查体无殊。
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Pre-operative
Figure 1. RMCA small aneurysm (A). Noted stenosis of the superior branch of left middle cerebral artery, which arose from the aneurysm neck of left MCA aneurysm (B). 右侧大脑中动脉小动脉瘤，左侧大脑中动脉上干起始部狭窄，发自左侧大脑中动脉动脉瘤瘤颈。
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Treatment Strategy
· Left MCA aneurysm：wide neck aneurysm with superior branch arising from the aneurysm neck.· Key point：Keep patent of the parent artery and the superior branch.· Strategy1. Stent assisted coiling.2. Put microcatheter tip adjacent to opening of the superior trunk with large coil technique.3. Application of small amount of Tirofiban during the procedure after angiographic confirmation of no hemorrhagic or ischemic complication.· Small right MCA aneurysm with regular shape.1. Stent remodeling technique. · 左侧大脑中动脉动脉瘤: 宽颈，左侧大脑中动脉上干发自动脉瘤瘤颈· 重点：保持载瘤动脉及上干通畅1. 支架辅助栓塞2. 将微导管头端置于上干开口，配合大圈技术保护3. 术中造影证实无颅内血管出血或闭塞后多次少量使用替罗非班· 右侧大脑中动脉小动脉瘤1. 支架辅助栓塞
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LMCA AN【SAC】
Figure 2.Measurement.测量。
Figure 3.General Heparinization. Headway-21 microcatheter with C curved tip was advanced to the main trunk of LMCA M2 segment. 全身肝素化。Headway-21微导管（头端C型）置于左侧大脑中动脉M2段主干。
Figure 4.Headway-17 microcatheter with S curved tip was placed adjacent to opening of LMCA superior branch. Headway-17(头端S弯)置于左侧大脑中动脉上干起始部开口。
Figure 5. Solitaire 4*20mm stent was released via the Headway-21 microcatheter. 释放Solitaire 4*20mm支架。
Figure 6. Working projection showed the position of the microcatheter tip and vasculature architect of LMCA aneurysm clearly. 工作角度造影清晰显示动脉瘤血管构筑及微导管头端的位置。
Figure 7. Echelon-10 microcatheter with S curved tip was advanced to the aneurysm sac. 将Echelon-10微导管（头端S型）在微导丝引导下置于动脉瘤腔。
Video 1. The frame coil Microplex-10 6mm*20cm was inserted.置入 Microplex-10 6mm*20cm成篮。
Figure 8. After inserting another Microplex-10 6mm*20cm and a Microplex-10 5mm*20cm, the microcatheter tip was pushed out of the aneurysm sac. Tirofiban 8ml was given via the guiding catheter. 在填入另一枚 Microplex-10 6mm*20cm及一枚 Microplex-10 5mm*20cm后，微导管头端被顶出瘤腔。经导引导管给予替罗非班8ml。
Figure 9. Another coiling catheter Headway-17 with S curved tip was inserted to the aneurysm sac.另一根栓塞微导管Headway-17（头端S型）被置于瘤腔内。
Figure 10. A Microplex-10 5mm*15cm and two Microplex-10 4mm*10cm coils were then inserted.先后填入一枚 Microplex-10 5mm*15cm和两枚 Microplex-10 4mm*10cm弹簧圈。
Figure 11. Angiography showed loose packing area close to superior branch opening with patent of parent artery and the superior branch. 造影示动脉瘤近上干起始部疏松栓塞，载瘤动脉及上干通畅。
Figure 12. After inserting three Hypersoft 3mm*8cm coils, Tirofiban 4ml was given. 先后填入三枚Hypersoft 3mm*8cm弹簧圈。予替罗非班4ml。
Video 2. Post-operative rotational angiography showed complete obliteration of the aneurysm with patent of the parent artery and the superior branch. 术后旋转造影示动脉瘤致密栓塞，上干及载瘤动脉通畅。
Figure 13. No hemorrhagic or ischemic complication was revealed. 未见出血或缺血性并发症。
Figure 14. Compared to pre-operative image，the parent artery was straightened gradually after stent implantation and embolization.与术前相比，载瘤动脉在支架置入及栓塞后逐步被拉直。
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RMCA AN【Single stent】
Figure 15. Working projection of right MCA aneurysm. 右侧大脑中动脉动脉瘤工作角度。
Figure 16. Headway-21 microcatheter with C curved tip was navigated to the right M2 segment. Headway-21微导管（头端C形弯）被置于右侧M2段主干。
Figure 17. Solitaire 4*20mm stent was deployed covering the aneurysm neck. 释放Solitaire 4*20mm支架覆盖瘤颈。
Figure 18. Post-stent angiography showed the aneurysm size shrank. 支架后造影示动脉瘤明显缩小。
Video 3. Tirofiban 4ml was given via the guide catheter. Right ICA angiography showed occlusion of the aneurysm sac with patent of the parent artery. No sign of hemorrhage or ischemia is revealed.予以替罗非班4ml。右侧颈内动脉造影示右侧大脑中动脉动脉瘤未显示，载瘤动脉通畅。颅内血管未见出血或梗塞征象。
Figure 19. The angle between the parent artery and the superior branch enlarged after stent implantation. 支架置入之后动脉瘤角度显著增大。
Figure 20. Post-operative MRI showed two small ischemic infarctions in the left parietal lobe. 术后MRI未见出血，左侧顶叶小梗塞灶。
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Summary
· Left MCA aneurysm with superior branch arising from the aneurysm neck.1. Large coils technique.2. Place microcathter close to the super branch opening to avoid the local densely packed. This microcathter could also be used for further packing of the other loosely packed sac .3. Loose pack the sac close to the branch.4. Avoid to select small coils.· Right MCA tiny AN with regular shape.1. Single stent remodeling technique can work.2. Waiting for long-term follow up. · 左侧大脑中动脉, 上干发自瘤颈1. 大圈技术2. 靠近上干开口的微导管可以预防局部致密填塞，还可以用来填塞动脉瘤其它部位3. 疏松填塞瘤腔靠近分支开口部分4.避免选择过小的圈· 右侧大脑中动脉小动脉瘤，形态规则1. 可以使用单支架置入技术2.远期效果有待随访结果验证
