Major complications of dural venous sinus stenting for idiopathic intracranial hypertension: case series and management considerations

Abstract

Background: Venous sinus stenting (VSS) is a safe, effective, and increasingly popular treatment option for selected patients with idiopathic intracranial hypertension (IIH). Serious complications associated with VSS are rarely reported.

Methods: Serious complications after VSS were identified retrospectively from multicenter databases. The cases are presented and management strategies are discussed.

Results: Six major acute and chronic complications after VSS were selected from a total of 811 VSS procedures and 1466 venograms for IIH. These included an acute subdural hematoma from venous extravasation, cases of both intraprocedural and delayed stent thrombosis, an ultimately fatal cerebellar hemorrhage resulting in acute obstructive hydrocephalus, venous microcatheter perforation during venography and manometry, and a patient who developed subarachnoid hemorrhage and subdural hematoma after cerebellar cortical vein perforation. The six cases are reviewed and learning points regarding complication avoidance and management are presented.

Conclusion: We report on six rare, major complications after VSS for IIH. Familiarity with these potential complications and appropriate timely management may allow for good clinical outcomes.

Keywords: complication; stent; vein.

Figure 1

Case 1: (A) Pre-stenting and (B) post-stenting venous phase angiogram demonstrating venous extravasation along the floor of the middle fossa (blue arrow). (C) Non-contrasted head CT obtained immediately after the patient decompensated in the PACU. (D) Non-contrasted head CT obtained postoperative day 1 after craniotomy for evacuation of the subdural hematoma. PACU, post-anesthesia care unit.

Figure 2

Case 2: AP venogram demonstrating (A) stenosis (red arrow) of the dominant right TS. (B) Thrombosis of the right TS stent (blue arrow). (C) AP venogram demonstrating thrombosis of the right TS stent (green arrow) and (D) following successful recanalization. AP, anteroposterior; TS, transverse sinus.

Figure 3

(A) Case 3: Axial CTA of the head demonstrating no enhancement or hemorrhage adjacent to the right TS stent (blue arrow). (B) Oblique catheter venogram on post-revascularization day 1 after 24 hours on tPA drip demonstrates some thrombus within the right TS stent (red arrow), with (C) resolution on post-revascularization day 2 (black arrow). (D) Case 4: Left sided cerebellar ICH with (E) obstructive hydrocephalus. (F) Case 6: Non-contrast axial head CT demonstrating SAH in the left choroidal fissure with IVH. CTA, CT angiography; ICH, intracerebral hemorrhage; IVH, intraventricular hemorrhage; SAH, subarachnoid hemorrhage; tPA, tissue plasminogen activator; TS, transverse sinus.

Figure 4

Case 5: (A) Lateral venogram demonstrating the tip of the microcatheter in the subdural space of the posterior fossa. (B) AP venous phase angiogram demonstrating no cortical venous extravasation. (C) DynaCT sagittal view demonstrating contrast in the posterior fossa subdural space (red arrows). (D) AP and (E) lateral venography after microcatheter withdrawal demonstrating no extravasation from the sinus. (F) Head CT 5 hours post-procedure demonstrating no subdural hematoma. AP, anteroposterior.