Pseudotumor cerebri syndrome: venous sinus obstruction and its treatment with stent placement

Brian K. Owler M.B.,B.S. 1 , Geoffrey Parker F.R.A.N.Z.C.R. 1 , G. Michael Halmagyi M.D., F.R.A.C.P. 1 , Victoria G. Dunne B.Sc. 1 , Verity Grinnell M.D. 1 , David McDowell F.R.A.C.S. 1 , and Michael Besser F.R.A.C.S., F.R.C.S.(C) 1
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  • 1 Departments of Neurosurgery, Neurology, and Radiology, Institute of Clinical Neurosciences, Royal Prince Alfred Hospital, and Department of Surgery, University of Sydney, Australia
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Object. Pseudotumor cerebri, or benign intracranial hypertension, is a condition of raised intracranial pressure in the absence of a mass lesion or cerebral edema. It is characterized by headache and visual deterioration that may culminate in blindness. Pseudotumor cerebri is caused by venous sinus obstruction in an unknown percentage of cases. The purpose of this study was to investigate the role of cerebral venous sinus disease in pseudotumor cerebri and the potential of endoluminal venous sinus stent placement as a new treatment.

Methods. Nine consecutive patients in whom diagnoses of pseudotumor cerebri had been made underwent examination with direct retrograde cerebral venography (DRCV) and manometry to characterize the morphological features and venous pressures in their cerebral venous sinuses. The cerebrospinal fluid (CSF) pressure was measured simultaneously in two patients. If patients had an amenable lesion they were treated using an endoluminal venous sinus stent. Five patients demonstrated morphological obstruction of the venous transverse sinuses (TSs). All lesions were associated with a distinct pressure gradient and raised proximal venous sinus pressures. Four patients underwent stent insertion in the venous sinuses and reported that their headaches improved immediately after the procedure and remained so at 6 months. Vision was improved in three patients, whereas it remained poor in one despite normalized CSF pressures.

Conclusions. Patients with pseudotumor cerebri should be evaluated with DRCV and manometry because venous TS obstruction is probably more common than is currently appreciated. In patients with a lesion of the venous sinuses, treatment with an endoluminal venous sinus stent is a viable alternative for amenable lesions.

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Contributor Notes

Address reprint requests to: Brian K. Owler, M.B., B.S., Department of Neurosurgery, Institute of Clinical Neurosciences, Royal Prince Alfred Hospital, Missenden Road, Camperdown New South Wales 2050, Sydney, Australia. email: brianowl@bigpond.com.
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