Although direct puncture of the cervical vertebral artery(VA)is not commonly performed in neuroendovascular therapy, it is sometimes inevitable for procedural or technical reasons. We report a case of a ruptured VA aneurysm that required direct cervical VA puncture for treatment. A 79-year-old man was transferred to our hospital with the diagnosis of subarachnoid hemorrhage. Cerebral angiography revealed a right VA-posterior inferior cerebellar artery aneurysm. The aneurysm showed downward projection due to retrograde flow of the right VA caused by chronic occlusion of the right subclavian artery. For endovascular treatment, the approach through the VA union via the left VA was thought to be most appropriate;however, the left VA was very tortuous and the microcatheter could not cross the VA union. We performed percutaneous direct puncture of the left cervical VA. An 18-G intravenous catheter needle(Surflo^®)was advanced and set into the C5/6 segment of the VA under biplane fluoroscopic road-mapping guidance. The microcatheter reached the aneurysm and coil embolization was successfully performed. The patient was kept intubated under general anesthesia overnight, to monitor for cervical subcutaneous hematoma. Several procedures for direct VA puncture have been reported. The major problem is the difficulty with hemostasis and maintenance of the airway is important. Although the indication is limited due to the difficulty of adjunctive techniques and postoperative antithrombotic therapy, direct VA puncture under biplane fluoroscopic guidance was useful in this case.