Objective: The "Sheep technique" is a special technique for navigating a balloon catheter that is difficult to navigate because of the steep angle of the branching vessel.
Case presentation: We treated two patients having intracranial aneurysms by endovascular therapy with the sheep technique. In both cases, initial balloon catheter navigation failed because the branch near the aneurysm was steep. With the aid of the sheep technique, the balloon catheter was successfully delivered into the target vessel. Coil embolization was then performed using a balloon remodeling technique.
Conclusion: The sheep technique is effective when balloon catheter delivery is difficult because the branch near the aneurysm is steep.

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Objective: We report the case of a large unruptured paraclinoid aneurysm treated by preoperative embolization of the ophthalmic artery and proximal occlusion of the parent internal carotid artery performed during external carotid-middle cerebral artery bypass surgery.
Case presentation: A 72-year-old woman presented with a transient loss of consciousness. Three-dimensional angiograms revealed a large paraclinoid aneurysm extending to the cavernous sinus. The supraclinoid carotid artery was compressed by the aneurysm and was displaced medially under the optic nerve. The ophthalmic artery, in this case, originated from the cavernous segment of the internal carotid artery (i.e., the dorsal ophthalmic artery). After balloon test occlusion of the ophthalmic artery, its origin was occluded with two detachable coils. Four days later, the cervical portion of the internal carotid artery was ligated during external carotid-middle cerebral artery bypass surgery. The aneurysm was no longer apparent in both intra- and post-operative angiography.
Conclusion: Our therapy needs no manipulation of the supraclinoid carotid artery and the optic nerve, avoiding visual impairment by surgery, and may be a good alternative treatment strategy when large or giant paraclinoid aneurysms extend to the cavernous sinus.

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Purpose: We report a case of posterior ischemic optic neuropathy which occurred after transarterial coil embolization for cavernous sinus dural arteriovenous fistula (CSdAVF).
Case: A 74-year-old female was diagnosed with left CSdAVF, as a result of a detailed examination for left orbital pain and diplopia, and transarterial coil embolization was undertaken. After surgery, left orbital pain was reduced, although left upper quadrantanopia was detected. On her 13th post-operative day, the visual acuity of the left eye was lost, and unilateral blindness was diagnosed. Her intraocular pressure was not high, and her funduscopic examination findings were normal. In an orbital diffusion-weighted MR image, a high-intensity lesion localized in the left optic nerve was identified, and ischemic optic neuropathy was diagnosed.
Conclusion: We experienced a case of serious cranial nerve defect due to transarterial coil embolization.

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Objective: Cervical internal carotid artery (ICA) vasospasms are rare, and their treatment is not established. We report 2 cases of recurrent cervical ICA vasospasms and their treatment using carotid artery stenting (CAS).
Case 1: A 47-year-old woman presented with dysarthria. Three-dimensional computed tomography angiography (3D-CTA) showed severe stenosis of the right cervical ICA, but her symptoms gradually improved. The patient underwent follow-up magnetic resonance angiography (MRA) every 3 months and was admitted to the hospital 2 times with left hemiparesis. In each ischemic attack, digital subtraction angiography (DSA) showed stenosis of the right cervical ICA. Percutaneous transluminal angioplasty was performed, and the stenotic ICA was recanalized. Subsequently, her symptoms improved. The cervical ICA vasospasm caused 3 ischemic attacks; as a result, we performed CAS to prevent further vasospasms.
Case 2: A 46-year-old woman was admitted with dysarthria and left hemiplegia. The patient had a history of recurrent transient cervical ICA stenosis accompanied by right hemiplegia. DSA on admission showed severe stenosis of the left cervical ICA. Stenosis due to vasospasm was diagnosed and CAS was performed. In both cases, the patients remained free of subjective symptoms for a 24-month period following CAS.
Conclusion: Cervical ICA vasospasms can occur spontaneously and should be considered in patients with repeated ischemic strokes. However, an effective standard treatment for vasospasm has not yet been established. For patients with repeated vasospasms, CAS may be effective for preventing spontaneous vasospasms.

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Objective: We report a case of maxillary arterio-venous malformation (AVM) with recurrent palatal hemorrhages successfully treated with direct puncture and injection of n-butyl-2-cyanoacrylate (NBCA).
Case presentation: A 47-year-old female had been followed up for multiple craniofacial AVMs. Endovascular treatment was planned because of exacerbation of recurrent bleeding from dilated abnormal vessels on the palate surface. Pre-treatment angiography revealed an intramaxillary AVM, part of which bulged into oral cavity suggesting a bleeding point. Direct puncture embolization was selected inasmuch as effective transarterial embolization might be made difficult by the presence of narrow and tortuous feeders. Diluted NBCA was directly injected into the lesion and complete hemostasis was achieved without any complications.
Conclusion: NBCA injection directly into a bleeding point of an AVM on the palate surface can be performed safely and effectively and therefore should be considered a primary treatment option.

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Objective: We report a rare case of spontaneous esophageal submucosal hematoma after coil embolization for unruptured intracranial aneurysm.
Case presentation: A 70-year-old woman presented with an unruptured paraclinoid internal carotid aneurysm of 7 mm in diameter. We prescribed two anti-platelet agents (aspirin and clopidogrel) for her before the embolization. With the patient under general anesthesia, we completely embolized the wide-neck aneurysm with platinum coils using a balloon remodeling technique. Intraoperative administration of intravenous heparin had prolonged her activated clotting time by more than 2.5 times that of the preoperative value. Following extubation, the patient vomited repeatedly, and felt strong pain in her chest and back. On the basis of contrast-enhanced computed tomography of the chest and abdomen, we diagnosed her as having a spontaneous esophageal submucosal hematoma. Conservative therapy led to good healing as indicated by follow-up upper gastrointestinal endoscopy.
Conclusion: Spontaneous esophageal submucosal hematoma is a rare disease. In the present case, both incidental overdose of heparin during coil embolization and repeated vomiting after extubation appeared to be the main causes of the esophageal submucosal hematoma. The possibility of this complication should be kept in mind to ensure that the anti-thrombotic therapy given in endovascular neurosurgery is appropriate.

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Objective: We recently developed and launched the 6Fr Cerulean catheter as the intermediate catheter of a triple coaxial system. We present our experience with the use of this triple coaxial system with a 6Fr Cerulean catheter.
Technique and Results: Our triple coaxial system with 4Fr Cerulean catheter insertion through a 6Fr guiding catheter was used in distal or tortuous access aneurysmal coil embolization. Because this triple coaxial system only allowed us to use a single microcatheter and did not allow us to carry out a balloon or stent-assisted technique at the same time, we adopted a triple coaxial system with 6Fr Cerulean catheter (ID 0.072) insertion through an 8Fr guiding catheter to perform neck remodeling or stent assisted coiling with the Enterprise vascular reconstruction device.
Conclusion: Neck remodeling or stent-assisted coiling can be performed using a triple coaxial system with 6Fr Cerulean catheter insertion through an 8Fr guiding catheter, and using a Cerulean catheter as an intermediate catheter.

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Objective: We report the effectiveness of embolization of cerebral aneurysms under high magnification fluoroscope using the biplane flat panel detector (BFD).
Methods: Three patients with small cerebral aneurysms (2 ruptured, 1 unruptured)were shown. These patients were treated with coil embolization using BFD (AXIOM Artis dBA Twin, SIEMENS) of all aneurysms.
Results: The magnification ratio of the flat panel of 11cm in diagonal length is about four times as large as the 42 cm flat panel. The tip of the microcatheter was clearly identified with the 11cm flat panel. The high magnified flat panel plane was suitable in the microcatheter and coil manipulation, while the other low magnified flat panel plane in the different angle was suitable to see the wide operative field including both the microcatheter and the tip of the guiding catheter. The coil herniation out of the aneurysm was easily detected with biplane fluoroscope.
Conculusion: The BFD was very useful to conduct the safe and effective coiling of the cerebral aneurysms.

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