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Intracranial circumferential fusiform aneurysms of the posterior circulation involving arterial branches or perforating vessels are difficult to treat. This article shows an endovascular reconstruction technique not yet described, using a telescoping self-expandable stent (LEO+) and flow-diverter device (SILK) at different surgical times. Two patients with circumferential fusiform aneurysm, one being an aneurysm of the segments P2 and P3 of the posterior cerebral artery, diagnosed after a headache, and the other a partially thrombosed aneurysm of the lower basilar artery, diagnosed following ischemia of the brain stem. Endovascular treatment was performed by means of a vascular reconstruction technique that used at different surgical times: overlapping; a telescoped self-expandable stent, LEO+; and a flow-diverter device, SILK. Angiographic control was carried out at 6 and 12 months, to evaluate arterial patency, flow maintenance in the arterial branches and perforating vessels, and thrombosis of the aneurysm. The combined use at different surgical times of the self-expandable stent and flow-diverter device was technically successful in both patients. There were no complications during the procedure, nor in the long-term follow-up with full arterial vascular reconstruction, maintenance of cerebral perfusion and complete aneurysm occlusion at the 6- and 12-month angiographic follow-up. There was no aneurysm recanalization nor intra-stent stenosis. Circumferential fusiform aneurysm of the posterior circulation involving arterial branches or perforating vessels to the brain stem may be treated with this arterial reconstruction technique at different surgical times, using the self-expandable stent called LEO+ and the flow-diverter device SILK, minimizing the risk of complications and failure of the endovascular technique, with the potential for arterial reconstruction with thrombosis of the aneurysmatic sac, as well as flow maintenance in the eloquent arteries, in this type of cerebral aneurysm.

The endovascular treatment of spontaneous dural cavernous sinus fistula (DAVF) can be accomplished by arterial approach, just with symptoms relief, or by numerous venous approaches through the inferior petrosal sinus, ophthalmic vein, anterior or posterior intercavernous sinus and facial vein. Our case suggests the approach to the cavernous sinus via the foramen ovale and emissary veins puncture as an alternative when there is no possibility of venous approach conventionally described. A 76-year-old woman presented with right conjunctival hyperemia, exophthalmos, intraocular pressure increasing and visual deficits in a period of six months. Angiographic diagnosis of spontaneous DAVF isolated from the cavernous sinus, Barrow Type C, with exclusive venous drainage through the superior ophthalmic vein. Endovascular treatment was performed under general anesthesia. Attempts to approach the cavernous sinus through the inferior petrosal sinus ipsilateral and contralateral intercavernous, facial vein and pterygoid plexus, as well as by dissection and direct puncture of the superior ophthalmic vein were not possible. An approach to the cavernous sinus was performed by puncturing the foramen ovale, catheterization of the emissary vein of the foramen ovale with occlusion of the fistula with microcoils. There was a symptomatic regression with gradual normalization of intraocular pressure, exophthalmos and conjunctival hyperemia in three months. The approach to the cavernous sinus through the foramen ovale and catheterization of the emissary cranial skull base vein is an exception and should be considered in cases of spontaneous and isolated DAVF not accessible by a conventional approach.