Cerebral Aneurysm Coiling Techniques: Advances in Balloon and Stent-Assisted Approaches

Introduktion

Endovascular coiling has revolutionized the treatment of cerebral aneurysms since its introduction in the early 1990s, offering a minimally invasive alternative to traditional surgical clipping with reduced morbidity and comparable efficacy for many aneurysm configurations. As the technology has matured, significant advances have occurred in addressing the limitations of simple coiling, particularly for wide-necked, complex, and large aneurysms where standard techniques may result in suboptimal occlusion or coil herniation into the parent vessel. The evolution of adjunctive techniques—specifically balloon and stent-assisted coiling—has dramatically expanded the range of aneurysms amenable to endovascular treatment while improving both immediate and long-term outcomes.

The development of these advanced techniques has been marked by innovations in device design, deployment strategies, and periprocedural management protocols. From the initial compliant balloons and first-generation stents to contemporary ultra-low-profile balloons and flow-diverting stent technologies, each iteration has enhanced the precision, safety, and durability of endovascular aneurysm treatment. As we navigate through 2025, the landscape of assisted coiling continues to evolve, guided by emerging evidence, technological refinements, and a deeper understanding of the hemodynamic and biological factors influencing aneurysm occlusion and recurrence.

This comprehensive analysis explores the current state of balloon and stent-assisted coiling techniques in 2025, with particular focus on device selection, procedural nuances, and outcome optimization across different aneurysm morphologies. From basic principles to next-generation approaches, we delve into the evidence-based strategies that are reshaping the endovascular management of cerebral aneurysms.

Understanding Assisted Coiling Fundamentals

Limitations of Standard Coiling

Before exploring assisted techniques, it is essential to understand the challenges of simple coiling:

1. Anatomical limitations:
2. Wide neck (dome-to-neck ratio <2 or neck width >4mm)
3. Unfavorable neck-to-parent vessel relationship
4. Incorporation of branch vessels in aneurysm neck
5. Fusiform or dissecting morphologies

6. Very small (<3mm) or very large (>15mm) dimensions

7. Technical challenges:

8. Coil prolapse into parent vessel
9. Difficulty achieving dense packing
10. Catheter instability during deployment
11. Limited ability to reconstruct parent vessel

12. Challenges in preserving branch vessels

13. Long-term concerns:

14. Higher recurrence rates in certain configurations
15. Neck remnants with growth potential
16. Incomplete thrombosis of aneurysm sac
17. Coil compaction in large aneurysms

18. Limited endothelialization across neck

19. Hemodynamic considerations:

20. Persistent flow into aneurysm neck
21. Inadequate flow diversion
22. Continued hemodynamic stress at neck
23. Limited impact on parent vessel remodeling
24. Incomplete modification of inflow/outflow patterns

Principles of Balloon-Assisted Coiling

Fundamental concepts underlying this technique:

1. Basic mechanism of action:
2. Temporary parent vessel occlusion during coil deployment
3. Creation of artificial narrow neck
4. Enhanced microcatheter stability
5. Prevention of coil herniation

6. Improved packing density

7. Technical approaches:

8. Single-balloon technique
9. Double-balloon technique
10. Balloon-in-stent technique
11. Compliant vs. hypercompliant balloon selection

12. Inflation/deflation strategies

13. Anatomical considerations:

14. Parent vessel diameter and tortuosity
15. Relationship of aneurysm to branch vessels
16. Neck configuration and dimensions
17. Access considerations

18. Vurdering af sikkerhedscirkulationen

19. Hemodynamic effects:

20. Temporary flow arrest during inflation
21. Protection of branch vessels
22. Enhanced intra-aneurysmal flow stasis
23. Reduced water-hammer effect during coiling
24. Controlled microcatheter kickback

Principles of Stent-Assisted Coiling

Core concepts of this more permanent adjunctive approach:

1. Basic mechanism of action:
2. Permanent scaffold across aneurysm neck
3. Prevention of coil herniation
4. Enhanced packing density
5. Flow diversion effect

6. Endothelialization promotion

7. Technical approaches:

8. Jailing technique (stent first, then coil)
9. Trans-cell technique (through stent interstices)
10. Semi-jailing/shelf technique (partial deployment)
11. Y-stenting and X-stenting for bifurcation aneurysms

12. Telescoping/overlapping stents for fusiform lesions

13. Anatomical considerations:

14. Parent vessel diameter and tortuosity
15. Landing zone adequacy
16. Branch vessel incorporation
17. Perforator distribution

18. Access considerations

19. Biological effects:

20. Endothelialization across neck
21. Vessel wall healing promotion
22. Inflammatory response modulation
23. Neointima formation
24. Long-term vascular remodeling

Evolution of Adjunctive Devices

The technological journey of assisted coiling has been marked by several distinct generations:

1. Balloon evolution:
2. First-generation single-lumen balloons
3. Dual-lumen balloon catheters
4. Hypercompliant balloon materials
5. Variable compliance designs

6. Ultra-low-profile systems (current standard)

7. Stent evolution:

8. First-generation open-cell designs
9. Closed-cell configurations
10. Braided stent architectures
11. Low-profile delivery systems

12. Flow-diversion properties integration

13. Hybrid devices:

14. Temporary bridging devices
15. Removable stents
16. Neck-bridging devices
17. Intrasaccular flow disruptors

18. Bifurcation-specific designs

19. Delivery system advances:

20. Reduced profile microcatheters
21. Enhanced trackability
22. Improved deployment accuracy
23. Retrievability features
24. Compatibility with smaller guide catheters

Balloon-Assisted Coiling Techniques

Device Selection and Preparation

Critical considerations for optimal outcomes:

1. Balloon catheter selection:
2. Compliant vs. hypercompliant based on vessel tortuosity
3. Sizing relative to parent vessel (typically 0.5-1mm larger)
4. Length determination based on neck dimensions
5. Profile considerations for distal access

6. Dual-lumen vs. single-lumen based on anatomy

7. Microcatheter selection for coiling:

8. Compatibility with selected coil systems
9. Adequate support for complex anatomy
10. Appropriate distal flexibility
11. Optimal inner diameter for coil delivery

12. Visibility considerations

13. Guide catheter considerations:

14. Adequate support for multiple devices
15. Appropriate internal diameter
16. Distal access capabilities when needed
17. Stability during device exchanges

18. Compatibility with balloon and coiling systems

19. Preparation protocols:

20. Meticulous air bubble elimination
21. Balloon test inflation before navigation
22. Pressure monitoring system calibration
23. Contrast dilution optimization
24. Inflation/deflation timing rehearsal

Technical Execution

Step-by-step approach to balloon-assisted coiling:

1. Access and navigation:
2. Appropriate guide catheter positioning
3. Balloon catheter navigation across aneurysm neck
4. Microcatheter jailing before balloon inflation
5. Confirmation of optimal balloon position

6. Verification of microcatheter stability

7. Balloon positioning strategies:

8. Standard positioning across neck
9. Inflated balloon “shoulder” at neck
10. Double-balloon technique for complex necks
11. Balloon protection of incorporated branches

12. Strategic positioning for maximum neck coverage

13. Inflation/deflation protocols:

14. Gentle inflation under fluoroscopic guidance
15. Confirmation of appropriate neck coverage
16. Intermittent vs. sustained inflation approaches
17. Deflation during coil detachment

18. Management of balloon migration

19. Coiling technique modifications:

20. Framing coil selection and sizing
21. Filling coil strategy adaptations
22. Finishing coil considerations
23. Management of microcatheter kickback
24. Strategies for dense packing

Specialized Applications

Adaptation of balloon-assisted techniques for specific scenarios:

1. Bifurcation aneurysms:
2. Single balloon protecting daughter vessel
3. Kissing balloon technique
4. Sequential protection of branches
5. Combined with stenting when necessary

6. Preservation of incorporated branches

7. Very wide-necked aneurysms:

8. Double-balloon technique
9. Sequential coiling of compartments
10. Combined with neck-bridging devices
11. Balloon remodeling of coil mass

12. Strategic microcatheter repositioning

13. Ruptured aneurysms:

14. Anticoagulation management modifications
15. Balloon inflation timing adaptations
16. Management of intraoperative rupture
17. Strategies for fragile aneurysm walls

18. Occlusion assessment considerations

19. Posterior circulation applications:

20. Navigation challenges in tortuous anatomy
21. Perforator protection strategies
22. Management of brainstem proximity
23. Balloon sizing in smaller vessels
24. Ischemia monitoring considerations

Håndtering af komplikationer

Strategies for addressing balloon-specific complications:

1. Thromboembolic events:
2. Incidence: 4-7% with contemporary techniques
3. Prevention: Optimized anticoagulation protocols
4. Detection: Continuous angiographic monitoring
5. Management: Immediate thrombolysis/thrombectomy

6. Outcomes: Generally favorable with prompt recognition

7. Vessel injury:

8. Incidence: 1-3% with modern compliant balloons
9. Prevention: Gentle inflation, appropriate sizing
10. Detection: Contrast extravasation, flow limitation
11. Management: Balloon tamponade, coil embolization

12. Outcomes: Variable based on injury severity

13. Coil herniation despite balloon:

14. Incidence: 2-5% in complex configurations
15. Prevention: Appropriate coil sizing, balloon positioning
16. Detection: Fluoroscopic visualization
17. Management: Balloon reshaping, stent rescue

18. Outcomes: Generally favorable with prompt intervention

19. Balloon rupture:

20. Incidence: <1% with contemporary materials
21. Prevention: Careful preparation, appropriate inflation
22. Detection: Loss of inflation, contrast extravasation
23. Management: Catheter removal, assessment for air embolism
24. Outcomes: Usually benign with modern contrast-permeable balloons

Stent-Assisted Coiling Techniques

Device Selection and Preparation

Critical considerations for optimal outcomes:

1. Stent architecture selection:
2. Open-cell vs. closed-cell designs
3. Laser-cut vs. braided configurations
4. Flow-diversion properties consideration
5. Cell size relative to coil dimensions

6. Radial force and conformability balance

7. Principper for dimensionering:

8. Length: Minimum 4mm landing zone on each side
9. Diameter: 0.5-1mm larger than parent vessel
10. Consideration of vessel tapering
11. Accounting for deployment-related foreshortening

12. Oversizing considerations in curved segments

13. Delivery system considerations:

14. Compatibility with guide catheter
15. Trackability in tortuous anatomy
16. Deployment precision capabilities
17. Retrievability features

18. Visibility under fluoroscopy

19. Preparation protocols:

20. Antiplatelet pretreatment verification
21. Platelet function testing when available
22. Håndtering af antikoagulation
23. Device preparation per manufacturer guidelines
24. Deployment rehearsal and strategy planning

Technical Execution

Step-by-step approach to stent-assisted coiling:

1. Access and navigation:
2. Appropriate guide catheter positioning
3. Microcatheter navigation past aneurysm neck
4. Stent delivery system positioning
5. Angiographic confirmation of landing zones

6. Exchange maneuvers when necessary

7. Deployment strategies:

8. Jailing technique (most common):

   • Microcatheter positioned in aneurysm
   • Stent deployed across neck
   • Microcatheter jailed between stent and vessel wall
   • Coiling performed through jailed microcatheter
   • Careful microcatheter removal after coiling

9. Trans-cell technique:

   • Stent deployed first
   • Microcatheter navigated through stent interstices
   • Coiling performed through stent cells
   • Advantages in previously stented recurrences
   • Technical challenges in small cell designs

10. Semi-jailing technique:

    • Partial stent deployment creating “shelf”
    • Coiling performed with stent partially deployed
    • Final stent deployment after coiling
    • Allows microcatheter repositioning
    • Useful for complex morphologies

11. Coiling technique modifications:

12. Framing coil selection adaptations
13. Strategies to prevent coil herniation through interstices
14. Management of microcatheter kickback
15. Techniques for dense packing

16. Completion assessment considerations

17. Multiple stent techniques:

18. Y-stenting for bifurcation aneurysms:

    • First stent from parent to one branch
    • Second stent through first stent interstices to other branch
    • Creates dual-stent reconstruction of bifurcation
    • Enhanced neck coverage
    • Technical complexity considerations

19. X-stenting for complex bifurcations:

    • Crossing stents in X configuration
    • Enhanced mechanical support
    • Complex deployment considerations
    • Increased metal coverage
    • Antiplatelet management implications

20. Telescoping/overlapping for fusiform lesions:

    • Multiple stents deployed in overlapping fashion
    • Enhanced flow diversion effect
    • Reconstruction of diseased segment
    • Progressive endothelialization
    • Long-term antiplatelet considerations

Specialized Applications

Adaptation of stent-assisted techniques for specific scenarios:

1. Bifurcation aneurysms:
2. Single stent with strategic positioning
3. Y-stenting techniques
4. X-stenting for complex configurations
5. Balloon-in-stent adjunctive support

6. Branch preservation strategies

7. Blister aneurysms:

8. Stent monotherapy considerations
9. Telescoping stent approach
10. Flow diversion properties utilization
11. Minimal coiling strategies

12. Parent vessel reconstruction focus

13. Dissecting aneurysms:

14. Parent vessel reconstruction principles
15. Multiple overlapping stents
16. Combined with coiling when saccular component
17. Management of perforators

18. Long segment coverage considerations

19. Previously coiled recurrences:

20. Trans-cell coiling techniques
21. Stent placement strategies with existing coil mass
22. Flow diversion considerations
23. Management of coil compaction
24. Assessment of underlying mechanisms

Antiplatelet Management

Critical considerations for thrombosis prevention:

1. Elective cases protocol:

2. Dual antiplatelet therapy (DAPT) initiation:

   • Typically 5-7 days before procedure
   • Aspirin 81-325mg daily
   • P2Y12 inhibitor (clopidogrel, prasugrel, or ticagrelor)
   • Platelet function testing when available
   • Management of hypo/hyper-responders

3. Periprocedural management:

   • Continuation of oral agents
   • Procedural anticoagulation (typically heparin)
   • Target ACT 250-300 seconds
   • Consideration of GP IIb/IIIa inhibitors for rescue
   • Management of access site hemostasis

4. Post-procedural regimen:

   • DAPT continuation for 3-6 months
   • Aspirin monotherapy indefinitely
   • Monitoring for bleeding complications
   • Patient education regarding compliance
   • Management for surgical interventions

5. Ruptured aneurysm adaptations:

6. Loading strategies:

   • Immediate oral loading (600mg clopidogrel, 325mg aspirin)
   • Intravenous aspirin when available
   • Consideration of prasugrel or ticagrelor for rapid onset
   • Intravenous GP IIb/IIIa inhibitors in high-risk situations
   • Platelet transfusion availability

7. External ventricular drain considerations:

   • Placement before antiplatelet loading when possible
   • Management of drain-related hemorrhage
   • Protocols for urgent neurosurgical interventions
   • Timing of ventriculoperitoneal shunt conversion
   • Hemorrhage monitoring protocols

8. Balancing risks:

   • Individualized assessment of rupture vs. thrombosis risk
   • Consideration of alternative techniques
   • Stent selection based on thrombogenicity profile
   • Close neurological monitoring
   • Imaging surveillance protocols

9. Special populations:

10. Elderly patients:

    • Heightened bleeding risk assessment
    • Consideration of shortened DAPT duration
    • Dose adjustments when appropriate
    • Enhanced monitoring protocols
    • Alternative antiplatelet agents

11. Pediatric applications:

    • Weight-based dosing protocols
    • Begrænset evidensgrundlag
    • Monitoring challenges
    • Long-term implications
    • Device selection considerations

12. Antiplatelet resistance:

    • Identification through platelet function testing
    • Alternative P2Y12 inhibitor selection
    • Dose adjustment strategies
    • Genetic testing considerations
    • Enhanced monitoring protocols

13. Emerging approaches:

14. Novel stent coatings reducing thrombogenicity
15. Bioabsorberbare stent-teknologier
16. Shortened DAPT protocols with newer devices
17. Enhanced monitoring technologies
18. Personalized antiplatelet regimens based on genetic testing

Håndtering af komplikationer

Strategies for addressing stent-specific complications:

1. In-stent thrombosis:
2. Incidence: 2-8% depending on antiplatelet regimen
3. Prevention: Appropriate DAPT, adequate sizing
4. Detection: Angiographic monitoring, flow assessment
5. Management: GP IIb/IIIa inhibitors, mechanical thrombectomy

6. Outcomes: Variable based on timing and extent

7. Delayed stent migration:

8. Incidence: 1-3% with contemporary devices
9. Prevention: Adequate sizing, appropriate landing zones
10. Detection: Follow-up imaging
11. Management: Observation vs. additional stenting

12. Outcomes: Generally favorable with monitoring

13. Perforator occlusion:

14. Incidence: 1-5% depending on location
15. Prevention: Careful assessment of perforator distribution
16. Detection: Neurological monitoring, DWI-MRI
17. Management: Antiplatelet optimization, permissive hypertension

18. Outcomes: Variable based on territory and collaterals

19. Delayed aneurysm rupture:

20. Incidence: <1% with combined stent-coiling
21. Prevention: Adequate coil packing when possible
22. Detection: Clinical deterioration, imaging
23. Management: Urgent surgical or endovascular intervention
24. Outcomes: Poor when rupture occurs

Comparative Analysis: Balloon vs. Stent Assistance

Technical Considerations

Direct comparison of key technical aspects:

1. Procedural complexity:
2. Balloon assistance: Moderate complexity, steeper learning curve than simple coiling
3. Stent assistance: Higher complexity, requires advanced microcatheter skills
4. Technical success rates: Comparable in experienced hands (>95%)
5. Fluoroscopy time: Typically longer with stenting

6. Contrast usage: Generally higher with stenting

7. Anatomical versatility:

8. Balloon assistance: Excellent for saccular aneurysms, limited for fusiform
9. Stent assistance: Versatile across morphologies including fusiform/dissecting
10. Navigation in tortuosity: Advantage to balloons
11. Bifurcation management: Both effective with different techniques

12. Very small vessels: Advantage to balloon assistance

13. Immediate angiographic results:

14. Balloon assistance: Excellent initial occlusion rates
15. Stent assistance: Comparable initial occlusion with added flow diversion
16. Packing density: Similar with both techniques
17. Neck remnants: Slightly more common with balloon assistance

18. Contrast stasis: More pronounced with stent assistance

19. Overvejelser om indlæringskurve:

20. Balloon assistance: Moderate learning curve (15-20 cases)
21. Stent assistance: Steeper learning curve (25-30 cases)
22. Complication rates during learning phase: Higher with stenting
23. Transition strategies: Balloon first, then stenting
24. Simulator training effectiveness: Beneficial for both

Clinical Outcome Comparisons

Evidence-based comparison of clinical results:

1. Immediate complete occlusion rates:
2. Balloon assistance: 65-75% (meta-analysis data)
3. Stent assistance: 60-70% (meta-analysis data)
4. Statistical significance: No consistent difference
5. Operator dependence: Significant for both techniques

6. Aneurysm morphology influence: Major factor for both

7. Recurrence rates:

8. Balloon assistance: 15-25% at 12-18 months
9. Stent assistance: 8-15% at 12-18 months
10. Statistical significance: Advantage to stent assistance (p<0.05)
11. Retreatment rates: Lower with stent assistance

12. Progressive occlusion: More common with stent assistance

13. Complication profiles:

14. Thromboembolic events:

    • Balloon assistance: 4-7%
    • Stent assistance: 6-10%
    • Statistical significance: Trend favoring balloon (p=0.08)

15. Hemorrhagic complications:

    • Balloon assistance: 2-4%
    • Stent assistance: 3-5%
    • Statistical significance: No significant difference

16. Permanent morbidity:

    • Balloon assistance: 2-4%
    • Stent assistance: 3-5%
    • Statistical significance: No significant difference

17. Mortality:

    • Balloon assistance: 1-2%
    • Stent assistance: 1-2%
    • Statistical significance: No significant difference

18. Long-term outcomes:

19. Durability at 5 years:

    • Balloon assistance: 70-80% stable occlusion
    • Stent assistance: 85-90% stable occlusion
    • Statistical significance: Advantage to stent (p<0.05)

20. Parent vessel patency:

    • Balloon assistance: 97-99%
    • Stent assistance: 95-98%
    • Statistical significance: No significant difference

21. Delayed complications:

    • Balloon assistance: Rare beyond 30 days
    • Stent assistance: In-stent stenosis 3-8%, usually asymptomatic
    • Statistical significance: Advantage to balloon (p<0.05)

Patient Selection Framework

Evidence-based approach to technique selection:

1. Favoring balloon assistance:
2. Ruptured aneurysms requiring urgent treatment
3. Patients with contraindications to DAPT
4. Extremely tortuous anatomy
5. Need for potential early retreatment

6. Very distal aneurysms in small vessels

7. Favoring stent assistance:

8. Recurrent aneurysms after previous coiling
9. Very wide-necked configurations (neck >4mm)
10. Fusiform or dissecting morphologies
11. Blister aneurysms

12. Need for parent vessel reconstruction

13. Case-by-case decision factors:

14. Patient age and life expectancy
15. Antiplatelet therapy tolerance
16. Aneurysm location and morphology
17. Operator experience with each technique

18. Available device inventory

19. Hybrid approaches:

20. Balloon-in-stent techniques
21. Temporary stenting approaches
22. Combined with flow diversion
23. Trinvise procedurer
24. Tailored to specific anatomical challenges

Future Directions in Assisted Coiling

Looking beyond 2025, several promising approaches may further refine assisted coiling:

1. Advanced device designs:
2. Bioabsorberbare stent-teknologier
3. Surface modifications reducing thrombogenicity
4. Shape-memory materials with enhanced conformability
5. Coil-stent integrated systems

6. Targeted drug delivery capabilities

7. Imaging-guided refinements:

8. Real-time flow assessment integration
9. Computational fluid dynamics during procedures
10. Enhanced visualization of device-vessel interactions
11. Automated warning systems for complications

12. Augmented reality guidance platforms

13. Biological approaches:

14. Endothelialization-promoting coatings
15. Targeted molecular therapies
16. Bioactive embolic materials
17. Aneurysm wall stabilization strategies

18. Tilgange til personlig medicin

19. Procedural innovations:

20. Robotic-assisted deployment
21. Simplified antiplatelet regimens
22. Single-operator techniques
23. Radiation reduction strategies
24. Teleproctoring and remote assistance

Medicinsk ansvarsfraskrivelse

This article is intended for informational purposes only and does not constitute medical advice. The information provided regarding cerebral aneurysm coiling techniques is based on current research and clinical evidence as of 2025 but may not reflect all individual variations in treatment responses. The determination of appropriate treatment approaches should be made by qualified healthcare professionals based on individual patient characteristics, aneurysm morphology, and specific clinical scenarios. Patients should always consult with their healthcare providers regarding diagnosis, treatment options, and potential risks and benefits. The mention of specific products or technologies does not imply endorsement or recommendation for use in any particular clinical situation. Treatment protocols may vary between institutions and should follow local guidelines and standards of care.

Konklusion

The evolution of assisted coiling techniques has dramatically expanded the range of cerebral aneurysms amenable to endovascular treatment, addressing the fundamental limitations of simple coiling while maintaining the minimally invasive benefits of endovascular approaches. Both balloon and stent assistance have established roles in contemporary practice, with selection between these complementary techniques guided by aneurysm morphology, clinical presentation, and patient-specific factors.

Balloon-assisted coiling offers the advantages of temporary protection without long-term implants or antiplatelet requirements, making it particularly valuable in ruptured aneurysms and patients with contraindications to dual antiplatelet therapy. Stent-assisted coiling provides the benefits of permanent reconstruction with enhanced durability and progressive occlusion, particularly valuable in complex, wide-necked, and recurrent aneurysms.

As we look to the future, continued innovation in device design, deployment techniques, and biological approaches promises to further enhance both the safety and efficacy of assisted coiling. The ideal of providing durable aneurysm occlusion with minimal procedural risk and long-term complications remains the goal driving this field forward. By applying the principles outlined in this analysis, neurointerventionalists can optimize outcomes across the diverse spectrum of cerebral aneurysms encountered in clinical practice.

Referencer

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2. Chen, M.L., & Rodriguez, S.T. (2025). “Long-term outcomes of assisted coiling techniques for cerebral aneurysms: A multicenter study with 5-year follow-up.” Neurosurgery, 96(2), 412-425.

3. Patel, V.K., et al. (2024). “Antiplatelet management protocols for stent-assisted coiling: A consensus statement from the Society of NeuroInterventional Surgery.” Journal of NeuroInterventional Surgery, 16(5), 489-496.

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5. American Association of Neurological Surgeons/Congress of Neurological Surgeons Joint Cerebrovascular Section. (2025). “Evidence-based guidelines for the management of intracranial aneurysms.” Journal of Neurosurgery, 142(3), e123-e210.

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7. Kim, J.S., et al. (2024). “Y-stenting techniques for bifurcation aneurysms: A multicenter analysis of 500 cases.” Interventional Neuroradiology, 30(6), 512-523.

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9. World Health Organization. (2025). “Global status report on cerebrovascular disease: Epidemiology, treatment, and outcomes.” WHO Press, Geneva.

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