Improved Ophthalmic Outcomes Following Venous Sinus Stenting in Idiopathic Intracranial Hypertension

Oyemade, Kafayat A.; Xu, Timothy T.; Brinjikji, Waleed; Cutsforth‐Gregory, Jeremy K.; Lanzino, Giuseppe; Kallmes, David F.; Moss, Heather; Dodd, Robert H.; Bhatti, M. Tariq; Chen, John J.

doi:10.3389/fopht.2022.910524

Cited by 10 publications

(9 citation statements)

References 30 publications

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“…Comparison to previous literature: Our study adds to the current scarcity of evidence on pharmacotherapeutic outcomes after TSS. Previous studies found that 31%-100% of patients can be weaned off ICP-related pharmacotherapy completely after TSS, [13][14][15][16][17][18][19][20] and that a further 17%-30% can be weaned to lower doses. 13,15,19 Our study showed similar rates of pharmacotherapy discontinuation (71%) and reduction (29%).…”

Section: Summary Of Resultsmentioning

confidence: 99%

“…In studies that enrolled patients with both fulminant and non-fulminant IIH, the rate at which visual acuity improves, remains stable, and worsens after TSS ranges from 8%-87%, 14%-92%, and 0%-21%, respectively. 13,15,18,[21][22][23][24][25][26][27] For VFMD, these values are 17%-80%, 9%-83%, and 0%-8%, respectively. 13,15,17,18,21,24,27 Among patients with fulminant IIH, the rate at which visual acuity improves, remains stable, and worsens after TSS ranges from 25-100%, 0-50%, and 25-100%, respectively.…”

Section: Summary Of Resultsmentioning

confidence: 99%

“…13,15,18,[21][22][23][24][25][26][27] For VFMD, these values are 17%-80%, 9%-83%, and 0%-8%, respectively. 13,15,17,18,21,24,27 Among patients with fulminant IIH, the rate at which visual acuity improves, remains stable, and worsens after TSS ranges from 25-100%, 0-50%, and 25-100%, respectively. 14,21 For VFMD, these values are 75-100%, 0%, and 0-25%, demonstrating less heterogeneity than VA outcomes.…”

Section: Summary Of Resultsmentioning

confidence: 99%

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Visual and pharmacotherapy outcomes after transverse sinus stenting for idiopathic intracranial hypertension

Handzic,

Xie,

Hendriks

et al. 2023

Preprint

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Background Transverse sinus stenting (TSS) is an increasingly commonly used treatment for patients with idiopathic intracranial hypertension (IIH). However, detailed neuro-ophthalmic evidence on visual and pharmacotherapy outcomes after TSS is scarce and heterogeneous. This study aimed to describe the visual outcomes of patients undergoing TSS for IIH and to ascertain the proportion of patients who could be weaned off intracranial pressure (ICP)-lowering medication after this procedure. Methods A retrospective chart review of all patients with IIH from two tertiary academic neuro-ophthalmology practices who underwent TSS between 2016 and 2022 was performed. Indications for stenting included failure of pharmacotherapy, intolerance of pharmacotherapy, and acute vision loss from severe papilledema. Data on demographics, symptoms, visual function, and TSS were collected. The paired Wilcoxon rank sum test was used to compare changes in visual acuity (VA) and visual field mean deviation (VFMD) between the baseline and most recent visits. Results Of 435 patients with IIH, 15 (13 women) met inclusion criteria. After TSS, ICP-lowering pharmacotherapy was discontinued in 10 patients and decreased in 4; one patient was not on ICP-lowering medication before TSS. All patients experienced resolution or improvement of symptoms (10 resolution, 4 improved, 1 asymptomatic before TSS) and papilledema (11 resolution, 4 improved) after stenting. Papilledema resolution was confirmed with optical coherence tomography-measured peripapillary nerve fibre layer thickness (median decrease 147 um, interquartile range 41.8 - 242.8, p<0.001). Change in VA between the baseline and most recent visit was not significant, but VFMD improved significantly after stenting (median increase 3.0, IQR 2.0 - 4.2, p<0.001). No patient developed transverse sinus restenosis nor in-stent thrombosis postoperatively across a median venogram follow-up of 20.8 weeks (11.3 - 49.8) and no patient required subsequent surgical intervention for IIH. Conclusion In this cohort of patients with IIH and fulminant presentation, medication resistance, or medication intolerance, TSS was an effective and safe treatment modality. Most patients were able to stop ICP-lowering medications while demonstrating striking improvement in symptomatology and visual function.

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Section: Summary Of Resultsmentioning

confidence: 99%

Section: Summary Of Resultsmentioning

confidence: 99%

Section: Summary Of Resultsmentioning

confidence: 99%

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Visual and pharmacotherapy outcomes after transverse sinus stenting for idiopathic intracranial hypertension

Handzic,

Xie,

Hendriks

et al. 2023

Preprint

View full text Add to dashboard Cite

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“…Nine of the studies used automated visual fields (HVF), among which 2 used a 24-2 program, 2 used a 30-2 program, and 4 did not specify. One study also used kinetic perimetry for a few patients with severe loss, 69 whereas another study did not describe the type of visual field analyzer used. Although 7 studies listed the MDs pre- and poststenting for each patient, 3 studies only included the average MD scores for the entire cohort.…”

Section: Meta-analysis Of Outcomes Data For Venous Stenting For Idiop...mentioning

confidence: 99%

Idiopathic Intracranial Venous Hypertension: Toward a Better Understanding of Venous Stenosis and the Role of Stenting in Idiopathic Intracranial Hypertension

Dinkin¹,

Patsalides²

2023

Journal of Neuro-Ophthalmology

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Background: Venous sinus stenosis, typically at the junction of the transverse and sigmoid sinus, is increasingly recognized as a contributor to the pathophysiology of idiopathic intracranial hypertension (IIH), whether it be the intrinsic type that does not reverse with normalization of intracranial pressure or the extrinsic type, which does. Efforts to treat the stenosis and reduce the associated transstenotic gradient through placement of a stent at the site of stenosis have been studied over the past 2 decades, primarily through retrospective studies, with variable emphasis on formal visual testing and direct assessment of poststent opening pressure. Most studies have presented evidence for utilization of stenting as an alternative to cerebrospinal fluid shunting or optic nerve sheath fenestration in patients with IIH who harbor the stenosis and are refractory to or intolerant of intracranial pressure–lowering medications, but an assessment of the current data is needed to better understand the role of stenting for this patient population. Evidence Acquisition: A search in PubMed was made for “IIH,” “papilledema,” and “venous stenting.” Data pre and post stenting, including symptoms attributable to IIH, intracranial pressure, papilledema, retinal nerve fiber layer thickening on optical coherence tomography, and visual field assessment (mean deviation), were collected. Need for retreatment and complications were assessed among all studies. Studies using stenting for special circumstances, such as cerebrospinal leaks or for stenosis along anomalous vessels, were reviewed. Results: In total, 49 studies (45 retrospective and 4 prospective) and 18 case reports (with 3 or less patients) were found and included in the analysis, for a total of 1,626 patients. In 250 patients in whom poststent intracranial pressure was measured, the mean value was 19.7 cm H2O, reduced from a mean of 33 cm H2O. Transient visual obscurations resolved in 79.6% of 201 patients who complained of it, pulsatile tinnitus resolved in 84.7% of 515, diplopia resolved in 93% of 86 patients, and nonspecific visual symptoms such as “blurry vision” improved in 76.2% of 537 patients. Headaches resolved in 36% and improved in a further 40.7% of 1,105 patients in whom they were documented before stenting. Of 1,116 with papilledema, 40.8% demonstrated resolution and 38.2% improvement. The mean retinal nerve fiber layer thickness improved from 170.2 µm to 89.2 µm among 402 eyes in which optical coherence tomography was used to measure it. Among 135 eyes in which formal visual fields were performed pre and post stenting, the prestent average mean deviation of −7.35 dB improved to −4.72 dB after stenting. Complications associated with stenting included in-stent stenosis or thrombosis, subdural hematoma, intracerebral hematoma, cerebral edema, stent migration, and death. A recurrence of symptoms requiring a follow-up surgical intervention occurred in 9%. Conclusions: A growing body of evidence supports the use of venous sinus stenting as a viable option for medically refractory IIH, especially when papilledema threatens visual function. Complication and failure rates seem to be similar to alternative surgical approaches, although serious neurological sequalae can rarely occur. Emerging studies evaluating stent type, including novel stents designed for use in the venous system, may help improve ease of the procedure and long-term success rates. Prospective head-to-head studies are needed to better understand the performance of stenting compared with other interventions.

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“…After many years evaluating VSS for IIH and reviewing numerous studies that have now analyzed visual outcomes after stenting, including a recent retrospective study incorporating visual fields and optical coherence tomography (1), I am convinced that it can be an effective intervention for patients with medically refractory disease. However, I agree with Dr. Friedman that serious neurological complications, including death, can rarely occur.…”

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confidence: 99%

Literature Commentary

2022

Journal of Neuro-Ophthalmology

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Improved Ophthalmic Outcomes Following Venous Sinus Stenting in Idiopathic Intracranial Hypertension

Cited by 10 publications

References 30 publications

Visual and pharmacotherapy outcomes after transverse sinus stenting for idiopathic intracranial hypertension

Visual and pharmacotherapy outcomes after transverse sinus stenting for idiopathic intracranial hypertension

Idiopathic Intracranial Venous Hypertension: Toward a Better Understanding of Venous Stenosis and the Role of Stenting in Idiopathic Intracranial Hypertension

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