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Response to: Correspondence on “Nickels and tines: the myth of nickel allergy in intracranial stents” by Apostolos et al
  1. Michael R Levitt1,2,3,
  2. Kevin N Vanent1,
  3. Emma M Federico1,4,
  4. David I Bass1,
  5. Guilherme Barros1,
  6. Jade Keen1,4
  1. 1 Neurological Surgery, University of Washington School of Medicine, Seattle, Washington, USA
  2. 2 Radiology, University of Washington, Seattle, Washington, USA
  3. 3 Mechanical Engineering, University of Washington, Seattle, Washington, USA
  4. 4 Stroke & Applied Neuroscience Center, University of Washington, Seattle, Washington, USA
  1. Correspondence to Dr Michael R Levitt, Neurological Surgery, University of Washington School of Medicine, Seattle, Washington, USA; mlevitt{at}

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We thank the authors for their interest1 in our benchtop study of nickel content and release in commonly used intracranial stents.2 We agree that an in vitro study such as ours is no substitute for the complex physiological environment of a living patient and that such results must be confirmed with careful clinical trials.

The first nickel-containing intracranial aneurysm stent was approved for use 20 years ago,3 and since that time thousands of patients have been successfully treated with this groundbreaking technology. Nickel allergy is estimated to affect 10–20% of the world population,4 but the incidence of in-stent stenosis or thrombosis after intracranial stenting does not approach this number in the many real-world post-market studies of nickel-containing devices.5–7 Thus, while the possibility of nickel hypersensitivity to intracranial stents exists, the real-world experience of the past two decades suggests that such events are rare even among patients with documented nickel allergy, and much less than …

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  • Contributors All authors critically reviewed the manuscript, provided final approval of the version to be published, and each agrees to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. MRL: Guarantor of the study.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests MRL is the recipient of unrestricted educational grants from Stryker and Medtronic, reports equity interest in Synchron, Cerebrotech, Proprio, Fluid Biotech, and Hyperion Surgical, is an advisor for Metis Innovative, and is a consultant for Medtronic and Aeaean Advisers. MRL is an assistant editor of social media for Journal of NeuroInterventional Surgery.

  • Provenance and peer review Commissioned; internally peer reviewed.

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