Cerebral aneurysm embolization using Guglielmi detachable coils has been approved for reimbursement in Japan since 1997; however, it was still considered an alternative treatment modality for the difficult open surgery. Thereafter, the advantages of using the endovascular procedure for ruptured intracranial aneurysms were reported in ISAT in 2002 and as a result this procedure became a big topic in aneurysm treatment. In November 2011, the Barrow Ruptured Aneurysm Trial also reported on the advantages afforded by the procedure, and it was concluded that "high-quality surgical clipping be available as an alternative treatment modality." Conversely, following the global trend towards endovascular aneurysm treatment, the craniotomy procedure has become an alternative treatment modality to be used only if conducting endovascular surgery is difficult. However, this indication status is only when dealing with general aneurysm treatment and there is no clear direction for difficult-to-treat cerebral aneurysms. Tailor-made treatment is needed ultimately, but I would like to consider a treatment strategy for difficult-to- treat cerebral aneurysms from the position of a certified endovascular treatment practitioner. There are still major issues remaining for wide neck aneurysms, giant aneurysms, aneurysms involving any arteries and partially thrombosed aneurysms. I would like to offer an overview of "the remaining issues in current neuroendovascular procedures" by presenting these cases.
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