Dural sinus stent placement for idiopathic intracranial hypertension

Clinical article

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Object

The use of unilateral dural sinus stent placement in patients with idiopathic intracranial hypertension (IIH) has been described by multiple investigators. To date there is a paucity of information on the angiographic and hemodynamic outcome of these procedures. The object of this study was to define the clinical, angiographic, and hemodynamic outcome of placement of unilateral dural sinus stents to treat intracranial venous hypertension in a subgroup of patients meeting the diagnostic criteria for IIH.

Methods

Eighteen consecutive patients with a clinical diagnosis of IIH were treated with unilateral stent placement in the transverse-sigmoid junction region. All patients had papilledema. All 12 female patients had headaches; 1 of 6 males had headaches previously that disappeared after weight loss. Seventeen patients had elevated opening pressures at lumbar puncture. Twelve patients had opening pressures of 33–55 cm H2O. All patients underwent diagnostic cerebral arteriography that showed venous outflow compromise by filling defects in the transverse-sigmoid junction region. All patients underwent intracranial selective venous pressure measurements across the filling defects. Follow-up arteriography was performed in 16 patients and follow-up venography/venous pressure measurements were performed in 15 patients.

Results

Initial pressure gradients across the filling defects ranged from 10.5 to 39 mm Hg. Nineteen stent procedures were performed in 18 patients. One patient underwent repeat stent placement for hemodynamic failure. Pressure gradients were reduced in every instance and ranged from 0 to 7 mm Hg after stenting. Fifteen of 16 patients in whom ophthalmological follow-up was performed experienced disappearance of papilledema. Follow-up arteriography in 16 patients at 5–99 months (mean 25.3 months, median 18.5 months) showed patency of all stents without in-stent restenosis. Two patients had filling defects immediately above the stent. Four other patients developed transverse sinus narrowing above the stent without filling defects. One of these patients underwent repeat stent placement because of hemodynamic deterioration. Two of the other 3 patients had hemodynamic deterioration with recurrent pressure gradients of 10.5 and 18 mm Hg.

Conclusions

All stents remained patent without restenosis. Stent placement is durable and successfully eliminates papilledema in appropriately selected patients. Continuing hemodynamic success in this series was 80%, and was 87% with repeat stent placement in 1 patient.

Abbreviations used in this paper: AVM = arteriovenous malformation; BMI = body mass index; ICP = intracranial pressure; IIH = idiopathic intracranial hypertension; ONSF = optic nerve sheath fenestration.

Article Information

Address correspondence to: David Kumpe, M.D., Department of Radiology, 12401 East 17th Avenue, Mail Stop L-954, Aurora, Colorado 80045. email: david.kumpe@ucdenver.edu.

Please include this information when citing this paper: published online December 9, 2011; DOI: 10.3171/2011.10.JNS101410.

© AANS, except where prohibited by US copyright law.

Headings

Figures

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    Case 5. Images from a 52-year-old man with progressive, rapidly decreasing visual acuity over 4 months. He underwent right ONSF 6 weeks prior to presentation. A: Digital subtraction angiogram of the right internal carotid artery, left anterior oblique projection, venous phase showing outflow almost exclusively via the left transverse sigmoid sinuses. The right transverse sinus and sigmoid sinus are small and receive drainage almost exclusively from the straight sinus. There was a pressure gradient (ΔP, between the torcular herophili and internal jugular vein) of 21 mm Hg across the filling defects in the left transverse sinus and transverse-sigmoid junction (patient awake). Arrows indicate venous pressures of 34 and 13 mm Hg in the lower superior sagittal sinus and torcular herophili compared with the lower left sigmoid sinus and upper left internal jugular vein. B: Left transverse sinus venogram before stent placement, with the patient under anesthesia. Pressure gradient was 8 mm Hg. The filling defect in the transverse sinus and transverse-sigmoid junction are evident. C: Left transverse sinus venogram immediately after placement of two 10 mm × 30 mm Precise stents. Pressure gradient was 0. The residual filling defect at the lower end of the stent (arrow) has no gradient across it. D: Digital subtraction angiogram of the right internal carotid artery, venous phase, obtained 41.5 months after stent placement. The stent is patent without restenosis. Pressure gradient is 1.5 mm Hg. The patient's right eye acuity remains abnormal, but improved from initial presentation, and the left eye vision is normal. There is no papilledema.

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    Case 9. Internal carotid artery angiogram, lateral oblique view, venous phase of a filling defect immediately above the stent, 30 months after placement of a 10 mm × 40 mm Zilver stent in a 27-year-old woman. The patient was 18 weeks pregnant at the time of stent placement. She had undergone bilateral ONSFs 2 months previously, after which her left eye vision rapidly deteriorated from 20/20 to 20/200. She was referred for urgent stent placement to preserve right eye acuity. The filling defect above the stent (arrow) was noted in retrospect after stent placement. The poststent gradient rose from 4 to 8.5 mm Hg at 18 months after stenting, and then fell to 5 mm Hg at 30 months after stent placement. Papilledema has not recurred. The decision was made at the present time to not perform repeat stent placement. Her visual acuity remains 20/20 in the right eye, with no change in the left eye.

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    Case 18. Digital subtraction angiograms of the left internal carotid artery, venous phase, obtained in a 26-year-old woman with a new headache pattern for 1 year, receiving chronic narcotics, found to have papilledema. A: The pressure gradient was 22 mm Hg across the filling defect in the left transverse-sigmoid junction (patient awake). B: The pressure gradient was 1 mm Hg immediately after stent placement. C: Eight months after stenting the pressure gradient was 18 mm Hg, with a tapered narrowing of the lateral transverse sinus above the stent (arrow).

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