scholarly journals Transverse venous stenting for the treatment of idiopathic intracranial hypertension, or pseudotumor cerebri

2018 ◽  
Vol 45 (1) ◽  
pp. E11 ◽  
Author(s):  
Justin M. Cappuzzo ◽  
Ryan M. Hess ◽  
John F. Morrison ◽  
Jason M. Davies ◽  
Kenneth V. Snyder ◽  
...  
Keyword(s):  
Pressure Gradient ◽  
Intracranial Hypertension ◽  
Idiopathic Intracranial Hypertension ◽  
Transverse Sinus ◽  
Venous Sinus ◽  
Venous Stenting ◽  
Shunt Placement ◽  
The Mean ◽  
Visual Disturbances

OBJECTIVEIdiopathic intracranial hypertension (IIH) is a commonly occurring disease, particularly among young women of child-bearing age. The underlying pathophysiology for this disease has remained largely unclear; however, the recent literature suggests that focal outflow obstruction of the transverse sinus may be the cause. The purpose of this study was to report one group’s early experience with transverse venous sinus stenting in the treatment of IIH and assess its effectiveness.METHODSThe authors performed a retrospective chart review to identify patients who had undergone stenting of an outflow-obstructed transverse venous sinus for the treatment of IIH at Gates Vascular Institute between January 2015 and November 2017. Patient demographic data of interest included age, sex, BMI, and history of smoking, hypertension, obstructive sleep apnea, hormonal contraceptive use, and acetazolamide therapy. Each patient’s presenting signs and symptoms and whether those symptoms improved with treatment were reviewed. The average opening lumbar puncture (LP) pressure preprocedure, average pressure gradient across the obstructed segment prior to stenting, treatment failure rate (need for shunt placement), and mean follow-up period were calculated.RESULTSOf the 18 patients who had undergone transverse venous stenting for IIH, 16 (88.9%) were women. The mean age of all the patients was 38.3 years (median 38 years). Mean BMI was 34.2 kg/m2 (median 33.9 kg/m2). Presenting symptoms were headache (16 patients [88.9%]), visual disturbances (13 patients [72.2%]), papilledema (8 patients [44.4%]), tinnitus (3 patients [16.7%]), and auditory bruit (3 patients [16.7%]). The mean opening LP pressure pre-procedure was 35.6 cm H2O (median 32 cm H2O). The mean pressure gradient measured proximally and distally to the area of focal obstruction within the transverse sinus was 16.5 cm H2O (median 15 cm H2O). Postprocedurally, 14 patients (77.8%) continued to have headaches; 6 (33.3%) continued to have visual disturbances. No patients continued to have auditory bruit (0%) or papilledema (0%). One patient (5.6%) had new-onset tinnitus postprocedure. Overall improvement of symptoms was noted in 16 patients (88.9%) postprocedure, with 1 patient (5.6%) requiring shunt placement and 2 other patients (11.1%) requiring postprocedural LP to monitor intracranial pressure to determine candidacy for further surgical interventions to treat residual symptoms. The mean duration of follow-up was 194.2 days.CONCLUSIONSTransverse sinus stenting is a rapidly developing technique that has shown good effectiveness and safety in the literature. Authors of the present study found that stenting a flow-obstructed transverse sinus in patients with IIH was a safe and effective way to treat the condition.

scholarly journals Transverse venous sinus stenting for idiopathic intracranial hypertension: Safety and feasibility

2018 ◽  
Vol 31 (5) ◽  
pp. 513-517 ◽  
Author(s):  
Jerry ME Koovor ◽  
Gloria V Lopez ◽  
Kalen Riley ◽  
Juan Tejada
Keyword(s):  
Computed Tomography ◽  
Pressure Gradient ◽  
Intracranial Hypertension ◽  
Idiopathic Intracranial Hypertension ◽  
Transverse Sinus ◽  
Venous Sinus ◽  
Sinus Stenosis ◽  
The Mean ◽  
Computed Tomography Venography

Purpose Transverse sinus stenosis is commonly seen in patients with idiopathic intracranial hypertension. It is not clear whether it is the cause or the result of idiopathic intracranial hypertension. Stenting for idiopathic intracranial hypertension has been carried out in several prior series. Our goal was to evaluate the clinical and imaging follow-up results of patients with idiopathic intracranial hypertension that underwent stenting for this condition at our center. Materials and Methods We reviewed the clinical, venographic and follow-up imaging data in patients who underwent elective transverse sinus stenting during the period from 2011 to 2017. Results In total, 18 patients with idiopathic intracranial hypertension were identified. The mean lumbar cerebrospinal fluid opening pressure recorded was 408 mmH20. Overall, 16 patients met the inclusion criteria and underwent transverse sinus stenting. At venography, the mean pressure gradient across the dominant transverse sinus stenosis was 21 mmHg. The pressure gradient immediately after stenting in all of those measured was negligible. Following stenting, headaches improved in 10 of the 16 cases, with persistent headaches in four patients, one of which had persistent baseline migraines. All cases showed resolution of the papilledema on follow up. Follow-up imaging with computed tomography venography showed that the stents remained widely patent. The follow up in clinic was done for a mean period of 35.5 months. Follow up with computed tomography venography was done for a mean of 10.3 months. Conclusion Venous sinus stenting is a safe and effective procedure. It relieves papilledema in all cases and improves headaches in most cases.

Pattern of pressure gradient alterations after venous sinus stenting for idiopathic intracranial hypertension predicts stent-adjacent stenosis: a proposed classification system

2017 ◽  
Vol 10 (4) ◽  
pp. 391-395 ◽  
Author(s):  
Daniel Raper ◽  
Thomas J Buell ◽  
Dale Ding ◽  
Ching-Jen Chen ◽  
Robert M Starke ◽  
...  
Keyword(s):  
Pressure Gradient ◽  
Intracranial Hypertension ◽  
Idiopathic Intracranial Hypertension ◽  
Venous Pressure ◽  
Patient Characteristics ◽  
Transverse Sinus ◽  
Venous Sinus ◽  
Type I ◽  
Type Ii ◽  
Type Iii

ObjectiveVenous sinus stenting (VSS) is a safe and effective treatment for idiopathic intracranial hypertension (IIH) with angiographic venous sinus stenosis. However, predictors of stent-adjacent stenosis (SAS) remain poorly defined.MethodsWe performed a retrospective review of 47 patients with IIH and intracranial venous stenosis who underwent VSS with pre- and post-stent venography. Patient characteristics, treatments and outcomes were reviewed. Changes in pressure gradient after VSS were classified according to pattern of gradient resolution into types I–III.ResultsType I gradient resolution, in which mean venous pressure (MVP) in the transverse sinus (TS) decreases towards MVP in the sigmoid sinus (SS), occurred in 18 patients (38.3%). Type II gradient resolution pattern, in which SS MVP increases towards that in the TS, occurred in 7patients (14.9%). Type III pattern, in which MVP equilibrates to a middle value, occurred in 22patients (46.8%). SAS occurred in 0%, 28.6%, and 22.7% of patients in types I, II and III, respectively. Compared with patients with type I gradient resolution, SAS was more common in those with type II (p=0.0181) and type III (p=0.0306) patterns.ConclusionsThe pattern of change in the trans-stenosis venous pressure gradient may be predictive of SAS and is a useful tool for classifying the response of the venous obstruction to stenting. A type I pattern appears to represent the ideal response to VSS. Some patients with type II and III changes, particularly if they have other predictors of recurrent stenosis, may benefit from longer initial stent constructs.

Venous sinus stenting for idiopathic intracranial hypertension: a systematic review and meta-analysis

2018 ◽  
Vol 11 (4) ◽  
pp. 380-385 ◽  
Author(s):  
Patrick Nicholson ◽  
Waleed Brinjikji ◽  
Ivan Radovanovic ◽  
Christopher Alan Hilditch ◽  
Anderson Chun On Tsang ◽  
...  
Keyword(s):  
Systematic Review ◽  
Intracranial Hypertension ◽  
Idiopathic Intracranial Hypertension ◽  
Meta Analysis ◽  
Venous Sinus ◽  
Pulsatile Tinnitus ◽  
Venous Stenting ◽  
Excellent Safety Profile ◽  
The Mean ◽  
Rate Of Improvement

BackgroundStenting of the intracranial venous sinuses is used as a treatment in certain cases of idiopathic intracranial hypertension (IIH). Interest in, and experience of, this technique is growing, particularly in recent years. We sought to provide an updated systematic review and meta-analysis of the use of venous stenting in these patients, examining clinical outcomes.MethodsA literature search of venous stenting in IIH patients was performed. Using random-effects meta-analysis, we evaluated the following outcomes: clinical resolution of papilledema; headaches and pulsatile tinnitus; recurrence of symptoms after stenting; and complications.ResultsTwenty articles from 18 different centers were included. In a total of 474 patients. 418 were female (88%). The mean age of the patients was 35, while the mean body mass index (BMI) was 35 kg/m2. Median follow-up was 18 months. The overall rate of improvement in papilloedema was 93.7% (95% CI 90.5% to 96.9%), while the overall rate of improvement or resolution of headache was 79.6% (95% CI 73.3% to 85.9%). Pulsatile tinnitus resolved in 90.3% (95% CI 83.8% to 96.70%), while the overall rate of recurrence of IIH symptoms after stenting was 9.8% (95% CI 6.7% to 13%). The rate of major complications was 1.9% (95% CI 0.07% to 3.1%).ConclusionsVenous sinus stenting in patients with IIH who are refractory to medical therapy appears to have an excellent safety profile and is associated with significant improvements in headaches, pulsatile tinnitus, and papilledema.

scholarly journals Transient resolution of venous sinus stenosis after high-volume lumbar puncture in a patient with idiopathic intracranial hypertension

2018 ◽  
Vol 129 (1) ◽  
pp. 153-156 ◽  
Author(s):  
Thomas J. Buell ◽  
Daniel M. S. Raper ◽  
I. Jonathan Pomeraniec ◽  
Dale Ding ◽  
Ching-Jen Chen ◽  
...  
Keyword(s):  
Pressure Gradient ◽  
Intracranial Hypertension ◽  
Lumbar Puncture ◽  
Idiopathic Intracranial Hypertension ◽  
High Volume ◽  
Transverse Sinus ◽  
Venous Sinus ◽  
Pressure Gradients ◽  
Cross Sectional ◽  
Sinus Stenosis

Stenosis of the transverse sinus (TS) and sigmoid sinus (SS), with a trans-stenosis pressure gradient, has been implicated in the pathophysiology of idiopathic intracranial hypertension (IIH). MRI has shown improvement in TS and SS stenosis after high-volume lumbar puncture (HVLP) in a subset of patients with IIH. The authors present the first report of an IIH patient with immediate post-HVLP TS and SS trans-stenosis pressure gradient reduction and an attendant increase in TS and SS cross-sectional area confirmed using intravascular ultrasonography (IVUS). Recurrence of the patient’s TS-SS stenosis coincided with elevated HVLP opening pressure, and venous sinus stent placement resulted in clinical improvement. This report suggests that TS and SS stenosis may be a downstream effect of elevated intracranial pressure in IIH, rather than its principal etiological mechanism. However, the authors hypothesize that endovascular stenting may obliterate a positive feedback loop involving trans-stenosis pressure gradients, and still benefit appropriately selected patients.

scholarly journals Stent Survival and Stent-Adjacent Stenosis Rates following Venous Sinus Stenting for Idiopathic Intracranial Hypertension: A Systematic Review and Meta-Analysis

2018 ◽  
Vol 7 (6) ◽  
pp. 490-500 ◽  
Author(s):  
Hamidreza Saber ◽  
Whitfield Lewis ◽  
Mahsa Sadeghi ◽  
Gary Rajah ◽  
Sandra Narayanan
Keyword(s):  
Systematic Review ◽  
Intracranial Hypertension ◽  
Idiopathic Intracranial Hypertension ◽  
Meta Analysis ◽  
Case Series ◽  
Causative Factor ◽  
Neurological Complications ◽  
Venous Sinus ◽  
Venous Stenting

Background: Idiopathic intracranial hypertension (IIH) is characterized by an elevated intracranial pressure without any identifiable causative factor such as an intracranial mass. Dural venous sinus stenosis (DVSS) has been suggested to be associated with IIH. Objective: We performed an updated systematic review and meta-analysis to determine clinical outcomes as well as stent survival and stent-adjacent stenosis rates in patients undergoing DVSS for the management of medically refractory IIH. Methods: We searched PubMed, Embase, and Cochrane databases to identify prospective or retrospective cohorts or case series of patients with IIH treated with DVSS between 2000 and 2017. Results: A total of 473 patients were included from 24 studies. Headache was present in 429 (91.8%) patients and resolved or improved in 319/413 (77.2%) after the procedure. Headache, papilledema, visual acuity, and tinnitus improved in 256/330 (77.6%), 247/288 (85.8%), 121/172 (70.3%), and 93/110 (84.5%) patients following DVSS at the final follow-up (mean of 18.3 months). In a meta-analysis of 395 patients with available follow-up data on stenting outcome (mean of 18.9 months), the stent survival and stent-adjacent stenosis rates were 84% (95% confidence interval [CI] 79–87%) and 14% (95% CI 11–18%), respectively. The rate of major neurological complications was less than 2%. Conclusion: Stent-adjacent stenosis is an important complication following venous stenting in patients with DVSS and IIH. Further studies are needed to identify determinants of stent-adjacent stenosis and stent nonsurvival.

scholarly journals Idiopathic Intracranial Hypertension: Contemporary Management and Endovascular Techniques

2020 ◽  
Vol 37 (02) ◽  
pp. 175-181
Author(s):  
David Case ◽  
Joshua Seinfeld ◽  
Christopher Roark ◽  
David Kumpe
Keyword(s):  
Intracranial Pressure ◽  
Pressure Gradient ◽  
Intracranial Hypertension ◽  
Stent Placement ◽  
Idiopathic Intracranial Hypertension ◽  
Venous Sinus ◽  
Endovascular Techniques ◽  
Increased Intracranial Pressure ◽  
Dural Venous Sinus

AbstractIdiopathic intracranial hypertension (IIH) is a disease process of abnormally increased intracranial pressure in the absence of a mass lesion. Medical management, optic nerve fenestration, and surgical shunting procedures have failed to produce consistently successful results. In an unknown percentage of cases, IIH is caused by dural venous sinus obstruction which can be cured by endovascular treatment with dural venous sinus stent placement. This helps prevent progressive vision loss and worsening papilledema caused by underlying increased intracranial pressure from venous outflow obstruction. Patients are required to have an established diagnosis of IIH, preferably made by a neuroophthalmologist, with clearly documented papilledema or at minimum visual disturbance along with lumbar puncture opening pressure greater than 25 cm H2O. Transverse to sigmoid sinus focal narrowing (intraluminal filling defect or extrinsic compression) must be seen during the venous phase of neuroangiography (NA) along with a pressure gradient of 10 mm Hg or greater across the focal narrowing during dural venous sinus pressure monitoring. A successful reduction is defined as a pressure gradient of less than 10 mm Hg after stent placement. Neuroophthalmologic follow-up occurs within 1 to 2 months to assess for changes in papilledema. If papilledema is unchanged or worsened, NA and hemodynamic evaluation is repeated for consideration of restenting. Appropriate patient selection criteria are required for IIH venous sinus stenting. The utilization of refined endovascular techniques along with postprocedure follow-up protocols can ultimately cure IIH for a select group of patients.

Venous Sinus Pulsatility and the Potential Role of Dural Incompetence in Idiopathic Intracranial Hypertension

Neurosurgery ◽  
2012 ◽  
Vol 71 (4) ◽  
pp. 877-884 ◽  
Author(s):  
Marc A. Lazzaro ◽  
Ziad Darkhabani ◽  
Bernd F. Remler ◽  
Sang H. Hong ◽  
Thomas J. Wolfe ◽  
...  
Keyword(s):  
Pressure Gradient ◽  
Intracranial Hypertension ◽  
Stent Implantation ◽  
Idiopathic Intracranial Hypertension ◽  
Potential Role ◽  
Transverse Sinus ◽  
Venous Sinus ◽  
Dural Sinus ◽  
Complete Understanding

Abstract BACKGROUND: Idiopathic intracranial hypertension (IIH) remains a poorly understood and therapeutically challenging disease. Enthusiasm has emerged for endovascular therapy with stent reconstruction of dural sinus narrowing; however, a complete understanding of the hydrodynamic dysequilibrium is lacking. OBJECTIVE: To review and characterize catheter manometry findings including pulsatility changes within the venous sinuses in IIH. METHODS: Cases of venous sinus stent implantation for IIH were retrospectively reviewed. RESULTS: Three cases of venous sinus stent implantation for treatment of IIH are reported. All cases demonstrated severe narrowing (>70%) within the transverse sinus and a high pressure gradient across the lesion (>30 mm Hg). Stent implantation resulted in pulsatility attenuation, correction of pressure gradient, and improvement of flow. CONCLUSION: We report the finding of high venous sinus pulsatility attenuation after stent implantation for dural sinus narrowing and propose the hypothesis that this finding is a marker of advanced dural sinus incompetence. This characteristic may be useful in identifying patients who would benefit from endovascular stent remodeling.

Dural sinus stenting for idiopathic intracranial hypertension: factors associated with hemodynamic failure and management with extended stenting

2016 ◽  
Vol 9 (9) ◽  
pp. 867-874 ◽  
Author(s):  
David A Kumpe ◽  
Joshua Seinfeld ◽  
Xianchen Huang ◽  
Quelin Mei ◽  
David E Case ◽  
...  
Keyword(s):  
Pressure Gradient ◽  
Intracranial Hypertension ◽  
Idiopathic Intracranial Hypertension ◽  
Female Gender ◽  
Transverse Sinus ◽  
Dural Sinus ◽  
Factors Associated ◽  
Extrinsic Compression ◽  
Hemodynamic Failure

BackgroundSome patients undergoing dural sinus stenting for idiopathic intracranial hypertension (IIH) develop clinical and hemodynamic failure (recurrence of the pressure gradient) owing to stent-adjacent stenosis.ObjectiveTo characterize factors associated with hemodynamic failure, and to describe outcomes of patients after repeat stenting.Materials and methodsWe reviewed the initial and follow-up clinical, venographic, and hemodynamic data in 39 patients with IIH treated over 17 years with stenting. Thirty-two had follow-up angiographic and hemodynamic data at 1–99 months (mean 27.6, median 19.5 months). Eight patients were treated with 12 repeat stenting procedures, including extended stenting into the superior sagittal sinus (SSS).ResultsAll patients had an initial successful hemodynamic result with the pressure gradient reduced from 10–43 to 0–7 mm Hg. 10/32 patients (31.3%), all women, developed new stenoses in the transverse sinus or posterior SSS above the stent with a recurrent pressure gradient. 7/9 patients with pure extrinsic stenosis of the transverse-sigmoid junction pre-stenting developed new stenoses and hemodynamic failure. All patients with hemodynamic failure who were restented had early and mid-term documented hemodynamic success at 1.7–50 months. They were free from papilledema at 3.8–50 months after the last restenting, and 11.5–99.5 months after initial stent placement (mean 45.3, median 38.5 months).ConclusionsPure extrinsic compression of the transverse-sigmoid junction and female gender were strongly associated with hemodynamic failure. Eight patients with hemodynamic failure who were restented had successful control of papilledema, including 4/4 who had extended stenting into the SSS.

Abstract 167: Efficacy of Endovascular Treatment for Idiopathic Intracranial Hypertension: Cerebral Venous Sinus Stenosis Treated by Stenting

Stroke ◽  
2020 ◽  
Vol 51 (Suppl_1) ◽  
Author(s):  
Jian Chen ◽  
Liqun Jiao ◽  
Wenbo Zhao ◽  
Yuchuan Ding ◽  
Hongqi Zhang ◽  
...  
Keyword(s):  
Pressure Gradient ◽  
Intracranial Hypertension ◽  
Idiopathic Intracranial Hypertension ◽  
Clinical Symptoms ◽  
Sinus Thrombosis ◽  
Venous Sinus ◽  
Surgical Approaches ◽  
Stenosis Rate ◽  
Sinus Stenosis

Objective: To explore the diagnosis of cerebral venous sinus stenosis (CVSS) in idiopathic intracranial hypertension (IIH), and to evaluate the efficacy and risk of venous sinus stenting treatment for CVSS. Methods: 40 patients with refractory IIH complicated with CVSS underwent examination with magnetic resonance venography (MRV), digital subtraction angiography (DSA) and direct retrograde cerebral venography and manometry to confirm morphologic features of IlH and measure venous pressure.The CSF pressure on lumbar puncture ranged from 250 to 500 mmH 2 O with normal composition. All patients had headache, and funduscopic examination demonstrated papilledema for all patients. 28 patients who showed severe stenosis of venous sinuses with the pressure gradient across the stenosis >100 mmH 2 O were treated with venous sinus stenting and were followed-up for more than 12 months.Intrasinus pressures were recorded before and after the procedure and correlated with clinical outcome during the follow-up period. Results: Sinus stenting angioplasty was successful in all 28 patients.In all patients venous sinus stenosis was improved after stenting procedure (the residual stenosis rate<20%) and intrasinus pressure was reduced (the pressure gradient vanished or<20 mmH 2 O ).The clinical symptoms in all the patients were improved or disappeared at discharge and intracranial pressures were normalized within 3 months after the procedure.During the follow-up period of (16.3±11) months (range 12 to 36 months),no patient had recurrence of IIH.In all cases, DSA or MRV was performed at 12-month follow-up and demonstrated the absence of sinus thrombosis or in-stent stenosis. Conclusions: Patients with refractory IIH should be assessed for CVSS. MRV or DSA was recommended for these patients as a routine work-up.Cerebral venography and manometry are helpful to evaluate the relation between venous outflow obstruction and intracranial hypertension.If severe CVSS is presented in patients who experienced medical treatment failure, endovascular stent placement could be an alternative to classic surgical approaches. Additional randomized and controlled clinical research is deserved.

Safety and efficacy of intravascular ultrasound as an adjunct to stenting for cerebral venous sinus stenosis–induced idiopathic intracranial hypertension: a pilot study

2020 ◽  
Vol 132 (3) ◽  
pp. 749-754 ◽  
Author(s):  
Feng Yan ◽  
Gary Rajah ◽  
Yuchuan Ding ◽  
Yang Hua ◽  
Hongqi Zhang ◽  
...  
Keyword(s):  
Intracranial Hypertension ◽  
Intravascular Ultrasound ◽  
Stent Placement ◽  
Idiopathic Intracranial Hypertension ◽  
Venous Sinus ◽  
Wall Thickening ◽  
Venous Stenting ◽  
Venous Stenosis ◽  
Sinus Stenosis

OBJECTIVESymptomatic intracranial hypertension can be caused by cerebral venous sinus stenosis (CVSS) and cerebral venous sinus thrombotic (CVST) stenosis, which is usually found in some patients with idiopathic intracranial hypertension (IIH). Recently, at the authors’ center, they utilized intravascular ultrasound (IVUS) as an adjunct to conventional venoplasty or stenting to facilitate diagnosis and accurate stent placement in CVSS.METHODSThe authors designed a retrospective review of their prospective database of patients who underwent IVUS-guided venous sinus stenting between April 2016 and February 2017. Clinical, radiological, and ophthalmological information was recorded and analyzed. IVUS was performed in 12 patients with IIH (9 with nonthrombotic CVSS, 3 with secondary stenosis combined with CVST) during venoplasty through venous access. The IVUS catheter was used from a proximal location to the site of stenosis. Post-stenting follow-up, including symptomatic improvement, stent patency, and adjacent-site stenosis, was assessed at 1 year.RESULTSThirteen stenotic cerebral sinuses in 12 patients were corrected using IVUS-guided stenting. No technical or neurological complications were encountered. The IVUS images were excellent for the diagnosis of the stenosis, and intraluminal thrombi were clearly visualized by using IVUS in 3 (25%) of the 12 patients. A giant arachnoid granulation was demonstrated in 1 (8.3%) of the 12 patients. Intravenous compartments or septations (2 of 12, 16.7%) and vessel wall thickening (6 of 12, 50%) were also noted. At 1-year follow-up, 10 of 12 patients were clinically symptom-free in our series.CONCLUSIONSIVUS is a promising tool with the potential to improve the diagnostic accuracy in IIH, aiding in identification of the types of intracranial venous stenosis, assisting in stent selection, and guiding stent placement. Further study of the utility of IVUS in venous stenting and venous stenosis pathology is warranted.

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