Anterior condylar confluent dural arteriovenous fistula (ACC DAVF) is relatively rare. We present five cases of ACC DAVF. From March 2011 to August 2014 we treated six lesions in five cases of ACC DAVF. The mean age was 65.6 years and all cases were male. The lesions were 2 cases of right, 2 cases of left, and one case of bilateral lesions. All cases presented with tinnitus. The feeding arteries were the ascending pharyngeal artery in 5 cases, the occipital artery in 2 cases, and the vertebral artery in 4 cases. Venous pouch was revealed in 4 cases, and the mean pouch size was 9.8 mm in diameter. Retrograde venous flow was evident in 4 cases. For all cases, we successfully performed transvenous coil embolization of the shunt. In 3 cases, we were able to perform balloon-assisted coil embolization of the shunt, which allowed the coils to be shorter and smaller, with an average length of 100 cm. The average number of coils was 10.4. In all cases, the shunt disappeared completely by angiography and the symptoms improved. There were no complications, such as hypoglossal nerve dysfunction after embolization. We demonstrated that balloon-assisted coil embolization for ACC DAVF was effective to prevent hypoglossal nerve palsy.

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Objective: We have already developed Masamune, double-lumen balloon microcatheter. Because of double lumen, it can be used not only as neck plasty balloon, but also as the catheter for coil insertion. We recently developed Super-Masamune, a new type of Masamune.
Method: The concept of development is that compliance of the Super-Masamune is equal to that of single-lumen balloon microcatheters, which is already commercially available. Material of the balloon is switched from silicone to styrene elastomer to improve compliance. Super-Masamune has a purge hole because styrene elastomer is not a semipermeable membrane. Then, animal experimentation using swines was performed. Effectiveness of Super-Masamune for neck plasty technique is evaluated in the aneurysm model of the swine. Vessel damage due to balloon inflation was evaluated by histological observations, and was compared with that of HyperForm, single lumen balloon microcatheter.
Result: Profile of Super-Masamune is similar to Masamune in spite of changing to styrene elastomer. The total length of Super-Masamune is 150 cm, distal diameter is 2.8F, proximal diameter is 3.4F, and inner diameter of recommended guiding catheter is 0.059 inch or more. Inner diameter is 0.40 mm, balloon length is 4 mm, and balloon diameter is 7 mm at recommended volume of 0.2 ml. Super-Masamune is more compliant than Masamune. Animal experimentation showed that Super-Masamune gives less damage to the vessel than HyperForm.
Conclusions: Super-Masamune is a very compliant double-lumen balloon microcatheter. It would extend the indication of intra-aneurysmal coil embolization. Super-Masamune has recently become commercially available in Japan.

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Objective: We recently developed Super-Masamune. It is a double lumen balloon microcatheter, which is recently approved as an assist balloon for aneurysmal coil embolization in Japan. We report our initial clinical experiences of Super-Masamune.
Case 1: A 73-year-old female with unruptured right internal carotid artery aneurysm was admitted for embolization. Super-Masamune was introduced into the aneurysm. At first, it was used as a standard microcatheter for coil insertion. Then, balloon of the super-Masamune was inflated, and the guide wire lumen of the super-Masamune was still used for coil insertion. Finally, the super-Masamune was moved to the internal carotid artery and was used as assist balloon.
Case 2: A 68-year-old female with unruptured basilar tip aneurysm was admitted for embolization. Most part of the aneurysm was ridden on the right posterior cerebral artery (PCA). Branching angle of the right PCA was very acute. So, super-Masamune was introduced into the left PCA. Even in this position, the balloon of super-Masamune was bulged into the right PCA and the neck of aneurysm was completely protected.
Conclusion: In clinical use, the balloon itself is very compliant. It easily herniates to free space and makes better neck protection possible. Because of double lumen, it can be used not only as neck plasty balloon, but also as the catheter for coil insertion.

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Objective: We report a case of acute internal carotid artery (ICA) severe stenosis completely recanalized using a stent placement and a Solitaire FR.
Case presentation: A 72-year-old man presented with sudden onset of left hemiplegia and dysarthria. MRI showed early ischemic changes in the right insular cortex and frontal cortex along with right severe ICA stenosis. Cerebral angiography demonstrated severe stenosis at the origin of the right ICA and middle cerebral artery (MCA) occlusion. The ICA stenosis was improved by stent placement at the origin of ICA, and MCA occlusion was done by thrombectomy using the Solitaire FR resulting in neurological improvement.
Conclusion: IV-tPA therapy was not particularly useful in patients with ICA severe stenosis. However, if standard medical management is ineffective in patients with acute cerebral infarction due to tandem arterial lesions, combined percutaneous revascularization of each lesions can prevent catastrophic events.

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Objective: In the treatment of coil embolization for cerebral aneurysms, follow-up imaging study is recommended because recurrence occurs in 10–20%. We report a valuable case in which an unruptured aneurysm treated with coil embolization was followed-up by periodic magnetic resonance angiography (MRA) and ruptured 6 years after coil embolization.
Case presentation: A 75-year-old man had a 7.9-mm unruptured basilar tip aneurysm. A coil embolization was performed. An angiogram 6 months after the embolization showed complete occlusion of the aneurysm. We performed follow-up MRA approximately every 6 months. MRA one and a half years after the embolization showed residual at the neck of the aneurysm, which was gradually growing. MRA three and a half years after the operation showed dome filling of the aneurysm. Angiograms at that time showed that the dome filling reached at the tip of the aneurysm although the size of the aneurysm was unchanged. The patient refused retreatment. MRA 4 years after the operation showed growth of the aneurysm. The patient refused retreatment again. Six years after the treatment, the aneurysm was ruptured. Although we treated the aneurysm by coil embolization, the patient died 2 months after the treatment.
Conclusion: This case report illustrates valuable serial MRA images of complete occlusion, residual of the neck, dome filling, and rupture. Although many more cases should be examined, in this case, retreatment should be performed when dome filling reaches at the tip of an aneurysm or the aneurysm shows growth.

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Objective: We report a rare case of internal carotid artery (ICA) aneurysm arising from the common trunk of the anterior choroidal artery (AChA) and posterior communicating artery (Pcom) that was successfully treated by coil embolization. Herein, we present a literature review of anatomical AChA variations.
Case presentation: A 73-year-old woman presented with an unruptured left ICA aneurysm. The AChA directly arising from the Pcom was shown on cerebral angiogram. We performed coil embolization and successfully preserved the AChA.
Conclusion: ICA aneurysm arising at the common trunk of the AChA and Pcom is rare. To avoid complication, precise preoperative assessment using 3D rotational angiography and the Allcock test is important.

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Objective: We herein report a successful case of carotid artery stenting (CAS) with direct puncture of brachial artery through a small skin incision.
Case presentation: An 80-year-old male presented with left hemianopsia. Brain MRI showed acute cerebral infarcts in the watershed territory between the middle cerebral artery and posterior cerebral artery, and MRA revealed severe stenosis of the right internal carotid artery (ICA) with unstable high-volume plaque. A balloon guide catheter was required advancing a microguide wire through the stenotic lesion; however, the use of the transfemoral route was thought to carry a high risk due to the presence of aneurysms in the thoracic aorta, abdominal aorta, and/or iliac artery associated with severe atherosclerotic changes. Therefore, we performed direct puncture of the right brachial artery through a small skin incision followed by the insertion of a 9-French guiding catheter. Stenting was then successfully performed under double protection without any complication.
Conclusion: This novel approach is considered to be effective for treating transfemoral CAS in cases requiring a proximal protection device.

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Objective: Obtaining a clear working projection image (WPI) is mandatory for secure and effective embolization of a cerebral aneurysm. However, there are some cases where contrast medium injection through a guiding catheter (GC) does not provide an optimal WPI due to overlapping of the arteries. Here, we report a case of an anterior communicating artery aneurysm which was successfully treated by modifying double microcatheter technique (DMT) in order to obtain an optimal WPI.
Case presentation: A 79-year-old woman was admitted to our hospital due to subarachnoid hemorrhage from an anterior communicating artery aneurysm. CTA revealed that the right A1 was too thin to be detected and that the aneurysmal neck was wide enough to involve both A2. Thus, an optimal working projection (WP) was to clarify relationship between both the A2 and the aneurysmal neck. Nevertheless, contrast medium injection through the guiding catheter at the WP provided an overlapping image of the aneurysm and the left internal carotid artery. Therefore, we introduced DMT to place one microcatheter (MC) at A1 to obtain an optimal WPI. The MC was further used for frame coil and kept holding the frame coil until the last filling coil was detached. In addition, another MC was first used to affirm the frame conformation, and then to fill coils. Preservation of the frame coil outline was confirmed by blank roadmap method during the procedure.
Conclusion: When a guiding catheter does not provide an optimal WPI, our modified DMT could be a choice.

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