Management of idiopathic intracranial hypertension in children utilizing venous sinus stenting

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.

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Safely traversing venous sinus stenosis: The "Cobra" technique

Interventional Neuroradiology ◽

10.1177/1591019919894802 ◽

2019 ◽

Vol 26 (2) ◽

pp. 231-234 ◽

Cited By ~ 1

Author(s):

Justin Schwarz ◽

Alejandro Santillan ◽

Athos Patsalides

Keyword(s):

Minimally Invasive ◽

Intracranial Hypertension ◽

Idiopathic Intracranial Hypertension ◽

Venous Sinus ◽

Minimally Invasive Treatment ◽

High Grade ◽

Invasive Treatment ◽

Inherent Difficulty ◽

Venous Stenosis ◽

Sinus Stenosis

Venous sinus stenting is an accepted and minimally invasive treatment for idiopathic intracranial hypertension associated with significant venous sinus stenosis. There is inherent difficulty in navigating past the region of venous stenosis in order to safely deliver and deploy a stent. We have developed the “Cobra” technique, which allows for the safe and efficient navigation past regions of high-grade venous sinus stenosis.

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Idiopathic intracranial hypertension with stenosis of a solitary occipital venous sinus treated with stenting

Interventional Neuroradiology ◽

10.1177/1591019920949094 ◽

2020 ◽

Vol 26 (5) ◽

pp. 664-667

Author(s):

Ali Al Balushi ◽

Cristiano Oliveira ◽

Athos Patsalides

Keyword(s):

Pressure Gradient ◽

Intracranial Hypertension ◽

Idiopathic Intracranial Hypertension ◽

Sinus Thrombosis ◽

Venous Sinus ◽

Ophthalmological Examination ◽

Opening Pressure ◽

Blurred Vision ◽

Occipital Sinus ◽

Nasal Defect

A 47-year-old live kidney-donor woman presented with headaches and blurred vision. Neuro-ophthalmological examination demonstrated papilledema and right eye inferior nasal defect. Brain MRV showed no sinus thrombosis but solitary right venous sinus draining the torcular Herophili to right jugular bulb. Lumbar puncture revealed elevated CSF opening pressure of 40 cm H2O with normal composition. She was diagnosed with idiopathic intracranial hypertension (IIH). She did not tolerate medical management and declined CSF diversion surgery. Cerebral angiography and venography showed venous outflow drainage from torcular Herophili through a solitary occipital sinus which has distal severe stenosis and pressure gradient of 10 mmHg. Balloon angioplasty and stenting of the occipital sinus were performed. Post-stenting, the stenosis and pressure gradient resolved. At 3-months follow-up, her symptoms and papilledema had resolved and CSF opening pressure was normal at 15 cm H2O. Aberrant cerebral venous anatomy may cause IIH and can be treatable with neuroendovascular techniques.

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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).

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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.

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Efficacy, complications and cost of surgical interventions for idiopathic intracranial hypertension: a systematic review of the literature

Acta Neurochirurgica ◽

10.1007/s00701-016-3010-2 ◽

2016 ◽

Vol 159 (1) ◽

pp. 33-49 ◽

Cited By ~ 38

Author(s):

Aristotelis V. Kalyvas ◽

Mark Hughes ◽

Christos Koutsarnakis ◽

Demetrios Moris ◽

Faidon Liakos ◽

...

Keyword(s):

Systematic Review ◽

Intracranial Hypertension ◽

Idiopathic Intracranial Hypertension ◽

Review Of The Literature ◽

Surgical Interventions

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Intracranial hypertension and papilloedema as a complication to low antiretroviral therapy adherence in a man living with chronic HIV

BMJ Case Reports ◽

10.1136/bcr-2020-237504 ◽

2021 ◽

Vol 14 (3) ◽

pp. e237504

Author(s):

Rosa Maja Møhring Gynthersen ◽

Helene Mens ◽

Marianne Wegener ◽

Neval Ete Wareham

Keyword(s):

Antiretroviral Therapy ◽

Intracranial Pressure ◽

Intracranial Hypertension ◽

Idiopathic Intracranial Hypertension ◽

Ventricular Volume ◽

Art Adherence ◽

Hiv Viral Load ◽

Blurred Vision ◽

Antiretroviral Therapy Adherence ◽

Acute Retroviral Syndrome

We describe a 61-year-old man living with HIV on antiretroviral therapy (ART), who presented with headache, dizziness and blurred vision. Latest CD4+ cell count 3 months prior to admission was 570×106 cells/mL and HIV viral load <20 copies/mL. The patient was diagnosed with cerebrospinal fluid (CSF) lymphocytic pleocytosis, raised intracranial pressure and papilloedema. Neuroimaging showed normal ventricular volume and no mass lesions, suggesting (1) neuroinfection (2) idiopathic intracranial hypertension or (3) retroviral rebound syndrome (RRS) as possible causes. Neuroinfection was ruled out and idiopathic intracranial hypertension seemed unlikely. Elevated plasma HIV RNA level was detected consistent with reduced ART adherence prior to admission. RRS is a virological rebound after ART interruption, which can mimic the acute retroviral syndrome of acute primary infection. To the best of our knowledge, we describe the second case of RRS presenting as CSF lymphocytic pleocytosis and elevated intracranial pressure after low ART adherence.

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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.

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