Transverse sinus stenting without surgical repair in idiopathic CSF rhinorrhea associated with transverse sinus stenoses: a pilot study

OBJECTIVE Based on their clinical and radiological patterns, idiopathic CSF rhinorrhea and idiopathic intracranial hypertension can represent different clinical expressions of the same underlying pathological process. Transverse sinus stenoses are associated with both diseases, resulting in eventual restriction of the venous CSF outflow pathway. While venous sinus stenting has emerged as a promising treatment for idiopathic intracranial hypertension, its efficiency on idiopathic CSF leaks has not been very well addressed in the literature so far. The purpose of this study was to report the results of transverse sinus stenting in patients with spontaneous CSF rhinorrhea associated with transverse sinus stenoses. METHODS From a prospectively collected database, the authors retrospectively collected the clinical and radiological features of the patients with spontaneous CSF leakage who were treated with venous sinus stenting. RESULTS Five female patients were included in this study. Transverse sinus stenoses were present in all patients, and other radiological signs of idiopathic intracranial hypertension were present in 4 patients. The median transstenotic pressure gradient was 6.5 mm Hg (range 3–9 mm Hg). Venous stenting resulted in the disappearance of the leak in 4 patients with no recurrence and no subsequent meningitis during the follow-up (median 12 months, range 6–63 months). CONCLUSIONS According to the authors’ results, venous sinus stenting may result in the disappearance of the leak in many cases of idiopathic CSF rhinorrhea. Larger comparative studies are needed to assess the efficiency and safety of venous stenting as a first-line approach in patients with spontaneous CSF rhinorrhea associated with transverse sinus stenoses.

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Transverse venous stenting for the treatment of idiopathic intracranial hypertension, or pseudotumor cerebri

Neurosurgical FOCUS ◽

10.3171/2018.5.focus18102 ◽

2018 ◽

Vol 45 (1) ◽

pp. E11 ◽

Cited By ~ 6

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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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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Pattern of pressure gradient alterations after venous sinus stenting for idiopathic intracranial hypertension predicts stent-adjacent stenosis: a proposed classification system

Journal of NeuroInterventional Surgery ◽

10.1136/neurintsurg-2017-013135 ◽

2017 ◽

Vol 10 (4) ◽

pp. 391-395 ◽

Cited By ~ 3

Author(s):

Daniel Raper ◽

Thomas J Buell ◽

Dale Ding ◽

Ching-Jen Chen ◽

Robert M Starke ◽

...

Keyword(s):

Pressure Gradient ◽

Intracranial Hypertension ◽

Idiopathic Intracranial Hypertension ◽

Venous Pressure ◽

Patient Characteristics ◽

Transverse Sinus ◽

Venous Sinus ◽

Type I ◽

Type Ii ◽

Type Iii

ObjectiveVenous sinus stenting (VSS) is a safe and effective treatment for idiopathic intracranial hypertension (IIH) with angiographic venous sinus stenosis. However, predictors of stent-adjacent stenosis (SAS) remain poorly defined.MethodsWe performed a retrospective review of 47 patients with IIH and intracranial venous stenosis who underwent VSS with pre- and post-stent venography. Patient characteristics, treatments and outcomes were reviewed. Changes in pressure gradient after VSS were classified according to pattern of gradient resolution into types I–III.ResultsType I gradient resolution, in which mean venous pressure (MVP) in the transverse sinus (TS) decreases towards MVP in the sigmoid sinus (SS), occurred in 18 patients (38.3%). Type II gradient resolution pattern, in which SS MVP increases towards that in the TS, occurred in 7patients (14.9%). Type III pattern, in which MVP equilibrates to a middle value, occurred in 22patients (46.8%). SAS occurred in 0%, 28.6%, and 22.7% of patients in types I, II and III, respectively. Compared with patients with type I gradient resolution, SAS was more common in those with type II (p=0.0181) and type III (p=0.0306) patterns.ConclusionsThe pattern of change in the trans-stenosis venous pressure gradient may be predictive of SAS and is a useful tool for classifying the response of the venous obstruction to stenting. A type I pattern appears to represent the ideal response to VSS. Some patients with type II and III changes, particularly if they have other predictors of recurrent stenosis, may benefit from longer initial stent constructs.

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Dynamic nature of intracranial venous sinuses in idiopathic intracranial hypertension

Interventional Neuroradiology ◽

10.1177/1591019919871393 ◽

2019 ◽

Vol 26 (1) ◽

pp. 118-120 ◽

Cited By ~ 3

Author(s):

Patrick Nicholson ◽

Stéphanie Lenck ◽

Walter Kucharczyk ◽

Vitor Mendes-Pereira

Keyword(s):

Case Report ◽

Intracranial Hypertension ◽

Medical Therapy ◽

Idiopathic Intracranial Hypertension ◽

Complete Resolution ◽

Transverse Sinus ◽

Venous Sinus ◽

Dynamic Nature ◽

Venous Sinuses ◽

Transverse Sinuses

There is increasing interest in venous sinus stenting in patients with idiopathic intracranial hypertension who are refractory to medical therapy. Often the transverse sinus stenoses are bilateral, however, and there is no clear evidence for whether we should stent one or both sides in these patients. Our practice is to first stent one side, and in this brief case report, we demonstrate complete resolution of the contralateral stenosis in one such patient who underwent stenting. Her symptoms also completely resolved, and so this case highlights the dynamic fluctuant nature of the transverse sinuses.

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Venous sinus stenting for idiopathic intracranial hypertension: a systematic review and meta-analysis

Journal of NeuroInterventional Surgery ◽

10.1136/neurintsurg-2018-014172 ◽

2018 ◽

Vol 11 (4) ◽

pp. 380-385 ◽

Cited By ~ 28

Author(s):

Patrick Nicholson ◽

Waleed Brinjikji ◽

Ivan Radovanovic ◽

Christopher Alan Hilditch ◽

Anderson Chun On Tsang ◽

...

Keyword(s):

Systematic Review ◽

Intracranial Hypertension ◽

Idiopathic Intracranial Hypertension ◽

Meta Analysis ◽

Venous Sinus ◽

Pulsatile Tinnitus ◽

Venous Stenting ◽

Excellent Safety Profile ◽

The Mean ◽

Rate Of Improvement

BackgroundStenting of the intracranial venous sinuses is used as a treatment in certain cases of idiopathic intracranial hypertension (IIH). Interest in, and experience of, this technique is growing, particularly in recent years. We sought to provide an updated systematic review and meta-analysis of the use of venous stenting in these patients, examining clinical outcomes.MethodsA literature search of venous stenting in IIH patients was performed. Using random-effects meta-analysis, we evaluated the following outcomes: clinical resolution of papilledema; headaches and pulsatile tinnitus; recurrence of symptoms after stenting; and complications.ResultsTwenty articles from 18 different centers were included. In a total of 474 patients. 418 were female (88%). The mean age of the patients was 35, while the mean body mass index (BMI) was 35 kg/m2. Median follow-up was 18 months. The overall rate of improvement in papilloedema was 93.7% (95% CI 90.5% to 96.9%), while the overall rate of improvement or resolution of headache was 79.6% (95% CI 73.3% to 85.9%). Pulsatile tinnitus resolved in 90.3% (95% CI 83.8% to 96.70%), while the overall rate of recurrence of IIH symptoms after stenting was 9.8% (95% CI 6.7% to 13%). The rate of major complications was 1.9% (95% CI 0.07% to 3.1%).ConclusionsVenous sinus stenting in patients with IIH who are refractory to medical therapy appears to have an excellent safety profile and is associated with significant improvements in headaches, pulsatile tinnitus, and papilledema.

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Transverse venous sinus stenting for idiopathic intracranial hypertension: Safety and feasibility

The Neuroradiology Journal ◽

10.1177/1971400918782320 ◽

2018 ◽

Vol 31 (5) ◽

pp. 513-517 ◽

Cited By ~ 3

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.

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Transient resolution of venous sinus stenosis after high-volume lumbar puncture in a patient with idiopathic intracranial hypertension

Journal of Neurosurgery ◽

10.3171/2017.3.jns163181 ◽

2018 ◽

Vol 129 (1) ◽

pp. 153-156 ◽

Cited By ~ 15

Author(s):

Thomas J. Buell ◽

Daniel M. S. Raper ◽

I. Jonathan Pomeraniec ◽

Dale Ding ◽

Ching-Jen Chen ◽

...

Keyword(s):

Pressure Gradient ◽

Intracranial Hypertension ◽

Lumbar Puncture ◽

Idiopathic Intracranial Hypertension ◽

High Volume ◽

Transverse Sinus ◽

Venous Sinus ◽

Pressure Gradients ◽

Cross Sectional ◽

Sinus Stenosis

Stenosis of the transverse sinus (TS) and sigmoid sinus (SS), with a trans-stenosis pressure gradient, has been implicated in the pathophysiology of idiopathic intracranial hypertension (IIH). MRI has shown improvement in TS and SS stenosis after high-volume lumbar puncture (HVLP) in a subset of patients with IIH. The authors present the first report of an IIH patient with immediate post-HVLP TS and SS trans-stenosis pressure gradient reduction and an attendant increase in TS and SS cross-sectional area confirmed using intravascular ultrasonography (IVUS). Recurrence of the patient’s TS-SS stenosis coincided with elevated HVLP opening pressure, and venous sinus stent placement resulted in clinical improvement. This report suggests that TS and SS stenosis may be a downstream effect of elevated intracranial pressure in IIH, rather than its principal etiological mechanism. However, the authors hypothesize that endovascular stenting may obliterate a positive feedback loop involving trans-stenosis pressure gradients, and still benefit appropriately selected patients.

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Predicting the need for retreatment in venous sinus stenting for idiopathic intracranial hypertension

Journal of NeuroInterventional Surgery ◽

10.1136/neurintsurg-2020-016550 ◽

2020 ◽

pp. neurintsurg-2020-016550

Author(s):

Joshua Kahan ◽

Sri Sundararajan ◽

Kenroy Brown ◽

Marc Dinkin ◽

Cristiano Oliveira ◽

...

Keyword(s):

Treatment Failure ◽

Intracranial Hypertension ◽

Lumbar Puncture ◽

Idiopathic Intracranial Hypertension ◽

Meta Analysis ◽

Transverse Sinus ◽

Venous Sinus ◽

Unknown Etiology ◽

Academic Center ◽

Increased Risk

BackgroundIdiopathic intracranial hypertension is a disease of raised intra-cranial pressure of unknown etiology. Lateral cerebral venous sinus stenosis (VSS) has been increasingly reported in these patients, and stenting has emerged as an alternative treatment for medically refractory symptoms. Treatment efficacy on meta-analysis appears promising, but identifying which patients are likely to benefit most, and which are likely to require repeat procedures, is currently unclear.MethodsWe retrospectively reviewed a prospectively collected database of 79 patients treated with venous sinus stenting at a single academic center with minimum follow-up of 18 months. We extracted baseline clinical data, as well as manometry at lumbar puncture and during angiography, and used logistic regression to identify parameters that could predict stent failure.ResultsRetreatment rate after successful VSS was 13.9%. Lumbar puncture opening pressure (OP) was shown to significantly predict treatment failure (ß=0.06; OR=1.064 (1.003–1.135); P=0.039). This effect remained significant when age, sex and body mass index were added to the model (ß=0.06; OR=1.066 (1.002–1.140); P=0.043). OP was correlated with venous sinus manometry readings in the superior sagittal and transverse sinus pre-stent placement, as well trans-stenotic gradient (P<0.001).ConclusionsHigher lumbar puncture OP was associated with an increased risk of stent failure in transverse sinus stenting for idiopathic intracranial hypertension, although the performance of this model as a linear discriminator was poor. Further studies are required to better assess which patients are at greatest risk of treatment failure.

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Severe cerebellar hemorrhage following transverse sinus stenting for idiopathic intracranial hypertension

Interventional Neuroradiology ◽

10.1177/1591019917734389 ◽

2017 ◽

Vol 24 (1) ◽

pp. 100-105 ◽

Cited By ~ 7

Author(s):

Pascale Lavoie ◽

Marie-Ève Audet ◽

Jean-Luc Gariepy ◽

Martin Savard ◽

Steve Verreault ◽

...

Keyword(s):

Intracranial Hypertension ◽

Idiopathic Intracranial Hypertension ◽

Obstructive Hydrocephalus ◽

Venous Drainage ◽

Transverse Sinus ◽

Level Of Evidence ◽

Cerebellar Hemorrhage ◽

Venous Stenting ◽

Brainstem Reflex ◽

Cerebral Mri

We report a severe adverse event occurring in the course of a cohort study (ISRCTN13784335) aimed at measuring the efficacy and safety of venous stenting in the treatment of patients with medically refractory idiopathic intracranial hypertension (IIH). The patient was a 41-year-old woman who was not overweight, who presented with severe headache, grade 1 bilateral papilledema and transient tinnitus, refractory to medical treatment. Right transverse sinus stenting was successfully performed. Following surgery, the patient’s state of consciousness decreased acutely with rapid and progressive loss of brainstem reflex. CT scan revealed acute cerebellar and intraventricular hemorrhage with obstructive hydrocephalus. Angioscan revealed normal venous sinus patency and cerebral MRI showed acute mesencephalic ischemia. Mechanical impairment of cerebellar venous drainage by the stent or venous perforation with the large guidewire used in this technique are two logical ways to explain the cerebellar hemorrhage seen in our patient. The risk of such a complication could probably be reduced using alternative tools and technique. However, given the low level of evidence around the safety of transverse sinus stenting in IIH, its formal assessment in clinical trials is required.

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Stent Survival and Stent-Adjacent Stenosis Rates following Venous Sinus Stenting for Idiopathic Intracranial Hypertension: A Systematic Review and Meta-Analysis

Interventional Neurology ◽

10.1159/000490578 ◽

2018 ◽

Vol 7 (6) ◽

pp. 490-500 ◽

Cited By ~ 14

Author(s):

Hamidreza Saber ◽

Whitfield Lewis ◽

Mahsa Sadeghi ◽

Gary Rajah ◽

Sandra Narayanan

Keyword(s):

Systematic Review ◽

Intracranial Hypertension ◽

Idiopathic Intracranial Hypertension ◽

Meta Analysis ◽

Case Series ◽

Causative Factor ◽

Neurological Complications ◽

Venous Sinus ◽

Venous Stenting

Background: Idiopathic intracranial hypertension (IIH) is characterized by an elevated intracranial pressure without any identifiable causative factor such as an intracranial mass. Dural venous sinus stenosis (DVSS) has been suggested to be associated with IIH. Objective: We performed an updated systematic review and meta-analysis to determine clinical outcomes as well as stent survival and stent-adjacent stenosis rates in patients undergoing DVSS for the management of medically refractory IIH. Methods: We searched PubMed, Embase, and Cochrane databases to identify prospective or retrospective cohorts or case series of patients with IIH treated with DVSS between 2000 and 2017. Results: A total of 473 patients were included from 24 studies. Headache was present in 429 (91.8%) patients and resolved or improved in 319/413 (77.2%) after the procedure. Headache, papilledema, visual acuity, and tinnitus improved in 256/330 (77.6%), 247/288 (85.8%), 121/172 (70.3%), and 93/110 (84.5%) patients following DVSS at the final follow-up (mean of 18.3 months). In a meta-analysis of 395 patients with available follow-up data on stenting outcome (mean of 18.9 months), the stent survival and stent-adjacent stenosis rates were 84% (95% confidence interval [CI] 79–87%) and 14% (95% CI 11–18%), respectively. The rate of major neurological complications was less than 2%. Conclusion: Stent-adjacent stenosis is an important complication following venous stenting in patients with DVSS and IIH. Further studies are needed to identify determinants of stent-adjacent stenosis and stent nonsurvival.

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