Dural venous sinus angioplasty and stenting for the treatment of idiopathic intracranial hypertension

Abstract

BackgroundLumboperitoneal shunt (LPS), ventriculoperitoneal shunt (VPS) and optic nerve sheath fenestration (ONSF) are accepted surgical therapies for medically refractory idiopathic intracranial hypertension (IIH). In the subset of patients with IIH and venous sinus stenosis, dural venous sinus stenting has emerged as an alternative surgical approach.MethodsAll cases of dural stents for IIH at our institution were retrospectively reviewed. Eligibility criteria included medically refractory IIH with documented papilledema and dural venous sinus stenosis of the dominant venous outflow system (gradient ≥10 mm Hg).ResultsFifteen cases (all women) of mean age 34 years were identified. All had failed medical therapy and six had failed surgical intervention. Technical success was achieved in all patients without major periprocedural complications. The mean preprocedural gradient across the venous stenosis was reduced from 24 mm Hg before the procedure to 4 mm Hg after the procedure. Headache resolved or improved in 10 patients. Papilledema resolved in all patients and visual acuity stabilized or improved in 14 patients. There were no instances of restenosis among the 14 patients with follow-up imaging.ConclusionIn this small case series, dural sinus stenting for IIH was performed safely with a high degree of technical success and with excellent clinical outcomes. These results suggest that angioplasty and stenting for the treatment of medically refractory IIH in patients with dural sinus stenosis warrants further investigation as an alternative to LPS, VPS and ONSF.

Meta-Analysis of CSF Diversion Procedures and Dural Venous Sinus Stenting in the Setting of Medically Refractory Idiopathic Intracranial Hypertension

“…Stents included the following: Bridge X3 stent (Medtronic, Santa Rosa, California), 16 S.M.A.R.T. stent (Cordis, Fremont, California), 16 Complete SE stent (Medtronic), 19 Zilver biliary stent (Cook Medical, Bloomington, Indiana), 6,20,21 (Worthington Biochemical, Lakewood, New Jersey), Precise self-expanding stent (Cordis), 21 or Acculink stent (Guidant, St. Paul, Minnesota). 21 After the intervention, headache improved in 83% (101/121 cases) and papilledema improved in 97% of patients (104/108 cases).…”

“…2 Although headache is the most common presenting symptom, seen in 92%-94% of patients, 4,5 IIH also represents a significant cause of chronic headaches. In some patients, there may be vision changes, [6][7][8][9] which, if not corrected, may progress to permanent visual loss. 10,11 The standard medical treatment includes weight loss, acetazolamide, diuretics, and repeat high-volume lumbar punctures.…”

“…Venous sinus stent placement was first described by Higgins et al 15 During the past 20 years, an increasing number of case reports and larger case series have described dural venous sinus stent placement, and reported high rates of technical success and favorable clinical outcomes. 6,7,[16][17][18][19][20][21] In this article, we present the results of the largest meta-analysis of optic nerve sheath fenestration, CSF diversion procedure, and venous sinus stent placement for medically refractory IIH from 1988 to present. We then compare these interventions with a focus on symptom improvement, complications, and the need for repeat procedures.…”

Optic nerve sheath fenestration for idiopathic intracranial hypertension: A seven year review of visual outcomes in a tertiary centre

“…In patients who have been diagnosed with idiopathic intracranial hypertension, when medical therapy fails or when visual dysfunction deteriorates, surgical therapies should be considered. The main procedures performed include lumboperitoneal shunt (LPS) [1][2][3], ventriculoperitoneal shunt (VPS) [3][4][5][6][7], optic nerve sheath fenestration (ONSF) [8][9][10][11] and dural venous sinus stenting (DVSS) [12]. With medical intervention, disease course is generally self-limiting.…”

Stents for Idiopathic Intracranial Hypertension: Meta-Analyzed, Hypo-Analyzed, and In Need of a Trial

“…The power in both the 2013 review and the current meta-analysis lies in the 52-patient study by Ahmed et al, 3 in which CSF opening pressure, an essential criterion for the diagnosis of idiopathic intracranial hypertension (IIH), was not documented in either 11 or 9 patients depending on which meta-analysis one chooses to read. Likewise, the 2 studies with 15 patients each (Fields et al 4 and Albuquerque et al 5 ) did not record the CSF opening pressure for any of their included patients; and both the 4-patient study (Owler et al 6 ) and the 18-patient study (Kumpe et al 7 ) did not record CSF opening pressure in 1 and 4 patients, respectively. A study of 10 patients noted to be without recorded CSF opening pressures in the 2013 analysis (Bussière et al 8 ) is noted in Table 4 of the 2015 meta-analysis as having an opening pressure range of 25-50 cm H 2 0.…”