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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Object

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.

Methods

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.

Results

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.

Conclusions

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: jasantosfranco@hotmail.com.

© AANS, except where prohibited by US copyright law.

Headings

Figures

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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.

References

1

Aenis MStancampiano APWakhloo AKLieber BB: Modeling of flow in a straight stented and nonstented side wall aneurysm model. J Biomech Eng 11:2062121997

2

Ahn JYHan IBKim TGYoon PHLee YJLee BH: Endovascular treatment of intracranial vertebral artery dissections with stent placement or stent-assisted coiling. AJNR Am J Neuroradiol 27:151415202006

3

Albuquerque FCFiorella DJHan PPDeshmukh VRKim LJMcDougall CG: Endovascular management of intracranial vertebral artery dissecting aneurysms. Neurosurg Focus 18:2E32005

4

Aletich VADebrum GMMisra MCharbel FAusman JI: The remodeling technique of balloon-assisted Guglielmi detachable coil placement in wide-necked aneurysms: experience at the University of Illinois at Chicago. J Neurosurg 93:3883962000

5

Allcock JAneurysms. Newton THPotts DG: Radiology of the Skull and the Brain St. LouisMosby1974. 24452486

6

Amagasaki KYagishita TYagi SKuroda KNishigaya KNukui H: Serial angiography and endovascular treatment of dissecting aneurysms of the anterior cerebral and vertebral arteries. Case report. J Neurosurg 91:6826861999

7

Benndorf GHerbon USollmann WPCampi A: Treatment of a ruptured dissecting vertebral artery aneurysm with double stent placement: case report. AJNR Am J Neuroradiol 22:184418482001

8

Brisman JLSong JKNewell DW: Cerebral aneurysms. N Engl J Med 355:9289392006

9

Canton GLevy DILasheras JC: Hemodynamic changes due to stent placement in bifurcating intracranial aneurysms. J Neurosurg 103:1461552005

10

Chiaradio JCGuzman LPadilla LChiaradio MP: Intravascular graft stent treatment of a ruptured fusiform dissecting aneurysm of the intracranial vertebral artery: technical case report. Neurosurgery 50:2132172002

11

Chiche LPraquin BKoskas FKieffer E: Spontaneous dissection of the extracranial vertebral artery: indications and long-term outcome of surgical treatment. Ann Vasc Surg 19:5102005

12

Cohen JEGomori JMUmansky F: Endovascular management of spontaneous bilateral symptomatic vertebral artery dissections. AJNR Am J Neuroradiol 24:205220562003

13

Coley SCClifton A: Dissecting vertebral artery aneurysm: diagnosis and coil embolization. Br J Radiol 72:4084111999

14

Conforto ABYamamoto FEvaristo EFPuglia P JrCaldas JGScaff M: Intracranial vertebral artery dissection presenting as subarachnoid hemorrhage: successful endovascular treatment. Acta Neurol Scand 103:64682001

15

de Bray JMPenisson-Besnier IDubas FEmile J: Extracranial and intracranial vertebrobasilar dissections: diagnosis and prognosis. J Neurol Neurosurg Psychiatry 63:46511997

16

Doerfler AWanke IEgelhof TStolke DForsting M: Double-stent method: therapeutic alternative for small wide-necked aneurysms. Technical note. J Neurosurg 100:1501542004

17

Fiorella DAlbuquerque FCDeshmukh VRMcDougall CG: Usefulness of the Neuroform stent for the treatment of cerebral aneurysms: results at initial (3–6-mo) follow-up. Neurosurgery 56:119111922005

18

Fiorella DAlbuquerque FCDeshmukh VRWoo HHRasmussen PAMasaryk TJ: Endovascular reconstruction with the Neuroform stent as monotherapy for the treatment of uncoilable intradural pseudoaneurysms. Neurosurgery 59:2913002006

19

Fiorella DAlbuquerque FCHan PMcDougall CG: Preliminary experience using the Neuroform stent for the treatment of cerebral aneurysms. Neurosurgery 54:6172004

20

Fiorella DAlbuquerque FCWoo HHRasmussen PAMasaryk TJMcDougall CG: Neuroform in-stent stenosis: incidence, natural history, and treatment strategies. Neurosurgery 59:34422006

21

Fisher CMKistler JPDavis JM: Relation of cerebral vasospasm to subarachnoid hemorrhage visualized by computerized tomographic scanning. Neurosurgery 6:191980

22

Flemming KDWiebers DOBrown RD JrLink MJNakatomi HHuston J III: Prospective risk of hemorrhage in patients with vertebrobasilar nonsaccular intracranial aneurysm. J Neurosurg 101:82872004

23

Fratkin JDZubkov A: Part 2: A pathological spectrum: basilar dolichoectasia and vertebral dissection, each with fatal subarachnoid hemorrhage. Semin Cerebrovasc Dis Stroke 4:69752004

24

Friedman AHDrake CG: Subarachnoid hemorrhage from intracranial dissecting aneurysm. J Neurosurg 60:3253341984

25

Geremia GBrack TBrennecke LHaklin MFalter R: Occlusion of experimentally created fusiform aneurysms with porous metallic stents. AJNR Am J Neuroradiol 21:7397452000

26

Geremia GHaklin MBrennecke L: Embolization of experimentally created aneurysms with intravascular stent devices. AJNR Am J Neuroradiol 15:122312311994

27

Guglielmi GViñuela FDuckwiler GDion JLylyk PBerenstein A: Endovascular treatment of posterior circulation aneurysms by electrothrombosis using electrically detachable coils. J Neurosurg 77:5155241992

28

Halbach VVHigashida RTDown CFFraser KWSmith TPTeitelbaum GP: Endovascular treatment of vertebral artery dissections and pseudoaneurysms. J Neurosurg 79:1831911993

29

Hamada JKai YMorioka MYano STodaka TUshio Y: Multimodal treatment of ruptured dissecting aneurysms of the vertebral artery during the acute stage. J Neurosurg 99:9609662003

30

Han PPAlbuquerque FCPonce FAMacKay CIZabranski JMSpetzler RF: Percutaneous intracranial stent placement for aneurysms. J Neurosurg 99:23302003

31

Hanel RABoulos ASSavageau EGLevy EIGuterman LRHopkins NL: Stent placement for the treatment of nonsaccular aneurysms of the vertebrobasilar system. Neurosurg Focus 18:2E82005

32

Higashida RTSmith WGress DUrwin RDowd CFBalousek PA: Intravascular stent and endovascular coil placement for a ruptured fusiform aneurysm of the basilar artery. Case report and review of the literature. J Neurosurg 87:9449491997

33

Hunt WEKosnik EJ: Timing and perioperative care in intracranial aneurysm surgery. Clin Neurosurg 21:79891974

34

Iihara KSakai NMurao KSakai HHigashi TKogure S: Dissecting aneurysms of the vertebral artery: a management strategy. J Neurosurg 97:2592672002

35

Inamasu JNakamura YSaito RKuroshima YMayanagi KIchikizaki : Endovascular treatment of ruptured vertebral artery dissection in the acute stage. Cerebrovasc Dis 16:3063082003

36

Islak CKocer NAlbayram SKizilkilic OUzma OCokyuksel O: Bare stent-graft technique: a new method of endoluminal vascular reconstruction for the treatment of giant and fusiform aneurysms. AJNR Am J Neuroradiol 23:158915952002

37

Jabbour PKoebbe CVeznedaroglu Benitez RPRosenwasser R: Stent-assisted coil placement for unruptured cerebral aneurysms. Neurosurg Focus 17:5E102004

38

Jamous MASatoh KMatsubara SSatomi JNakajima NUno M: Ischemic basilar artery dissecting aneurysm treated by stenting only–case report. Neurol Med Chir (Tokyo) 44:77812004

39

Joo JYAhn JYChung YSHan IBChung SSYoon PH: Treatment of intra- and extracranial arterial dissections using stents and embolization. Cardiovasc Intervent Radiol 28:5956022005

40

Kaku YYoshimura SYamakawa HSakai N: Failure of stent-assisted endovascular treatment for ruptured dissecting aneurysms of the basilar artery. Neuroradiology 45:22262003

41

Kurata AOhmomo TMisayaka YFujii KKan SKitahara T: Coil Embolization for the treatment of ruptured dissecting vertebral aneurysms. AJNR Am J Neuroradiol 22:11182001

42

Lanzino GWakhloo AKFessler RDHartney MLGuterman LRHopkins N: Efficacy and current limitations of intravascular stents for intracranial internal carotid, vertebral, and basilar artery aneurysms. J Neurosurg 91:5385461999

43

Lavine SDLarsen DWGiannota SLTeitelbaum GP: Parent vessel Guglielmi detachable coil herniation during wide-necked aneurysm embolization: treatment with intracranial stent placement: two technical case reports. Neurosurgery 46:101310172000

44

Leibowitz RMarcellus MLChang SDSteinberg GKMarks MP: Parent vessel occlusion for vertebrobasilar fusiform and dissecting aneurysms. AJNR Am J Neuroradiol 24:9029072003

45

Levy EIBoulos ASBendok BRKim SHQureshi AIGuterman LR: Brainstem infarction after delayed thrombosis of a stented vertebral artery fusiform aneurysm: case report. Neurosurgery 51:128012852002

46

Lieber BBStancampiano APWakhloo AK: Alteration of hemodynamics in aneurysm models by stenting: influence of stent porosity. Ann Biomed Eng 25:4604691997

47

Locksley HB: Natural history of subarachnoid hemorrhage, intracranial aneurysms and arteriovenous malformations. Based on 6368 cases in the cooperative study. J Neurosurg 25:2192391966

48

Lylyk PCeratto RHurvitz DBasso A: Treatment of a vertebral dissecting aneurysm with stents and coils: technical case report. Neurosurgery 43:3853881998

49

Lylyk PCohen JECeratto RFerrario AMiranda C: Combined endovascular treatment of dissecting vertebral artery aneurysms by using stents and coils. J Neurosurg 94:4274322001

50

Lylyk PFerrario APasbon BMiranda CDoroszuk G: Buenos Aires experience with the Neuroform self-expanding stent for the treatment of intracranial aneurysms. J Neurosurg 102:2352412005

51

MacKay CIHan PPAlbuquerque FCMcDougall CG: Recurrence of a vertebral artery dissecting pseudoaneurysm after successful stent-supported coil embolization: case report. Neurosurgery 53:7547612003

52

Mangrum WIHuston J IIILink MJWiebers DOMcClelland RLChristianson TJ: Enlarging vertebrobasilar nonsaccular intracranial aneurysms: frequency, predictors, and clinical outcome of growth. J Neurosurg 102:72792005

53

Mawad MECekirge SCiceri ESaatci A: Endovascular treatment of giant and large intracranial aneurysms by using a combination of stent placement and liquid polymer injection. J Neurosurg 96:4744822002

54

Mehta BBurke TKole MBydon ASeyfried DMalik G: Stent-within-a-stent technique for the treatment of dissecting vertebral artery aneurysms. AJNR Am J Neuroradiol 24:181418182003

55

Mizutani TKojima HAsamoto SMiki Y: Recurrent subarachnoid hemorrhage from untreated ruptured vertebrobasilar dissecting aneurysms. Neurosurgery 36:9059131995

56

Moret JCognard CWeill ACastaings LRey A: [Reconstruction technic in the treatment of wide-neck intracranial aneurysms. Long-term angiographic and clinical results. Apropos of 56 cases.]. J Neuroradiol 24:30441997. (Fr)

57

Nichols DABrown RD JrThielen KRMeyer FBAtkinson JLPiepgras DG: Endovascular treatment of ruptured posterior circulation aneurysms using electrolytically detachable coils. J Neurosurg 87:3743801997

58

O'Shaughnessy BAGetch CCBendok BRBatjer HH: Late morphological progression of a dissecting basilar artery aneurysm after staged bilateral vertebral artery occlusion: case report. Surg Neurol 63:2362432005

59

Ogilvy CSHoh BLSinger RJPutman CM: Clinical and radiographic outcome in the management of posterior circulation aneurysms by use of direct surgical or endovascular techniques. Neurosurgery 51:14222002

60

Pierot LBoulin ACastaings LRey AMoret J: Selective occlusion of basilar artery aneurysms using controlled detachable coils: report of 35 cases. Neurosurgery 38:9489541996

61

Price RFSellar RLeung CO'Sullivan MJ: Traumatic vertebral arterial dissection and vertebrobasilar arterial thrombosis successfully treated with endovascular thrombolysis and stenting. AJNR Am J Neuroradiol 19:167716801998

62

Rabinov JDHellinger FRMorris PPOgilvy CSPutman CM: Endovascular management of vertebrobasilar dissecting aneurysms. AJNR Am J Neuroradiol 24:142114282003

63

Ramgren BCronqvist MRomner BBrandt LHoltås SLarson EM: Vertebrobasilar dissection with subarachnoid hemorrhage: a retrospective study of 29 patients. Neuroradiology 47:971042005

64

Rankin J: Cerebral vascular accidents in patients over the age of 60. II. Prognosis. Scott Med J 2:2002151957

65

Sadasivan CLeber BBGuonis MJLopes DKHopkins LN: Angiographic quantification of contrast medium washout from cerebral aneurysms after stent placement. AJNR Am J Neuroradiol 23:121412212002

66

Saeed ABShuaib AAl-Sulaiti GEmery D: Vertebral artery dissection: warning symptoms, clinical features and prognosis in 26 patients. Can J Neurol Sci 27:2922962000

67

Sani SJobe KWLopes DK: Treatment of wide-necked cerebral aneurysms with the Neuroform2 Treo stent. A prospective 6-month study. Neurosurg Focus 18:2E42005

68

Sasaki OHiroshi OKoike TKoitzumi TTanaya R: A clinico-pathological study of dissecting aneurysms of the intracranial vertebral artery. J Neurosurg 75:8748821991

69

Sawada MKaku YYoshimura SKawaguchi MMatsuhisa THirata T: Antegrade recanalization of a completely embolized vertebral artery after endovascular treatment of a ruptured intracranial dissecting aneurysm. Report of two cases. J Neurosurg 102:1611662005

70

Schievink WI: Spontaneous dissection of the carotid and vertebral arteries. N Engl J Med 344:8989062001

71

Sekhon LHSMorgan MKSorby WGrinnell V: Combined endovascular stent implantation and endosaccular coil placement for the treatment of a wide-necked vertebral artery aneurysm: technical case report. Neurosurgery 43:3803841998

72

Thanvi BMunshi SKDawson SLRobinson TG: Carotid and vertebral artery dissection syndromes. Postgrad Med J 81:3833882005

73

Turjman FMassoud TFJi CGuglielmi CViñuela FRobert J: Combined stent implantation and endosaccular coil placement for treatment of experimental wide-necked aneurysms: a feasibility study in swine. AJNR Am J Neuroradiol 15:108710901994

74

Vanninen RManninen HRonkainen A: Broad-based intracranial aneurysms: thrombosis induced by stent placement. AJNR Am J Neuroradiol 24:2632662003

75

Wakhloo AKLanzino GLieber BBHopkins LN: Stents for intracranial aneurysms: the beginning of a new endovascular era?. Neurosurgery 43:3773791998

76

Wakhloo AKSchellhammer Fde Vries JHaberstroh JSchumacher M: Self-expanding and balloon-expandable stents in the treatment of carotid aneurysms: an experimental study in a canine model. AJNR Am J Neuroradiol 15:4935021994

77

Wakhloo AKTio FOLieber BBSchellhammer FGraf MHopkins LN: Self-expanding nitinol stents in canine vertebral arteries: hemodynamics and tissue response. AJNR Am J Neuroradiol 16:104310511995

78

Wells-Roth DBiondi AJanardhan VChapple KGobin YPRiina HA: Endovascular procedures for treating wide-necked aneurysms. Neurosurg Focus 18:2E72005

79

Willing SJSkidmore FDonaldson JNobo ULChernukha K: Treatment of acute intracranial vertebrobasilar dissection with angioplasty and stent placement: report of two cases. AJNR Am J Neuroradiol 24:9859892003

80

Yamaura ITani EYokota MNakano AFukami MKaba K: Endovascular treatment of ruptured dissecting aneurysms aimed at occlusion of the dissected site by using Guglielmi detachable coils. J Neurosurg 90:8538561999

81

Yaşargil MG SrYoung PHTeddy PJClinical considerations, surgery of the intracranial aneurysm and results. Yaşargil MG: Microneurosurgery Vol II:StuttgartThieme Medical Publishers1984. 260269

82

Yasui NHadeishi HNishimura HUemura K: Tohoku Ruptured Vertebrobasilar Aneurysm Study Group: Cooperative study of ruptured vertebrobasilar artery aneurysms in the Tohoku district in Japan. Neurol Med Chir (Tokyo) 43:2192272003

83

Yasui TKomiyama MNishikawa MNakajima H: Subarachnoid hemorrhage from vertebral artery dissecting aneurysms involving the origin of the posteroinferior cerebellar artery: report of two cases and review of the literature. Neurosurgery 46:1962012000

84

Yasui TKomiyama MNishikawa MNakajima HKobayashi YInoue T: Fusiform vertebral artery aneurysms as a cause of dissecting aneurysms. Report of two autopsy cases and a review of the literature. J Neurosurg 91:1391441999

85

Zenteno MModenesi Freitas JMAburto-Murrieta YKoppe GMachado ELee A: Balloon-expandable stenting with and without coiling for wide-neck and complex aneurysms. Surg Neurol 66:6036102006

86

Zenteno MSantos-Franco JAburto-Murrieta YModenesi-Freitas JMRamírez-Guzmán GGómez-Llata S: Superior cerebellar artery aneurysms treated using the sole stenting approach. J Neurosurg 107:8608642007

87

Zenteno MAMurillo-Bonilla LMGuinto GGomez CRMartinez SRHiguera-Calleja J: Sole stenting bypass for the treatment of vertebral artery aneurysms: technical case report. Neurosurgery 57:1 SupplE2082005

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