Use of the sole stenting technique for the management of aneurysms in the posterior circulation in a prospective series of 20 patients

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The use of intracranial stents in stent-assisted coil embolization is now a current neurosurgical practice worldwide. The clinical utility of these stents in the sole stenting (SS) technique, however, has not been thoroughly described, and the published reports of this experience are scarce. This study was designed to evaluate SS treatment of dissecting and nondissecting aneurysms of the posterior circulation.


This prospective and descriptive study was conducted in 20 consecutive patients who harbored single aneurysms of the posterior circulation and who were treated using the SS approach in the last 3 years. The clinical and radiological assessment and follow-up of the patients were evaluated using the modified Rankin scale as well as with computed tomography angiography and digital subtraction angiography at discharge and at 1, 3, 6, and 12 months.


Eleven of the 20 patients had subarachnoid hemorrhages, 3 presented with ischemia, 1 presented with brainstem compression, and the remaining 5 patients had incidentally discovered, asymptomatic lesions. Only 1 patient had a complication (occipital infarction) attributable to the SS procedure. One patient died of rebleeding 2 weeks after the procedure. At 1 month, 40% of the patients had a subtotal or total occlusion, which increased to 55% at 3 months and 85% at 6 months, with a final subtotal or total occlusion rate of 80% at 1 year. The SS procedure in 1 case was considered a failure at 6 months because no change had been noted since the 1-month follow-up. One case showed partial occlusion and 1 case showed recanalization.


Use of SS for aneurysms in the posterior circulation complex is a safe and effective technique, demonstrating an occlusion rate of 80% at the 1-year follow up.

Abbreviations used in this paper: BA = basilar artery; BES = balloon-expandable stent; CSF = cerebrospinal fluid; CT = computed tomography; DS = digital subtraction; GDC = Guglielmi detachable coil; MR = magnetic resonance; mRS = modified Rankin scale; PCA = posterior cerebral artery; PICA = posterior inferior cerebellar artery; SAH = subarachnoid hemorrhage; SCA = superior cerebellar artery; SES = self-expandable stent; SS = sole stenting; VA = vertebral artery; VBJ = vertebrobasilar junction.

Article Information

Address correspondence to: J. A. Santos-Franco, M.D., Department of Neurological Endovascular Therapy, Instituto Nacional de Neurología y Neurocirugía, Insurgentes Sur 3877, Col. La Fama, México D.F., México 14269. email:

© AANS, except where prohibited by US copyright law.



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    Illustration of the 4 types of V4 aneurysms according to their relationship to the origin of the PICA. The number of each type found in this patient series is also noted in each panel. A: Pre-PICA = proximal to the PICA. B: ParaPICA = lesions not strictly involving the PICA, but whose treatment by stent placement involves the PICA origin because the aneurysm is extremely close to it. C: InPICA = lesions involving the origin of the PICA. D: PostPICA = distal to the PICA.

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    Line graph showing trends in the occlusion rate over time for both dissecting (Dissec.) and nondissecting (Non dissec.) aneurysms treated using the SS technique. Dissecting aneurysms tended to occlude more rapidly.

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    Case 4. Images showing a dissecting aneurysm of the V4 segment of the right VA. A–C: Preoperative DS angiograms (A and B) and a CT angiogram (C) showing a dissecting aneurysm (open arrow) with angulation of the parent vessel (thick dark arrow and line). A prelesional stenosis (thin dark arrow) as well as a double lumen sign can be seen. D: Immediate postoperative DS angiogram reveals geometrical changes such as straightening of the parent vessel (thick dark arrow and line) and no hemodynamic changes, as the aneurysm remains visible (open arrow) with preservation of the distal flow to the basilar trunk. E–H: Follow-up CT angiogram (F) and DS angiograms (E, G, and H) at 3 months (E), 6 months (F and G), and 1 year (H), showing a progressive thrombosis of the lesion (open arrows). The 6-month DS angiogram (G) illustrates the so-called “saw image,” revealing a slight protrusion of the contrast medium through the struts of the stent into the thrombosed aneurysm.

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    Case 5. Images showing a laterobasilar wide-neck saccular aneurysm with partial thrombosis. A and B: Preprocedural CT angiogram (A) and DS angiogram (B) show the initial views of the aneurysm (open arrows). C–F: Follow-up imaging at 3 months using CT angiography (C) and DS angiography (D) show only a slight filling of the aneurysm (partial occlusion). The 1-year follow-up with CT angiography (E) and DS angiography (F) disclosed a total occlusion of the lesion. Notice the thin arrows in panels C and E pointing to the markers of the Neuroform stent. G and H: Initial (G) and final (H) MR images show the evolution of the aneurysm (thin arrows) which decreased in size, decreasing the mass effect on the cerebral peduncle.

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    Case 8. Images showing an incidental aneurysm in the right prebulbar cistern. A–C: Preprocedural DS angiograms. A: After injection from the right VA, a wide-neck saccular aneurysm (open arrow) at the PICA segment of V4 is noted. The VBJ can be observed (asterisk) with reflux into the left VA. B: A sequence of the right subclavian artery shows the V1 segment during the scheduled procedure for correction of the aneurysm. The previously placed stents recoiled (thick dark arrows) and prevented any access through this approach. C: A sequence from the left VA shows the right angle of the two V4 segments at the VBJ and the patent aneurysm (open arrow). This image allowed us to plan a navigation from the left VA into the right VA. D–F: Postprocedural CT angiograms. The immediate postprocedural image (D) and follow-up images at 3 months (E) and 1 year (F) shows a progressive shrinking and final occlusion of the aneurysm (open arrows). The PICA can be seen at the rostral tip of the stent, which remains patent (thin arrows).

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    Case 16. Images showing a wide-neck saccular aneurysm. A and B: Preprocedural DS angiogram (A) and CT angiogram (B) show a wide-neck saccular aneurysm of the middle basilar trunk. The angulation of the parent vessel can be seen (dark arrow and line) and the aneurysm (open arrow) is precisely located at this point. C–E: Transprocedural imaging. The DS angiogram (C) displays the image of a straight vessel (thin arrows) during the placement of the device, with a patent aneurysm (open arrow). The immediate DS angiogram (D) shows no angiographic change of the aneurysm itself (open arrow) and no geometrical changes in the anatomy of the vessel and its angulation (dark arrow and line). There was an unusual sluggish intraaneurysmal vortex motion image (open arrow) going far beyond the late venous phase (E). F: Postprocedural CT angiogram at 1 week showed no change in hemodynamics (open arrow) or geometry (dark arrow and line). The patient rebled and died 3 weeks after this image was obtained.

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    Illustration showing the possible causes of failure of the SS technique. Arrows indicate blood flow. A: An undersized stent. B: Stent placed distal to the lesion. C: Noncorrection of the angle. D: Important vessel arising from the aneurysm.



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