Treatment of intracranial bifurcation aneurysms with “X” stent-assisted coiling: A case series and literature review


      • In selected cases, “X” stent-assisted coiling is safe and effective for intracranial bifurcation aneurysms.



      To clarify the safety and efficacy of “X” stent-assisted coiling (X-stenting) for the treatment of intracranial bifurcation aneurysms and to review the literature.


      We retrospectively reported five consecutive patients with six intracranial bifurcation aneurysms who underwent X-stenting between June 2014 and June 2020. The clinical and angiographic results were analyzed. We also performed an extensive PubMed review of medical literature up to June 2021.


      Endovascular procedures were successfully applied to all six aneurysms. No procedure-related complications were noted. Follow-up angiograms were available for all patients and revealed occlusion in five aneurysms and improvement in one aneurysm. Clinical follow-up was performed for all patients, and the mRS score at follow-up was 0 in all patients. Thus, good outcomes were achieved in all patients, and no ischemic or hemorrhagic events were observed.


      X-stenting appears to be safe for treating intracranial bifurcation aneurysms and effective in immediate and short-term outcome. Further research is required with well-designed, prospective studies with large sample sizes.



      X-stenting (“X”stent-assisted coiling), FD (flow diverter), SAC (stent-assisted coiling), AComA (anterior communicating artery), fVBA (fenestrated vertebrobasilar artery), SAH (subarachnoid hemorrhage), LVIS (Low-profile Visualized Intraluminal Support), mRS (modified Rankin Scale), DSA (digital subtraction angiography), MRA (magnetic resonance angiography), BA (basilar artery), WEB (woven endbridge)
      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to Journal of Stroke and Cerebrovascular Diseases
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • Gonzalez N.
        • Sedrak M.
        • Martin N.
        • et al.
        Impact of anatomic features in the endovascular embolization of 181 anterior communicating artery aneurysms.
        Stroke. 2008; 39 ([published Online First: 2008/07/12]): 2776-2782
        • Piotin M.
        • Blanc R.
        • Spelle L.
        • et al.
        Stent-assisted coiling of intracranial aneurysms: clinical and angiographic results in 216 consecutive aneurysms.
        Stroke. 2010; 41 ([published Online First: 2009/12/05]): 110-115
        • Nishido H.
        • Piotin M.
        • Bartolini B.
        • et al.
        Analysis of complications and recurrences of aneurysm coiling with special emphasis on the stent-assisted technique.
        AJNR Am J Neuroradiol. 2014; 35 ([published Online First: 2013/08/03]): 339-344
        • Bartolini B.
        • Blanc R.
        • Pistocchi S.
        • et al.
        Y" and "X" stent-assisted coiling of complex and wide-neck intracranial bifurcation aneurysms.
        AJNR Am J Neuroradiol. 2014; 35 ([published Online First: 2014/07/26]): 2153-2158
        • Weinberg J.H.
        • Sweid A.
        • Asada A.
        • et al.
        Coil embolization of wide-neck bifurcation aneurysms via shouldering and framing: a safe alternative to conventional techniques.
        World Neurosurg. 2020; 139 ([published Online First: 2020/04/29]): e800-ee06
        • Cagnazzo F.
        • Limbucci N.
        • Nappini S.
        • et al.
        Y-stent-assisted coiling of wide-neck bifurcation intracranial aneurysms: a meta-analysis.
        AJNR Am J Neuroradiol. 2019; 40 ([published Online First: 2018/12/14]): 122-128
        • Aydin K.
        • Stracke C.P.
        • Barburoglu M.
        • et al.
        Long-termoutcomes of wide-necked intracranial bifurcation aneurysms treated with T-stent-assisted coiling.
        J Neurosurg. 2019; ([published Online First: 2019/12/08]): 1-10
        • Ciccio G.
        • Robert T.
        • Smajda S.
        • et al.
        Double stent assisted coiling of intracranial bifurcation aneurysms in Y and X configurations with the Neuroform ATLAS stent: immediate and mid term angiographic and clinical follow-up.
        J Neurointerven Surg. 2019; 11 ([published Online First: 2019/07/29]): 1239-1242
        • Boddu S.R.
        • Link T.W.
        • Santillan A.
        • et al.
        Double stent-assisted (Y and X) coil embolization of unruptured intracranial saccular aneurysms using the low-profile visualized intraluminal support device-single center experience.
        J Vasc Interv Neurol. 2019; 10 ([published Online First: 2019/07/17]): 1-9
        • Cohen J.E.
        • Melamed I.
        • Itshayek E.
        X-microstenting and transmesh coiling in the management of wide-necked tent-like anterior communicating artery aneurysms.
        J Clin Neurosci. 2014; 21 (official journal of the Neurosurgical Society of Australasia[published Online First: 2013/12/03]): 664-667
        • Saatci I.
        • Geyik S.
        • Yavuz K.
        • et al.
        X-configured stent-assisted coiling in the endovascular treatment of complex anterior communicating artery aneurysms: a novel reconstructive technique.
        AJNR Am J Neuroradiol. 2011; 32 ([published Online First: 2010/07/03]): E113-E117
        • Lazzaro M.A.
        • Zaidat O.O.
        X-configuration intersecting Enterprise stents for vascular remodeling and assisted coil embolization of a wide neck anterior communicating artery aneurysm.
        J Neurointerv Surg. 2011; 3 ([published Online First: 2011/10/13]): 348-351
        • Menendez J.Y.
        • Harrigan M.R.
        X-configuration stent-assisted coiling.
        World Neurosurg. 2010; 74 ([published Online First: 2011/02/09]): 143-144
        • Zelenak K.
        • Zelenakova J.
        • DeRiggo J.
        • et al.
        Flow changes after endovascular treatment of a wide-neck anterior communicating artery aneurysm by using X-configured kissing stents (cross-kissing stents) technique.
        Cardiovasc Intervent Radiol. 2011; 34 ([published Online First: 2011/04/01]): 1308-1311
        • Michelozzi C.
        • Darcourt J.
        • Guenego A.
        • et al.
        Flow diversion treatment of complex bifurcation aneurysms beyond the circle of Willis: complications, aneurysm sac occlusion, reabsorption, recurrence, and jailed branch modification at follow-up.
        J Neurosurg. 2018; 131 ([published Online First: 2018/12/24]): 1751-1762
        • Caroff J.
        • Mihalea C.
        • Dargento F.
        • et al.
        Woven Endobridge (WEB) Device for endovascular treatment of ruptured intracranial wide-neck aneurysms: a single-center experience.
        Neuroradiology. 2014; 56 ([published Online First: 2014/06/16]): 755-761
        • Liebig T.
        • Killer-Oberpfalzer M.
        • Gal G.
        • et al.
        The safety and effectiveness of the contour neurovascular system (Contour) for the treatment of bifurcation aneurysms: the CERUS study.
        Neurosurgery. 2021; ([published Online First: 2022/02/04])
        • Xue G.
        • Zuo Q.
        • Duan G.
        • et al.
        Dual stent-assisted coil embolization for intracranial wide-necked bifurcation aneurysms: a single-center experience and a systematic review and meta-analysis.
        World Neurosurg. 2019; 126 ([published Online First: 2019/03/04]): e295-e313
        • Chow M.M.
        • Woo H.H.
        • Masaryk T.J.
        • et al.
        A novel endovascular treatment of a wide-necked basilar apex aneurysm by using a Y-configuration, double-stent technique.
        AJNR Am J Neuroradiol. 2004; 25 ([published Online First: 2004/03/24]): 509-512
        • Caroff J.
        • Neki H.
        • Mihalea C.
        • et al.
        Flow-diverter stents for the treatment of saccular middle cerebral artery bifurcation aneurysms.
        AJNR Am J Neuroradiol. 2016; 37 ([published Online First: 2015/09/26]): 279-284
        • Tang H.
        • Li S.
        • Xu F.
        • et al.
        Low-profile LEO baby stents using dual stenting technique in treating complex intracranial aneurysms located in small artery: initial and mid-term outcome.
        J Clin Neurosci. 2022; 98 (official journal of the Neurosurgical Society of Australasia[published Online First: 2022/02/14]): 109-114
        • Zhao K.J.
        • Yang P.F.
        • Huang Q.H.
        • et al.
        Y-configuration stent placement (crossing and kissing) for endovascular treatment of wide-neck cerebral aneurysms located at 4 different bifurcation sites.
        AJNR Am J Neuroradiol. 2012; 33 ([published Online First: 2012/04/21]): 1310-1316
        • Sato K.
        • Matsumoto Y.
        • Kanoke A.
        • et al.
        Y-configuration stenting for coil embolization of complex intracranial aneurysms: distinguishing between use of crossing-Y and kissing-Y.
        World Neurosurg. 2021; 146 ([published Online First: 2020/11/28]): e1054-e1e62
        • Zhu D.
        • Fang Y.
        • Yang P.
        • et al.
        Overlapped stenting combined with coiling for blood blister-like aneurysms: comparison of low-profile visualized intraluminal support (LVIS) stent and non-LVIS stent.
        World Neurosurg. 2017; 104 ([published Online First: 2017/04/01]): 729-735
        • Tian Z.
        • Zhang M.
        • Li G.
        • et al.
        Hemodynamic differences by increasing low profile visualized intraluminal support (LVIS) stent local compaction across intracranial aneurysm orifice.
        Interv Neuroradiol. 2020; 26 (journal of peritherapeutic neuroradiology, surgical procedures and related neurosciences[published Online First: 2020/08/25]): 557-565