Pseudotumor Cerebri: A New Door Opens for Treatment

Crosa, Roberto; Marabotto, O.; Meehroff, G.; Legnani, Cristina; Boschi, Jorge; Negrotto, A.; TerBrugge, K G; Lasjaunias, P.

doi:10.1177/159101990701300204

Cited by 9 publications

(3 citation statements)

References 19 publications

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“…1). 2,6,7,[10][11][12][13][14][15][16]18,19,[21][22][23]25,28,29,[31][32][33][34][35][36][37][38][39][42][43][44] As a group, the venous pressure gradients across the stenotic segments ranged from 2 to 77 mm Hg with a mean of 22.1 mm Hg. The mean duration of clinical follow-up was 18.3 months.…”

Section: Resultsmentioning

confidence: 99%

Fifty shades of gradients: does the pressure gradient in venous sinus stenting for idiopathic intracranial hypertension matter? A systematic review

McDougall

Ban

Beecher

et al. 2019

Journal of Neurosurgery

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OBJECTIVE The role of venous sinus stenting (VSS) for idiopathic intracranial hypertension (IIH) is not well understood. The aim of this systematic review is to attempt to identify subsets of patients with IIH who will benefit from VSS based on the pressure gradients of their venous sinus stenosis. METHODS MEDLINE/PubMed was searched for studies reporting venous pressure gradients across the stenotic segment of the venous sinus, pre- and post-stent pressure gradients, and clinical outcomes after VSS. Findings are reported according to the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. RESULTS From 32 eligible studies, a total of 186 patients were included in the analysis. Patients who had favorable outcomes had higher mean pressure gradients (22.8 ± 11.5 mm Hg vs 17.4 ± 8.0 mm Hg, p = 0.033) and higher changes in pressure gradients after stent placement (19.4 ± 10.0 mm Hg vs 12.0 ± 6.0 mm Hg, p = 0.006) compared with those with unfavorable outcomes. The post-stent pressure gradients between the 2 groups were not significantly different (2.8 ± 4.0 mm Hg vs 2.7 ± 2.0 mm Hg, p = 0.934). In a multivariate stepwise logistic regression controlling for age, sex, body mass index, CSF opening pressure, pre-stent pressure gradient, and post-stent pressure gradient, the change in pressure gradient with stent placement was found to be an independent predictor of favorable outcome (p = 0.028). Using a pressure gradient of 21 as a cutoff, 81/86 (94.2%) of patients with a gradient > 21 achieved favorable outcomes, compared with 82/100 (82.0%) of patients with a gradient ≤ 21 (p = 0.022). CONCLUSIONS There appears to be a relationship between the pressure gradient of venous sinus stenosis and the success of VSS in IIH. A randomized controlled trial would help elucidate this relationship and potentially guide patient selection.

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Section: Resultsmentioning

confidence: 99%

Fifty shades of gradients: does the pressure gradient in venous sinus stenting for idiopathic intracranial hypertension matter? A systematic review

McDougall

Ban

Beecher

et al. 2019

Journal of Neurosurgery

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“…When 2 studies appeared to consist of mostly overlapping patient sets, only the larger study was used whenever possible. In total, 49 studies with 4 or more stented patients (4 prospective 19,[25][26][27] and 45 retrospective 20,21, ) and 18 reports with 1-3 patients [71][72][73][74][75][76][77][78][79][80][81][82][83][84][85][86][87][88] were found, yielding a total of 1,626 IIH patients treated with venous stenting. Figure 1 details a demonstrative case in which a worsening of visual fields despite medical treatment led to the decision to advance to venous stenting.…”

Section: Meta-analysis Of Outcomes Data For Venous Stenting For Idiop...mentioning

confidence: 99%

Idiopathic Intracranial Venous Hypertension: Toward a Better Understanding of Venous Stenosis and the Role of Stenting in Idiopathic Intracranial Hypertension

Dinkin¹,

Patsalides²

2023

Journal of Neuro-Ophthalmology

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Background: Venous sinus stenosis, typically at the junction of the transverse and sigmoid sinus, is increasingly recognized as a contributor to the pathophysiology of idiopathic intracranial hypertension (IIH), whether it be the intrinsic type that does not reverse with normalization of intracranial pressure or the extrinsic type, which does. Efforts to treat the stenosis and reduce the associated transstenotic gradient through placement of a stent at the site of stenosis have been studied over the past 2 decades, primarily through retrospective studies, with variable emphasis on formal visual testing and direct assessment of poststent opening pressure. Most studies have presented evidence for utilization of stenting as an alternative to cerebrospinal fluid shunting or optic nerve sheath fenestration in patients with IIH who harbor the stenosis and are refractory to or intolerant of intracranial pressure–lowering medications, but an assessment of the current data is needed to better understand the role of stenting for this patient population. Evidence Acquisition: A search in PubMed was made for “IIH,” “papilledema,” and “venous stenting.” Data pre and post stenting, including symptoms attributable to IIH, intracranial pressure, papilledema, retinal nerve fiber layer thickening on optical coherence tomography, and visual field assessment (mean deviation), were collected. Need for retreatment and complications were assessed among all studies. Studies using stenting for special circumstances, such as cerebrospinal leaks or for stenosis along anomalous vessels, were reviewed. Results: In total, 49 studies (45 retrospective and 4 prospective) and 18 case reports (with 3 or less patients) were found and included in the analysis, for a total of 1,626 patients. In 250 patients in whom poststent intracranial pressure was measured, the mean value was 19.7 cm H2O, reduced from a mean of 33 cm H2O. Transient visual obscurations resolved in 79.6% of 201 patients who complained of it, pulsatile tinnitus resolved in 84.7% of 515, diplopia resolved in 93% of 86 patients, and nonspecific visual symptoms such as “blurry vision” improved in 76.2% of 537 patients. Headaches resolved in 36% and improved in a further 40.7% of 1,105 patients in whom they were documented before stenting. Of 1,116 with papilledema, 40.8% demonstrated resolution and 38.2% improvement. The mean retinal nerve fiber layer thickness improved from 170.2 µm to 89.2 µm among 402 eyes in which optical coherence tomography was used to measure it. Among 135 eyes in which formal visual fields were performed pre and post stenting, the prestent average mean deviation of −7.35 dB improved to −4.72 dB after stenting. Complications associated with stenting included in-stent stenosis or thrombosis, subdural hematoma, intracerebral hematoma, cerebral edema, stent migration, and death. A recurrence of symptoms requiring a follow-up surgical intervention occurred in 9%. Conclusions: A growing body of evidence supports the use of venous sinus stenting as a viable option for medically refractory IIH, especially when papilledema threatens visual function. Complication and failure rates seem to be similar to alternative surgical approaches, although serious neurological sequalae can rarely occur. Emerging studies evaluating stent type, including novel stents designed for use in the venous system, may help improve ease of the procedure and long-term success rates. Prospective head-to-head studies are needed to better understand the performance of stenting compared with other interventions.

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“…However, two (16.6%) cases were entirely "headache-free;" surprisingly, this finding was not discussed further. [11] De Simone et al[12] reported on two PTCS patients without headache. They concluded that the lack of headache in one patient may reflect an inherited condition of protection against neurovascular headache development, since neither the patient nor her first-degree relatives reported headache in their lives.…”

Section: Suggested Pseudotumor Cerebri Syndromementioning

confidence: 99%

Primary pseudotumor cerebri syndrome without headache: a report of 3 cases and review of the literature

Amin¹

2015

Gulhane Med J

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Background: Pseudotumor cerebri syndrome (PTCS) encompasses a variable combination of signs and symptoms of raised intracranial pressure without a brain tumor or space occupying lesion. The lack of continuous pancephalic/retro-orbital headache or pulsating tinnitus is a well-documented observation. Cases' presentation: We report on 3 non-obese women who presented with progressive visual loss. All of them stated that their headache was mild, nonsignificant, intermittent, or migraine-like which did resolve spontaneously or after the use of oral paracetamol. Nausea and/or vomiting were present. Variable degrees of reduction in the visual acuity, enlargement of the physiological blond spot, peripheral visual field constriction, papilloedema, and secondary optic atrophy were found. Their CSF opening pressure was 42, 37, and 39 cm H2O respectively; other CSF parameters were normal. Their diagnosis was primary PTCS. Conclusion: PTCS remains a diagnostic challenge. The lack of significant headache (and obesity) contributed to the delayed diagnosis with resultant visual loss.

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Pseudotumor Cerebri: A New Door Opens for Treatment

Cited by 9 publications

References 19 publications

Fifty shades of gradients: does the pressure gradient in venous sinus stenting for idiopathic intracranial hypertension matter? A systematic review

Fifty shades of gradients: does the pressure gradient in venous sinus stenting for idiopathic intracranial hypertension matter? A systematic review

Idiopathic Intracranial Venous Hypertension: Toward a Better Understanding of Venous Stenosis and the Role of Stenting in Idiopathic Intracranial Hypertension

Primary pseudotumor cerebri syndrome without headache: a report of 3 cases and review of the literature

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