Idiopathic Intracranial Hypertension. A Systematic Analysis of Transverse Sinus Stenting

Abstract

Background: Idiopathic intracranial hypertension (IIH) is a disorder characterized by signs and symptoms of increased intracranial pressure without structural cause seen on conventional imaging. Hallmark treatment after failed medical management, has been CSF shunting or optic nerve fenestration with the goal of treatment being preservation of vision. Recently, there have been multiple case reports and case series on dural sinus stenting for this disorder.

Objective: We aim to review all published cases and case series of dural sinus stenting for IIH, with analysis of patient presenting symptoms, objective findings (CSF pressures, papilledema, pressure gradients across dural sinuses), follow-up of objective findings, and complications.

Methods: A Medline search was performed to identify studies meeting pre-specified criteria of a case report or case series of patients treated with dural sinus stent placement for IIH. The manuscripts were reviewed and data was extracted.

Results: A total of 22 studies were identified, of which 19 studies representing 207 patients met criteria and were included in the analysis. Only 3 major complications related to procedure were identified. Headaches resolved or improved in 81% of patients. Papilledema improved the (172/189) 90%. Sinus pressure decreased from an average of 30.3 to 15 mm Hg. Sinus pressure gradient decreased from 18.5 (n=185) to 3.2 mm Hg (n=172). Stenting had an overall symptom improvement rate of 87%.

Conclusion: Although all published case reports and case series are nonrandomized, the low complication and high symptom improvement rate make dural sinus stenting for IIH a potential alternative surgical treatment. Standardized patient selection and randomization trials or registry are warranted.

Keywords: Idiopathic intracranial hypertension; Pseudotumor Cerebri; Venous stenosis; angiography; sinus stenting; stenosis; stenting.

Figures

Fig. 1

a, b Venography via microcatheter run from the superior sagittal sinus. c, d Single shot of the microcatheter. A sample of areas of interest is shown and the mean pressure is labeled. The superior sagittal sinus pressure is 29 mm Hg and the sigmoid sinus pressure is 18 mm Hg, giving a gradient of 11 mm Hg. Notice the sheath and guide catheter in the jugular bulb. e Single shot with guide catheter taken across the area of stenosis with a stiff microwire in the superior sagittal sinus in AP view. f, g Single shot of the stent in AP and lateral projection. h, i Venography performed again from the superior sagittal sinus microcatheter run poststenting. j, k Single shot of the microcatheter after treatment. A sample of areas of interest is imaged with a mean pressure labeled poststenting. The superior sagittal sinus pressure is 22 mm Hg and the sigmoid sinus pressure is 18 mm Hg, giving a gradient of 4 mm Hg.