Dural venous sinus stenting for medically and surgically refractory idiopathic intracranial hypertension

Abstract

Background Idiopathic intracranial hypertension (IIH) is a syndrome defined by elevated intracranial hypertension without radiographic evidence of a mass lesion in the brain. Dural venous sinus stenosis has been increasingly recognized as a treatable cause, and dural venous sinus stenting (DVSS) is increasingly performed. Methods A 5 year single-center retrospective analysis of consecutive patients undergoing DVSS for medically refractory IIH. Results There were 43 patients with a mean imaging follow-up of 6.5 months and a mean clinical follow-up period of 13.5 months. DVSS was performed as the first procedure for medically refractory IIH in 81.4% of patients, whereas 18.6% of patients included had previously had a surgical procedure (ventriculoperitoneal (VP) shunt or optic nerve sheath fenestration (ONSF)). Headache was present in all patients and after DVSS improved or remained stable in 69.2% and 30.8%, respectively. Visual acuity changes and visual field changes were present in 88.4% and 37.2% of patients, respectively. Visual field improved or remained unchanged in 92%, but worsened in 8% after stenting. There was a stent patency rate of 81.8%, with an 18.2% re-stenosis rate. Of the 43 procedures performed, there was a 100% technical success rate with zero major or minor complications. Conclusion Based on this single-center retrospective analysis, DVSS can be performed with high technical success and low complication rates. A majority of patients presented primarily with headache, and these patients had excellent symptom relief with DVSS alone. Patients presenting with visual symptoms had lower success rates, and this population, if stented, should be carefully followed for progression of symptoms.

Keywords: Idiopathic intracranial hypertension; dural venous sinus stenting; pseudotumor cerebri.

Figure 1.

Proximal to the venous stenosis in sigmoid sinus (long dashed arrow), 5F diagnostic catheter across stenosis in the distal transverse sinus (solid arrow), and tip of 035 guide wire in proximal superior sagittal sinus (small dashed arrow).

Figure 2.

Venogram showing tip of Neuron Max 088 guiding catheter distal to the venous stenosis in distal transverse sinus (long dashed arrow) after advancing over diagnostic catheter and 035 wire.

Figure 3.

Road map image demonstrating position of stent across target stenosis (short solid arrow at distal and proximal ends of stent delivery) over 014 microwire prior to stent delivery and after proximal withdrawal of Neuron Max 088 guiding catheter (long dashed arrow).

Figure 4.

Native unsubtracted image demonstrating position of self-expanding stent across target stenosis (short solid arrow at distal and proximal ends of stent delivery) with no residual stenosis and stable position of Neuron Max 088 guiding catheter (long dashed arrow).