An Evaluation of Styloidectomy as an Adjunct or Alternative to Jugular Stenting in Idiopathic Intracranial Hypertension and Disturbances of Cranial Venous Outflow

Abstract

Background The extent to which intracranial venous sinus obstruction contributes to idiopathic intracranial hypertension (IIH) is debated. The extent to which extracranial venous obstruction contributes to IIH is virtually unexplored. This article describes an interventional approach to extracranial venous outflow in a group of patients with severe intractable symptoms. Objective To describe our technique and experience of styloidectomy combined with jugular stenting in the treatment of skull base narrowing of the jugular veins. Methods Retrospective review of all styloidectomies undertaken at our institution (n = 34), as an adjunct or alternative to jugular venous stenting, with a view to improving cranial venous outflow. Results Eleven styloidectomies were for delayed complications of jugular stenting. Of seven with stent dysfunction, three were improved and four unchanged. Of seven with accessory nerve compression (three had both), four resolved and three improved. In 23 instances, styloidectomy preceded or obviated jugular stenting. Two had a virtual resolution of symptoms, 13 were improved, and 8 were unchanged. Conclusion Styloidectomy can replace, salvage, or complement jugular venous stenting in IIH and disturbances of cranial venous outflow.

Keywords: cranial venous outflow; idiopathic intracranial hypertension; jugular stenting; styloidectomy.

Figures

Fig. 1

In-stent narrowing, presumed from intermittent compression between styloid process and lateral mass of C1: (A) Axial CT scan showing the styloid process (simple arrow) in close proximity to the lateral mass of C1 (asterisk) with the stent (block arrow) in between. Unsubtracted (B) and subtracted (C) frontal films during catheter venogram showing narrowing of the vascular lumen inside the jugular stent at the same level (arrowheads = styloid process). CT, computed tomography.

Fig. 2

Primary styloidectomy followed by stenting: Axial CT scan after intravenous contrast at the C1 level show (A) the jugular veins (simple arrows) narrowed between the styloid processes (block arrows) and lateral masses of C1 (asterisks). (B) Following styloidectomy there is a locule of air at the site of resection (block arrow). (C) Following stenting the stent (simple arrow) dilates the internal jugular vein. CT, computed tomography.

Fig. 3

Schematic of clinical outcomes of 23 primary styloidectomies and follow-up jugular stentings. After styloidectomy symptoms virtually resolved in 1 case (resolved), improved to such an extent in 4 cases that no further treatment was contemplated (improved) and were unchanged or only minimally improved in 18 (unchanged). Of these 16 cases were stented. In one case, symptoms virtually resolved. In nine they were improved and in six unchanged. Some patients in these last two categories, on this level, had further procedures. *One patient in this group had contemporaneous ipsilateral sigmoid sinus and jugular stentings ^Two patients in this group had contemporaneous transverse sinus and jugular stentings. One had a fatal postoperative subdural hemorrhage.