Dural sinus stent placement for idiopathic intracranial hypertension

2012 ◽  
Vol 116 (3) ◽  
pp. 538-548 ◽  
Author(s):  
David A. Kumpe ◽  
Jeffrey L. Bennett ◽  
Joshua Seinfeld ◽  
Victoria S. Pelak ◽  
Ashish Chawla ◽  
...  
Keyword(s):  
Intracranial Hypertension ◽  
Stent Placement ◽  
Idiopathic Intracranial Hypertension ◽  
Venous Pressure ◽  
Dural Sinus ◽  
Pressure Gradients ◽  
Pressure Measurements ◽  
Junction Region ◽  
Hemodynamic Deterioration

Object The use of unilateral dural sinus stent placement in patients with idiopathic intracranial hypertension (IIH) has been described by multiple investigators. To date there is a paucity of information on the angiographic and hemodynamic outcome of these procedures. The object of this study was to define the clinical, angiographic, and hemodynamic outcome of placement of unilateral dural sinus stents to treat intracranial venous hypertension in a subgroup of patients meeting the diagnostic criteria for IIH. Methods Eighteen consecutive patients with a clinical diagnosis of IIH were treated with unilateral stent placement in the transverse-sigmoid junction region. All patients had papilledema. All 12 female patients had headaches; 1 of 6 males had headaches previously that disappeared after weight loss. Seventeen patients had elevated opening pressures at lumbar puncture. Twelve patients had opening pressures of 33–55 cm H2O. All patients underwent diagnostic cerebral arteriography that showed venous outflow compromise by filling defects in the transverse-sigmoid junction region. All patients underwent intracranial selective venous pressure measurements across the filling defects. Follow-up arteriography was performed in 16 patients and follow-up venography/venous pressure measurements were performed in 15 patients. Results Initial pressure gradients across the filling defects ranged from 10.5 to 39 mm Hg. Nineteen stent procedures were performed in 18 patients. One patient underwent repeat stent placement for hemodynamic failure. Pressure gradients were reduced in every instance and ranged from 0 to 7 mm Hg after stenting. Fifteen of 16 patients in whom ophthalmological follow-up was performed experienced disappearance of papilledema. Follow-up arteriography in 16 patients at 5–99 months (mean 25.3 months, median 18.5 months) showed patency of all stents without in-stent restenosis. Two patients had filling defects immediately above the stent. Four other patients developed transverse sinus narrowing above the stent without filling defects. One of these patients underwent repeat stent placement because of hemodynamic deterioration. Two of the other 3 patients had hemodynamic deterioration with recurrent pressure gradients of 10.5 and 18 mm Hg. Conclusions All stents remained patent without restenosis. Stent placement is durable and successfully eliminates papilledema in appropriately selected patients. Continuing hemodynamic success in this series was 80%, and was 87% with repeat stent placement in 1 patient.

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.

scholarly journals Endovascular Stenting for Idiopathic Intracranial Hypertension

2014 ◽  
Vol 4 (2) ◽  
pp. 49-52 ◽  
Author(s):  
Faizan Khan ◽  
Dana Iancu
Keyword(s):  
Intracranial Hypertension ◽  
Stent Placement ◽  
Idiopathic Intracranial Hypertension ◽  
Venous Pressure ◽  
Elevated Pressure ◽  
Transverse Sinus ◽  
Endovascular Stenting ◽  
Sinus Stenosis ◽  
Stenotic Segment

Transverse sinus stenosis (TSS) is often observed in patients with idiopathic intracranial hypertension (IIH). Studies show that all symptoms of IIH can be resolved by transverse sinus stent placement. We present a case of a 39-year-old woman diagnosed with IIH presented with papilledema and severe headaches. The consideration of interventional management was necessitated by the preceding failure of several months of medical treatment. Her vascular imaging demonstrated stenosis of the transverse sinus and her intracranial venous pressure measurements indicated elevated pressure with a high pressure gradient across the stenosis. She underwent transverse sinus stent placement across the stenotic segment. After this intervention, her symptoms improved and her intracranial pressure normalized. The imaging follow-up revealed efficacious patency of the stent. Based on a mathematical model, we suggest that a Starling-like resistor demonstrating a collapsible transverse sinus can permanently be replaced by a rigid-walled sinus upon employment of an endovascular stent in the stenotic transverse sinus, which should be considered as an alternative to other surgical procedures for IIH patients.

scholarly journals Fifty shades of gradients: does the pressure gradient in venous sinus stenting for idiopathic intracranial hypertension matter? A systematic review

2019 ◽  
Vol 130 (3) ◽  
pp. 999-1005 ◽  
Author(s):  
Cameron M. McDougall ◽  
Vin Shen Ban ◽  
Jeffrey Beecher ◽  
Lee Pride ◽  
Babu G. Welch
Keyword(s):  
Systematic Review ◽  
Pressure Gradient ◽  
Intracranial Hypertension ◽  
Stent Placement ◽  
Idiopathic Intracranial Hypertension ◽  
Venous Pressure ◽  
Venous Sinus ◽  
Stepwise Logistic Regression ◽  
Pressure Gradients ◽  
Sinus Stenosis

OBJECTIVEThe role of venous sinus stenting (VSS) for idiopathic intracranial hypertension (IIH) is not well understood. The aim of this systematic review is to attempt to identify subsets of patients with IIH who will benefit from VSS based on the pressure gradients of their venous sinus stenosis.METHODSMEDLINE/PubMed was searched for studies reporting venous pressure gradients across the stenotic segment of the venous sinus, pre- and post-stent pressure gradients, and clinical outcomes after VSS. Findings are reported according to the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines.RESULTSFrom 32 eligible studies, a total of 186 patients were included in the analysis. Patients who had favorable outcomes had higher mean pressure gradients (22.8 ± 11.5 mm Hg vs 17.4 ± 8.0 mm Hg, p = 0.033) and higher changes in pressure gradients after stent placement (19.4 ± 10.0 mm Hg vs 12.0 ± 6.0 mm Hg, p = 0.006) compared with those with unfavorable outcomes. The post-stent pressure gradients between the 2 groups were not significantly different (2.8 ± 4.0 mm Hg vs 2.7 ± 2.0 mm Hg, p = 0.934). In a multivariate stepwise logistic regression controlling for age, sex, body mass index, CSF opening pressure, pre-stent pressure gradient, and post-stent pressure gradient, the change in pressure gradient with stent placement was found to be an independent predictor of favorable outcome (p = 0.028). Using a pressure gradient of 21 as a cutoff, 81/86 (94.2%) of patients with a gradient > 21 achieved favorable outcomes, compared with 82/100 (82.0%) of patients with a gradient ≤ 21 (p = 0.022).CONCLUSIONSThere appears to be a relationship between the pressure gradient of venous sinus stenosis and the success of VSS in IIH. A randomized controlled trial would help elucidate this relationship and potentially guide patient selection.

A descriptive study of venous sinus pressures and gradients in patients with idiopathic intracranial hypertension

2019 ◽  
Vol 12 (3) ◽  
pp. 320-325 ◽  
Author(s):  
Kyle M Fargen ◽  
Rebecca M Garner ◽  
Carol Kittel ◽  
Stacey Q Wolfe
Keyword(s):  
Pressure Gradient ◽  
Intracranial Hypertension ◽  
Idiopathic Intracranial Hypertension ◽  
Venous Pressure ◽  
Venous Sinus ◽  
Pressure Gradients ◽  
Inclusion Criteria ◽  
Non Invasive ◽  
Sagittal Sinus ◽  
The Relationship

ObjectiveTo determine the relationship between normal physiologic and pathologic venous sinus pressures in patients with idiopathic intracranial hypertension (IIH), which is poorly understood.MethodsRetrospective analysis was performed to identify patients with medically refractory IIH who were evaluated by angiography and retrograde venography with venous manometry. Patients were further subdivided into groups based on anatomic factors.Results104 patients met inclusion criteria for the study. In the absence of non-invasive venographic screening, 58% of patients in this series were found to have pressure gradients of ≥8 mm Hg; 93% were located near the transverse-sigmoid sinus junction. Opening pressure (OP) is strongly predictive of superior sagittal sinus (SSS) pressures (p<0.001) and also of the presence of a pressure gradient ≥8 mm Hg (p<0.001). Twenty-three percent of patients with an OP <25 had a pressure gradient ≥8 mm Hg compared with 77% of patients with an OP ≥35. Analysis of patients with OP ≤20 suggests that SSS pressures in patients without IIH should be less than 16–18 mm Hg with total cranial gradients <5 mm Hg. Across all patients, a pressure decrement of approximately 1 mm Hg occurs with progressively more caudal transition across anatomic points of measurement.ConclusionsThis study describes intracranial and extracranial venous pressure measurements and gradients in different subgroups of patients with IIH. OP is highly predictive of intracranial venous pressures and significant venous pressure gradients.

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.

Dural sinus stenting for idiopathic intracranial hypertension: factors associated with hemodynamic failure and management with extended stenting

2016 ◽  
Vol 9 (9) ◽  
pp. 867-874 ◽  
Author(s):  
David A Kumpe ◽  
Joshua Seinfeld ◽  
Xianchen Huang ◽  
Quelin Mei ◽  
David E Case ◽  
...  
Keyword(s):  
Pressure Gradient ◽  
Intracranial Hypertension ◽  
Idiopathic Intracranial Hypertension ◽  
Female Gender ◽  
Transverse Sinus ◽  
Dural Sinus ◽  
Factors Associated ◽  
Extrinsic Compression ◽  
Hemodynamic Failure

BackgroundSome patients undergoing dural sinus stenting for idiopathic intracranial hypertension (IIH) develop clinical and hemodynamic failure (recurrence of the pressure gradient) owing to stent-adjacent stenosis.ObjectiveTo characterize factors associated with hemodynamic failure, and to describe outcomes of patients after repeat stenting.Materials and methodsWe reviewed the initial and follow-up clinical, venographic, and hemodynamic data in 39 patients with IIH treated over 17 years with stenting. Thirty-two had follow-up angiographic and hemodynamic data at 1–99 months (mean 27.6, median 19.5 months). Eight patients were treated with 12 repeat stenting procedures, including extended stenting into the superior sagittal sinus (SSS).ResultsAll patients had an initial successful hemodynamic result with the pressure gradient reduced from 10–43 to 0–7 mm Hg. 10/32 patients (31.3%), all women, developed new stenoses in the transverse sinus or posterior SSS above the stent with a recurrent pressure gradient. 7/9 patients with pure extrinsic stenosis of the transverse-sigmoid junction pre-stenting developed new stenoses and hemodynamic failure. All patients with hemodynamic failure who were restented had early and mid-term documented hemodynamic success at 1.7–50 months. They were free from papilledema at 3.8–50 months after the last restenting, and 11.5–99.5 months after initial stent placement (mean 45.3, median 38.5 months).ConclusionsPure extrinsic compression of the transverse-sigmoid junction and female gender were strongly associated with hemodynamic failure. Eight patients with hemodynamic failure who were restented had successful control of papilledema, including 4/4 who had extended stenting into the SSS.

Safety and efficacy of intravascular ultrasound as an adjunct to stenting for cerebral venous sinus stenosis–induced idiopathic intracranial hypertension: a pilot study

2020 ◽  
Vol 132 (3) ◽  
pp. 749-754 ◽  
Author(s):  
Feng Yan ◽  
Gary Rajah ◽  
Yuchuan Ding ◽  
Yang Hua ◽  
Hongqi Zhang ◽  
...  
Keyword(s):  
Intracranial Hypertension ◽  
Intravascular Ultrasound ◽  
Stent Placement ◽  
Idiopathic Intracranial Hypertension ◽  
Venous Sinus ◽  
Wall Thickening ◽  
Venous Stenting ◽  
Venous Stenosis ◽  
Sinus Stenosis

OBJECTIVESymptomatic intracranial hypertension can be caused by cerebral venous sinus stenosis (CVSS) and cerebral venous sinus thrombotic (CVST) stenosis, which is usually found in some patients with idiopathic intracranial hypertension (IIH). Recently, at the authors’ center, they utilized intravascular ultrasound (IVUS) as an adjunct to conventional venoplasty or stenting to facilitate diagnosis and accurate stent placement in CVSS.METHODSThe authors designed a retrospective review of their prospective database of patients who underwent IVUS-guided venous sinus stenting between April 2016 and February 2017. Clinical, radiological, and ophthalmological information was recorded and analyzed. IVUS was performed in 12 patients with IIH (9 with nonthrombotic CVSS, 3 with secondary stenosis combined with CVST) during venoplasty through venous access. The IVUS catheter was used from a proximal location to the site of stenosis. Post-stenting follow-up, including symptomatic improvement, stent patency, and adjacent-site stenosis, was assessed at 1 year.RESULTSThirteen stenotic cerebral sinuses in 12 patients were corrected using IVUS-guided stenting. No technical or neurological complications were encountered. The IVUS images were excellent for the diagnosis of the stenosis, and intraluminal thrombi were clearly visualized by using IVUS in 3 (25%) of the 12 patients. A giant arachnoid granulation was demonstrated in 1 (8.3%) of the 12 patients. Intravenous compartments or septations (2 of 12, 16.7%) and vessel wall thickening (6 of 12, 50%) were also noted. At 1-year follow-up, 10 of 12 patients were clinically symptom-free in our series.CONCLUSIONSIVUS is a promising tool with the potential to improve the diagnostic accuracy in IIH, aiding in identification of the types of intracranial venous stenosis, assisting in stent selection, and guiding stent placement. Further study of the utility of IVUS in venous stenting and venous stenosis pathology is warranted.

Reductions in bilateral transverse sinus pressure gradients with unilateral transverse venous sinus stenting for idiopathic intracranial hypertension

2020 ◽  
pp. neurintsurg-2020-016170
Author(s):  
Anthony Larson ◽  
Lorenzo Rinaldo ◽  
John J Chen ◽  
Jeremy Cutsforth-Gregory ◽  
Amy R Theiler ◽  
...  
Keyword(s):  
Intracranial Hypertension ◽  
Stent Placement ◽  
Idiopathic Intracranial Hypertension ◽  
Transverse Sinus ◽  
Venous Sinus ◽  
Pressure Gradients ◽  
Before And After ◽  
Sinus Stenosis ◽  
The Mean ◽  
The Right

BackgroundVenous sinus stenting is an effective treatment for papilledema associated with idiopathic intracranial hypertension (IIH). It is unclear whether unilateral transverse-sigmoid sinus (TSS) stenting adequately decompresses the contralateral TSS system in cases of bilateral transverse sinus stenosis. The objective of this study was to compare changes in bilateral TSS pressure gradients following unilateral TSS stenting in a series of patients with IIH.MethodsConsecutive patients from a single institution who underwent venous sinus stenting for IIH with measurement of bilateral pressure gradients before and after stenting for IIH were enrolled. Pressure gradients in both TSS pre- and post-stenting were measured during the procedure. The TSS with the highest gradient was stented. Changes in TSS pressure gradients following stent placement were calculated for both TSS. Mean changes in pressure gradients of ipsilateral and contralateral TSS were calculated.ResultsSixteen patients with IIH who underwent TSS stenting were included. All were female. Mean age was 36.4 years. The right-sided TSS was the stented side in 12 (75.0%) patients. The mean pre-stent pressure gradient of the ipsilateral TSS was 19.3 mmHg (SD=10.8), which was reduced to a mean of 3.8 mmHg (3.4) following stent placement (P =<0.0001). On the contralateral (non-stented) side, the mean pre-stent gradient of 15.1 mmHg (7.5) was reduced to a mean of 7.8 mmHg (6.6) following stenting (P=0.006).ConclusionsThe use of a single stent provides some venous decompression of the contralateral non-stented stenosis in most cases of IIH treated with endovascular therapy.

scholarly journals Endovascular treatment of idiopathic intracranial hypertension caused by multiple venous sinus stenoses

2019 ◽  
Vol 10 ◽  
pp. 47 ◽  
Author(s):  
Yudai Morisaki ◽  
Ichiro Nakagawa ◽  
Koji Omoto ◽  
Takeshi Wada ◽  
Kimihiko Kichikawa ◽  
...  
Keyword(s):  
Endovascular Treatment ◽  
Intracranial Hypertension ◽  
Stent Placement ◽  
Idiopathic Intracranial Hypertension ◽  
Venous Pressure ◽  
Transverse Sinus ◽  
Venous Sinus ◽  
Sagittal Sinus ◽  
Sinus Stenosis ◽  
Cerebral Venous Pressure

Background: Idiopathic intracranial hypertension (IIH) shows symptoms by elevating intracranial pressure. Although sinus stenosis has been detected in many patients with IIH, the role of sinus stenosis in IIH remains obscure. Endovascular treatment for IIH due to transverse sinus stenosis has been frequently documented; however, IIH due to multiple sinus stenoses including the superior sagittal sinus (SSS) is rare. Here, we report a case of IIH due to multiple sinus stenoses treated by sinus stenting. Case Presentation: A 47-year-old woman suffered from intractable headache with IIH presented with stenosis of the right transverse and SSS. Stent placement was carried out since intracranial hypertension and trans-stenotic cerebral venous pressure gradient (CVPG) were presented, and her intractable headache disappeared. Conclusion: IIH can be caused by venous sinus stenoses and stent placement could be an appropriate treatment in patients who demonstrated a CVPG.

Management of Idiopathic Intracranial Hypertension during the COVID19 Pandemic

2020 ◽  
Vol 15 ◽  
Author(s):  
Ayman G. Elnahry ◽  
Gehad A. Elnahry
Keyword(s):  
Intracranial Hypertension ◽  
Idiopathic Intracranial Hypertension ◽  
Sinus Thrombosis ◽  
Cerebral Venous Sinus Thrombosis ◽  
Fundus Photography ◽  
Young Females ◽  
Optic Nerve Sheath Fenestration ◽  
Threatening Condition ◽  
Coronavirus Infection

Background: In the current coronavirus disease 2019 (COVID-19) pandemic, health systems are struggling to prioritize care for affected patients, however, physicians globally are also attempting to maintain care for other lessthreatening medical conditions that may lead to permanent disabilities if untreated. Idiopathic intracranial hypertension (IIH) is a relatively common condition affecting young females that could lead to permanent blindness if not properly treated. In this article, we provide some insight and recommendations regarding the management of IIH during the pandemic. Methods: The diagnosis, follow-up, and treatment methods of IIH during the COVID-19 pandemic period are reviewed. COVID-19 as a mimic of IIH is also discussed. Results: Diagnosis and follow-up of papilledema due to IIH during the COVID-19 pandemic can be facilitated by nonmydriatic fundus photography and optical coherence tomography. COVID-19 may mimic IIH by presenting as cerebral venous sinus thrombosis, papillophlebitis, or meningoencephalitis, so a high index of suspicious is required in these cases. When surgical treatment is indicated, optic nerve sheath fenestration may be the primary procedure of choice during the pandemic period. Conclusion: IIH is a serious vision threatening condition that could lead to permanent blindness and disability at a relatively young age if left untreated. It could be the first presentation of a COVID-19 infection. Certain precautions during the diagnosis and management of this condition could be taken that may allow appropriate care to be delivered to these patients while minimizing the risk of coronavirus infection.

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