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

Abstract

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.

Stent Survival and Stent-Adjacent Stenosis Rates following Venous Sinus Stenting for Idiopathic Intracranial Hypertension: A Systematic Review and Meta-Analysis

“…Some studies have suggested that longer stents or the use of more than 1 stent may reduce the risk of juxta-stent stenosis after venous stenting, especially in the setting of extrinsic compression or very high-pressure gradients [7]. A recent study by Asif et al [18] reported similar stent survival rates of 87% at 120 days. However, complications were slightly higher at 4.9% and efficacy for reduction of papilledema was lower (63% reduction) than in our study.…”

Men Are from Mars, Idiopathic Intracranial Hypertension Is from Venous: The Role of Venous Sinus Stenosis and Stenting in Idiopathic Intracranial Hypertension

“…21 The appropriate cut-off has not been established to determine which patients are appropriate candidates for stenting, although most interventionalists have used a minimum TSG of 4 to 10 mm Hg. 6,[22][23][24][25][26] Some groups measure the TSG before and after lumbar puncture and do not proceed with stenting if the TSG resolves (suggesting an extrinsic stenosis), believing that only intrinsic stenosis plays a causative role in the disease. However, the positive feedback loop theory discussed earlier and evidence demonstrating efficacy of stenting in patients with both intrinsic and extrinsic stenosis (see later) support consideration of the procedure in both cases.…”

“…In all, we found 808 cases of venous stenting performed for IIH, collated from 30 studies with four or more patients and 12 case reports or series with three or fewer patients. 6,10,20,22,23, Whenever possible, we excluded studies in which the majority of patients had already been reported on. A representative case is depicted in ►Fig.…”

Understanding the complex pathophysiology of idiopathic intracranial hypertension and the evolving role of venous sinus stenting: a comprehensive review of the literature

“…Starke et al 40 reviewed 17 studies from 2002 to 2014 with 185 patients receiving VSS (Tables 2 and 3 in their report). 1,[3][4][5]7,9,10,14,17,18,21,24,29,31,32,35,36,41,45 The locations of stent placement were not included. The authors reported that 78.3% of patients presenting with headache experienced some relief or complete resolution following stent placement.…”

“…40 Others have reported re-vision rates with VSS as high as 13%. 2 While additional studies have shown lower complication rates with VSS than with shunting, 5 the clinical outcomes are not easily comparable, and a randomized, prospective study would provide the greatest evidence to determine the optimal treatment option.…”