Symptomatic delayed coil migration after balloon assisted embolization: An underreported adverse event?

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Barium swallow, showing left displacement and constriction of the esophagus, with no pass of contrast into the cavity." ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "Aleix Rosselló, Jose Luis Sanmillán, Luis López-Obarrio, Iván Pelegrín, Andreu Gabarrós, Oscar Godino" "autores" => array:6 [ 0 => array:2 [ "nombre" => "Aleix" "apellidos" => "Rosselló" ] 1 => array:2 [ "nombre" => "Jose Luis" "apellidos" => "Sanmillán" ] 2 => array:2 [ "nombre" => "Luis" "apellidos" => "López-Obarrio" ] 3 => array:2 [ "nombre" => "Iván" "apellidos" => "Pelegrín" ] 4 => array:2 [ "nombre" => "Andreu" "apellidos" => "Gabarrós" ] 5 => array:2 [ "nombre" => "Oscar" "apellidos" => "Godino" ] ] ] ] ] "idiomaDefecto" => "en" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S113014731830023X?idApp=UINPBA00004B" "url" => "/11301473/0000003000000002/v1_201902260607/S113014731830023X/v1_201902260607/en/main.assets" ] "en" => array:20 [ "idiomaDefecto" => true "cabecera" => "Case Report" "titulo" => "Symptomatic delayed coil migration after balloon assisted embolization: An underreported adverse event?" "tieneTextoCompleto" => true "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "87" "paginaFinal" => "93" ] ] "autores" => array:1 [ 0 => array:4 [ "autoresLista" => "Lino Fonseca, Rafael Najarro-Quispe, Ana Rodríguez-Hernández, Ramon Torné, Dario Gándara-Sabatini, Fuat Arikan, Pilar Baños-Carrasco" "autores" => array:7 [ 0 => array:3 [ "nombre" => "Lino" "apellidos" => "Fonseca" "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "1" "identificador" => "fn0005" ] ] ] 1 => array:3 [ "nombre" => "Rafael" "apellidos" => "Najarro-Quispe" "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "b" "identificador" => "aff0010" ] 1 => array:2 [ "etiqueta" => "1" "identificador" => "fn0005" ] ] ] 2 => array:4 [ "nombre" => "Ana" "apellidos" => "Rodríguez-Hernández" "email" => array:1 [ 0 => "ana.neurosurgery@hotmail.com" ] "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "b" "identificador" => "aff0010" ] 1 => array:2 [ "etiqueta" => "*" "identificador" => "cor0005" ] ] ] 3 => array:3 [ "nombre" => "Ramon" "apellidos" => "Torné" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "c" "identificador" => "aff0015" ] ] ] 4 => array:3 [ "nombre" => "Dario" "apellidos" => "Gándara-Sabatini" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "b" "identificador" => "aff0010" ] ] ] 5 => array:3 [ "nombre" => "Fuat" "apellidos" => "Arikan" "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "b" "identificador" => "aff0010" ] 1 => array:2 [ "etiqueta" => "d" "identificador" => "aff0020" ] ] ] 6 => array:3 [ "nombre" => "Pilar" "apellidos" => "Baños-Carrasco" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "b" "identificador" => "aff0010" ] ] ] ] "afiliaciones" => array:4 [ 0 => array:3 [ "entidad" => "Department of Neurological Surgery, Centro Hospitalar Lisboa Central – Hospital São José, Lisbon, Portugal" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Department of Neurological Surgery, Vall d’Hebron University Hospital, Barcelona, Spain" "etiqueta" => "b" "identificador" => "aff0010" ] 2 => array:3 [ "entidad" => "Department of Neurological Surgery, Clinic Hospital, Barcelona, Spain" "etiqueta" => "c" "identificador" => "aff0015" ] 3 => array:3 [ "entidad" => "Neurotraumatology and Neurosurgery Research Unit (UNINN), Vall d’Hebron Research Institute, Universitat Autonoma de Barcelona (UAB), Spain" "etiqueta" => "d" "identificador" => "aff0020" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Migración Sintomática Tardía de Coil tras Embolización Asistida con Balón: ¿un evento adverso infra descrito?" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0020" "etiqueta" => "Fig. 4" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr4.jpeg" "Alto" => 602 "Ancho" => 1298 "Tamanyo" => 65079 ] ] "descripcion" => array:1 [ "en" => "Cerebral angiography, internal carotid artery injection, oblique projection demonstrated migration of 2 coil loops, one to calloso-marginal branch and the other to pericallosal branch of the right anterior cerebral artery." ] ] ] "textoCompleto" => "IntroductionAs endovascular techniques develop, broad-neck aneurysms previously regarded as better suited for microsurgical clipping, are now increasingly being addressed with balloon and stent assisted embolization. These new techniques had not been tested against clipping in a randomized controlled trial. Furthermore, their use has widely spread before long term results are known. As these new techniques rise, so might do their potential complications. Therefore, thorough report and review of such potential complications should be mandatory.Periprocedural coil migration with stent-assisted or balloon-remodeling coiling is listed as one likely complication of these techniques. Its incidence has been estimated somewhere around 2–6%.<a class="elsevierStyleCrossRef" href="#bib0155">1</a> Delayed coil migration, on the other hand, has been scarcely reported and is less documented. During a balloon-assisted coiling procedure, the temporary inflation of a largable balloon prevents coil migration into a parent artery and improves coil packing.<a class="elsevierStyleCrossRefs" href="#bib0160">2–7</a> Nevertheless, intraprocedural displacement of coils can occur during the placement of the final coil into the aneurysm sac to maximize the packing density, as a result of displacement of a previous intrasacular coil by the final coil, or following balloon deflation.<a class="elsevierStyleCrossRef" href="#bib0190">8</a> Management strategies include microsurgical removal, coil retrieval with different devices, stent placement, and anticoagulation or antiplatelet therapy.<a class="elsevierStyleCrossRef" href="#bib0195">9</a> However, coil migration may happen days or even months after the procedure and may potentially carry a higher morbidity and mortality related to delayed thromboembolic events or direct vessel occlusion. Here we report a case of a delayed coil migration after balloon assisted embolization of a ruptured anterior communicating artery (ACoA) aneurysm. We review similar cases previously reported on the literature and thoroughly analyze the likely causes of this adverse event, management strategies, clinical outcomes and overall incidence.Case reportA 54-year-old man with history of chronic alcoholism and smoking, was referred to our emergency department because of a generalized tonic–clonic seizure preceded by a sudden severe headache. Neurological examination only revealed signs of meningeal irritation and a mild bradipsiquia. Non contrast head CT revealed a subarachnoid hemorrhage Fisher grade IV, with no signs of acute hydrocephalus. A cerebral angiogram demonstrated a saccular bilobed aneurysm located on the ACoA (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>). The maximal diameter of the aneurysm was 7mm and the neck was measured as 5mm (aspect ratio 7:5=1.4). Despite the unfavorable ratio, endovascular coiling was offered as the first treatment option based on the patient medical problems (coagulopathy related to chronic alcoholism).<elsevierMultimedia ident="fig0005"></elsevierMultimedia>Coil embolization was performed with a balloon-assisted technique using a 4mm×11mm Secpter XC™ balloon (Microvention, Inc., Tustin, CA, USA) and a total of 13 Target® Nano-coils (Striker, Inc., Kalamazoo, MI, USA) measuring from 0.4 to 6cm. A complete angiographic occlusion of the aneurysm was achieved (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>). However, at the end of the procedure, a nonocclusive embolism of the left anterior cerebral artery was observed and the patient showed a mild paresis (4/5) of the right arm. He was then kept on heparin for 24h and his right arm showed a complete recovery.<elsevierMultimedia ident="fig0010"></elsevierMultimedia>On postcoiling day 11, the patient presented a sudden left hemiplegia. The head CT demonstrated two metallic artifacts at the pericallosal cistern suggesting the migration of embolization material from the aneurysm sac (<a class="elsevierStyleCrossRef" href="#fig0015">Fig. 3</a>). No established infarction on the anterior cerebral artery territory was seen at that time. Subsequent cerebral angiography demonstrated migration of 2 coil loops, one to calloso-marginal branch and the other to pericallosal branch of the right anterior cerebral artery (<a class="elsevierStyleCrossRef" href="#fig0020">Fig. 4</a>). The capillary phase showed a defect corresponding to the ischemic region. Coil retrieval was attempted but deemed not feasible. A stent (LVIS® 3.5mm×20mm – Microvention, Inc., Tustin, CA, USA) was deployed to secure pericallosal flow, but the calloso-marginal branch remained occluded. The patient was started on antiplatelet therapy with aspirin.<elsevierMultimedia ident="fig0015"></elsevierMultimedia><elsevierMultimedia ident="fig0020"></elsevierMultimedia>A postprocedure CT scan showed an already established stroke involving the medial aspect of the right frontal lobe and the patient did not recover the hemiplegia. Three weeks later, a sudden decreased level of consciousness was noted. A new head CT scan revealed a hemorrhagic transformation of the ischemic territory and signs of intracranial hypertension (<a class="elsevierStyleCrossRef" href="#fig0025">Fig. 5</a>). The family rejected further intervention and active care was withdrawn with consequent death of the patient.<elsevierMultimedia ident="fig0025"></elsevierMultimedia>DiscussionDespite the wide spread of embolization techniques, broad-necked intracranial aneurysms pose a challenge to these techniques and are still considered better candidates for microsurgical clipping.<a class="elsevierStyleCrossRefs" href="#bib0185">7–10</a> Nevertheless, various endovascular options like stent-assisted and balloon-assisted coiling have been developed to deal with these challenging lesions. Financial drivers toward embolization, patient preference (perceived benefit of “minimally invasive”, less pain or marketing) and lack of neurosurgical expertise might tip the balance against clipping despite the void of solid scientific evidence.As these new endovascular techniques spread, so might do their potential complications. One such complication is the scarcely reported delayed coil migration that our patient suffered. A literature review revealed another 14 cases of delayed coil migration that have been summarized on <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>.<a class="elsevierStyleCrossRefs" href="#bib0185">7,11–19</a><elsevierMultimedia ident="tbl0005"></elsevierMultimedia>Analyzing all available cases, two main reasons seem to be responsible for a delayed coil migration. In those cases of stent-assisted embolization, fine coils might escape from the stent struts when using a loose mesh design.<a class="elsevierStyleCrossRef" href="#bib0220">14</a> When using balloon assisted embolization, any coil movement after placement is usually evident immediately after balloon deflation.<a class="elsevierStyleCrossRef" href="#bib0230">16</a> However, delayed coil migration can also happen with this technique. Ultrasoft or small coils used in the final packing of the aneurysm might remain initially stable after balloon deflation. Later on, if a proper adherence of the spirals is not developed, these last ultrasoft coils might displace from the aneurysm sac days or even months after the initial procedure.<a class="elsevierStyleCrossRefs" href="#bib0235">17,18</a> As deducted from our case and previous reports, aneurysm shape, coil size, stent design, and underpacking or overpacking generating unstable coils, seem to be predisposing factors for delayed coil migration.<a class="elsevierStyleCrossRef" href="#bib0245">19</a>Clinical outcome after a delayed coil migration might vary widely. However, from our literature review, a trend might be inferred. Delayed coil migration after stent assisted embolization seems to course as an asymptomatic event, most likely due to antiplatelet therapy administered for the stent. Antiplatelet drugs would produce a neointima over the migrated coil preventing its thrombosis. On the other hand, delayed coil migration after simple coiling or balloon assisted techniques seems to render a disastrous clinical outcome as illustrated in the present case.The different management strategies described when dealing with a delayed coil migration have been summarized in <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>. In a few cases diagnosed as incidental findings in asymptomatic patients, a “wait and see” strategy was adopted and no specific treatment was performed. In other cases with mild symptoms, antiplatelet or anticoagulant therapy was started. When severe deficits were observed, authors usually opted for removing the migrated spiral. Surgical options include direct removal of the coil or revascularization bypass with trapping of the occluded segment. Endovascular retrieval is usually performed for immediate coil displacement, but it could be dangerous for delayed coil migration since the coil might have already adhered to the vessel wall. Alternatively, a stent can be placed to trap the migrated coil as was done in our case. In a previous similar case, Kamide et al. reported an excellent result with this technique.<a class="elsevierStyleCrossRef" href="#bib0245">19</a> However, major concerns include causing further migration of the coil when introducing the stent and injuring the parent vessel when navigating through a distal branch. In our case, stent deployment was uneventful in the pericallosal artery but deemed unfeasible in the callosomarginal branch and the ischemic complication progressed despite our best efforts. Furthermore, the associated antiplatelet therapy might have facilitated the hemorrhagic transformation of our patient's stroke. Therefore, bailout stent deployment should not be generally recommended since further research is warranted to validate it.There is strong evidence that much of the information on new techniques adverse events remains unpublished and poor reporting of them in journals has been repeatedly highlighted.<a class="elsevierStyleCrossRefs" href="#bib0250">20–23</a> Particularly, delayed coil migration was never reported on the initial cohorts and systematic reviews of balloon and stent assisted techniques.<a class="elsevierStyleCrossRefs" href="#bib0270">24–30</a> Therefore, one final concern with delayed coil migration is that it might be an underreported adverse event. Our study aims to raise further awareness of the unreported and/or unknown negative results of otherwise promising endovascular techniques. Ethical challenges raised by endovascular innovation are not easy to address. It would be desirable that novel endovascular or surgical interventions were as thoroughly assessed as new drugs are. However, classic randomized controlled trials of new endovascular techniques are cumbersome and expensive and have proved once and again that are not necessary the most accurate way to ensure the safety of new techniques. The resources and expertise available on clinical trials might differ quite a lot from day-to-day wide-world practice. Evidence from other studies like case series and case reports should also be considered and their publication must be encouraged. However, the information provided by those studies might fall short from needed. Advocating large scale registries with standardized and transparent data collection might be one of the answers.ConclusionsAs illustrated by this study, new endovascular techniques are increasingly perceived as the safer option in any type of aneurysm despite lack of strong evidence to support such belief. Reports of adverse results with these new techniques might not be accurate for various reasons, and severe adverse events might be recognized long time after the technique is out in the market. Nevertheless, reasons like money drivers, perception of less invasiveness and even lack of neurosurgical expertise to oppose it, might tip the balance in their favor. Pushing the endovascular envelope in broad-neck aneurysms might produce cases of delayed coil migration like the one described here. The best rescue treatment option is not well established and patient's outcome might go from excellent to disastrous. This scarcely reported complication would require large population registries to better understand its real incidence and try to infer the best management options." "textoCompletoSecciones" => array:1 [ "secciones" => array:9 [ 0 => array:3 [ "identificador" => "xres1155380" "titulo" => "Abstract" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0005" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec1082934" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres1155381" "titulo" => "Resumen" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0010" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec1082933" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:2 [ "identificador" => "sec0010" "titulo" => "Case report" ] 6 => array:2 [ "identificador" => "sec0015" "titulo" => "Discussion" ] 7 => array:2 [ "identificador" => "sec0020" "titulo" => "Conclusions" ] 8 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2017-11-06" "fechaAceptado" => "2018-02-18" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec1082934" "palabras" => array:5 [ 0 => "Broad-neck aneurysm" 1 => "Balloon assisted coiling" 2 => "Stent assisted coiling" 3 => "Adverse event" 4 => "Coil migration" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec1082933" "palabras" => array:5 [ 0 => "Aneurismas de cuello ancho" 1 => "Embolización asistida por balón" 2 => "Stent asistido" 3 => "Eventos adversos" 4 => "Migración de coil" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:2 [ "titulo" => "Abstract" "resumen" => "Microsurgical clipping is still regarded as the gold-standard treatment for broad-neck intracranial aneurysms. New endovascular techniques like balloon or stent assisted coiling are quickly rising to the challenge and showing promising outcomes. As a result, broad-neck aneurysms are increasingly addressed by these techniques despite they have not been tested against clipping in a randomized controlled trial and long-term complications might be unknown yet. Intraprocedural coil migration has been well documented in the literature, but the same complication in a delayed fashion is scarcely reported. We present a case of delayed coil migration occurring after a balloon-assisted embolization of a wide-necked intracranial aneurysm and we perform a literature review for similar cases. We discuss how, despite seeming an extremely rare complication, with new endovascular techniques increasingly perceived as the safer option in any aneurysm, potential adverse events may become more frequent. Strategies proposed to address this developing scenario are also reviewed." ] "es" => array:2 [ "titulo" => "Resumen" "resumen" => "El clipaje microquirúrgico todavía se considera el tratamiento de elección para los aneurismas intracraneales de cuello ancho. Técnicas de embolización asistida por balón o stent se han desarrollado para estas lesiones y muestran resultados prometedores. Como consecuencia, los aneurismas de cuello ancho se abordan cada vez más mediante estas técnicas, a pesar de que no existen ensayos controlados aleatorizados al respecto, y las complicaciones a largo plazo podrían ser desconocidas. La migración intraprocedimiento de un coil está bien documentada, pero la misma complicación de forma tardía apenas está descrita. Presentamos un caso de migración tardía de un coil tras embolización asistida con balón de un aneurisma intracraneal de cuello ancho y revisamos la literatura para casos similares. Argumentamos que, a pesar de parecer una complicación extremadamente rara, con la creciente percepción de que las nuevas técnicas endovasculares son la opción más segura en cualquier aneurisma, los potenciales eventos adversos pueden aumentar. También revisamos las estrategias propuestas para abordar este nuevo escenario." ] ] "NotaPie" => array:1 [ 0 => array:3 [ "etiqueta" => "1" "nota" => "Both authors contributed equally." "identificador" => "fn0005" ] ] "multimedia" => array:6 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 821 "Ancho" => 950 "Tamanyo" => 56493 ] ] "descripcion" => array:1 [ "en" => "Cerebral angiography, internal carotid artery injection, lateral projection showing a saccular bilobed aneurysm at the anterior communicating artery." ] ] 1 => array:7 [ "identificador" => "fig0010" "etiqueta" => "Fig. 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 843 "Ancho" => 950 "Tamanyo" => 76891 ] ] "descripcion" => array:1 [ "en" => "Cerebral angiography, internal carotid artery injection, lateral projection showing the complete occlusion of the aneurysm after coil embolization with balloon-assisted technique." ] ] 2 => array:7 [ "identificador" => "fig0015" "etiqueta" => "Fig. 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 665 "Ancho" => 1200 "Tamanyo" => 73963 ] ] "descripcion" => array:1 [ "en" => "Axial non-contrast brain CT scan reveals two metallic artifacts at the pericallosal cistern suggesting the migration of embolization material from the aneurysm sac." ] ] 3 => array:7 [ "identificador" => "fig0020" "etiqueta" => "Fig. 4" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr4.jpeg" "Alto" => 602 "Ancho" => 1298 "Tamanyo" => 65079 ] ] "descripcion" => array:1 [ "en" => "Cerebral angiography, internal carotid artery injection, oblique projection demonstrated migration of 2 coil loops, one to calloso-marginal branch and the other to pericallosal branch of the right anterior cerebral artery." ] ] 4 => array:7 [ "identificador" => "fig0025" "etiqueta" => "Fig. 5" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr5.jpeg" "Alto" => 1124 "Ancho" => 950 "Tamanyo" => 86323 ] ] "descripcion" => array:1 [ "en" => "Axial non-contrast head CT scan revealed an ischemic event with hemorrhagic transformation on the territory of the right anterior cerebral artery and signs of intracranial hypertension." ] ] 5 => array:8 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at1" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:2 [ "leyenda" => "AcomA, anterior communicating artery; ICA, internal carotid artery; MCA, middle cerebral artery; PcomA, posterior communicating artery; SAH, subarachnoid hemorrhage; SHA, superior hypophyseal artery; TIA, transient ischemic attack; DSA, digital subtraction angiography." "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">No. \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Author, year \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Age, y \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Sex \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Location \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Shape \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Dome/neck, mm \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Initial presentation \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Symptoms \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Treatment \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Outcome \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Phatouros et al., 1999<a class="elsevierStyleCrossRef" href="#bib0205">11</a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">69 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">F \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Right MCA \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">NA \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">4/NA \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">SAH \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">None \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">No therapy \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Good \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Phatouros et al., 1999<a class="elsevierStyleCrossRef" href="#bib0205">11</a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">55 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">M \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Right MCA \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">NA \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">4/NA \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">SAH \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">None \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">No therapy \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Good \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Phatouros et al., 1999<a class="elsevierStyleCrossRef" href="#bib0205">11</a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">60 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">M \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Left MCA \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">NA \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">9.5/NA \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">SAH \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Right-arm dysesthesia \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">No therapy \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Good \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">4 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Phatouros et al., 1999<a class="elsevierStyleCrossRef" href="#bib0205">11</a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">38 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">F \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Left SHA \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Broad neck \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">6.5/3.5 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">SAH \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Right hemiparesis and dysphasia \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Endovascular retrieval after surgery \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Right hemiparesis \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">5 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Lenthall et al, 2000<a class="elsevierStyleCrossRef" href="#bib0210">12</a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">61 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">M \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Basilar artery trunk \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Sacullar \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">9.6/NA \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">SAH \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">None \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">No therapy \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Good, occlusion of left SCA \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">6 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Thornton et al., 2000<a class="elsevierStyleCrossRef" href="#bib0215">13</a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">44 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">F \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Right PcomA \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Broad neck \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">3/2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">SAH \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Left hemiparesis \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Surgery \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Left hemiparesis \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">7 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Thornton et al., 2000<a class="elsevierStyleCrossRef" href="#bib0215">13</a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">62 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">M \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Left SHA \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Broad neck \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">4/2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Incidental \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Right hand dysesthesia \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Surgery \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Good \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">8 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Gao et al, 2006<a class="elsevierStyleCrossRef" href="#bib0220">14</a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">60 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">F \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Left PcomA \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Broad neck \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">NA \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Incidental \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">None \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Antiplatelet medication \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Good \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">9 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Haraguchi et al., 2007<a class="elsevierStyleCrossRef" href="#bib0225">15</a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">77 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">F \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Basilar artery trunk \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Sacullar \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">8.8/5.8 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Headache, no SAH \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Onset of consciousness \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Thrombolysis \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Left homonymous hemianopsia \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">10 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Fiorella et at, 2009<a class="elsevierStyleCrossRef" href="#bib0230">16</a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">56 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">M \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">AcomA \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Broad neck \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">4.5/3.9 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">SAH \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Right lower extremity paresis \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Antiplatelet medication \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Right lower extremity paresis \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">11 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Motegi et al., 2010<a class="elsevierStyleCrossRef" href="#bib0185">7</a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">59 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">M \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">ICA terminal \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Broad neck \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">7/6 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Incidental \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">TIA, disorientation \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Antiplatelet, anticoagulant therapy after surgery. \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Good \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">12 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Banerjee et al., 2011<a class="elsevierStyleCrossRef" href="#bib0235">17</a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">24 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">M \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">AcomA \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Sacullar \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">5/2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">SAH \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">None \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Surgery \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Good \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">13 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Wada et al., 2012<a class="elsevierStyleCrossRef" href="#bib0240">18</a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">64 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">F \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Left choroidal artery \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Broad neck \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">4.5/3.9 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">SAH \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Right hemiparesis, aphasia \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Surgery \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Good \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">14 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Kamide et al., 2017<a class="elsevierStyleCrossRef" href="#bib0245">19</a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">77 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">F \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Left PComA \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Broad neck \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">6.1/6.5 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">SAH \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">None \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Endovascular, stent assisted \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Good \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">15 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Present case \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">54 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">M \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">AcomA \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Broad neck, bilobed \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">8/5 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">SAH \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Left hemiplegia \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Failure endovascular retrieval \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Death \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1972397.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Summary of clinical features of 15 cases of delayed coil migration." ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0015" "bibliografiaReferencia" => array:30 [ 0 => array:3 [ "identificador" => "bib0155" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Management strategies for intraprocedural coil migration during endovascular treatment of intracranial aneurysms" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "D. 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Case Report

Symptomatic delayed coil migration after balloon assisted embolization: An underreported adverse event?

Migración Sintomática Tardía de Coil tras Embolización Asistida con Balón: ¿un evento adverso infra descrito?

Lino Fonsecaa,1, Rafael Najarro-Quispeb,1, Ana Rodríguez-Hernándezb,

Autor para correspondencia

ana.neurosurgery@hotmail.com

Corresponding author.

, Ramon Tornéc, Dario Gándara-Sabatinib, Fuat Arikanb,d, Pilar Baños-Carrascob

a Department of Neurological Surgery, Centro Hospitalar Lisboa Central – Hospital São José, Lisbon, Portugal

b Department of Neurological Surgery, Vall d’Hebron University Hospital, Barcelona, Spain

c Department of Neurological Surgery, Clinic Hospital, Barcelona, Spain

d Neurotraumatology and Neurosurgery Research Unit (UNINN), Vall d’Hebron Research Institute, Universitat Autonoma de Barcelona (UAB), Spain

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          "en" => "<p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Cerebral angiography&#44; internal carotid artery injection&#44; oblique projection demonstrated migration of 2 coil loops&#44; one to calloso-marginal branch and the other to pericallosal branch of the right anterior cerebral artery&#46;</p>"
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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">As endovascular techniques develop&#44; broad-neck aneurysms previously regarded as better suited for microsurgical clipping&#44; are now increasingly being addressed with balloon and stent assisted embolization&#46; These new techniques had not been tested against clipping in a randomized controlled trial&#46; Furthermore&#44; their use has widely spread before long term results are known&#46; As these new techniques rise&#44; so might do their potential complications&#46; Therefore&#44; thorough report and review of such potential complications should be mandatory&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">Periprocedural coil migration with stent-assisted or balloon-remodeling coiling is listed as one likely complication of these techniques&#46; Its incidence has been estimated somewhere around 2&#8211;6&#37;&#46;<a class="elsevierStyleCrossRef" href="#bib0155"><span class="elsevierStyleSup">1</span></a> Delayed coil migration&#44; on the other hand&#44; has been scarcely reported and is less documented&#46; During a balloon-assisted coiling procedure&#44; the temporary inflation of a largable balloon prevents coil migration into a parent artery and improves coil packing&#46;<a class="elsevierStyleCrossRefs" href="#bib0160"><span class="elsevierStyleSup">2&#8211;7</span></a> Nevertheless&#44; intraprocedural displacement of coils can occur during the placement of the final coil into the aneurysm sac to maximize the packing density&#44; as a result of displacement of a previous intrasacular coil by the final coil&#44; or following balloon deflation&#46;<a class="elsevierStyleCrossRef" href="#bib0190"><span class="elsevierStyleSup">8</span></a> Management strategies include microsurgical removal&#44; coil retrieval with different devices&#44; stent placement&#44; and anticoagulation or antiplatelet therapy&#46;<a class="elsevierStyleCrossRef" href="#bib0195"><span class="elsevierStyleSup">9</span></a> However&#44; coil migration may happen days or even months after the procedure and may potentially carry a higher morbidity and mortality related to delayed thromboembolic events or direct vessel occlusion&#46; Here we report a case of a delayed coil migration after balloon assisted embolization of a ruptured anterior communicating artery &#40;ACoA&#41; aneurysm&#46; We review similar cases previously reported on the literature and thoroughly analyze the likely causes of this adverse event&#44; management strategies&#44; clinical outcomes and overall incidence&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Case report</span><p id="par0015" class="elsevierStylePara elsevierViewall">A 54-year-old man with history of chronic alcoholism and smoking&#44; was referred to our emergency department because of a generalized tonic&#8211;clonic seizure preceded by a sudden severe headache&#46; Neurological examination only revealed signs of meningeal irritation and a mild bradipsiquia&#46; Non contrast head CT revealed a subarachnoid hemorrhage Fisher grade IV&#44; with no signs of acute hydrocephalus&#46; A cerebral angiogram demonstrated a saccular bilobed aneurysm located on the ACoA &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#46; The maximal diameter of the aneurysm was 7<span class="elsevierStyleHsp" style=""></span>mm and the neck was measured as 5<span class="elsevierStyleHsp" style=""></span>mm &#40;aspect ratio 7&#58;5<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>1&#46;4&#41;&#46; Despite the unfavorable ratio&#44; endovascular coiling was offered as the first treatment option based on the patient medical problems &#40;coagulopathy related to chronic alcoholism&#41;&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0020" class="elsevierStylePara elsevierViewall">Coil embolization was performed with a balloon-assisted technique using a 4<span class="elsevierStyleHsp" style=""></span>mm<span class="elsevierStyleHsp" style=""></span>&#215;<span class="elsevierStyleHsp" style=""></span>11<span class="elsevierStyleHsp" style=""></span>mm Secpter XC&#8482; balloon &#40;Microvention&#44; Inc&#46;&#44; Tustin&#44; CA&#44; USA&#41; and a total of 13 Target<span class="elsevierStyleSup">&#174;</span> Nano-coils &#40;Striker&#44; Inc&#46;&#44; Kalamazoo&#44; MI&#44; USA&#41; measuring from 0&#46;4 to 6<span class="elsevierStyleHsp" style=""></span>cm&#46; A complete angiographic occlusion of the aneurysm was achieved &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>&#41;&#46; However&#44; at the end of the procedure&#44; a nonocclusive embolism of the left anterior cerebral artery was observed and the patient showed a mild paresis &#40;4&#47;5&#41; of the right arm&#46; He was then kept on heparin for 24<span class="elsevierStyleHsp" style=""></span>h and his right arm showed a complete recovery&#46;</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0025" class="elsevierStylePara elsevierViewall">On postcoiling day 11&#44; the patient presented a sudden left hemiplegia&#46; The head CT demonstrated two metallic artifacts at the pericallosal cistern suggesting the migration of embolization material from the aneurysm sac &#40;<a class="elsevierStyleCrossRef" href="#fig0015">Fig&#46; 3</a>&#41;&#46; No established infarction on the anterior cerebral artery territory was seen at that time&#46; Subsequent cerebral angiography demonstrated migration of 2 coil loops&#44; one to calloso-marginal branch and the other to pericallosal branch of the right anterior cerebral artery &#40;<a class="elsevierStyleCrossRef" href="#fig0020">Fig&#46; 4</a>&#41;&#46; The capillary phase showed a defect corresponding to the ischemic region&#46; Coil retrieval was attempted but deemed not feasible&#46; A stent &#40;LVIS<span class="elsevierStyleSup">&#174;</span> 3&#46;5<span class="elsevierStyleHsp" style=""></span>mm<span class="elsevierStyleHsp" style=""></span>&#215;<span class="elsevierStyleHsp" style=""></span>20<span class="elsevierStyleHsp" style=""></span>mm &#8211; Microvention&#44; Inc&#46;&#44; Tustin&#44; CA&#44; USA&#41; was deployed to secure pericallosal flow&#44; but the calloso-marginal branch remained occluded&#46; The patient was started on antiplatelet therapy with aspirin&#46;</p><elsevierMultimedia ident="fig0015"></elsevierMultimedia><elsevierMultimedia ident="fig0020"></elsevierMultimedia><p id="par0030" class="elsevierStylePara elsevierViewall">A postprocedure CT scan showed an already established stroke involving the medial aspect of the right frontal lobe and the patient did not recover the hemiplegia&#46; Three weeks later&#44; a sudden decreased level of consciousness was noted&#46; A new head CT scan revealed a hemorrhagic transformation of the ischemic territory and signs of intracranial hypertension &#40;<a class="elsevierStyleCrossRef" href="#fig0025">Fig&#46; 5</a>&#41;&#46; The family rejected further intervention and active care was withdrawn with consequent death of the patient&#46;</p><elsevierMultimedia ident="fig0025"></elsevierMultimedia></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Discussion</span><p id="par0035" class="elsevierStylePara elsevierViewall">Despite the wide spread of embolization techniques&#44; broad-necked intracranial aneurysms pose a challenge to these techniques and are still considered better candidates for microsurgical clipping&#46;<a class="elsevierStyleCrossRefs" href="#bib0185"><span class="elsevierStyleSup">7&#8211;10</span></a> Nevertheless&#44; various endovascular options like stent-assisted and balloon-assisted coiling have been developed to deal with these challenging lesions&#46; Financial drivers toward embolization&#44; patient preference &#40;perceived benefit of &#8220;minimally invasive&#8221;&#44; less pain or marketing&#41; and lack of neurosurgical expertise might tip the balance against clipping despite the void of solid scientific evidence&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">As these new endovascular techniques spread&#44; so might do their potential complications&#46; One such complication is the scarcely reported delayed coil migration that our patient suffered&#46; A literature review revealed another 14 cases of delayed coil migration that have been summarized on <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#46;<a class="elsevierStyleCrossRefs" href="#bib0185"><span class="elsevierStyleSup">7&#44;11&#8211;19</span></a></p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0045" class="elsevierStylePara elsevierViewall">Analyzing all available cases&#44; two main reasons seem to be responsible for a delayed coil migration&#46; In those cases of stent-assisted embolization&#44; fine coils might escape from the stent struts when using a loose mesh design&#46;<a class="elsevierStyleCrossRef" href="#bib0220"><span class="elsevierStyleSup">14</span></a> When using balloon assisted embolization&#44; any coil movement after placement is usually evident immediately after balloon deflation&#46;<a class="elsevierStyleCrossRef" href="#bib0230"><span class="elsevierStyleSup">16</span></a> However&#44; delayed coil migration can also happen with this technique&#46; Ultrasoft or small coils used in the final packing of the aneurysm might remain initially stable after balloon deflation&#46; Later on&#44; if a proper adherence of the spirals is not developed&#44; these last ultrasoft coils might displace from the aneurysm sac days or even months after the initial procedure&#46;<a class="elsevierStyleCrossRefs" href="#bib0235"><span class="elsevierStyleSup">17&#44;18</span></a> As deducted from our case and previous reports&#44; aneurysm shape&#44; coil size&#44; stent design&#44; and underpacking or overpacking generating unstable coils&#44; seem to be predisposing factors for delayed coil migration&#46;<a class="elsevierStyleCrossRef" href="#bib0245"><span class="elsevierStyleSup">19</span></a></p><p id="par0050" class="elsevierStylePara elsevierViewall">Clinical outcome after a delayed coil migration might vary widely&#46; However&#44; from our literature review&#44; a trend might be inferred&#46; Delayed coil migration after stent assisted embolization seems to course as an asymptomatic event&#44; most likely due to antiplatelet therapy administered for the stent&#46; Antiplatelet drugs would produce a neointima over the migrated coil preventing its thrombosis&#46; On the other hand&#44; delayed coil migration after simple coiling or balloon assisted techniques seems to render a disastrous clinical outcome as illustrated in the present case&#46;</p><p id="par0055" class="elsevierStylePara elsevierViewall">The different management strategies described when dealing with a delayed coil migration have been summarized in <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#46; In a few cases diagnosed as incidental findings in asymptomatic patients&#44; a &#8220;wait and see&#8221; strategy was adopted and no specific treatment was performed&#46; In other cases with mild symptoms&#44; antiplatelet or anticoagulant therapy was started&#46; When severe deficits were observed&#44; authors usually opted for removing the migrated spiral&#46; Surgical options include direct removal of the coil or revascularization bypass with trapping of the occluded segment&#46; Endovascular retrieval is usually performed for immediate coil displacement&#44; but it could be dangerous for delayed coil migration since the coil might have already adhered to the vessel wall&#46; Alternatively&#44; a stent can be placed to trap the migrated coil as was done in our case&#46; In a previous similar case&#44; Kamide et al&#46; reported an excellent result with this technique&#46;<a class="elsevierStyleCrossRef" href="#bib0245"><span class="elsevierStyleSup">19</span></a> However&#44; major concerns include causing further migration of the coil when introducing the stent and injuring the parent vessel when navigating through a distal branch&#46; In our case&#44; stent deployment was uneventful in the pericallosal artery but deemed unfeasible in the callosomarginal branch and the ischemic complication progressed despite our best efforts&#46; Furthermore&#44; the associated antiplatelet therapy might have facilitated the hemorrhagic transformation of our patient&#39;s stroke&#46; Therefore&#44; bailout stent deployment should not be generally recommended since further research is warranted to validate it&#46;</p><p id="par0060" class="elsevierStylePara elsevierViewall">There is strong evidence that much of the information on new techniques adverse events remains unpublished and poor reporting of them in journals has been repeatedly highlighted&#46;<a class="elsevierStyleCrossRefs" href="#bib0250"><span class="elsevierStyleSup">20&#8211;23</span></a> Particularly&#44; delayed coil migration was never reported on the initial cohorts and systematic reviews of balloon and stent assisted techniques&#46;<a class="elsevierStyleCrossRefs" href="#bib0270"><span class="elsevierStyleSup">24&#8211;30</span></a> Therefore&#44; one final concern with delayed coil migration is that it might be an underreported adverse event&#46; Our study aims to raise further awareness of the unreported and&#47;or unknown negative results of otherwise promising endovascular techniques&#46; Ethical challenges raised by endovascular innovation are not easy to address&#46; It would be desirable that novel endovascular or surgical interventions were as thoroughly assessed as new drugs are&#46; However&#44; classic randomized controlled trials of new endovascular techniques are cumbersome and expensive and have proved once and again that are not necessary the most accurate way to ensure the safety of new techniques&#46; The resources and expertise available on clinical trials might differ quite a lot from day-to-day wide-world practice&#46; Evidence from other studies like case series and case reports should also be considered and their publication must be encouraged&#46; However&#44; the information provided by those studies might fall short from needed&#46; Advocating large scale registries with standardized and transparent data collection might be one of the answers&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Conclusions</span><p id="par0065" class="elsevierStylePara elsevierViewall">As illustrated by this study&#44; new endovascular techniques are increasingly perceived as the safer option in any type of aneurysm despite lack of strong evidence to support such belief&#46; Reports of adverse results with these new techniques might not be accurate for various reasons&#44; and severe adverse events might be recognized long time after the technique is out in the market&#46; Nevertheless&#44; reasons like money drivers&#44; perception of less invasiveness and even lack of neurosurgical expertise to oppose it&#44; might tip the balance in their favor&#46; Pushing the endovascular envelope in broad-neck aneurysms might produce cases of delayed coil migration like the one described here&#46; The best rescue treatment option is not well established and patient&#39;s outcome might go from excellent to disastrous&#46; This scarcely reported complication would require large population registries to better understand its real incidence and try to infer the best management options&#46;</p></span></span>"
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        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Microsurgical clipping is still regarded as the gold-standard treatment for broad-neck intracranial aneurysms&#46; New endovascular techniques like balloon or stent assisted coiling are quickly rising to the challenge and showing promising outcomes&#46; As a result&#44; broad-neck aneurysms are increasingly addressed by these techniques despite they have not been tested against clipping in a randomized controlled trial and long-term complications might be unknown yet&#46; Intraprocedural coil migration has been well documented in the literature&#44; but the same complication in a delayed fashion is scarcely reported&#46; We present a case of delayed coil migration occurring after a balloon-assisted embolization of a wide-necked intracranial aneurysm and we perform a literature review for similar cases&#46; We discuss how&#44; despite seeming an extremely rare complication&#44; with new endovascular techniques increasingly perceived as the safer option in any aneurysm&#44; potential adverse events may become more frequent&#46; Strategies proposed to address this developing scenario are also reviewed&#46;</p></span>"
      ]
      "es" => array:2 [
        "titulo" => "Resumen"
        "resumen" => "<span id="abst0010" class="elsevierStyleSection elsevierViewall"><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">El clipaje microquir&#250;rgico todav&#237;a se considera el tratamiento de elecci&#243;n para los aneurismas intracraneales de cuello ancho&#46; T&#233;cnicas de embolizaci&#243;n asistida por bal&#243;n o stent se han desarrollado para estas lesiones y muestran resultados prometedores&#46; Como consecuencia&#44; los aneurismas de cuello ancho se abordan cada vez m&#225;s mediante estas t&#233;cnicas&#44; a pesar de que no existen ensayos controlados aleatorizados al respecto&#44; y las complicaciones a largo plazo podr&#237;an ser desconocidas&#46; La migraci&#243;n intraprocedimiento de un coil est&#225; bien documentada&#44; pero la misma complicaci&#243;n de forma tard&#237;a apenas est&#225; descrita&#46; Presentamos un caso de migraci&#243;n tard&#237;a de un coil tras embolizaci&#243;n asistida con bal&#243;n de un aneurisma intracraneal de cuello ancho y revisamos la literatura para casos similares&#46; Argumentamos que&#44; a pesar de parecer una complicaci&#243;n extremadamente rara&#44; con la creciente percepci&#243;n de que las nuevas t&#233;cnicas endovasculares son la opci&#243;n m&#225;s segura en cualquier aneurisma&#44; los potenciales eventos adversos pueden aumentar&#46; Tambi&#233;n revisamos las estrategias propuestas para abordar este nuevo escenario&#46;</p></span>"
      ]
    ]
    "NotaPie" => array:1 [
      0 => array:3 [
        "etiqueta" => "1"
        "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Both authors contributed equally&#46;</p>"
        "identificador" => "fn0005"
      ]
    ]
    "multimedia" => array:6 [
      0 => array:7 [
        "identificador" => "fig0005"
        "etiqueta" => "Fig&#46; 1"
        "tipo" => "MULTIMEDIAFIGURA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "figura" => array:1 [
          0 => array:4 [
            "imagen" => "gr1.jpeg"
            "Alto" => 821
            "Ancho" => 950
            "Tamanyo" => 56493
          ]
        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Cerebral angiography&#44; internal carotid artery injection&#44; lateral projection showing a saccular bilobed aneurysm at the anterior communicating artery&#46;</p>"
        ]
      ]
      1 => array:7 [
        "identificador" => "fig0010"
        "etiqueta" => "Fig&#46; 2"
        "tipo" => "MULTIMEDIAFIGURA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "figura" => array:1 [
          0 => array:4 [
            "imagen" => "gr2.jpeg"
            "Alto" => 843
            "Ancho" => 950
            "Tamanyo" => 76891
          ]
        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Cerebral angiography&#44; internal carotid artery injection&#44; lateral projection showing the complete occlusion of the aneurysm after coil embolization with balloon-assisted technique&#46;</p>"
        ]
      ]
      2 => array:7 [
        "identificador" => "fig0015"
        "etiqueta" => "Fig&#46; 3"
        "tipo" => "MULTIMEDIAFIGURA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "figura" => array:1 [
          0 => array:4 [
            "imagen" => "gr3.jpeg"
            "Alto" => 665
            "Ancho" => 1200
            "Tamanyo" => 73963
          ]
        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Axial non-contrast brain CT scan reveals two metallic artifacts at the pericallosal cistern suggesting the migration of embolization material from the aneurysm sac&#46;</p>"
        ]
      ]
      3 => array:7 [
        "identificador" => "fig0020"
        "etiqueta" => "Fig&#46; 4"
        "tipo" => "MULTIMEDIAFIGURA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "figura" => array:1 [
          0 => array:4 [
            "imagen" => "gr4.jpeg"
            "Alto" => 602
            "Ancho" => 1298
            "Tamanyo" => 65079
          ]
        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Cerebral angiography&#44; internal carotid artery injection&#44; oblique projection demonstrated migration of 2 coil loops&#44; one to calloso-marginal branch and the other to pericallosal branch of the right anterior cerebral artery&#46;</p>"
        ]
      ]
      4 => array:7 [
        "identificador" => "fig0025"
        "etiqueta" => "Fig&#46; 5"
        "tipo" => "MULTIMEDIAFIGURA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "figura" => array:1 [
          0 => array:4 [
            "imagen" => "gr5.jpeg"
            "Alto" => 1124
            "Ancho" => 950
            "Tamanyo" => 86323
          ]
        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Axial non-contrast head CT scan revealed an ischemic event with hemorrhagic transformation on the territory of the right anterior cerebral artery and signs of intracranial hypertension&#46;</p>"
        ]
      ]
      5 => array:8 [
        "identificador" => "tbl0005"
        "etiqueta" => "Table 1"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "detalles" => array:1 [
          0 => array:3 [
            "identificador" => "at1"
            "detalle" => "Table "
            "rol" => "short"
          ]
        ]
        "tabla" => array:2 [
          "leyenda" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">AcomA&#44; anterior communicating artery&#59; ICA&#44; internal carotid artery&#59; MCA&#44; middle cerebral artery&#59; PcomA&#44; posterior communicating artery&#59; SAH&#44; subarachnoid hemorrhage&#59; SHA&#44; superior hypophyseal artery&#59; TIA&#44; transient ischemic attack&#59; DSA&#44; digital subtraction angiography&#46;</p>"
          "tablatextoimagen" => array:1 [
            0 => array:2 [
              "tabla" => array:1 [
                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">No&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Author&#44; year&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Age&#44; y&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Sex&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Location&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Shape&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Dome&#47;neck&#44; mm&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Initial presentation&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Symptoms&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Treatment&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Outcome&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Phatouros et al&#46;&#44; 1999<a class="elsevierStyleCrossRef" href="#bib0205"><span class="elsevierStyleSup">11</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">69&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">F&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Right MCA&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">NA&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">4&#47;NA&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">SAH&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">None&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">No therapy&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Good&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Phatouros et al&#46;&#44; 1999<a class="elsevierStyleCrossRef" href="#bib0205"><span class="elsevierStyleSup">11</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">55&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">M&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Right MCA&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">NA&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">4&#47;NA&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">SAH&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">None&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">No therapy&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Good&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Phatouros et al&#46;&#44; 1999<a class="elsevierStyleCrossRef" href="#bib0205"><span class="elsevierStyleSup">11</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">60&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">M&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Left MCA&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">NA&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">9&#46;5&#47;NA&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">SAH&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Right-arm dysesthesia&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">No therapy&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Good&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Phatouros et al&#46;&#44; 1999<a class="elsevierStyleCrossRef" href="#bib0205"><span class="elsevierStyleSup">11</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">38&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">F&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Left SHA&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Broad neck&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">6&#46;5&#47;3&#46;5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">SAH&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Right hemiparesis and dysphasia&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Endovascular retrieval after surgery&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Right hemiparesis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Lenthall et al&#44; 2000<a class="elsevierStyleCrossRef" href="#bib0210"><span class="elsevierStyleSup">12</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">61&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">M&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Basilar artery trunk&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Sacullar&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">9&#46;6&#47;NA&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">SAH&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">None&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">No therapy&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Good&#44; occlusion of left SCA&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">6&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Thornton et al&#46;&#44; 2000<a class="elsevierStyleCrossRef" href="#bib0215"><span class="elsevierStyleSup">13</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">44&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">F&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Right PcomA&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Broad neck&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">3&#47;2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">SAH&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Left hemiparesis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Surgery&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Left hemiparesis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">7&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Thornton et al&#46;&#44; 2000<a class="elsevierStyleCrossRef" href="#bib0215"><span class="elsevierStyleSup">13</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">62&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">M&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Left SHA&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Broad neck&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">4&#47;2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Incidental&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Right hand dysesthesia&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Surgery&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Good&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">8&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Gao et al&#44; 2006<a class="elsevierStyleCrossRef" href="#bib0220"><span class="elsevierStyleSup">14</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">60&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">F&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Left PcomA&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Broad neck&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">NA&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Incidental&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">None&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Antiplatelet medication&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Good&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">9&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Haraguchi et al&#46;&#44; 2007<a class="elsevierStyleCrossRef" href="#bib0225"><span class="elsevierStyleSup">15</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">77&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">F&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Basilar artery trunk&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Sacullar&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">8&#46;8&#47;5&#46;8&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Headache&#44; no SAH&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Onset of consciousness&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Thrombolysis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Left homonymous hemianopsia&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">10&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Fiorella et at&#44; 2009<a class="elsevierStyleCrossRef" href="#bib0230"><span class="elsevierStyleSup">16</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">56&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">M&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">AcomA&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Broad neck&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">4&#46;5&#47;3&#46;9&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">SAH&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Right lower extremity paresis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Antiplatelet medication&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Right lower extremity paresis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">11&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Motegi et al&#46;&#44; 2010<a class="elsevierStyleCrossRef" href="#bib0185"><span class="elsevierStyleSup">7</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">59&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">M&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">ICA terminal&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Broad neck&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">7&#47;6&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Incidental&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">TIA&#44; disorientation&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Antiplatelet&#44; anticoagulant therapy after surgery&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Good&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">12&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Banerjee et al&#46;&#44; 2011<a class="elsevierStyleCrossRef" href="#bib0235"><span class="elsevierStyleSup">17</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">24&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">M&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">AcomA&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Sacullar&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">5&#47;2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">SAH&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">None&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Surgery&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Good&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">13&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Wada et al&#46;&#44; 2012<a class="elsevierStyleCrossRef" href="#bib0240"><span class="elsevierStyleSup">18</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">64&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">F&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Left choroidal artery&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Broad neck&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">4&#46;5&#47;3&#46;9&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">SAH&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Right hemiparesis&#44; aphasia&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Surgery&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Good&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">14&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Kamide et al&#46;&#44; 2017<a class="elsevierStyleCrossRef" href="#bib0245"><span class="elsevierStyleSup">19</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">77&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">F&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Left PComA&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Broad neck&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">6&#46;1&#47;6&#46;5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">SAH&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">None&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Endovascular&#44; stent assisted&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Good&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">15&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Present case&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">54&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">M&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">AcomA&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Broad neck&#44; bilobed&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">8&#47;5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">SAH&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Left hemiplegia&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Failure endovascular retrieval&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Death&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
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                0 => "xTab1972397.png"
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        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">Summary of clinical features of 15 cases of delayed coil migration&#46;</p>"
        ]
      ]
    ]
    "bibliografia" => array:2 [
      "titulo" => "References"
      "seccion" => array:1 [
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          "identificador" => "bibs0015"
          "bibliografiaReferencia" => array:30 [
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                      "autores" => array:1 [
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                            1 => "K&#46;C&#46; Liu"
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            6 => array:3 [
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                        "itemHostRev" => array:3 [
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Información del artículo

ISSN: 11301473
Idioma original: Inglés

DOI:10.1016/j.neucir.2018.02.005

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