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.

Abstract 1122‐000232: The Importance of Performing Venous Pressure Measurements Following Venous Sinus Stenting for Idiopathic Intracranial Hypertension

2021 ◽  
Vol 1 (S1) ◽  
Author(s):  
Yazan Radaideh
Keyword(s):  
Pressure Gradient ◽  
Intracranial Hypertension ◽  
Stent Placement ◽  
Idiopathic Intracranial Hypertension ◽  
Venous Pressure ◽  
Sigmoid Sinus ◽  
Venous Sinus ◽  
Pressure Measurements ◽  
Sinus Stenosis ◽  
The Right

Introduction : Although venous sinus stenting is an established treatment for medically refractory idiopathic intracranial hypertension, a subset of patients shows little or no improvement of symptoms after stenting. While this could be related to a number of factors, failure to sufficiently address the pressure gradient is one that can be recognized during the treatment procedure. We describe two patients who had a persistent venous pressure gradient after stent placement. Once identified, a second stent was placed with subsequent resolution of the pressure gradient. Methods : This retrospective chart review identified patients at a single institution who underwent venous sinus stenting and required immediate placement of a second venous sinus stent for a persistent pressure gradient. Results : Two patients with refractory idiopathic intracranial hypertension underwent cerebral angiography with venous manometry. In the first patient, unilateral venous sinus stenosis was present with a maximum pressure of 50 mmHg, which only decreased to 30 mmHg after placement of a right transverse‐sigmoid sinus stent. Subsequent manometry revealed a persistent gradient between the superior sagittal sinus and the right transverse sinus, which resolved after placement of a second stent in this location. In the second patient, bilateral stenosis was observed at the transverse‐sigmoid sinus junction; the maximum venous pressure was 40 mmHg, and a gradient of 30 mmHg was measured at the right transverse‐sigmoid junction, where a venous sinus stent was placed. Venous sinus pressure measurements performed immediately after the stent placement demonstrated a persistent pressure gradient of 20 mmHg in the contralateral transverse‐sigmoid sinus junction, which resolved after contralateral stent placement. Both patients showed sustained improvement in their symptoms at 1 year follow up. Conclusions : In some patients with idiopathic intracranial hypertension and venous sinus stenosis, a single stent may not sufficiently reduce the pressure gradient. A second stent may be required; however, this is only detectable with post‐stent pressure measurements. Performing manometry after stent placement should be routinely performed in order to detect persistent venous pressure gradient.

Venous sinus stenting for idiopathic intracranial hypertension is not associated with cortical venous occlusion

2015 ◽  
Vol 8 (6) ◽  
pp. 594-595 ◽  
Author(s):  
Michael R Levitt ◽  
Felipe C Albuquerque ◽  
Andrew F Ducruet ◽  
M Yashar S Kalani ◽  
Celene B Mulholland ◽  
...  
Keyword(s):  
Intracranial Hypertension ◽  
Idiopathic Intracranial Hypertension ◽  
Venous Occlusion ◽  
Venous Sinus ◽  
Radiological Data ◽  
Angiographic Data ◽  
Intracranial Complications ◽  
Dural Venous Sinus

BackgroundThe effect of dural venous sinus stenting has been investigated for the treatment of idiopathic intracranial hypertension (IIH) but the effect of stenting on the long-term patency of the cortical draining veins, especially the vein of Labbé (VOL), remains unknown.MethodsWe reviewed our database of 38 patients with IIH with 41 stented dural venous sinuses between October 2006 and December 2014. Demographic, clinical, and radiological data were reviewed. Follow-up catheter angiographic data were included when available.ResultsStent placement spanned the ostium of the VOL in 35 patients (92.1%), with no immediate effect on the drainage of the VOL. Follow-up angiography (mean 35.1 months, range 1.7–80.7 months) was available in 24 patients, 21 of whom had stents spanning the VOL ostium. The VOL remained patent without occlusion or drainage alteration in all 21 patients. There were no immediate or long-term intracranial complications.ConclusionsDural venous sinus stenting for patients with IIH does not affect the immediate or long-term patency of the VOL and is not associated with intracranial complications.

Venous sinus stenting in patients without idiopathic intracranial hypertension

2016 ◽  
Vol 9 (5) ◽  
pp. 512-515 ◽  
Author(s):  
Michael R Levitt ◽  
Felipe C Albuquerque ◽  
Bradley A Gross ◽  
Karam Moon ◽  
Ashutosh P Jadhav ◽  
...  
Keyword(s):  
Intracranial Hypertension ◽  
Idiopathic Intracranial Hypertension ◽  
Sinus Thrombosis ◽  
Venous Sinus ◽  
Congenital Hydrocephalus ◽  
Pulsatile Tinnitus ◽  
Venous Sinus Thrombosis ◽  
Sinus Stenosis ◽  
Dural Venous Sinus

BackgroundVenous sinus stenting is an effective treatment for patients with idiopathic intracranial hypertension (IIH) and venous sinus stenosis.ObjectiveTo determine the usefulness of venous sinus stenting in the treatment of patients with symptomatic venous sinus stenosis without a diagnosis of IIH.MethodsWe performed a retrospective review of a prospective multicenter database of patients undergoing venous sinus stenting between January 2008 and February 2016. Patients with acute dural venous sinus thrombosis, arteriovenous fistula or arteriovenous malformation, or IIH were excluded. Clinical, radiological, and ophthalmological information was recorded.ResultsNine patients met the inclusion criteria and underwent venous sinus stenting for symptomatic dural venous sinus stenosis. Reasons for treatment included isolated unilateral pulsatile tinnitus (n=1), congenital hydrocephalus (n=2), unilateral pulsatile tinnitus following prior venous sinus thrombosis (n=1), acquired hydrocephalus following dural sinus thrombosis (n=2), meningitis (n=2) and tumor invasion into the dural venous sinus (n=1). Six patients underwent lumbar puncture or shunt tap, and all of these patients had elevated intracranial pressure. All stenoses were located in the transverse sinus, transverse–sigmoid junction and/or jugular bulb, and all were treated with self-expanding bare-metal stents. At follow-up, clinical symptoms had resolved in all but two patients, both of whom had congenital hydrocephalus and pre-existing shunts. There was no significant in-stent stenosis, and patients with ophthalmological follow-up demonstrated improvement of papilledema.ConclusionsDural venous sinus stenting may be an effective treatment for patients with symptomatic venous sinus stenosis without IIH in carefully selected cases, but may not be effective in resolving the symptoms of congenital hydrocephalus.

Retrograde 3D rotational venography (3DRV) for venous sinus stent placement in idiopathic intracranial hypertension

2017 ◽  
Vol 10 (8) ◽  
pp. 777-779 ◽  
Author(s):  
Christopher C Young ◽  
Ryan P Morton ◽  
Basavaraj V Ghodke ◽  
Michael R Levitt
Keyword(s):  
Intracranial Hypertension ◽  
Stent Placement ◽  
Idiopathic Intracranial Hypertension ◽  
Three Dimensional ◽  
Venous Sinus ◽  
Flat Panel ◽  
Venous Sinuses ◽  
Contrast Enhanced ◽  
Sinus Stenosis ◽  
Dural Venous Sinus

BackgroundDural venous sinus stenting has emerged as an effective and durable treatment for idiopathic intracranial hypertension (IIH). Improved visualization of the venous sinuses can improve stent placement.MethodsWe present two cases of IIH treated with venous sinus stenting in which retrograde three-dimensional rotational venography (3DRV) provided superior anatomical details of the venous sinuses for optimal sizing and positioning of stent.ResultsComparison of pre-stent 3DRV with post-stent contrast-enhanced flat panel detector CT allowed confirmation of stent placement and the result of stenosis dilation.ConclusionThis 3DRV technique provides precise visualization of venous sinus stenosis prior to stenting without the need for arterial cerebral angiography during the treatment course.

Dural venous sinus stenting for treatment of pediatric idiopathic intracranial hypertension

2020 ◽  
pp. neurintsurg-2020-016183
Author(s):  
Katriel E Lee ◽  
Aqib Zehri ◽  
Sauson Soldozy ◽  
Hasan Syed ◽  
Joshua S Catapano ◽  
...  
Keyword(s):  
Intracranial Hypertension ◽  
Idiopathic Intracranial Hypertension ◽  
Pediatric Patients ◽  
Pediatric Population ◽  
Case Series ◽  
Venous Sinus ◽  
Retrospective Case ◽  
Safety And Efficacy ◽  
Dural Venous Sinus

BackgroundDural venous sinus stenting (VSS) is an effective treatment for idiopathic intracranial hypertension (IIH) in adult patients. There are no published series to date evaluating safety and efficacy of VSS in pediatric patients.ObjectiveTo report on procedural device selection and technique as well as safety and efficacy of VSS for pediatric patients with medically refractory IIH due to underlying venous sinus stenosis.MethodsA multi-institutional retrospective case series identified patients with medically refractory IIH aged less than 18 years who underwent VSS.Results14 patients were identified at four participating centers. Patient ages ranged from 10 to 17 years, and 10 patients (71.4%) were female. Mean body mass index was 25.7 kg/m2 (range 15.8–34.6 kg/m2). Stenting was performed under general endotracheal anesthesia in all except two patients. The average trans-stenotic gradient during diagnostic venography was 10.6 mm Hg. Patients had stents placed in the superior sagittal sinus, transverse sinus, sigmoid sinus, occipital sinus, and a combination. Average follow-up was 1.7 years after stenting. Six patients out of 10 (60%) had reduced medication dosing, 12 of 14 patients (85.7%) had improvements in headaches, two patients (100%) with pre-stent tinnitus had resolution of symptoms, and four (80%) of five patients with papilledema had improvement on follow-up ophthalmological examinations. Two patients (14.3%) developed postprocedural groin hematomas, one patient (7.1%) developed a groin pseudoaneurysm, and one patient (7.1%) had postprocedural groin bleeding. No other procedural complications occurred. Four patients (28.6%) required further surgical treatment (cerebrospinal shunting and/or stenting) after their first stenting procedure.ConclusionsThis series suggests that VSS is feasible in a pediatric population with IIH and has a low complication rate and good clinical outcomes.

scholarly journals Dural venous sinus stenting for medically and surgically refractory idiopathic intracranial hypertension

2017 ◽  
Vol 23 (2) ◽  
pp. 186-193 ◽  
Author(s):  
Sudhakar R Satti ◽  
Lakshmi Leishangthem ◽  
Alejandro Spiotta ◽  
M Imran Chaudry
Keyword(s):  
Visual Field ◽  
Intracranial Hypertension ◽  
Retrospective Analysis ◽  
Idiopathic Intracranial Hypertension ◽  
Venous Sinus ◽  
Complication Rates ◽  
Single Center ◽  
Technical Success ◽  
Dural Venous Sinus

Background Idiopathic intracranial hypertension (IIH) is a syndrome defined by elevated intracranial hypertension without radiographic evidence of a mass lesion in the brain. Dural venous sinus stenosis has been increasingly recognized as a treatable cause, and dural venous sinus stenting (DVSS) is increasingly performed. Methods A 5 year single-center retrospective analysis of consecutive patients undergoing DVSS for medically refractory IIH. Results There were 43 patients with a mean imaging follow-up of 6.5 months and a mean clinical follow-up period of 13.5 months. DVSS was performed as the first procedure for medically refractory IIH in 81.4% of patients, whereas 18.6% of patients included had previously had a surgical procedure (ventriculoperitoneal (VP) shunt or optic nerve sheath fenestration (ONSF)). Headache was present in all patients and after DVSS improved or remained stable in 69.2% and 30.8%, respectively. Visual acuity changes and visual field changes were present in 88.4% and 37.2% of patients, respectively. Visual field improved or remained unchanged in 92%, but worsened in 8% after stenting. There was a stent patency rate of 81.8%, with an 18.2% re-stenosis rate. Of the 43 procedures performed, there was a 100% technical success rate with zero major or minor complications. Conclusion Based on this single-center retrospective analysis, DVSS can be performed with high technical success and low complication rates. A majority of patients presented primarily with headache, and these patients had excellent symptom relief with DVSS alone. Patients presenting with visual symptoms had lower success rates, and this population, if stented, should be carefully followed for progression of symptoms.

scholarly journals Incidence and predictors of dural venous sinus pressure gradient in idiopathic intracranial hypertension and non-idiopathic intracranial hypertension headache patients: results from 164 cerebral venograms

2017 ◽  
Vol 126 (2) ◽  
pp. 347-353 ◽  
Author(s):  
Michael R. Levitt ◽  
Randall J. Hlubek ◽  
Karam Moon ◽  
M. Yashar S. Kalani ◽  
Peter Nakaji ◽  
...  
Keyword(s):  
Pressure Gradient ◽  
Intracranial Hypertension ◽  
Idiopathic Intracranial Hypertension ◽  
Venous Pressure ◽  
Venous Sinus ◽  
Patient Demographics ◽  
Procedural Complications ◽  
Dural Venous Sinus ◽  
Cerebral Venous Pressure ◽  
Headache Patients

OBJECTIVE Cerebral venous pressure gradient (CVPG) from dural venous sinus stenosis is implicated in headache syndromes such as idiopathic intracranial hypertension (IIH). The incidence of CVPG in headache patients has not been reported. METHODS The authors reviewed all cerebral venograms with manometry performed for headache between January 2008 and May 2015. Patient demographics, headache etiology, intracranial pressure (ICP) measurements, and radiographic and manometric results were recorded. CVPG was defined as a difference ≥ 8 mm Hg by venographic manometry. RESULTS One hundred sixty-four venograms were performed in 155 patients. There were no procedural complications. Ninety-six procedures (58.5%) were for patients with IIH. The overall incidence of CVPG was 25.6% (42 of 164 procedures): 35.4% (34 of 96 procedures) in IIH patients and 11.8% (8 of 68 procedures) in non-IIH patients. Sixty procedures (36.6%) were performed in patients with preexisting shunts. Seventy-seven patients (49.7%) had procedures preceded by an ICP measurement within 4 weeks of venography, and in 66 (85.7%) of these patients, the ICP had been found to be elevated. CVPG was seen in 8.3% (n = 5) of the procedures in the 60 patients with a preexisting shunt and in 0% (n = 0) of the 11 procedures in the 77 patients with normal ICP (p < 0.001 for both). Noninvasive imaging (MR venography, CT venography) was assessed prior to venography in 112 (68.3%) of 164 cases, and dural venous sinus abnormalities were demonstrated in 73 (65.2%) of these cases; there was a trend toward CVPG (p = 0.07). Multivariate analysis demonstrated an increased likelihood of CVPG in patients with IIH (OR 4.97, 95% CI 1.71–14.47) and a decreased likelihood in patients with a preexisting shunt (OR 0.09, 95% CI 0.02–0.44). CONCLUSIONS CVPG is uncommon in IIH patients, rare in those with preexisting shunts, and absent in those with normal ICP.

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.

scholarly journals Venous sinus stenting as a treatment approach in patients with idiopathic intracranial hypertension and encephaloceles

2020 ◽  
pp. 159101992095686
Author(s):  
Gerald T Drocton ◽  
Alexander Copelan ◽  
Laura Eisenmenger ◽  
Javier E Villanueva-Meyer ◽  
William P Dillon ◽  
...  
Keyword(s):  
Intracranial Hypertension ◽  
Idiopathic Intracranial Hypertension ◽  
Treatment Approach ◽  
Filling Defect ◽  
Brain Parenchyma ◽  
Venous Sinus ◽  
External Compression ◽  
Dural Venous Sinus ◽  
Adjacent Brain

Background Stenosis of a dural venous sinus is the most common cause of idiopathic intracranial hypertension (IIH) and can be classified as either intrinsic or extrinsic. Intrinsic stenoses are characterized by a focal filling defect within the sinus secondary to an enlarged arachnoid granulation or fibrous septa while extrinsic stenoses tend to be long and smooth-tapered and are most commonly secondary to external compression from the adjacent brain parenchyma. Brain herniations, or encephaloceles, into arachnoid granulations in dural venous sinuses have rarely been reported in the literature in patients with IIH. We propose that dural venous sinus stenting (VSS) may be a safe and effective treatment approach in patients with an encephalocele and IIH. Methods We retrospectively analyze three cases of patients with encephalocele who underwent VSS for treatment of medically refractory IIH at our institution. Results One patient underwent stenting ipsilateral and two patients underwent stenting contralateral to the side of their encephaloceles. No technical related issues or complications occurred during either of the three stenting procedures. Two out of the three patients had complete resolution in their IIH-related symptoms and normalization of cerebrospinal (CSF) pressures shortly after stenting. We await clinical follow-up in the third patient. Conclusions Our results suggest that VSS is a technically feasible and effective approach in treating patients with medically refractory IIH and encephaloceles.

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.

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