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<meta name="DC.Title" content="When Is Carotid Angioplasty and Stenting the Cost-Effective Alternative for Revascularization of Symptomatic Carotid Stenosis? A Canadian Health System Perspective" />
<meta name="DC.Identifier" content="10.3174/ajnr.A3682" />
<meta name="DC.Date" content="2014-02-01" />
<meta name="DC.Publisher" content="American Journal of Neuroradiology" />
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<meta name="DC.Description" content="BACKGROUND AND PURPOSE: Carotid revascularization procedures can be complicated by stroke. Additional disability adds to the already high costs of the procedure. To weigh the cost and benefit, we estimated the cost-utility of carotid angioplasty and stenting compared with carotid endarterectomy among patients with symptomatic carotid stenosis, with special emphasis on scenario analyses that would yield carotid angioplasty and stenting as the cost-effective alternative relative to carotid endarterectomy.

MATERIALS AND METHODS: A cost-utility analysis from the perspective of the health system payer was performed by using a Markov analytic model. Clinical estimates were based on a meta-analysis. The procedural costs were derived from a microcosting data base. The costs for hospitalization and rehabilitation of patients with stroke were based on a Canadian multicenter study. Utilities were based on a randomized controlled trial.

RESULTS: In the base case analysis, carotid angioplasty and stenting were more expensive (incremental cost of $6107) and had a lower utility (−0.12 quality-adjusted life years) than carotid endarterectomy. The results are sensitive to changes in the risk of clinical events and the relative risk of death and stroke. Carotid angioplasty and stenting were more economically attractive among high-risk surgical patients. For carotid angioplasty and stenting to become the preferred option, their costs would need to fall from more than $7300 to $4350 or less and the risks of the periprocedural and annual minor strokes would have to be equivalent to that of carotid endarterectomy.

CONCLUSIONS: In the base case analysis, carotid angioplasty and stenting were associated with higher costs and lower utility compared with carotid endarterectomy for patients with symptomatic carotid stenosis. Carotid angioplasty and stenting were cost-effective for patients with high surgical risk.

BURST
:   Burden of Ischemic Stroke
CAS
:   carotid angioplasty and stenting
CEA
:   carotid endarterectomy
CREST
:   Carotid Revascularization Endarterectomy versus Stenting Trial
EVA-3S
:   Endarterectomy versus Angioplasty in Patients with Symptomatic Severe Carotid Stenosis
MI
:   myocardial infarction
QALY
:   quality-adjusted life years
SAPPHIRE
:   Stenting and Angioplasty with Protection in Patients at High Risk for Endarterectomy" />
<meta name="DC.Contributor" content="M.A. Almekhlafi" />
<meta name="DC.Contributor" content="M.D. Hill" />
<meta name="DC.Contributor" content="S. Wiebe" />
<meta name="DC.Contributor" content="M. Goyal" />
<meta name="DC.Contributor" content="D. Yavin" />
<meta name="DC.Contributor" content="J.H. Wong" />
<meta name="DC.Contributor" content="F.M. Clement" />
<meta name="article:published_time" content="2014-02-01" />
<meta name="article:section" content="Interventional" />
<meta name="citation_title" content="When Is Carotid Angioplasty and Stenting the Cost-Effective Alternative for Revascularization of Symptomatic Carotid Stenosis? A Canadian Health System Perspective" />
<meta name="citation_abstract" lang="en" content="&lt;h3&gt;BACKGROUND AND PURPOSE:&lt;/h3&gt;
&lt;p&gt;Carotid revascularization procedures can be complicated by stroke. Additional disability adds to the already high costs of the procedure. To weigh the cost and benefit, we estimated the cost-utility of carotid angioplasty and stenting compared with carotid endarterectomy among patients with symptomatic carotid stenosis, with special emphasis on scenario analyses that would yield carotid angioplasty and stenting as the cost-effective alternative relative to carotid endarterectomy.&lt;/p&gt;&lt;h3&gt;MATERIALS AND METHODS:&lt;/h3&gt;
&lt;p&gt;A cost-utility analysis from the perspective of the health system payer was performed by using a Markov analytic model. Clinical estimates were based on a meta-analysis. The procedural costs were derived from a microcosting data base. The costs for hospitalization and rehabilitation of patients with stroke were based on a Canadian multicenter study. Utilities were based on a randomized controlled trial.&lt;/p&gt;&lt;h3&gt;RESULTS:&lt;/h3&gt;
&lt;p&gt;In the base case analysis, carotid angioplasty and stenting were more expensive (incremental cost of $6107) and had a lower utility (−0.12 quality-adjusted life years) than carotid endarterectomy. The results are sensitive to changes in the risk of clinical events and the relative risk of death and stroke. Carotid angioplasty and stenting were more economically attractive among high-risk surgical patients. For carotid angioplasty and stenting to become the preferred option, their costs would need to fall from more than $7300 to $4350 or less and the risks of the periprocedural and annual minor strokes would have to be equivalent to that of carotid endarterectomy.&lt;/p&gt;&lt;h3&gt;CONCLUSIONS:&lt;/h3&gt;
&lt;p&gt;In the base case analysis, carotid angioplasty and stenting were associated with higher costs and lower utility compared with carotid endarterectomy for patients with symptomatic carotid stenosis. Carotid angioplasty and stenting were cost-effective for patients with high surgical risk.&lt;/p&gt;" />
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<meta name="twitter:title" content="When Is Carotid Angioplasty and Stenting the Cost-Effective Alternative for Revascularization of Symptomatic Carotid Stenosis? A Canadian Health System Perspective" />
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<meta name="twitter:description" content="BACKGROUND AND PURPOSE: Carotid revascularization procedures can be complicated by stroke. Additional disability adds to the already high costs of the procedure. To weigh the cost and benefit, we estimated the cost-utility of carotid angioplasty and stenting compared with carotid endarterectomy among patients with symptomatic carotid stenosis, with special emphasis on scenario analyses that would yield carotid angioplasty and stenting as the cost-effective alternative relative to carotid endarterectomy.

MATERIALS AND METHODS: A cost-utility analysis from the perspective of the health system payer was performed by using a Markov analytic model. Clinical estimates were based on a meta-analysis. The procedural costs were derived from a microcosting data base. The costs for hospitalization and rehabilitation of patients with stroke were based on a Canadian multicenter study. Utilities were based on a randomized controlled trial.

RESULTS: In the base case analysis, carotid angioplasty and stenting were more expensive (incremental cost of $6107) and had a lower utility (−0.12 quality-adjusted life years) than carotid endarterectomy. The results are sensitive to changes in the risk of clinical events and the relative risk of death and stroke. Carotid angioplasty and stenting were more economically attractive among high-risk surgical patients. For carotid angioplasty and stenting to become the preferred option, their costs would need to fall from more than $7300 to $4350 or less and the risks of the periprocedural and annual minor strokes would have to be equivalent to that of carotid endarterectomy.

CONCLUSIONS: In the base case analysis, carotid angioplasty and stenting were associated with higher costs and lower utility compared with carotid endarterectomy for patients with symptomatic carotid stenosis. Carotid angioplasty and stenting were cost-effective for patients with high surgical risk.

BURST
:   Burden of Ischemic Stroke
CAS
:   carotid angioplasty and stenting
CEA
:   carotid endarterectomy
CREST
:   Carotid Revascularization Endarterectomy versus Stenting Trial
EVA-3S
:   Endarterectomy versus Angioplasty in Patients with Symptomatic Severe Carotid Stenosis
MI
:   myocardial infarction
QALY
:   quality-adjusted life years
SAPPHIRE
:   Stenting and Angioplasty with Protection in Patients at High Risk for Endarterectomy" />
<meta name="og-title" property="og:title" content="When Is Carotid Angioplasty and Stenting the Cost-Effective Alternative for Revascularization of Symptomatic Carotid Stenosis? A Canadian Health System Perspective" />
<meta name="og-url" property="og:url" content="http://ajnr-stage2.stage.highwire.org/content/35/2/327" />
<meta name="og-site-name" property="og:site_name" content="American Journal of Neuroradiology" />
<meta name="og-description" property="og:description" content="BACKGROUND AND PURPOSE: Carotid revascularization procedures can be complicated by stroke. Additional disability adds to the already high costs of the procedure. To weigh the cost and benefit, we estimated the cost-utility of carotid angioplasty and stenting compared with carotid endarterectomy among patients with symptomatic carotid stenosis, with special emphasis on scenario analyses that would yield carotid angioplasty and stenting as the cost-effective alternative relative to carotid endarterectomy.

MATERIALS AND METHODS: A cost-utility analysis from the perspective of the health system payer was performed by using a Markov analytic model. Clinical estimates were based on a meta-analysis. The procedural costs were derived from a microcosting data base. The costs for hospitalization and rehabilitation of patients with stroke were based on a Canadian multicenter study. Utilities were based on a randomized controlled trial.

RESULTS: In the base case analysis, carotid angioplasty and stenting were more expensive (incremental cost of $6107) and had a lower utility (−0.12 quality-adjusted life years) than carotid endarterectomy. The results are sensitive to changes in the risk of clinical events and the relative risk of death and stroke. Carotid angioplasty and stenting were more economically attractive among high-risk surgical patients. For carotid angioplasty and stenting to become the preferred option, their costs would need to fall from more than $7300 to $4350 or less and the risks of the periprocedural and annual minor strokes would have to be equivalent to that of carotid endarterectomy.

CONCLUSIONS: In the base case analysis, carotid angioplasty and stenting were associated with higher costs and lower utility compared with carotid endarterectomy for patients with symptomatic carotid stenosis. Carotid angioplasty and stenting were cost-effective for patients with high surgical risk.

BURST
:   Burden of Ischemic Stroke
CAS
:   carotid angioplasty and stenting
CEA
:   carotid endarterectomy
CREST
:   Carotid Revascularization Endarterectomy versus Stenting Trial
EVA-3S
:   Endarterectomy versus Angioplasty in Patients with Symptomatic Severe Carotid Stenosis
MI
:   myocardial infarction
QALY
:   quality-adjusted life years
SAPPHIRE
:   Stenting and Angioplasty with Protection in Patients at High Risk for Endarterectomy" />
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    <div class="highwire-article-citation highwire-citation-type-highwire-article node12805--5" data-node-nid="12805" id="top-node-12805--6460809583" data-pisa="ajnr;35/2/327" data-pisa-master="ajnr;ajnr.A3682" data-apath="/ajnr/35/2/327.atom" data-hw-author-tooltip-instance="highwire_author_tooltip"><div class="highwire-cite highwire-cite-highwire-article highwire-citation-jcore-article-title-complete clearfix has-author-tooltip highwire-citation-highwire-article-top-a">
  
  
      <div class="highwire-cite-overline"><span  class="highwire-cite-metadata-article-type highwire-cite-metadata">Research Article</span><span class="separator-pipe"></span><span  class="highwire-cite-metadata-art-cat highwire-cite-metadata"><span class="wrapper">Interventional</span></span></div>
  
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      <h1 class="highwire-cite-title" id="page-title">When Is Carotid Angioplasty and Stenting the Cost-Effective Alternative for Revascularization of Symptomatic Carotid Stenosis? A Canadian Health System Perspective</h1>  
    	<div class="highwire-cite-authors"><span  class="highwire-citation-authors"><span class="highwire-citation-author first" data-delta="0">M.A. Almekhlafi</span>, <span class="highwire-citation-author" data-delta="1">M.D. Hill</span>, <span class="highwire-citation-author" data-delta="2">S. Wiebe</span>, <span class="highwire-citation-author" data-delta="3">M. Goyal</span>, <span class="highwire-citation-author" data-delta="4">D. Yavin</span>, <span class="highwire-citation-author" data-delta="5">J.H. Wong</span> and <span class="highwire-citation-author" data-delta="6">F.M. Clement</span></span></div>
  
    	<div class="highwire-cite-metadata"><span  class="highwire-cite-metadata-journal highwire-cite-metadata">American Journal of Neuroradiology </span><span  class="highwire-cite-metadata-date highwire-cite-metadata">February 2014,  </span><span  class="highwire-cite-metadata-volume highwire-cite-metadata">35 </span><span  class="highwire-cite-metadata-issue highwire-cite-metadata">(2) </span><span  class="highwire-cite-metadata-pages highwire-cite-metadata">327-332; </span><span  class="highwire-cite-metadata-doi highwire-cite-metadata">DOI: https://doi.org/10.3174/ajnr.A3682 </span></div>
  
  
  
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<div id="hw-article-author-popups-top-node-12805--6460809583" style="display: none;"><div class="author-tooltip-0"><div class="author-tooltip-name">M.A. Almekhlafi </div><div class="author-tooltip-affiliation"><span class="author-tooltip-text"><div class='author-affiliation'><span class='nlm-sup'>a</span>From the Departments of Clinical Neurosciences (M.A.A., M.D.H., S.W., M.G., D.Y., J.H.W.)</div><div class='author-affiliation'><span class='nlm-sup'>e</span>Department of Internal Medicine (M.A.A.), King Abdulaziz University, Jeddah, Saudi Arabia.</div></span></div><ul class="author-tooltip-find-more"><li class="author-tooltip-gs-link first"><a href="/lookup/google-scholar?link_type=googlescholar&amp;gs_type=author&amp;author%5B0%5D=M.A.%2BAlmekhlafi%2B" target="_blank" class="" data-icon-position="" data-hide-link-title="0">Find this author on Google Scholar</a></li><li class="author-tooltip-pubmed-link"><a href="/lookup/external-ref?access_num=Almekhlafi%20M&amp;link_type=AUTHORSEARCH" target="_blank" class="" data-icon-position="" data-hide-link-title="0">Find this author on PubMed</a></li><li class="author-site-search-link last"><a href="/search/author1%3AM.A.%2BAlmekhlafi%2B" rel="nofollow" class="" data-icon-position="" data-hide-link-title="0">Search for this author on this site</a></li></ul></div><div class="author-tooltip-1"><div class="author-tooltip-name">M.D. Hill </div><div class="author-tooltip-affiliation"><span class="author-tooltip-text"><div class='author-affiliation'><span class='nlm-sup'>a</span>From the Departments of Clinical Neurosciences (M.A.A., M.D.H., S.W., M.G., D.Y., J.H.W.)</div><div class='author-affiliation'><span class='nlm-sup'>b</span>Medicine (M.D.H.)</div><div class='author-affiliation'><span class='nlm-sup'>c</span>Community Health Sciences (M.D.H., S.W., F.M.C.)</div><div class='author-affiliation'><span class='nlm-sup'>d</span>Radiology (M.G., M.D.H.), Hotchkiss Brain Institute, University of Calgary, Calgary, Alberta, Canada</div></span></div><ul class="author-tooltip-find-more"><li class="author-tooltip-gs-link first"><a href="/lookup/google-scholar?link_type=googlescholar&amp;gs_type=author&amp;author%5B0%5D=M.D.%2BHill%2B" target="_blank" class="" data-icon-position="" data-hide-link-title="0">Find this author on Google Scholar</a></li><li class="author-tooltip-pubmed-link"><a href="/lookup/external-ref?access_num=Hill%20M&amp;link_type=AUTHORSEARCH" target="_blank" class="" data-icon-position="" data-hide-link-title="0">Find this author on PubMed</a></li><li class="author-site-search-link last"><a href="/search/author1%3AM.D.%2BHill%2B" rel="nofollow" class="" data-icon-position="" data-hide-link-title="0">Search for this author on this site</a></li></ul></div><div class="author-tooltip-2"><div class="author-tooltip-name">S. Wiebe </div><div class="author-tooltip-affiliation"><span class="author-tooltip-text"><div class='author-affiliation'><span class='nlm-sup'>a</span>From the Departments of Clinical Neurosciences (M.A.A., M.D.H., S.W., M.G., D.Y., J.H.W.)</div><div class='author-affiliation'><span class='nlm-sup'>c</span>Community Health Sciences (M.D.H., S.W., F.M.C.)</div></span></div><ul class="author-tooltip-find-more"><li class="author-tooltip-gs-link first"><a href="/lookup/google-scholar?link_type=googlescholar&amp;gs_type=author&amp;author%5B0%5D=S.%2BWiebe%2B" target="_blank" class="" data-icon-position="" data-hide-link-title="0">Find this author on Google Scholar</a></li><li class="author-tooltip-pubmed-link"><a href="/lookup/external-ref?access_num=Wiebe%20S&amp;link_type=AUTHORSEARCH" target="_blank" class="" data-icon-position="" data-hide-link-title="0">Find this author on PubMed</a></li><li class="author-site-search-link last"><a href="/search/author1%3AS.%2BWiebe%2B" rel="nofollow" class="" data-icon-position="" data-hide-link-title="0">Search for this author on this site</a></li></ul></div><div class="author-tooltip-3"><div class="author-tooltip-name">M. Goyal </div><div class="author-tooltip-affiliation"><span class="author-tooltip-text"><div class='author-affiliation'><span class='nlm-sup'>a</span>From the Departments of Clinical Neurosciences (M.A.A., M.D.H., S.W., M.G., D.Y., J.H.W.)</div><div class='author-affiliation'><span class='nlm-sup'>d</span>Radiology (M.G., M.D.H.), Hotchkiss Brain Institute, University of Calgary, Calgary, Alberta, Canada</div></span></div><ul class="author-tooltip-find-more"><li class="author-tooltip-gs-link first"><a href="/lookup/google-scholar?link_type=googlescholar&amp;gs_type=author&amp;author%5B0%5D=M.%2BGoyal%2B" target="_blank" class="" data-icon-position="" data-hide-link-title="0">Find this author on Google Scholar</a></li><li class="author-tooltip-pubmed-link"><a href="/lookup/external-ref?access_num=Goyal%20M&amp;link_type=AUTHORSEARCH" target="_blank" class="" data-icon-position="" data-hide-link-title="0">Find this author on PubMed</a></li><li class="author-site-search-link last"><a href="/search/author1%3AM.%2BGoyal%2B" rel="nofollow" class="" data-icon-position="" data-hide-link-title="0">Search for this author on this site</a></li></ul></div><div class="author-tooltip-4"><div class="author-tooltip-name">D. Yavin </div><div class="author-tooltip-affiliation"><span class="author-tooltip-text"><div class='author-affiliation'><span class='nlm-sup'>a</span>From the Departments of Clinical Neurosciences (M.A.A., M.D.H., S.W., M.G., D.Y., J.H.W.)</div></span></div><ul class="author-tooltip-find-more"><li class="author-tooltip-gs-link first"><a href="/lookup/google-scholar?link_type=googlescholar&amp;gs_type=author&amp;author%5B0%5D=D.%2BYavin%2B" target="_blank" class="" data-icon-position="" data-hide-link-title="0">Find this author on Google Scholar</a></li><li class="author-tooltip-pubmed-link"><a href="/lookup/external-ref?access_num=Yavin%20D&amp;link_type=AUTHORSEARCH" target="_blank" class="" data-icon-position="" data-hide-link-title="0">Find this author on PubMed</a></li><li class="author-site-search-link last"><a href="/search/author1%3AD.%2BYavin%2B" rel="nofollow" class="" data-icon-position="" data-hide-link-title="0">Search for this author on this site</a></li></ul></div><div class="author-tooltip-5"><div class="author-tooltip-name">J.H. Wong </div><div class="author-tooltip-affiliation"><span class="author-tooltip-text"><div class='author-affiliation'><span class='nlm-sup'>a</span>From the Departments of Clinical Neurosciences (M.A.A., M.D.H., S.W., M.G., D.Y., J.H.W.)</div></span></div><ul class="author-tooltip-find-more"><li class="author-tooltip-gs-link first"><a href="/lookup/google-scholar?link_type=googlescholar&amp;gs_type=author&amp;author%5B0%5D=J.H.%2BWong%2B" target="_blank" class="" data-icon-position="" data-hide-link-title="0">Find this author on Google Scholar</a></li><li class="author-tooltip-pubmed-link"><a href="/lookup/external-ref?access_num=Wong%20J&amp;link_type=AUTHORSEARCH" target="_blank" class="" data-icon-position="" data-hide-link-title="0">Find this author on PubMed</a></li><li class="author-site-search-link last"><a href="/search/author1%3AJ.H.%2BWong%2B" rel="nofollow" class="" data-icon-position="" data-hide-link-title="0">Search for this author on this site</a></li></ul></div><div class="author-tooltip-6"><div class="author-tooltip-name">F.M. Clement </div><div class="author-tooltip-affiliation"><span class="author-tooltip-text"><div class='author-affiliation'><span class='nlm-sup'>c</span>Community Health Sciences (M.D.H., S.W., F.M.C.)</div></span></div><ul class="author-tooltip-find-more"><li class="author-tooltip-gs-link first"><a href="/lookup/google-scholar?link_type=googlescholar&amp;gs_type=author&amp;author%5B0%5D=F.M.%2BClement%2B" target="_blank" class="" data-icon-position="" data-hide-link-title="0">Find this author on Google Scholar</a></li><li class="author-tooltip-pubmed-link"><a href="/lookup/external-ref?access_num=Clement%20F&amp;link_type=AUTHORSEARCH" target="_blank" class="" data-icon-position="" data-hide-link-title="0">Find this author on PubMed</a></li><li class="author-site-search-link last"><a href="/search/author1%3AF.M.%2BClement%2B" rel="nofollow" class="" data-icon-position="" data-hide-link-title="0">Search for this author on this site</a></li></ul></div></div></div>  </div>

  
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    <div class="highwire-markup"><div xmlns="http://www.w3.org/1999/xhtml" xmlns:xhtml="http://www.w3.org/1999/xhtml" class="section ref-list" id="ref-list-1"><h2>References</h2><ol class="cit-list ref-use-labels"><li><span class="ref-label">1.</span><a class="rev-xref-ref" href="#xref-ref-1-1" title="View reference 1. in text" id="ref-1">↵</a>

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<div class="cit ref-cit ref-journal" id="cit-35.2.327.2" data-doi="10.1056/NEJMoa0912321"><div class="cit-metadata"><ol class="cit-auth-list"><li><span class="cit-auth"><span class="cit-name-surname">Brott</span>  <span class="cit-name-given-names">TG</span></span>, </li><li><span class="cit-auth"><span class="cit-name-surname">Hobson</span>  <span class="cit-name-given-names">RW</span>  <span class="cit-name-suffix">2nd</span>.</span>, </li><li><span class="cit-auth"><span class="cit-name-surname">Howard</span>  <span class="cit-name-given-names">G</span></span>, </li><li><span class="cit-etal">et al</span></li></ol><cite>. <span class="cit-article-title">Stenting versus endarterectomy for treatment of carotid-artery stenosis</span>. <abbr class="cit-jnl-abbrev">N Engl J Med</abbr> <span class="cit-pub-date">2010</span>;<span class="cit-vol">363</span>:<span class="cit-fpage">11</span>–<span class="cit-lpage">23</span></cite></div><div class="cit-extra"><a href="/lookup/external-ref?access_num=10.1056/NEJMoa0912321&amp;link_type=DOI" class="cit-ref-sprinkles cit-ref-sprinkles-doi cit-ref-sprinkles-crossref"><span>CrossRef</span></a><a href="/lookup/external-ref?access_num=20505173&amp;link_type=MED&amp;atom=%2Fajnr%2F35%2F2%2F327.atom" class="cit-ref-sprinkles cit-ref-sprinkles-medline"><span>PubMed</span></a><a href="/lookup/external-ref?access_num=000279343000004&amp;link_type=ISI" class="cit-ref-sprinkles cit-ref-sprinkles-newisilink cit-ref-sprinkles-webofscience"><span>Web of Science</span></a></div></div></li><li><span class="ref-label">3.</span><a class="rev-xref-ref" href="#xref-ref-3-1" title="View reference 3. in text" id="ref-3">↵</a>

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        	<div class="highwire-cite-metadata"><span  class="highwire-cite-metadata-volume highwire-cite-metadata">Vol. 35</span>, <span  class="highwire-cite-metadata-issue highwire-cite-metadata">Issue 2 </span><div  class="highwire-cite-metadata-pubdate highwire-cite-metadata">1 Feb 2014 </div></div>
      
      
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    	<div class="highwire-cite-metadata"><span  class="highwire-cite-metadata-journal highwire-cite-metadata">American Journal of Neuroradiology </span><span  class="highwire-cite-metadata-date highwire-cite-metadata">Feb 2014, </span><span  class="highwire-cite-metadata-volume highwire-cite-metadata">35 </span><span  class="highwire-cite-metadata-issue highwire-cite-metadata">(2) </span><span  class="highwire-cite-metadata-pages highwire-cite-metadata">327-332; </span><span  class="highwire-cite-metadata-doi highwire-cite-metadata"><span class="label">DOI:</span> 10.3174/ajnr.A3682 </span></div>
  
  
  
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    	<div class="highwire-cite-metadata"><span  class="highwire-cite-metadata-journal highwire-cite-metadata">American Journal of Neuroradiology </span><span  class="highwire-cite-metadata-date highwire-cite-metadata">Feb 2014, </span><span  class="highwire-cite-metadata-volume highwire-cite-metadata">35 </span><span  class="highwire-cite-metadata-issue highwire-cite-metadata">(2) </span><span  class="highwire-cite-metadata-pages highwire-cite-metadata">327-332; </span><span  class="highwire-cite-metadata-doi highwire-cite-metadata"><span class="label">DOI:</span> 10.3174/ajnr.A3682 </span></div>
  
  
  
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