intracranial aneurysm embolization

An intracranial aneurysm is an abnormal bulging part of the intracranial artery lumen, which occurs mostly in the cerebral artery ring and its main branches. Direct surgery is still the main method for the treatment of intracranial aneurysms. In recent years, endovascular embolization has been carried out and there are prospects for development. Treatment of diseases: intracranial aneurysms Indication 1. Intracranial saccular aneurysms without hemorrhage, all of which can be treated with endovascular embolization at the base of the brain, especially for the end of the basilar artery, the basilar artery, and the internal carotid artery, which are dangerous for surgery and have less risk of endovascular embolization. Cavernous sinus aneurysms should be the first choice. 2. Intracranial saccular aneurysm rupture and hemorrhage, the condition is I, II, III, and even belong to IV, V patients; the general condition of the patient is not suitable for craniotomy or the patient refuses craniotomy. Contraindications 1. The patient has severe arteriosclerosis, vascular distortion, or severe vasospasm after rupture and bleeding, and the microcatheter cannot pass through the blood vessels into the aneurysm cavity. 2. After the aneurysm rupture and hemorrhage, the patient's condition is in the stage of sudden death, and it is not suitable for embolization in the aneurysm. Preoperative preparation 1. After rupture of intracranial aneurysm, when waiting for surgery, patients should take appropriate measures such as lowering blood pressure, lowering temperature, lowering intracranial pressure, anti-cerebral vasospasm, antifibrinolytic and extraventricular drainage, etc., and actively create conditions and strive for Perform an endovascular embolization treatment. 2. Other preparations for the patient 1 Detailed medical history, comprehensive physical examination and systematic neurological examination. 2 Those with a history of epilepsy were treated with antiepileptic drugs before surgery. 3 preoperatively according to the condition of the CT scan plus enhanced scan, MRI, MRA examination. 4 blood, urine routine, bleeding, clotting time, liver and kidney function, chest fluoroscopy, heart, EEG, etc. before surgery. 5 fasting before surgery, iodine allergy test, puncture site (such as the perineum) preparation skin, indwelling catheter. 6 Use a cloth strap to restrain the limbs. 3. Puncture cannula (1) General use: 1 puncture needle of 16G or 18G, 1 set of 6F catheter sheath, 1 5F contrast catheter, 1 6F guide tube or 1 FasGuide guide tube, Balt hardness gradient guide tube (Casasco) 1 piece, 2 two-way switch, 2 Y-shaped joints with valve, 6 pieces of disinfectant tape (1.25cm×10cm), 1 connecting tube (75cm), 1 with three-way connecting tube (30cm), large stainless steel bowl No. 3, medium 2, 1 small, non-ionic contrast agent, such as Omnipaque 100ml, 2% lidocaine 20ml, dexamethasone 20mg, heparin 12500U × 2. One of the 20 or 22 stainless steel skin puncture needles. (2) Equipment required for transporting electroplated platinum micro-coil: 1 Excel-14, Excelsior-1018 double-labeled micro-catheter, Seeker Lite-10, Fas Dasher-14, Mach Design-18, Seeker Lite-18, Taper One design-18 micro-guide wire. 2 electroplated platinum micro coils of various specifications. 2 sets of 3GDC DC electrolyzers. Surgical procedure 1. Electrolytic platinum micro-coil embolization technology operation and use method of GDC DC electrolysis device (1) The Seldinger method was used to routinely insert the 6F catheter sheath, 6F guide tube or Tracker-38, Casasco guide tube, and then guide the tube to the affected internal carotid artery or under the TV surveillance. Vertebral artery, reaching the level of the 2nd cervical vertebra. The tail end of the guiding tube is connected with the Y-shaped valve joint, the side arm is connected with the soft-connecting tube with the three-way, and then connected with the arterial pressurized infusion, the open pressurized infusion bag is slowly dripped into the physiological saline, and the patient is given systemic heparin. Chemical. If you need to perform whole brain angiography, you should first understand the location, size and shape of the aneurysm. (2) According to the shape and size of the aneurysm, choose the appropriate Excel-14 or Excelsior-1018 microcatheter and GDC platinum micro coil. The choice of micro-coil depends on the ratio of the tumor cavity to the tumor neck. Generally, the aneurysm cavity: tumor neck = 4:1, which is most suitable for GDC embolization, not <3:1, the neck width is >4mm, it is not suitable for GDC embolization. treatment. The diameter of the first and second coils shall not be less than the width of the neck of the neck, otherwise the GDC may have an aortic aneurysm. The first and second GDC platinum micro-coil rings select a common type with strong elasticity to make them enter the aneurysm, and can be closely attached to the wall of the tumor to form a basket-like structure, and then use a soft filling space for the basket-like structure. In order to achieve the purpose of tightly filling the aneurysm. (3) The Y-shaped valve at the end of the guide tube has a valve arm inserted into an Excel-14 or Excelsior-1018 microcatheter. Under the guidance of a television monitor and trace-mapping, a controllable platinum guide wire is used. The catheter is introduced into the aneurysm cavity, the tip of which is in the middle of the aneurysm cavity, the platinum guide wire is withdrawn, the low concentration contrast agent is aspirated with a 1 ml syringe, and a small amount (<0.5 ml) is gently injected through the microcatheter to understand the catheter in the aneurysm. The location of the cavity. (4) Connect the Y-shaped valve connector at the end of the Excel-14 or Excelsior-1018 micro-catheter. The side arm is connected with the two-way connecting tube. The two-way connecting tube is again with a pressure of 52 kPa (400 mmHg) and 1 drop/3. The ~5s pressurized infusion bag is connected, and the open pressurized infusion is adjusted to slowly drip into the physiological saline. (5) Before inserting the GDC platinum micro-coil, it should be checked first. The left thumb of the operator is fixed to guide the distal side of the sheath screw lock structure, the right thumb is fixed to the proximal side, and the sheath is rotated counterclockwise to guide the sheath. The screw lock is released, no longer jammed, and the wire of the GDC platinum micro-coil ring can be moved without resistance in the guiding sheath tube. The GDC platinum micro-coil is pushed out to guide the sheath tube, and the GDC electrolysis point is placed in the assistant's palm. Whether it is malfunctioning, whether the memory shape of the coil is elongated and deformed. If it is still intact, it is pulled back into the guiding sheath. The thumb and fingers of the two hands respectively grasp the far and near side of the guiding sheath spiral structure, the left hand is fixed, the right hand is rotated clockwise, and the spiral structure is adopted. Locked. (6) Insert the GDC platinum micro-coil guide wire through the micro-duct tail-shaped Y-valve into the sheath-guided tube, so that the leading end of the guiding sheath is tightly connected with the micro-duct tail, and the Y-shaped valve is tightened to fix the guiding sheath. The assistant slowly pushes the GDC platinum micro-coil into the Excel-14 or Excelsior-1018 microcatheter, loosens the Y-valve, slowly pulls out the guiding sheath, saves it and does not discard it, in case it needs to withdraw from the GDC platinum microspring Use it again when you circle. Under the guidance of the TV monitor and tracer, the GDC platinum micro-coil is slowly pushed in without resistance. When it enters the aneurysm, it is spirally coiled, and the wall of the aneurysm is in a basket shape. When the impervious X-ray indicator on the conveying wire exceeds the second indicator of the Excel-14 or Excelsior-1018 microcatheter, when it overlaps, it means that the electrolysis point connecting the GDC platinum microcoil has sent the microcatheter into the aneurysm. Inside. (7) Carefully check and judge whether the model of the selected GDC matches the size and shape of the aneurysm, and whether the GDC enters the aneurysm is accurate. If there is no doubt, it can be prepared for electrolysis. The puncture side groin was inserted into the subcutaneous muscle with a 20 or 22 stainless steel needle, and the black negative electrode connecting wire front hook of the GDC dedicated DC electrolysis device was connected to the stainless steel puncture needle (loop electrode). Connect the front end micro-hook of the red positive wire to the non-insulated nude part of the GDC platinum micro-coil guide wire tail. Insert the other ends of the positive and negative wires into the positive and negative terminals of the DC electrolyzer. When it is ready, the position of GDC in the aneurysm and the position of the marking on the guide wire are confirmed again under TV fluoroscopy, and the electrolysis can be started. (8) Fix the DC electrolyzer on the table or shelf, press the on/off button of the GDC DC electrolyzer, all the displays will flash, perform 3s self-test, then the current will flash 3 times, indicating 1mA current setting It takes about 10 seconds to reach the set output current value. When the GDC platinum micro coil is released from the stainless steel guide wire, it will appear: 1 current stops. 2 All displays freeze and show the last voltage, current and time. 3 DC electrolysis device emits a beep 5 times (buzzer 1/2s, stop 1/2s). 4 The yellow electrolysis check light is on. 5 detacth shows the arrow flashing. (9) Confirm whether the micro coil is released under fluoroscopy, and slowly pull back the GDC platinum micro coil guide wire. If the coil does not move, it means it has been released. If the coil moves, it means that it is not released. The release time can be extended, and the current button of the DC electrolysis device is pressed, that is, the current output is restored, and the original current and voltage are restored to 10 seconds. The time display starts timing immediately after the adjustment again. If the electrolysis device reappears the signal again, it is confirmed under the TV monitor again whether the micro coil is released. (10) Once it is confirmed that the micro coil is released, remove the red electrode at the end of the guide wire and slowly withdraw the guide wire from the microcatheter. Turn off the DC electrolysis device. If you need to add a micro coil, repeat the above steps until the aneurysm is tightly packed. (11) Carefully pull out the Excel-14 or Excelsior-1018 microcatheter under TV surveillance, and observe the aneurysm embolization again through the guiding tube. (12) At the end of treatment, the guiding tube and the catheter sheath were pulled out, and the puncture site was pressed for 15 to 20 minutes, and the sterile gauze was covered without bleeding. 2. Precautions for using GDC platinum micro coils and DC electrolyzers (1) GDC cannot be removed by a non-dedicated DC electrolyzer, and the GDC DC electrolyzer cannot be disinfected. (2) The battery should be replaced before each operation and/or when the battery indicator light is flashing. (3) During the GDC release process, if the patient feels that the circuit electrode is uncomfortable, the current can be reduced. Press the current button (current) for 0.5 mA, press twice for 0.75 mA, and return to 1 mA for 3 times. When changing the current during the release process: 1 does not affect the function of the DC electrolyzer, but may increase the release time. 2 time recording is not reset. 3 has a slight effect on the required voltage. (4) If the detachment has just started for a few seconds, the detaching display flashes, which may be poor contact. The maximum may be at the patient circuit electrode or at the GDC input stainless steel wire end. Please turn off the GDC power supply, unplug the cable, and start over. . (5) After the GDC is released, the DC electrolyzer enters the pause state. Do not turn off the power at this time, otherwise the release time will return to the 0 position. (6) If the patient feels that the pain or the release time of the circuit electrode is prolonged, re-piercing and inserting a new puncture needle to form a new circuit electrode. (7) Once the operation is completed, the positive and negative connection wires are discarded, and the DC electrolyzer is stored in a dry, clean, and safe environment. 3. Tumor-assisted arterial balloon occlusion surgery steps (1) A suitable type of Magic-BD or coaxial catheter with X-ray labeled balloon will be installed. The Y-shaped valve at the end of the 8F guiding tube has a valve arm inserted, and the soft and bendable part of the front of the catheter enters the guide. After the catheter is introduced, the guide wire is pulled out. (2) A 1 ml syringe with a non-ionic contrast agent containing 180 mg of iodine per ml was attached to the end of the Magic-BD or coaxial catheter. After draining the air in the catheter, the dose of the contrast agent in the 1 ml syringe was recorded. (3) Send the Magic-BD or coaxial catheter into the guiding tube under the TV surveillance, use the natural impact force of the blood flow to send the balloon to the aneurysm opening or the artery, and slowly fill the balloon to open the aneurysm or The tumor-bearing artery was completely blocked, the vascular occlusion test was performed, and the contrast agent was injected through the guiding tube, and it was confirmed that the occlusion was completely occluded, and the occlusion time was recorded and the condition was closely observed. (4) According to the need, the catheter inserted into the 6F catheter sheath to the contralateral internal carotid artery, vertebral artery angiography, to understand whether the cranial medial branch circulation is good. (5) If the patient can withstand the occlusion test for half an hour and the angiography confirms that the cranial medial branch is good, the balloon can be released and placed in the tumor-bearing artery. (6) At the proximal end of the tumor-bearing artery, a second protective balloon or coil is placed under the first balloon. If the first balloon is filled with HEMA, it is not necessary to place a second protective balloon or coil. (7) Underwent cerebral angiography of the affected side and contralateral side to understand the aneurysm occlusion. After the treatment, the fish sperm white egg and heparin were given as appropriate, the catheter and the catheter sheath were pulled out, and the puncture site was pressed for 15-20 min. When there was no bleeding, the sterile gauze was covered and pressure-wrapped. complication 1. Intraoperative aneurysm rupture: The aneurysm can be naturally ruptured during operation, or the aneurysm can be ruptured due to the introduction of microcatheters or microcoils into the aneurysm lumen. In order to prevent the aneurysm from rupturing, the operation must be gentle. It is best to use the tracer when feeding the microcatheter or microcoil. It must not be blindly fed into the microcatheter. The microspring coil must be gentle and should be as low as possible. blood pressure. 2. Intracranial giant aneurysm with wall thrombus shedding, cerebral embolism can occur, and even severely endanger the patient's life.