Venous sinus stenting for reduction of intracranial pressure in IIH: a prospective pilot study

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OBJECTIVE

Idiopathic intracranial hypertension (IIH) may cause blindness due to elevated intracranial pressure (ICP). Venous sinus stenosis has been identified in select patients, leading to stenting as a potential treatment, but its effects on global ICP have not been completely defined. The purpose of this pilot study was to assess the effects of venous sinus stenting on ICP in a small group of patients with IIH.

METHODS

Ten patients for whom medical therapy had failed were prospectively followed. Ophthalmological examinations were assessed, and patients with venous sinus stenosis on MR angiography proceeded to catheter angiography, venography with assessment of pressure gradient, and ICP monitoring. Patients with elevated ICP measurements and an elevated pressure gradient across the stenosis were treated with stent placement.

RESULTS

All patients had elevated venous pressure (mean 39.5 ± 14.9 mm Hg), an elevated gradient across the venous sinus stenosis (30.0 ± 13.2 mm Hg), and elevated ICP (42.2 ± 15.9 mm Hg). Following stent placement, all patients had resolution of the stenosis and gradient (1 ± 1 mm Hg). The ICP values showed an immediate decrease (to a mean of 17.0 ± 8.3 mm Hg), and further decreased overnight (to a mean of 8 ± 4.2 mm Hg). All patients had subjective and objective improvement, and all but one improved during follow-up (median 23.4 months; range 15.7–31.6 months). Two patients developed stent-adjacent stenosis; retreatment abolished the stenosis and gradient in both cases. Patients presenting with papilledema had resolution on follow-up funduscopic imaging and optical coherence tomography (OCT) and improvement on visual field testing. Patients presenting with optic atrophy had optic nerve thinning on follow-up OCT, but improved visual fields.

CONCLUSIONS

For selected patients with IIH and venous sinus stenosis with an elevated pressure gradient and elevated ICP, venous sinus stenting results in resolution of the venous pressure gradient, reduction in ICP, and functional, neurological, and ophthalmological improvement. As patients are at risk for stent-adjacent stenosis, further follow-up is necessary to determine long-term outcomes and gain an understanding of venous sinus stenosis as a primary or secondary pathological process behind elevated ICP.

ABBREVIATIONS BMI = body mass index; ICA = internal carotid artery; ICP = intracranial pressure; IIH = idiopathic intracranial hypertension; OCT = optical coherence tomography.

Article Information

Correspondence Robert M. Starke, University of Miami, Department of Neurological Surgery & Radiology, 1475 NW 12th Ave., C212, Box 356340, Miami, Florida 33136. email: bobby.starke@gmail.com.

INCLUDE WHEN CITING Published online December 23, 2016; DOI: 10.3171/2016.8.JNS16879.

Drs. Liu and Starke contributed equally to this work.

Disclosures The authors report no conflict of interest concerning the materials or methods used in this study or the findings specified in this paper.

© AANS, except where prohibited by US copyright law.

Headings

Figures

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    Functional outcomes as assessed by means of the modified Rankin Scale (mRS) prior to stenting, prior to discharge, and on follow-up.

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    Case 2. Preoperative ophthalmological examination findings. A: Images from preoperative funduscopic examination showing papilledema. B: Results of visual field testing showing bilateral arcuate defects. C: Results of optical coherence tomography showing marked nerve fiber layer thickening. Figure is available in color online only.

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    Case 2. Preoperative imaging studies. A: Preoperative coronal T2-weighted (left) and Gd-enhanced T1-weighted (right) MR images showing distension of the perioptic subarachnoid spaces and an empty sella. B: Cerebral angiography. Anteroposterior (AP) (left) and lateral (right) views of a right internal carotid artery (ICA) injection in the venous phase showing prominent focal stenosis of the right transverse sinus (solid arrows) and stenosis of the left transverse sinus, with diminished flows (dashed arrow). C: Cerebral venography. AP view of a superior sagittal sinus injection, performed during venous manometry, which showed a trans-stenosis pressure gradient of 37 mm Hg (mean venous pressures of 46 and 9 mm Hg proximal and distal to the stenosis, respectively).

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    Case 2. Postoperative studies. A: Angiogram (unsubtracted view) obtained after intraparenchymal ICP monitor placement (dashed arrow) and endovascular stenting of the dominant right transverse sinus (solid arrow). B: Results of ICP monitoring showing a reduction of the preoperative ICP (23–55 mm Hg over a 24-hour period) to 14 mm Hg immediately after stenting and then to a mean ICP of 3 mm Hg the next day (range 2–16 mm Hg). C and D: Images from follow-up cerebral venography, AP view of a superior sagittal sinus injection (C), and cerebral angiography, lateral view of a right ICA injection in the venous phase (D), showing patency of the stent. Figure is available in color online only.

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    Case 2. Follow-up ophthalmological examination findings. A: Images from funduscopic examination showing resolution of papilledema. B: Results of visual field testing showing improvement of the bilateral arcuate defects. C: Results of optical coherence tomography showing resolution of nerve fiber thickening. Figure is available in color online only.

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