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Safety and Clinical Outcomes after Transverse Venous Sinus Stenting for Treatment of Refractory Idiopathic Intracranial Hypertension: Single Center Experience.

ABSTRACT: Background:Idiopathic intracranial hypertension (IIH) is a syndrome of elevated intracranial pressure of unknown etiology. Unilateral or bilateral transverse sinus (TS) or transverse-sigmoid junction stenosis is present in about 30%-93% of these patients. There is an ongoing debate on whether venous sinus stenosis is the cause of IIH or a result of it. The subset of IIH patients who continue to have clinical deterioration despite maximum medical therapy is termed as "refractory IIH." Traditionally, cerebrospinal fluid diversion surgeries (ventriculoperitoneal shunt and lumboperitoneal shunt) and optic nerve sheath fenestration (ONSF) were the mainstays of treatment for refractory IIH. In the last decade, venous sinus stenting (VSS) has emerged as a safe and effective option for treating refractory IIH patients with venous sinus stenosis. Through this study, we want to share our experience with venous stenting in refractory IIH patients with venous sinus stenosis associated with a significant pressure gradient (?10 mm Hg). Methods:Retrospective chart review of all the patients diagnosed with refractory IIH who underwent VSS or angioplasty at our comprehensive stroke center from November 2016 to March 2019. Results:A total of seven refractory IIH patients underwent VSS or angioplasty within the specified period. The mean age was 39 years. Eighty-five percent of the patients were women (n = 6). The mean body mass index (BMI) was 37 kg/m2. Headache was the most common symptom (85%, n = 6) followed by transient visual obscurations (71%, n = 5) and pulsatile tinnitus (57%; n = 4). All patients had papilledema. Fifty-seven percent of patients (n = 4) had impaired visual field. Mean lumbar opening pressure was 40.6 cm H2O (SD = 9.66; 95% CI = 33.5-47.7). All patients were on maximum doses of acetazolamide ± furosemide. Six patients (85%) had dominant right transverse-sigmoid sinus. Fifty-seven percent of the patients had severe right transverse ± sigmoid sinus stenosis (n = 4) and the rest (43%) had bilateral TS stenosis (n = 3). Prestenting mean trans-stenosis pressure gradient was 18 mm Hg (SD = 6.16; 95% CI = 13.43-22.57). Six patients (85%) were treated with TS stenting and one (15%) with only angioplasty. Poststenting mean trans-stenosis pressure gradient was 4.8 mm Hg (SD = 6.6; 95% CI = -0.1-9.7). All patients were able to come off their medications with significant improvement in neurological and ophthalmological signs and symptoms. No procedure-related complications occurred. Conclusion:TS stenting ± angioplasty is a safe and effective means of treating refractory IIH with venous sinus stenosis associated with a significant pressure gradient (?10 mm Hg).

SUBMITTER: Kulhari A

PROVIDER: S-EPMC6998806 | biostudies-literature | 2020 Jan

REPOSITORIES: biostudies-literature

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Safety and Clinical Outcomes after Transverse Venous Sinus Stenting for Treatment of Refractory Idiopathic Intracranial Hypertension: Single Center Experience.

Kulhari Ashish A He Ming M Fourcand Farah F Singh Amrinder A Zacharatos Haralabos H Mehta Siddhart S Kirmani Jawad F JF

Journal of vascular and interventional neurology 20200101 1

<h4>Background</h4>Idiopathic intracranial hypertension (IIH) is a syndrome of elevated intracranial pressure of unknown etiology. Unilateral or bilateral transverse sinus (TS) or transverse-sigmoid junction stenosis is present in about 30%-93% of these patients. There is an ongoing debate on whether venous sinus stenosis is the cause of IIH or a result of it. The subset of IIH patients who continue to have clinical deterioration despite maximum medical therapy is termed as "refractory IIH." Tra ...[more]

PMID: 32071666

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Project description:Background and purposeIn medically refractory idiopathic intracranial hypertension, optic nerve sheath fenestration or CSF shunting is considered the next line of management. Venous sinus stenosis has been increasingly recognized as a treatable cause of elevated intracranial pressure in a subset of patients. In this article, we present the results of the largest meta-analysis of optic nerve sheath fenestration, CSF shunting, and dural venous sinus stenting. This is the only article that compares these procedures, to our knowledge.Materials and methodsWe performed a PubMed search of all peer-reviewed articles from 1988 to 2014 for patients who underwent a procedure for medically refractory idiopathic intracranial hypertension.ResultsOptic nerve sheath fenestration analysis included 712 patients. Postprocedure, there was improvement of vision in 59%, headache in 44%, and papilledema in 80%; 14.8% of patients required a repeat procedure with major and minor complication rates of 1.5% and 16.4%, respectively. The CSF diversion procedure analysis included 435 patients. Postprocedure, there was improvement of vision in 54%, headache in 80%, and papilledema in 70%; 43% of patients required at least 1 additional surgery. The major and minor complication rates were 7.6% and 32.9%, respectively. The dural venous sinus stenting analysis included 136 patients. After intervention, there was improvement of vision in 78%, headache in 83%, and papilledema in 97% of patients. The major and minor complication rates were 2.9% and 4.4%, respectively. Fourteen additional procedures were performed with a repeat procedure rate of 10.3%. Three patients had contralateral stent placement, while 8 had ipsilateral stent placement within or adjacent to the original stent. Only 3 patients required conversion to CSF diversion or 2.2% of patients with stents.ConclusionsPatients with medically refractory idiopathic intracranial hypertension have traditionally undergone a CSF diversion procedure as the first intervention. This paradigm may need to be re-examined, given the high technical and clinical success and low complication rates with dural venous sinus stenting.

Dataset Information

Safety and Clinical Outcomes after Transverse Venous Sinus Stenting for Treatment of Refractory Idiopathic Intracranial Hypertension: Single Center Experience.

Publications

Safety and Clinical Outcomes after Transverse Venous Sinus Stenting for Treatment of Refractory Idiopathic Intracranial Hypertension: Single Center Experience.

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