title: Venous sinus stenting for reduction of intracranial pressure in IIH: a prospective pilot study.
abstract: OBJECTIVE Idiopathic intracranial hypertension (IIH) may cause blindness due to elevated intracranial pressure (ICP). Venous sinus stenosis has been identified in select patients, leading to stenting as a potential treatment, but its effects on global ICP have not been completely defined. The purpose of this pilot study was to assess the effects of venous sinus stenting on ICP in a small group of patients with IIH. METHODS Ten patients for whom medical therapy had failed were prospectively followed. Ophthalmological examinations were assessed, and patients with venous sinus stenosis on MR angiography proceeded to catheter angiography, venography with assessment of pressure gradient, and ICP monitoring. Patients with elevated ICP measurements and an elevated pressure gradient across the stenosis were treated with stent placement. RESULTS All patients had elevated venous pressure (mean 39.5 ± 14.9 mm Hg), an elevated gradient across the venous sinus stenosis (30.0 ± 13.2 mm Hg), and elevated ICP (42.2 ± 15.9 mm Hg). Following stent placement, all patients had resolution of the stenosis and gradient (1 ± 1 mm Hg). The ICP values showed an immediate decrease (to a mean of 17.0 ± 8.3 mm Hg), and further decreased overnight (to a mean of 8 ± 4.2 mm Hg). All patients had subjective and objective improvement, and all but one improved during follow-up (median 23.4 months; range 15.7-31.6 months). Two patients developed stent-adjacent stenosis; retreatment abolished the stenosis and gradient in both cases. Patients presenting with papilledema had resolution on follow-up funduscopic imaging and optical coherence tomography (OCT) and improvement on visual field testing. Patients presenting with optic atrophy had optic nerve thinning on follow-up OCT, but improved visual fields. CONCLUSIONS For selected patients with IIH and venous sinus stenosis with an elevated pressure gradient and elevated ICP, venous sinus stenting results in resolution of the venous pressure gradient, reduction in ICP, and functional, neurological, and ophthalmological improvement. As patients are at risk for stent-adjacent stenosis, further follow-up is necessary to determine long-term outcomes and gain an understanding of venous sinus stenosis as a primary or secondary pathological process behind elevated ICP.
authors.affiliation: Departments of 1 Neurological Surgery.|Radiology and Medical Imaging.
authors.forename: Kenneth C
authors.initials: KC
authors.lastname: Liu
authors.affiliation: Departments of 1 Neurological Surgery.
authors.forename: Robert M
authors.initials: RM
authors.lastname: Starke
authors.affiliation: Radiology and Medical Imaging.
authors.forename: Christopher R
authors.initials: CR
authors.lastname: Durst
authors.affiliation: Departments of 1 Neurological Surgery.
authors.forename: Tony R
authors.initials: TR
authors.lastname: Wang
authors.affiliation: Departments of 1 Neurological Surgery.
authors.forename: Dale
authors.initials: D
authors.lastname: Ding
authors.affiliation: Departments of 1 Neurological Surgery.|Radiology and Medical Imaging.
authors.forename: R Webster
authors.initials: RW
authors.lastname: Crowley
authors.affiliation: Departments of 1 Neurological Surgery.|Ophthalmology, and.|Neurology, University of Virginia, Charlottesville, Virginia.
authors.forename: Steven A
authors.initials: SA
authors.lastname: Newman
mesh_terms: D000293:Adolescent; D000328:Adult; D003392:Cranial Sinuses / Q000601:surgery*; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D010865:Pilot Projects; D011446:Prospective Studies; D011559:Pseudotumor Cerebri / Q000601:surgery*; D012189:Retrospective Studies; D015607:Stents; D016896:Treatment Outcome
keywords: BMI = body mass index; ICA = internal carotid artery; ICP = intracranial pressure; IIH = idiopathic intracranial hypertension; OCT = optical coherence tomography; idiopathic intracranial hypertension; interventional neurosurgery; optical coherence tomography; pressure gradient; pseudotumor cerebri; stent; venous stenosis