Transverse Sinus Stenting for Idiopathic Intracranial Hypertension: A Review of 52 Patients and of Model Predictions

Abstract

BACKGROUND AND PURPOSE:Transverse sinus stenosis is common in patients with IIH. While the role of transverse sinus stenosis in IIH pathogenesis remains controversial, modeling studies suggest that stent placement within a transverse sinus stenosis with a significant pressure gradient should decrease cerebral venous pressure, improve CSF resorption in the venous system, and thereby reduce intracranial (CSF) pressure, improving the symptoms of IIH and reducing papilledema. We aimed to determine if IIH could be reliably treated by stent placement in transverse sinus stenosis.

Transverse Sinus Stenting for Pseudotumor Cerebri: A Cost Comparison with CSF Shunting

“…The benefit of venous stenting in PTC is now clear, [1][2][3] and a lower complication rate (9.3% of patients in our own study) compared with shunting has been reported in all studies. We have now shown that the cost of stenting is also significantly less than that of shunting.…”

“…In some cases, the entire transverse sinus has been stented. 1 Given this significant difference in the repeat rates of the 2 procedures, the cost per 100 cases does not represent the total longer term cost per patient of ongoing revisions. Because the venous stent group was followed up to 12 years, it is reasonable to view the absolute number of repeat procedures as representative.…”

“…Also, the need for additional venous stenting, while low, has been further lowered with time, due to a better understanding of the mechanism by which stents lower intracranial pressure and the availability of longer stents. We have proposed 1 that stenting prevents compression of the transverse sinuses by intracranial hypertension itself, breaking a positive feedback cycle. A stent creates a rigid, noncollapsible transverse sinus, one no longer vulnerable to compression from intracranial hypertension so that CSF absorption is improved, lowering intracranial pressure.…”

“…T ransverse sinus venous stent placement is an effective treatment for pseudotumor cerebri (PTC) [1][2][3] ; however, its cost has not been assessed or compared with the cost of the traditional alternative-CSF shunting. The annual cost of treating PTC in the United States exceeds US $444 million, and the annual cost of all CSF shunts-not just for PTC-exceeds $1 billion.…”

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“…13 A pivotal question regarding transverse sinus stenosis in IIH is whether this abnormality is the cause or consequence of the elevated intracranial pressure. 21 Mathematical models support the hypothesis that the transverse sinus is a compliant structure to the point of being vulnerable to extrinsic compression, which may obstruct the venous drainage, resulting in venous and intracranial hypertension. 24 On the other hand, results published in recent years, which show clinical improvement in some patients after the reconstruction of the transverse sinus with endovascular stents, reinforce the hypothesis that the stenosis established in the sinus independently causes the venous flow blockage.…”