Intracranial Venous Sinus Stenting: A Review of Idiopathic Intracranial Hypertension and Expanding Indications

Abstract

Idiopathic intracranial hypertension (IIH) is a functionally limiting disorder secondary to increased intracranial pressures (ICPs) with a prevalence of one per 100,000 persons. It is estimated to cost >$400 million per year in productively. Symptoms classically consist of chronic headaches, papilledema, and visual loss. The pathophysiology is unknown but postulated to involve increased resistance to cerebrospinal fluid (CSF) absorption. Traditional treatments involve weight loss, acetazolamide, CSF diversion, or optic nerve fenestration. More recent technology has allowed exploration of venous sinus stenosis. Through venous sinus stenting (VSS), the ICPs and venous sinus pressures decrease. After treatment, >75% exhibit an improvement in headaches, ~50% improvement in tinnitus, and ~50 % improvement in ophthalmologic testing. Complications are rare but involve stent stenosis, femoral pseudoaneurysm, and hemorrhages. Future studies will look into controlled studies for VSS as well as expansion to other venous structures of the intracranial circulation.

Intracranial Venous Sinus Stenting in Idiopathic Intracranial Hypertension: A Case Report and Review of the Literature

“…IIH is a disorder secondary to persistent elevated ICP without an otherwise distinguishable pathology [ 15 ]. First described by German physician Heinrich Quincke, it was later labeled benign intracranial hypertension by Foley [ 15 , 16 ]. The diagnosis is based on the classic triad of chronic headaches, papilledema, and the absence of structural pathologies such as intracranial lesions or ventriculomegaly.…”

“…Regardless, the procedure can be effective in preventing the positive feedback loop and breaking the starling-like resistor effect [ 21 ]. By facilitating the distal cerebral outflow, the trans-arachnoid villi gradient can increase, leading to improved CSF resorption [ 15 ]. Appropriate preoperative workup for VSS includes visual field testing, papilledema evaluation, ICP measurement (via ICP monitor or lumbar puncture), and MR venography/cerebral angiography for venous manometry.…”

“…Antiplatelet medication (aspirin 325 and clopidogrel 75 mg daily) is prescribed for 1 week before VSS to keep the P2Y 12 response unit (PRU) and aspirin response units (ARU) levels in the optimal range. Generally, patients are placed on dual antiplatelet therapy for 1 to 6 months and aspirin 325 for a further 3 months to lifetime use [ 15 ]. Several large case series have demonstrated a high success rates for headache symptom relief after VSS [ 15 , 22 , 23 , 24 ].…”

“…Generally, patients are placed on dual antiplatelet therapy for 1 to 6 months and aspirin 325 for a further 3 months to lifetime use [ 15 ]. Several large case series have demonstrated a high success rates for headache symptom relief after VSS [ 15 , 22 , 23 , 24 ]. One paper reported improvement in headache severity in about 80% of patients, and stenosis resolution in the stented segment in 100% of patients over a 2.5 year follow-up, with no complication noted [ 22 ].…”

Magnetic resonance venography for 3-dimensional live guidance during venous sinus stenting

“…As the procedure involves advancing (micro)wires, (micro)catheters, and stents in venous sinuses in a retrograde fashion, there is a risk of inadvertent placement of a wire in a cortical vein resulting in catastrophic hemorrhage (Lavoie et al 2018 ). Of course, one way to make catheterization of the venous system safer is obtaining road map via a trans-arterial injection (Daggubati and Liu 2019 ).…”