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Kenneth C. Liu, Robert M. Starke, Christopher R. Durst, Tony R. Wang, Dale Ding, R. Webster Crowley and Steven A. Newman

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.

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Dale Ding, Robert M. Starke, Christopher R. Durst, R. Webster Crowley and Kenneth C. Liu

Increasing evidence supports dural venous sinus stenosis as the patho-etiology of pseudotumor cerebri (PTC) in a subset of affected patients. In this video, we demonstrate our technique for 1) diagnostic venous manometry to identify a flow-limiting stenosis of the transverse sinus in a PTC patient; and 2) successful treatment of the patient with venous stenting across the structural and physiological stricture in the dural sinus. The pressure gradient decreased from 20 mmHg pre-stent to 3 mmHg post-stent. In order to further quantify the effect of our intervention, concurrent intracranial pressure monitoring was performed.

The video can be found here: http://youtu.be/auxRg17F8yI.

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Robert M. Starke, Dale Ding, Christopher R. Durst, R. Webster Crowley and Kenneth C. Liu

Dissecting vertebral artery (VA) aneurysms are difficult to obliterate when the parent artery cannot be safely occluded. In this video, we demonstrate a combined microsurgical and endovascular treatment technique for a ruptured, dissecting VA aneurysm incorporating the origin of the posterior inferior cerebellar artery (PICA). We first performed a PICA-PICA side-to-side bypass to preserve flow through the right PICA. An endovascular approach was then utilized to embolize the proximal portion of the aneurysm from the right VA and the distal portion of the aneurysm from the left VA.

The video can be found here: http://youtu.be/dkkKsX2BiJI.

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Christopher R. Durst, Robert M. Starke, John R. Gaughen Jr., Scott Geraghty, K. Derek Kreitel, Ricky Medel, Nicholas Demartini, Kenneth C. Liu, Mary E. Jensen and Avery J. Evans

Object

The endovascular treatment of wide-necked aneurysms can be technically challenging due to distal coil migration or impingement of the parent vessel. In this paper, the authors illustrate an alternative method for the treatment of wide-necked intracranial aneurysms using a dual microcatheter technique.

Methods

The authors' first 100 consecutive patients who underwent coil embolization of a wide-necked aneurysm using a dual microcatheter technique are reported. With this technique, 2 microcatheters are used to introduce coils into the aneurysm. The coils are deployed either sequentially or concurrently to form a stable construct and prevent coil herniation or migration. Angiographic and clinical outcomes are reported.

Results

The technical success rate of the dual microcatheter technique is 91% with a morbidity and mortality of 1% and 2%, respectively. Clinical outcomes are excellent with 93% of patients demonstrating a modified Rankin Scale score of 0–2 at long-term follow-up regardless of their score at presentation. Retreatment rates are 18%.

Conclusions

The dual microcatheter technique may be a safe and efficacious first line of treatment for widenecked aneurysms.