Idiopathic intracranial hypertension: 120-day clinical, radiological, and manometric outcomes after stent insertion into the dural venous sinus

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OBJECTIVE

Idiopathic intracranial hypertension (IIH) is commonly associated with venous sinus stenosis. In recent years, transvenous dural venous sinus stent (DVSS) insertion has emerged as a potential therapy for resistant cases. However, there remains considerable uncertainty over the safety and efficacy of this procedure, in particular the incidence of intraprocedural and delayed complications and in the longevity of sinus patency, pressure gradient obliteration, and therapeutic clinical outcome. The aim of this study was to determine clinical, radiological, and manometric outcomes at 3–4 months after DVSS in this treated IIH cohort.

METHODS

Clinical, radiographic, and manometric data before and 3–4 months after DVSS were reviewed in this single-center case series. All venographic and manometric procedures were performed under local anesthesia with the patient supine.

RESULTS

Forty-one patients underwent DVSS venography/manometry within 120 days. Sinus pressure reduction of between 11 and 15 mm Hg was achieved 3–4 months after DVSS compared with pre-stent baseline, regardless of whether the procedure was primary or secondary (after shunt surgery). Radiographic obliteration of anatomical stenosis correlating with reduction in pressure gradients was observed. The complication rate after DVSS was 4.9% and stent survival was 87.8% at 120 days. At least 20% of patients developed restenosis following DVSS and only 63.3% demonstrated an improvement or resolution of papilledema.

CONCLUSIONS

Reduced venous sinus pressures were observed at 120 days after the procedure. DVSS showed lower complication rates than shunts, but the clinical outcome data were less convincing. To definitively compare the outcomes between DVSS and shunts in IIH, a randomized prospective study is needed.

ABBREVIATIONS DVSS = dural venous sinus stent; ICP = intracranial pressure; IIH = idiopathic intracranial hypertension; LP = lumboperitoneal; SSS = superior sagittal sinus; VP = ventriculoperitoneal.

Article Information

Correspondence Hasan Asif, Victor Horsley Department of Neurosurgery, National Hospital for Neurology and Neurosurgery, Queen Square, London WC1N 3BG, United Kingdom. email: hasan.asif@doctors.org.uk.

INCLUDE WHEN CITING Published online October 6, 2017; DOI: 10.3171/2017.4.JNS162871.

Drs. Asif and Craven contributed equally to this work.

Disclosures Dr. Watkins reports honoraria and advisory board participation for Medtronic, St. Jude Medical, B Braun, and Codman.

© AANS, except where prohibited by US copyright law.

Headings

Figures

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    Bar graphs showing changes in symptoms (A–C) and clinical signs (D–F) following DVSS in primary and secondary groups.

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    Proportional representation of resolution or improvement in symptoms (A) and signs (B), comparing primary and secondary groups.

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    A: Transverse sinus stenosis with a significant pressure gradient before stent insertion. B: Obliteration of the sinus stenosis and pressure gradient after stenting. The values represent pressure (mm Hg) measured at these locations.

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    Graphs of mean and individual patient results for SSS pressure. A and B: The total prestent SSS pressure of 28.2 ± 9.01 mm Hg was reduced to 17.5 ± 6.94 mm Hg 3–4 months (3m) after stent placement (p < 0.0001). The prestent pressure gradient was reduced from 17.5 ± 8.01 mm Hg to 6.17 ± 4.40 mm Hg 3–4 months after stenting (p < 0.0001). C and D: The primary procedure prestent SSS pressure of 28.6 ± 9.33 mm Hg was reduced to 16.8 ± 7.38 mm Hg at 3–4 months after stenting (p < 0.0001). The prestent pressure gradient was reduced from 17.9 ± 7.36 mm Hg to 5.42 ± 4.17 mm Hg 3–4 months after stenting (p < 0.0001). E and F: The secondary procedure prestent SSS pressure of 27.6 ± 8.71 mm Hg was reduced to 17.8 ± 4.40 mm Hg at 3–4 months after stent placement (p < 0.001). The prestent pressure gradient was reduced from 17.0 ± 8.89 mm Hg to 7.13 ± 4.31 mm Hg 3–4 months after stenting (p < 0.001). ****p < 0.0001, ***p < 0.001.

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    Kaplan-Meier curves of the retreatment analysis for total stent retreatment rates (A) and primary versus secondary retreatment rates (B).

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