Primary balloon angioplasty of venous Sinus stenosis in idiopathic intracranial hypertension

Abstract

Background Venous sinus stenosis (VSS) stenting has emerged as an effective treatment for patients with Idiopathic Intracranial Hypertension (IIH). However, stenting carries risk of in-stent stenosis/thrombosis and cumulative bleeding risk from long-term dual antiplatelet (DAPT) use. Thus, we investigated the potential safety and efficacy of primary balloon angioplasty as an alternative to stenting in IIH. Methods A prospectively maintained single-center registry of IIH patients undergoing endovascular procedures was queried. Inclusion criteria included patients with confirmed IIH and angiographically demonstrable VSS who underwent interventions from 2012- 2021. Patients were dichotomized into primary balloon angioplasty (Group A) and primary stenting (Group S), comparing clinical outcomes using bivariate analyses. Results 62 patients were included with median age of 33 [IQR 26-37], 74% females. Group A (9/62) and Group S (53/62) had similar baseline characteristics. Papilledema improvement was higher in Group S at 6 weeks and 6 months (44 vs. 93, p = 0.002 and 44 vs. 92%, p = 0.004), with similar improvements across all symptoms. Group S had higher mean post-procedure venous pressure gradient change (8 vs. 3 mmHg, p = 0.02) and a lower CSF opening pressure at 6 months (23 vs. 36 cmH2O, p < 0.001). VPS rescue rate was higher in Group A (44 vs. 2%, p = 0.001). There was only one procedural complications; a subdural hematoma in Group A. Conclusions Primary VSS balloon angioplasty provides a marginal and short-lived improvement of IIH symptoms compared to stenting. These findings suggest a cautious and limited role for short-term rescue angioplasty in poor shunting and stenting candidates with refractory IIH.

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

“…Carter et al 106 described a 15-year-old who was treated with venoplasty alone, with the resolution of papilledema at discharge and a sustained resolution of symptoms of high ICP at 1 year. However, Martinez-Gutierrez et al 64 compared 53 stented patients with 9 who underwent only balloon angioplasty and found a lower rate of improvement in papilledema (44% vs 93%), headache (44% vs 92%), and visual disturbance (50% vs 92%) at 6 weeks in the angioplasty group. The mean change in OP was only 6 cm H 2 O (vs 13 in the stented group), and 44% ultimately required a VPS to control ICP (vs 2% in the stenting group).…”

Venous Sinus Stenting for Low Pressure Gradient Stenoses in Idiopathic Intracranial Hypertension

“…1 As such, venous sinus stenting has emerged as a promising treatment for IIH. [3][4][5][6][7][8] Owing to the low prevalence of IIH with concurrent VSS and the heterogeneity of the disease, conducting large-scale studies has proven challenging. An expanding literature of singlecenter or small multicenter experiences with VSS stenting has provided promising evidence of potential efficacy of this treatment but has also highlighted the immense diversity in patient selection criteria.…”