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· Main complaint: Sudden onset of unsteady gait and distortion of commissure six months ago.· Medical history: Brain stem infarction 8 years ago. No hypertension or diabetes.· Medication: Clopidogrel, Atorvastatin. · 主訴：突發(fā)行走不穩(wěn)、口角歪斜6個(gè)月· 既往史：8年前腦干梗死。否認(rèn)高血壓或糖尿病病史。 
Figure 1. Angiodysplasia.CTA shows left vertebral-basilar artery dissection (A). HR-MRI shows intimal flap and abnormal enhancement of left vertebral artery wall (B) , enlarged left ICA (C). 血管發(fā)育不良。CTA可見左側(cè)椎基底動(dòng)脈夾層(A)。HR-MRI可見內(nèi)膜瓣及左側(cè)椎動(dòng)脈壁異常強(qiáng)化(B)，左側(cè)頸內(nèi)動(dòng)脈擴(kuò)張(C)。Figure 2. Bilateral ICA angiography reveals undeveloped right A1 segment. 雙側(cè)頸內(nèi)動(dòng)脈造影顯示右側(cè)A1段未發(fā)育。Figure 3. Left ICA angiography confirms left ICA irregular dilatation without primitive posterior communicating artery. 左側(cè)頸內(nèi)動(dòng)脈血管造影證實(shí)左側(cè)頸內(nèi)動(dòng)脈不規(guī)則擴(kuò)張，無原始后交通動(dòng)脈。Figure 4. Angiography shows the occlusion of right VA and segmental stenosis of right CCA, brachiocephalic trunk and subclavian artery, indicating the diagnosis of dissection. 血管造影提示右椎動(dòng)脈閉塞，右頸總動(dòng)脈、頭臂干和鎖骨下動(dòng)脈節(jié)段性狹窄，提示多發(fā)夾層。Video 1. Angiography confirms the dissection of left VA and BA, showing segmental stenosis of BA and aneurysmal dilatation of left VA. Right SCA arose from the stenotic segment of BA. 血管造影證實(shí)左側(cè)椎動(dòng)脈、基底動(dòng)脈夾層，可見基底動(dòng)脈節(jié)段性狹窄，左椎動(dòng)脈動(dòng)脈瘤樣擴(kuò)張，右側(cè)小腦上動(dòng)脈發(fā)自基底動(dòng)脈狹窄段。BA dissection: Stent angioplasty. Since right SCA arises from stenotic segment of BA, balloon dilation was not selected.Left VA aneurysmal dilatation: reconstruct the vessel wall with large coils assisted stenting technique.基底動(dòng)脈夾層：支架成形術(shù)。右側(cè)小腦上動(dòng)脈自基底動(dòng)脈狹窄段發(fā)出，故不選擇球囊擴(kuò)張。左側(cè)椎動(dòng)脈動(dòng)脈瘤樣擴(kuò)張：行大圈輔助支架成形術(shù)重構(gòu)血管壁。Figure 5. Measurement. 測(cè)量。Figure 6. General heparinization. 8F guidecatheter and Navien (115cm) catheter were placed in V4 segment of left VA. Headway-21 microcatheter was navigated to P2 segment of right PCA. 全身肝素化。將8F導(dǎo)引管和Navien(115cm)導(dǎo)管置于左側(cè)椎動(dòng)脈V4段，Headway-21微導(dǎo)管到達(dá)右側(cè)大腦后動(dòng)脈P2段。Video 2. LVIS 5.5mm*20mm was placed in the proximal segment of the BA stenotic lesion .LVIS 5.5mm*20 mm放置于基底動(dòng)脈狹窄段近端。Figure 7. Post stent angiography. 支架置入后血管造影。Figure 8. Measurement of segmental dilatation and stenosis of left VA V4 segment. 左椎動(dòng)脈V4段節(jié)段性狹窄和擴(kuò)張的測(cè)量。Figure 9. Echelon-10 was placed in the proximal segment of the target lesion. Keep the coil loops loose and even. Echelon-10放置在目標(biāo)病變的近端。保持彈簧圈襻疏松和均勻。Figure 10. Microplex 10mm*30cm (2) and 9mm*30cm (1) were inserted. 填入Microplex 10mm*30cm 2枚和9mm*30cm 一枚。Video 3. LVIS 5.5mm*25mm was deployed in the left V4 segment , pressing coils to the vessel walls and keeping the patent of parent artery. 在左椎動(dòng)脈V4段放置LVIS 5.5mm*25mm支架，使彈簧圈貼壁，保持載瘤動(dòng)脈通暢。Figure 11. Massage the stent. 按摩支架。Figure 12 GIF. Solitaire 6mm*30mm was deployed overlapping LVIS 5.5mm*25mm.Solitaire 6mm*30mm支架與前一枚LVIS 5.5mm*25mm支架套疊釋放。Figure 13. Tirofiban(Xinweining) 14ml was given via the guiding catheter. 經(jīng)導(dǎo)引管給予替羅非班(欣維寧)14ml。Figure 14 GIF. Post-operative angiography shows occlusion of the aneurysm with the patent of parent artery. 術(shù)后血管造影提示動(dòng)脈瘤栓塞，載瘤動(dòng)脈通暢。Figure 15. 3D reconstruction of the vessels, coils and stents. 血管、彈簧圈、支架三維重建。Figure 16. DynaCT shows no hemorrhage or infarction. DynaCT未見出血或梗死。· Early treatment for the left vertebral-basilar artery dissecting aneurysm can avoid subsequent complicated treatment and mass effect of brain stem.· Proper coil selection by the diameter of the segment, loosely pack the left VA dissecting aneurysm and push the stent while deploying can make the LVIS stent fully deployed. Further more, Solitaire stent providing good radial support can reinforce the prior LVIS stent.· Right CCA, brachiocephalic trunk and subclavian artery dissections with stenosis can be followed up or treated if necessary.· Flow diverter can be chosen if the dissecting aneurysm recurred in follow-up angiography.· 早期治療左椎基底動(dòng)脈夾層動(dòng)脈瘤可避免后續(xù)復(fù)雜的治療和腦干占位效應(yīng)。· 根據(jù)病變段直徑選擇合適的彈簧圈，疏松填塞左椎動(dòng)脈夾層動(dòng)脈瘤，在釋放支架時(shí)推動(dòng)支架，可以使LVIS支架充分打開。此外，Solitaire支架提供良好的徑向支撐力，可加固先前的LVIS支架。· 右側(cè)頸總動(dòng)脈、頭臂干和鎖骨下動(dòng)脈夾層狹窄可隨訪，或在必要時(shí)進(jìn)行治療。· 如果夾層動(dòng)脈瘤在后續(xù)造影中發(fā)現(xiàn)復(fù)發(fā)，可以選擇血流導(dǎo)向裝置治療。
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