Objectives: The opportunities for endovascular revascularization of symptomatic chronic internal carotid artery occlusions are increasing. The purpose of this review is to describe the technical difficulty, the clinical effectiveness, and the future perspective.
Method: A literature search was conducted using Pubmed database to retrieve articles including the key words of “chronic carotid artery occlusion revascularization.”
Results: Revascularization can promise high prophylactic effects of ischemic stroke in the hemodynamically compromised cases. Various factors such as development of specialized devices, detailed description of the lesion characters, and progress in diagnostic imaging technique may broaden the chances of revascularization.
Conclusion: Endovascular revascularization can be an alternative method for the treatment of symptomatic chronic internal carotid artery occlusions in the near future.

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Objective: When a growing unruptured intracranial aneurysm (UIA) is detected by serial magnetic resonance angiography (MRA) in elderly patients aged 80 years or older, it is difficult to decide the treatment strategy of the UIAs in the elderly (80 years or older) because aneurysm growth correlates with higher risk of rupture in spite of their potentially shorter life expectancy and hazards related to treatment. We present, here, 4 cases of growing asymptomatic UIA in the elderly (80 years or older) in whom endovascular treatment was performed successfully and had good midterm outcomes.
Method: Four consecutive patients who underwent endovascular treatment between April 2009 and March 2013 were retrospectively evaluated.
Result: All the four patients were women and their mean age at the time of endovascular treatment was 81.8 years (range, 81–83 years). All were healthy and were able to carry out their activities of daily life. But they presented with growing UIAs, including middle cerebral artery aneurysms (n=3) and a posterior communicating artery aneurysm (n=1). The size of the aneurysms on admission was mean 5.0 mm (range, 3.3–6.5 mm). The aneurysms had increased in maximum diameter by mean 2.0 times (range, 1.6–3.0 times) during observation (range 24–64 months) and grown to the size of mean 9.4 mm (range 7.1–11.7 mm). All patients underwent coil embolization (2 patients using stent assisted technique) successfully without any procedure-related complication. Complete obliteration was achieved in one aneurysm, with a small neck remnant in three aneurysms. At discharge, all patients had modified Rankin Scale (mRS) score 0. During follow-up interval (range 6–47 months), all patients maintained mRS 0 without any treatment-related complication. All patients underwent follow-up imaging by angiography or MRA. The mean imaging follow-up period was 16.8 months (range, 6–43 months) and no interval change of the degree of aneurysm occlusions was demonstrated.
Conclusion: We suggest that endovascular treatment for growing UIAs of patients aged 80 years or older appears to be safe and effective if we can keep very low procedural risks.

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Objectives: Behavior of the coils and microcatheters during coil ejection from the microcatheter is influenced not only by the characteristic features themselves but also by the properties of delivery wires. Elasticity and bending features of delivery wires of soft coils in five brands (Axium Helix, Deltaplush, ED coil Extrasoft, Galaxy Complex Xtrasoft, Target Ultra) are examined.
Methods: Delivery wires are pinched by tweezers at 30 mm or 20 mm proximal from detaching point, and repelling force was measured when the wires were bended to the point of length of 15 mm or 10 mm each. Configurations of bended wires were also investigated.
Results: Average repelling force (×10⁻³N) of Axium, Deltaplush, ED, Galaxy, and Target were 3.822, 4.41, 2.548, 3.136, and 4.018 each in 30 mm group, and 7.105, 9.996, 4.312, 5.488, 6.174 each in 20-mm group, respectively. Wires showed continuous curve in three brands of Axium, ED, and Target, and non-continuous curve with buckle at 10-mm short of detaching point in the remaining Deltaplush and Galaxy coils.
Conclusions: To finish coil embolization treatment safely and effectively, coils should be chosen according to proper understanding of characteristic features of each delivery wires.

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Objective: In this report, a case with a true posterior communicating artery aneurysm that showed rapid growth and repetitive recanalization after coiling and that was successfully obliterated using a double-microcatheter technique via two different routes is presented.
Case: A 52-year-old woman who had undergone a coil embolization for a ruptured, saccular aneurysm arising at a non-branching site of the left posterior communicating artery two months previously presented with the sudden onset of a headache. A CT scan revealed a subarachnoid hemorrhage, and cerebral angiography showed recanalization in association with the rapid growth of the aneurysm. The aneurysm continued to grow despite two additional coil embolizations. Finally, the aneurysm was successfully embolized using coils through two microcatheters navigated via the ipsilateral internal carotid artery and the left vertebral artery.
Conclusion: This is the first report of coiling using the double-microcatheter technique via two distinct routes. This method is a safe and effective treatment option for true posterior communicating aneurysms.

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Objective: We report a rare case of a ruptured aneurysm at proximal portion of the anterior inferior cerebellar artery (AICA) treated by endovascular coil embolization with AICA preservation.
Case: The patient was a 61-year-old woman with a World Federation of Neurosurgical Societies (WFNS) Grade II subarachnoid hemorrhage due to an aneurysm rupture in the right proximal AICA. Technical difficulty of catheter control caused by severe stenosis proximal to the aneurysm and tortuosity of the AICA, resulted in insufficient occlusion of aneurysm. Strict follow-up with repeated angiography revealed no recanalization of the aneurysm. The aneurysm and AICA was finally occluded at the 20-month follow-up with good collateral flow to the affected territory via the right superior cerebellar artery and the left posterior inferior cerebellar artery. Patient has been clinically stable for 4.5 years since the onset without any aneurysmal rebleeding.
Conclusions: All cases of proximal AICA aneurysms were reported as dissection or fusiform aneurysm, associated with hypoplasia or absence of the ipsilateral posterior inferior cerebellar artery. Although result of initial endovascular treatment was incomplete due to technical difficulty, patient has been stable without any aneurysmal regrowth nor rebleeding. We consider that our experience is one of the reference to investigate similar cases.

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Objectives: Dissecting aneurysms (DAs) truly localized at the posterior inferior cerebellar artery (PICA) are rare. In addition, bilateral dissecting aneurysms of PICA have never been reported in the literature to our knowledge. We report a case of bilateral DAs of the PICA presented with subarachnoid hemorrhage.
Case presentation: A 41-year-old male was referred to the emergency care center of our institute due to sudden onset of posterior cervical pain and dizziness. He was neurologically intact with clear consciousness. CT showed subarachnoid hemorrhage (Fisher Grade 3), and cerebral angiography revealed DAs at anterior medullary segment to lateral medullary segment of bilateral posterior inferior cerebellar artery. He underwent parent artery occlusion (PAO) for the right lesion which showed increase in size during conservative treatment. In spite of negative result of preoperative balloon test occlusion of the right vertebral artery at the origin of the right PICA, he suffered acute infarction in the right cerebellum and medulla after PAO with temporary partial right Wallenberg syndrome and the right limb ataxia. The left lesion showed spontaneous decrease in size at 6 months follow-up angiography.
Conclusions: An extremely rare case of bilateral DAs of the PICA is presented. Endovascular treatment for this lesion is feasible though more prudent preoperative evaluation is required.

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Objectives: We report a case of dural arteriovenous fistula at the craniocervical junction fed by multiple arteries manifesting as subarachnoid hemorrhage at onset.
Case presentation: A 45-year-old male suffered subarachnoid hemorrhage. Investigation of the bleeding source found a dural arteriovenous fistula at the left craniocervical junction fed by the meningeal branch of the left vertebral artery, left ascending pharyngeal artery, occipital artery, and deep cervical artery. Transection of the emissary veins via craniotomy following two intravascular embolization procedures resulted in disappearance of the shunt.
Conclusions: Multiplanar reconstruction images of the three-dimensional digital subtraction angiography were useful to identify the dural arteriovenous fistula at the craniocervical junction fed by multiple arteries. Palliative embolization and open surgery were effective combination therapy for this case.

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Objective: We report a case of ischemic optic neuropathy (ION) occurred after carotid artery stenting (CAS) for symptomatic carotid artery stenosis.
Case presentation: A 72-year-old man was admitted to our hospital with left transit ischemic attack, and was diagnosed with symptomatic right carotid artery stenosis. He suffered loss of visual acuity and visual field of right eye one day after CAS. He was diagnosed ION by funduscopic examination.
Conclusion: We experienced a rare case of ION after CAS.

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