Impaired drainage of vein of Labbé following venous sinus stenting for idiopathic intracranial hypertension

PurposeThe impact of venous sinus stenting (VSS) on vein of Labbé (VOL) drainage is poorly understood. The purpose of the study is to examine the incidence and potential high risk factors of impaired VOL drainage among idiopathic intracranial hypertension (IIH) patients following VSS.Materials and methodsInstitutional review board approved prospective evaluation of all IIH patients who underwent VSS over a 5 year period (January 2012 to December 2017) at Weill Cornell Medical Center constituted the study population. Patient demographics, procedural details (laterality of stenting, balloon angioplasty, number of stents, and stent diameters), morphology of the VOL and changes in the flow in the VOL, type of sinus stenosis, and transverse sinus symmetry were evaluated. We used χ2 analysis to evaluate impaired VOL drainage against other variables. Statistical significance was set at 0.05.Results70 consecutive patients (67 women, 3 men) with a mean age of 31±9.8 years underwent VSS. Stenosis was extrinsic in 63% (n=44) and intrinsic in 37% (n=26) of patients. Impaired drainage of the VOL was detected in 9/70 (13%) patients. Ipsilateral VOL was recognized as dominant in 20% (n=14), co-dominant in 51% (n=36), and non-dominant in 29% (n=20) of patients. Impaired VOL drainage was significantly associated with ipsilateral VOL dominance (P=0.001) and stent diameter of ≥9 mm (P=0.042). All patients demonstrated widely patent VOL on follow-up contrast enhanced MR venography at 3 months and 24 months.ConclusionImpaired drainage of the ipsilateral VOL is a potential consequence of VSS with 13% incidence, and has significant association with ipsilateral superficial cortical venous drainage via dominant VOL and stent diameter of ≥9 mm.Clinical trial registrationNCT01407809.

Download Full-text

Factors Associated With Adherence to Outpatient Follow-Up in Patients With Idiopathic Intracranial Hypertension (IIH)

Frontiers in Ophthalmology ◽

10.3389/fopht.2021.770807 ◽

2021 ◽

Vol 1 ◽

Author(s):

Rem Aziz ◽

Asha Shah ◽

Heather E. Moss

Keyword(s):

Intracranial Hypertension ◽

Idiopathic Intracranial Hypertension ◽

Vision Loss ◽

Medical Center ◽

Statistical Significance ◽

Academic Medical Center ◽

Estimating Equation ◽

Appointment Adherence ◽

Factors Associated

Idiopathic intracranial hypertension (IIH) is a chronic condition characterized by raised intracranial pressure of undetectable origin, that causes morbidity due to debilitating headaches and vision loss. Continuity of outpatient care is important to monitor for permanent vision loss, manage symptoms and limit emergency care. The purpose of this retrospective study was to identify factors associated with neuro-ophthalmology follow-up appointment completion among patients with IIH at a US academic medical center in order to establish evidence-based interventions to improve adherence patterns. Included are 111 completed or no-show neuro-ophthalmology return outpatient appointments by 23 subjects with IIH. Generalized estimating equation models were used to assess association between appointment completion status and factors previously shown to be associated with appointment adherence. Appointments were more likely to be completed during the summer (p=0.08) and by subjects with headache symptoms (p=0.06), however none of the patient factors reached statistical significance. Completed and no-show appointments did not differ by subject demographic or insurance factors. Further studies are needed to identify risk factors for lack of appointment adherence by patients with IIH, particularly those amenable to intervention, in order to improve continuity of care for IIH.

Download Full-text

Intracranial Venous Sinus Stenting in Idiopathic Intracranial Hypertension: A Case Report and Review of the Literature

Brain Sciences ◽

10.3390/brainsci11030382 ◽

2021 ◽

Vol 11 (3) ◽

pp. 382

Author(s):

Dinesh Ramanathan ◽

Zachary D. Travis ◽

Emmanuel Omosor ◽

Taylor Wilson ◽

Nikhil Sahasrabudhe ◽

...

Keyword(s):

Intracranial Hypertension ◽

Idiopathic Intracranial Hypertension ◽

Vision Loss ◽

Transverse Sinus ◽

Venous Sinus ◽

Subdural Hygroma ◽

Presenting Symptoms ◽

Minimal Improvement ◽

Sinus Stenosis ◽

Work Up

We describe a case of severe headaches, double vision, and progressive vision loss secondary to a ruptured intracranial cyst (IAC) in a 31-year-old woman with no relevant past medical history. The case is peculiar because drainage of the subdural hygroma led to a minimal improvement in vision with persistent elevated intracranial pressure (ICP). Further exploration revealed transverse sinus stenosis necessitating stenting. Evaluation post-stenting showed marked reduction of ICP and improvement in symptoms. This report underscores the importance of comprehensive work-up and suspicion of multiple underlying etiologies that may be crucial to complete resolution of presenting symptoms in some cases. We provide an overview of the clinical indications and evidence for venous sinus stenting in treating idiopathic intracranial hypertension (IIH).

Download Full-text

Intracranial Venous Hypertension and Venous Sinus Stenting in the Modern Management of Idiopathic Intracranial Hypertension

Life ◽

10.3390/life11060508 ◽

2021 ◽

Vol 11 (6) ◽

pp. 508

Author(s):

Robert K. Townsend ◽

Kyle M. Fargen

Keyword(s):

Intracranial Hypertension ◽

Young Women ◽

Idiopathic Intracranial Hypertension ◽

Venous Hypertension ◽

Venous Sinus ◽

Venous Outflow ◽

The Status ◽

Insight Into ◽

Symptom Recurrence

Idiopathic intracranial hypertension (IIH) is a debilitating condition that has traditionally been difficult to treat. In recent years, there has been increasing focus on the role of intracranial venous hypertension in the pathophysiology of IIH. Based on increased understanding of this pathophysiology, venous sinus stenting (VSS) has emerged as a safe and reliable treatment for a certain population of patients with IIH. Stratifying patients with IIH based on the status of their venous outflow can provide insight into which patients may enjoy reduction in their symptoms after VSS and provides information regarding why some patients may have symptom recurrence. The traditional view of IIH as a disease due to obesity in young women has been cast into doubt as the understanding of the role of intracranial venous hypertension has improved.

Download Full-text

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

Stroke: Vascular and Interventional Neurology ◽

10.1161/svin.01.suppl_1.000232 ◽

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.

Download Full-text

Contrast enhanced magnetic resonance venography in the follow-up evaluation of idiopathic intracranial hypertension patients with cerebral venous sinus stenting

Clinical Imaging ◽

10.1016/j.clinimag.2018.04.016 ◽

2018 ◽

Vol 50 ◽

pp. 330-335

Author(s):

Srikanth R. Boddu ◽

Pierre Gobin ◽

Cristiano Oliveira ◽

Marc Dinkin ◽

Athos Patsalides

Keyword(s):

Magnetic Resonance ◽

Intracranial Hypertension ◽

Idiopathic Intracranial Hypertension ◽

Magnetic Resonance Venography ◽

Venous Sinus ◽

Contrast Enhanced

Download Full-text

Management of idiopathic intracranial hypertension in children utilizing venous sinus stenting

Interventional Neuroradiology ◽

10.1177/1591019920976234 ◽

2020 ◽

pp. 159101992097623

Author(s):

Justin Schwarz ◽

Ali Al Balushi ◽

Sri Sundararajan ◽

Marc Dinkin ◽

Cristiano Oliveira ◽

...

Keyword(s):

Intracranial Hypertension ◽

Surgical Procedures ◽

Medical Management ◽

Idiopathic Intracranial Hypertension ◽

Venous Sinus ◽

Lateral Sinus ◽

Invasive Treatment ◽

Blurred Vision ◽

Surgical Interventions ◽

Persistent Symptoms

Background Venous sinus stenting (VSS) is an accepted and minimally invasive treatment for adult idiopathic intracranial hypertension (IIH) associated with lateral sinus stenosis (LSS). The efficacy and safety of venous sinus stenting (VSS) in children with IIH has not been established. Methods This is a retrospective analysis of IIH patients 18 years of age or younger with LSS treated with VSS at our institution. Included patients have fulminant disease course or are refractory or intolerant to medical management. Results Eight patients were identified; 4 males and 4 females. Mean age is 13.4 years (range 4–18). All patients had severe headaches, 5 had blurred vision, 3 had diplopia and 3 had pulsatile tinnitus. Papilledema was present in 4 patients. Three patients had prior surgical procedures. Four patients were intolerant to medical management, 3 were refractory and 1 had fulminant course. Cerebral venography demonstrated severe stenosis of the dominant sinus in 6 patients and of bilateral co-dominant sinuses in 2 patients. Six patients had intrinsic stenosis and 2 had extrinsic stenosis. Venous sinus stenting (VSS) resulted in improvement of symptoms, papilledema and normalization of CSF opening pressure in 7 patients. No immediate complications were observed. Mean follow-up period is 21 months (range 6–42). Two patients required re-stenting; one responded well and the other had persistent symptoms and underwent subsequent surgical procedures of CSF diversion, suboccipital decompression and duraplasty which were also ineffective. Conclusion VSS may provide a viable option for pediatric IIH patients who are intolerant to medication, have failed conservative management or prior surgical interventions, or present with fulminant disease.

Download Full-text

11βHSD1 Inhibition with AZD4017 Improves Lipid Profiles and Lean Muscle Mass in Idiopathic Intracranial Hypertension

The Journal of Clinical Endocrinology & Metabolism ◽

10.1210/clinem/dgaa766 ◽

2020 ◽

Vol 106 (1) ◽

pp. 174-187

Author(s):

Rowan S Hardy ◽

Hannah Botfield ◽

Keira Markey ◽

James L Mitchell ◽

Zerin Alimajstorovic ◽

...

Keyword(s):

Intracranial Hypertension ◽

Muscle Mass ◽

Idiopathic Intracranial Hypertension ◽

Hepatic Function ◽

Lipid Profiles ◽

Gamma Glutamyl Transferase ◽

Peripheral Tissues ◽

Lean Muscle Mass ◽

Glutamyl Transferase ◽

The Impact

Abstract Background The enzyme 11β-hydroxysteroid dehydrogenase type 1 (11β-HSD1) determines prereceptor metabolism and activation of glucocorticoids within peripheral tissues. Its dysregulation has been implicated in a wide array of metabolic diseases, leading to the development of selective 11β-HSD1 inhibitors. We examined the impact of the reversible competitive 11β-HSD1 inhibitor, AZD4017, on the metabolic profile in an overweight female cohort with idiopathic intracranial hypertension (IIH). Methods We conducted a UK multicenter phase II randomized, double-blind, placebo-controlled trial of 12-week treatment with AZD4017. Serum markers of glucose homeostasis, lipid metabolism, renal and hepatic function, inflammation and androgen profiles were determined and examined in relation to changes in fat and lean mass by dual-energy X-ray absorptiometry. Results Patients receiving AZD4017 showed significant improvements in lipid profiles (decreased cholesterol, increased high-density lipoprotein [HDL] and cholesterol/HDL ratio), markers of hepatic function (decreased alkaline phosphatase and gamma-glutamyl transferase), and increased lean muscle mass (1.8%, P < .001). No changes in body mass index, fat mass, and markers of glucose metabolism or inflammation were observed. Patients receiving AZD4017 demonstrated increased levels of circulating androgens, positively correlated with changes in total lean muscle mass. Conclusions These beneficial metabolic changes represent a reduction in risk factors associated with raised intracranial pressure and represent further beneficial therapeutic outcomes of 11β-HSD1 inhibition by AZD4017 in this overweight IIH cohort. In particular, beneficial changes in lean muscle mass associated with AZD4017 may reflect new applications for this nature of inhibitor in the management of conditions such as sarcopenia.

Download Full-text