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Václavů L. Editorial for "Differentiation Between the Low and High Trans-Stenotic Pressure Gradient in Patients With Idiopathic Intracranial Hypertension Using 4D Flow MRI-Derived Hemodynamic Parameters". J Magn Reson Imaging 2024; 59:1580-1581. [PMID: 37615314 DOI: 10.1002/jmri.28968] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2023] [Accepted: 08/04/2023] [Indexed: 08/25/2023] Open
Affiliation(s)
- Lena Václavů
- C.J. Gorter MRI Center, Department of Radiology, Leiden University Medical Center, Leiden, The Netherlands
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Handzic A, Tao BK, O'Cearbhaill RM, Nicholson PJ, Margolin EA, Micieli JA. Assessment of Reversibility of Transverse Venous Sinus Stenosis in Patients With Papilledema. J Neuroophthalmol 2024:00041327-990000000-00577. [PMID: 38373047 DOI: 10.1097/wno.0000000000002090] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/20/2024]
Abstract
BACKGROUND Bilateral transverse venous sinus stenosis (TVSS) or stenosis of a dominant venous sinus has been found to be very sensitive radiological findings in patients with intracranial hypertension (IH), yet there is still an ongoing debate whether they constitute reversible or permanent phenomena. Thus, the purpose of this study was to investigate the reversibility of TVSS in patients with IH, including conservatively treated patients with signs of IH as defined by the presence of papilledema. METHODS This was a retrospective chart review of all patients diagnosed with IH between 2016 and 2022, assessed from 2 tertiary university-affiliated neuro-ophthalmology practices. Inclusion criteria were the presence of papilledema, as quantified by optical coherence tomography, and bilateral TVSS, which is considered typical of IH on neuroimaging. During follow-up, included patients must have had confirmation of papilledema resolution as well as subsequent neuroimaging after conservative treatment or cerebrospinal fluid flow diversion. Patients with dural sinus vein thrombosis or intrinsic stenosis from sinus trabeculations or significant arachnoid granulations were excluded from the study. Either CT venography or MRI/MR venography was reviewed by a fellowship-trained neuroradiologist, and the degree of stenosis was scored through the combined conduit score (CCS), as described by Farb et al. The primary outcome was to assess TVSS changes after resolution or improvement of papilledema. RESULTS From 435 patients, we identified a subset of 10 who satisfied all inclusion criteria. Our cohort comprised entirely women with a median age of 29.5 years and a median BMI of 32.5 kg/m2. Treatment consisted of acetazolamide in 7 patients, of which 1 had additional topiramate and 2 underwent cerebrospinal fluid flow diversion. Furthermore, 6 patients demonstrated significant weight loss during follow-up. For the primary outcome, 5 of 10 patients exhibited no appreciable TVSS change, and 5 patients demonstrated significant improvement in TVSS, of which 4 received conservative treatment only. Papilledema resolution or improvement was statistically significantly associated with increasing average CCS, TVSS diameter, and grade. CONCLUSIONS We were able to demonstrate that TVSS can be both irreversible and reversible in patients with resolved papilledema. The finding of TVSS reversibility from conservative treatment alone is novel and has important implications to optimize patient care. Future studies should work to identify factors associated with irreversible TVSS for subsequent targeted intervention and prevention.
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Affiliation(s)
- Armin Handzic
- Department of Ophthalmology and Vision Sciences (AH, EAM, JAM), Faculty of Medicine, University of Toronto, Toronto, Canada; Faculty of Medicine (BKT), University of British Columbia, Vancouver, Canada; Division of Neuroradiology (RMOC, PJN), Department of Radiology, Faculty of Medicine, University of Toronto, Toronto, Canada; Division of Neurology (EAM, JAM), Department of Medicine, Faculty of Medicine, University of Toronto, Toronto, Canada; and Kensington Vision and Research Center (JAM), Toronto, Canada
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Han G, Wan S, Dandu C, Zhou D, Ding Y, Ji X, Meng R. Intensive mannitol slow infusion post-stenting may attenuate stenting-related early adverse effects in patients with cerebral venous sinus stenosis. CNS Neurosci Ther 2024; 30:e14350. [PMID: 37424178 PMCID: PMC10848041 DOI: 10.1111/cns.14350] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2023] [Revised: 06/18/2023] [Accepted: 06/26/2023] [Indexed: 07/11/2023] Open
Abstract
AIMS To analyze intensive slow mannitol poststenting on attenuating stenting-related early adverse effects in cerebral venous sinus stenosis (CVSS). METHODS This real-world study enrolled subacute or chronic CVSS patients from January 2017 through March 2022 and divided them into DSA only and stenting post-DSA groups. The later group was subdivided into control (without extra mannitol use) and intensive slow mannitol subgroup (immediate extra mannitol 250-500 mL, 2 mL/min infusion post-stenting) after signed informed consent. All data were compared. RESULTS A total of 95 eligible patients entered into final analysis, in which 37 cases underwent DSA only and 58 cases underwent stenting post-DSA. Finally, 28 patients were entered into intensive slow mannitol subgroup and 30 in control. Stenting group vs. DSA group, HIT-6 scores and WBC counts were higher in the former (both p < 0.001). Intensive slow mannitol subgroup vs. control on the third day post-stenting, a statistically significant reductions were noticed in the former on WBC counts (6.19 ± 1.86 × 109 /L vs. 9.59 ± 2.05 × 109 /L); HIT-6 scores (degree of headache) (40.00 (38.00-40.00) vs. 49.00 (41.75-55.25)) and brain edema surrounding the stent on CT maps (17.86% vs.96.67%), all p < 0.001. CONCLUSIONS Stenting-related severe headache, inflammatory biomarkers elevation, and brain edema aggravation can be attenuated by intensive slow mannitol infusion.
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Affiliation(s)
- Guangyu Han
- Department of Neurology, Xuanwu HospitalCapital Medical UniversityBeijingChina
- Advanced Center of StrokeBeijing Institute for Brain DisordersBeijingChina
- National Center for Neurological Disorders, Xuanwu HospitalCapital Medical UniversityBeijingChina
| | - Shuling Wan
- Department of Neurology, Xuanwu HospitalCapital Medical UniversityBeijingChina
- Advanced Center of StrokeBeijing Institute for Brain DisordersBeijingChina
- National Center for Neurological Disorders, Xuanwu HospitalCapital Medical UniversityBeijingChina
| | - Chaitu Dandu
- Department of NeurosurgeryWayne State University School of MedicineDetroitMichiganUSA
| | - Da Zhou
- Department of Neurology, Xuanwu HospitalCapital Medical UniversityBeijingChina
- Advanced Center of StrokeBeijing Institute for Brain DisordersBeijingChina
- National Center for Neurological Disorders, Xuanwu HospitalCapital Medical UniversityBeijingChina
| | - Yuchuan Ding
- Department of NeurosurgeryWayne State University School of MedicineDetroitMichiganUSA
| | - Xunming Ji
- National Center for Neurological Disorders, Xuanwu HospitalCapital Medical UniversityBeijingChina
| | - Ran Meng
- Department of Neurology, Xuanwu HospitalCapital Medical UniversityBeijingChina
- Advanced Center of StrokeBeijing Institute for Brain DisordersBeijingChina
- National Center for Neurological Disorders, Xuanwu HospitalCapital Medical UniversityBeijingChina
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Chen X, Ren Y, Chen F. Severe bilateral papilledema after sigmoid sinus constriction surgery: a case report. BMC Ophthalmol 2023; 23:500. [PMID: 38066460 PMCID: PMC10704719 DOI: 10.1186/s12886-023-03252-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2023] [Accepted: 12/01/2023] [Indexed: 12/18/2023] Open
Abstract
BACKGROUND Papilledema is a common sign of various diseases in the eye. It could result from any conditions of increased intracranial pressure (ICP). Underlying the etiology of papilledema and appropriate treatment in time is essential. CASE REPORT We present a case of severe bilateral papilledema after sigmoid sinus constriction surgery. A 25-year-old female presented with a 1-month history of bilateral blurred vision, headache, and vomiting. The patient had a history of right-side sigmoid sinus constriction surgery for pulsatile tinnitus (PT) one month before in another hospital. Fundus examination showed severe bilateral papilledema. Lumbar puncture showed an elevated cerebrospinal fluid (CSF) opening pressure of 29 cm H2O. Neuroimaging examination demonstrated the right sigmoid sinus filling defect as changes after surgery. We referred the patient to the initial surgeon, who repaired the sigmoid sinus on the right side by removing the implanted gelatin sponge, as diuretic treatment could not be effective. Intracranial hypertension symptoms and signs improved soon after eliminating sigmoid sinus stenosis. Neuroimaging showed resolved right sigmoid sinus stenosis after the second surgery. CSF opening pressure was 14.5 cm H2O at the 1-month follow-up. Fundus examination showed entirely resolved papilledema. Three years of follow-up showed no recurrence. CONCLUSIONS This is the first clinical report of intracranial hypertension associated with sigmoid sinus constriction surgery. Although rare, rapid detection and adequate etiology management could lead to a good prognosis. It highlights the need for ophthalmologists to be aware of the diagnostic approach to papilledema and enhance cooperation with multidisciplinary departments. The most likely cause of the intracranial hypertension was dominant sinus surgical constriction by mechanical external compression, as confirmed by the complete clinical remission following the second operation to remove the implanted gelatin sponge. Thus, this case also highlights the importance of selecting the appropriate therapeutic option for PT. Surgical sinus constriction should no longer be considered a viable option for PT treatment.
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Affiliation(s)
- Xi Chen
- Department of Ophthalmology, Northern Jiangsu People's Hospital, Yangzhou, Jiangsu Province, China
- Clinical Medical College, Yangzhou University, Yangzhou, Jiangsu Province, China
| | - Yizhou Ren
- Department of Ophthalmology, Northern Jiangsu People's Hospital, Yangzhou, Jiangsu Province, China
- Clinical Medical College, Yangzhou University, Yangzhou, Jiangsu Province, China
| | - Fang Chen
- Department of Ophthalmology, Northern Jiangsu People's Hospital, Yangzhou, Jiangsu Province, China.
- Clinical Medical College, Yangzhou University, Yangzhou, Jiangsu Province, China.
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Horev A, Ben-Arie G, Walter E, Tsumi E, Regev T, Aloni E, Biederko R, Zlotnik Y, Lebowitz Z, Shelef I, Honig A. Emergent cerebral venous stenting: A valid treatment option for fulminant idiopathic intracranial hypertension. J Neurol Sci 2023; 452:120761. [PMID: 37572407 DOI: 10.1016/j.jns.2023.120761] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2023] [Revised: 07/04/2023] [Accepted: 07/31/2023] [Indexed: 08/14/2023]
Abstract
BACKGROUND Fulminant idiopathic intracranial hypertension (FIIH) is characterized by rapid, severe, progressive vision loss and often treated surgically. Cerebral transverse venous stenting (CTVS) is efficacious in IIH patients, but emergent CTVS in FIIH is rarely reported. We present our experience with emergent CTVS in patients with FIIH. METHODS Since 01/2019, an institutional protocol allowed emergent CTVS in FIIH patients with bilateral transverse sinus stenosis and gradient pressure > 15 on digital subtraction angiography (DSA). We retrospectively analyzed a prospective registry of all IIH patients with details of neurological and neuro-ophthalmological assessments before and after treatment, and subjective assessments of headache and tinnitus were made pre-and post-procedure. RESULTS 259 IIH patients, including 49 who underwent CTVS, were registered. Among them, five female patients met inclusion criteria for FIIH and underwent emergent CTVS. FIIH patients were younger (18.8 ± 1.64 vs 27.7 ± 4.85, p < 0.01), mean BMI was lower (30.8 ± 10.57 vs 34.6 ± 4.3, p < 0.01), and lumbar puncture opening pressure higher (454 ± vs 361 ± 99.4, p < 0.01) than that of IIH patients. They presented with acute visual loss, severe headache, papilledema, significant bilateral transverse sinus stenosis on CT-venography, and mean dominant side gradient pressure of 26.4 ± 6.2 on DSA. CTVS was performed without significant complications, resulting in remarkable improvement in headache, optical coherence tomography, and visual fields within 1 week. At 1-year follow-up (four patients) and 6-month follow-up (1 patient), there was complete resolution of papilledema and headache, and marked improvement in visual acuity. CONCLUSIONS In these patients, emergent-CTVS was a safe and effective treatment option for FIIH. Further evaluation is warranted.
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Affiliation(s)
- Anat Horev
- Department of Neurology, Soroka Medical Center, Beer Sheva, Israel.
| | - Gal Ben-Arie
- Department of Radiology, Soroka Medical Center, Beer Sheva, Israel.
| | - Eyal Walter
- Department of Ophthalmology, Soroka Medical Center, Beer Sheva, Israel
| | - Erez Tsumi
- Department of Ophthalmology, Soroka Medical Center, Beer Sheva, Israel.
| | - Tamir Regev
- Department of Ophthalmology, Soroka Medical Center, Beer Sheva, Israel.
| | - Eyal Aloni
- Department of Ophthalmology, Barzilai Medical Center, Ashkelon, Israel
| | - Ron Biederko
- Clinical Research Center, Soroka University Medical Center, Faculty of Health Sciences, Ben Gurion University of the Negev, Beer Sheva, Israel
| | - Yair Zlotnik
- Department of Neurology, Soroka Medical Center, Beer Sheva, Israel.
| | - Zachary Lebowitz
- Medical School for International Health, Ben Gurion University of the Negev, Beer Sheva, Israel.
| | - Ilan Shelef
- Department of Radiology, Soroka Medical Center, Beer Sheva, Israel.
| | - Asaf Honig
- Department of Neurology, Soroka Medical Center, Beer Sheva, Israel.
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Wang S, Tong X, Li X, Liu L, Liu Z, Mo D, Wang Y. Association of post-intervention pressure gradient with symptom-free at 6 months in idiopathic intracranial hypertension with venous sinus stenosis treated by stenting. Interv Neuroradiol 2023; 29:413-418. [PMID: 35469507 PMCID: PMC10399497 DOI: 10.1177/15910199221095044] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2022] [Accepted: 03/16/2022] [Indexed: 11/16/2022] Open
Abstract
OBJECTIVE This study aimed to identify the key factors that might affect the clinical outcome of patients with idiopathic intracranial hypertension (IIH) and Venous sinus stenting (VSS). METHODS We performed an analysis of a prospectively collected database of patients with IIH and VSS who underwent stenting. The trans-stenotic pressure gradient was measured before and after intervention. In additional, patients' baseline characteristics, procedure details and clinical outcomes at 6-month follow-up (including changes in headache, visual impairment, papilledema, etc.) were recorded. The effects of post-intervention pressure gradient on symptom-free at 6 months were explored using logistic regression analysis, generalized additive model and receiver operator characteristic (ROC) curve. RESULTS Of 101 patients included in this study, the median pressure gradient across stenosis decreased from 19 mmHg before intervention to 2 mmHg after intervention. At 6 months, symptom-free was observed in 58 cases (57.4%). Multivariable logistic analysis and generalized additive model showed that post-intervention pressure gradient (increased by 1 mmHg) was independently and linearly correlated with symptom-free (OR = 0.79, 95% CI = 0.67-0.94). Moreover, the post-intervention pressure gradient revealed moderate discrimination with an area under ROC curve of 0.68 (95% CI = 0.57-0.78). Similar associations were observed for the disappearance of headache and papilledema, but not for the visual recovery. CONCLUSION The post-intervention pressure gradient may be a valid and reliable predictor of 6-month clinical outcome in patients with IIH and VSS treated by stenting. Nevertheless, external validation with blinded outcome is still needed to confirm its performance before clinical application.
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Affiliation(s)
- Sujie Wang
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing, China
- Tangshan Gongren Hospital, Hebei Medical University, Tangshan, Hebei, China
| | - Xu Tong
- Department of Interventional Neuroradiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Xiaoqing Li
- Department of Interventional Neuroradiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Lian Liu
- Department of Interventional Neuroradiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Zhenqiang Liu
- Department of Interventional Neuroradiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Dapeng Mo
- Department of Interventional Neuroradiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Yilong Wang
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing, China
- Advanced Innovation Center for Human Brain Protection, Capital Medical University, Beijing, China
- Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing, China
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Tosi U, Ramos A, Rampichini M, Alexiades G, Boddu S, Cisse B, Kacker A, Patsalides A, Tabaee A, Schwarz J, Schwartz TH, Ramakrishna R. Combined surgical repair and venous sinus stenting for patients with skull base encephaloceles secondary to dural venous sinus stenosis. Acta Neurochir (Wien) 2023; 165:2283-2292. [PMID: 37344735 DOI: 10.1007/s00701-023-05680-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2023] [Accepted: 06/09/2023] [Indexed: 06/23/2023]
Abstract
BACKGROUND Chronically elevated intracranial pressure (ICP) seen in idiopathic intracranial hypertension (IIH) can cause the development of skull base encephaloceles and cerebrospinal fluid (CSF) leaks. Surgical repair and ventriculoperitoneal shunt (VPS) placement are mainstays of treatment. Venous sinus stenting (VSS) is a newly accepted treatment modality. The goal of this study was thus to determine if VSS can be used to treat symptoms and prevent recurrence after surgical encephalocele repair. METHODS Retrospective chart review of patients that had surgical repair of encephaloceles followed by VSS for symptomatic stenosis with elevated pressure gradient. RESULTS A total of 13 patients underwent a combined encephalocele repair and VSS. Seventy-two percent were female; 46% had headaches, 69% pulsatile tinnitus, and 92% CSF rhinorrhea or otorrhea. One had seizures. Mean lumbar opening pressure was 23.3 ± 2.6 cm H2O; the average sagittal-to-jugular pressure gradient was 12.7 ± 1.8 cmH2O and was elevated in all patients. Four patients had middle fossa craniotomy for repair of tegmen defect (one bilateral); one had a retrosigmoid craniotomy for repair of a sigmoid plate defect. Eight had an endoscopic endonasal repair for sphenoid or cribriform plate encephalocele. There were no VSS procedural complications or complications associated with dual antiplatelet therapy. One patient had meningitis after endoscopic repair that was treated with antibiotics. One patient had recurrence of both CSF leak and venous stenosis adjacent to the stent requiring repeat repair and VSS. There was no further recurrence. CONCLUSION In patients with dural sinus stenosis and encephaloceles requiring repair, VSS can be performed safely within weeks of surgery for relief of symptoms, resolution of underlying pathology, and prevention of CSF leak recurrence.
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Affiliation(s)
- Umberto Tosi
- Department of Neurological Surgery, NewYork-Presbyterian, Weill Cornell Medicine, 525 E 68th St, Box 99, New York, NY, 10065, USA
| | - Alexander Ramos
- Department of Neurological Surgery, NewYork-Presbyterian, Weill Cornell Medicine, 525 E 68th St, Box 99, New York, NY, 10065, USA
| | - Margherita Rampichini
- Department of Neurological Surgery, NewYork-Presbyterian, Weill Cornell Medicine, 525 E 68th St, Box 99, New York, NY, 10065, USA
| | - George Alexiades
- Department of Otolaryngology, NewYork-Presbyterian, Weill Cornell Medicine, New York, NY, USA
| | - Srikanth Boddu
- Department of Neurological Surgery, NewYork-Presbyterian, Weill Cornell Medicine, 525 E 68th St, Box 99, New York, NY, 10065, USA
| | - Babacar Cisse
- Department of Neurological Surgery, NewYork-Presbyterian, Weill Cornell Medicine, 525 E 68th St, Box 99, New York, NY, 10065, USA
| | - Ashutosh Kacker
- Department of Otolaryngology, NewYork-Presbyterian, Weill Cornell Medicine, New York, NY, USA
| | - Athos Patsalides
- Department of Neurological Surgery, NewYork-Presbyterian, Weill Cornell Medicine, 525 E 68th St, Box 99, New York, NY, 10065, USA
| | - Abtin Tabaee
- Department of Otolaryngology, NewYork-Presbyterian, Weill Cornell Medicine, New York, NY, USA
| | - Justin Schwarz
- Department of Neurological Surgery, NewYork-Presbyterian, Weill Cornell Medicine, 525 E 68th St, Box 99, New York, NY, 10065, USA
| | - Theodore H Schwartz
- Department of Neurological Surgery, NewYork-Presbyterian, Weill Cornell Medicine, 525 E 68th St, Box 99, New York, NY, 10065, USA
- Department of Otolaryngology, NewYork-Presbyterian, Weill Cornell Medicine, New York, NY, USA
| | - Rohan Ramakrishna
- Department of Neurological Surgery, NewYork-Presbyterian, Weill Cornell Medicine, 525 E 68th St, Box 99, New York, NY, 10065, USA.
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Perdomo Luna CA, Campaña Perilla L, Cardona JD, Jimenez-Hakim E, Mejía JA. Coronary Stent for Right Transverse Venous Sinus Stenosis in a Patient With Symptomatic Idiopathic Intracranial Hypertension. Cureus 2023; 15:e36073. [PMID: 37056521 PMCID: PMC10093783 DOI: 10.7759/cureus.36073] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/10/2023] [Indexed: 03/14/2023] Open
Abstract
A 59-year-old woman was referred to the neuro-interventional team with complaints of headache, papilledema, and visual disturbances. Imaging and Lumbar puncture revealed signs consistent with idiopathic intracranial hypertension with stenosis of the right transverse venous sinus. The neurosurgery board chose to treat her with an endovascular approach and stenting. During the procedure, the right jugular vein revealed decreased blood flow. This led to a left jugular vein access through the confluence of venous dural sinuses. However, an incomplete confluence required the catheter to ascend the superior sagittal sinus before descending to the right transverse sinus. The carotid catheter system kept herniating up the SSS, risking rupture. Given the intraoperative findings and the available equipment, a more flexible coronary catheter system was chosen. This catheter device allowed plasty and successful stent deployment. A lumbar puncture was performed, and the patient was discharged. A follow-up MRI at five weeks showed signs of intracranial hypertension improvement and the patient reported Improvement in symptoms. To our knowledge, this is the first time this type of device has been used in this anatomical location for this pathology.
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Xue X, Zhou C, Gao Y, Ji X, Zhang X. Optic nerve sheath fenestration for visual impairment in cerebral venous diseases. Front Neurol 2023; 14:1065315. [PMID: 36761350 PMCID: PMC9902767 DOI: 10.3389/fneur.2023.1065315] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2022] [Accepted: 01/06/2023] [Indexed: 01/26/2023] Open
Abstract
Objective Visual impairment is the most common clinical feature of cerebral venous sinus occlusion or cerebral venous thrombosis-induced intracranial hypertension, which can result in optic atrophy, leading to irreversible vision loss, visual field defections, and finally, permanent blindness. Papilledema is a typical early pathophysiological alteration in visual impairment. Optic nerve sheath fenestration (ONSF) has become increasingly accepted as an option to prevent or halt progressive visual loss owing to its low risk and complications. The objective of this study is to review the latest research progress on ONSF for the treatment of visual impairment related to cerebral venous diseases. Methods Study were searched following PRISMA guidelines based on three electronic databases (Pubmed, Embase and Medline-Ovid). We used the following keywords and variations as keywords to identify studies: "optic nerve sheath fenestration, papilledema, cerebral venous diseases, cerebral venous stenosis, cerebral venous thrombosis, idiopathic intracranial hypertension". The publication date of studies was restricted between 1,872.1.1 and 2,021.12.31. The application of ONSF in papilledema due to cerebral venous diseases is reviewed. Additionally, the common surgical approaches as well as advantages and disadvantages are also described graphically. Results With the improvement of specific details of the ONSF procedure and surgical instruments, complications of ONSF have reduced and its safety has been significantly improved, although the number of clinically investigated cases in the literature remains low. Conclusion We recommend that ONSF should be considered as an imperative alternative to reduce or delay the visual morbidity of cerebral venous diseases, although there is yet no consensus on the optimal surgical timing.
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Affiliation(s)
- Xiao Xue
- Department of Ophthalmology, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Chen Zhou
- Department of Neurology, Xuanwu Hospital, Capital Medical University, Beijing, China
- Laboratory of Brain Disorders, Ministry of Science and Technology, Beijing Institute of Brain Disorders of Capital Medical University, Beijing, China
| | - Yuan Gao
- Department of Biomedical Engineering, School of Biological Science and Medical Engineering, Beihang University, Beijing, China
| | - Xunming Ji
- Laboratory of Brain Disorders, Ministry of Science and Technology, Beijing Institute of Brain Disorders of Capital Medical University, Beijing, China
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Xuxiang Zhang
- Department of Ophthalmology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
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Barrero Ruiz E, Iglesias Moroño S, Ros López B, Morales Martinez A, Díaz T, Arráez Sánchez MÁ. Life-threatening idiopathic intracranial hypertension: the role of venous sinus stenting. Childs Nerv Syst 2022; 38:1433-1443. [PMID: 35687167 DOI: 10.1007/s00381-022-05564-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/02/2022] [Accepted: 05/17/2022] [Indexed: 11/30/2022]
Abstract
BACKGROUND Idiopathic intracranial hypertension (IIH) is a clinical syndrome characterised by raised intracranial pressure with no discernible aetiology. It is relatively rare in children and its demographic features may differ from those of adults. The relationship between IIH and venous sinus stenosis (VSS) is well known. As VSS plays an important role in the pathophysiology, treatments have been developed aimed at improving venous blood outflow in refractory IIH. In the last two decades, venous sinus stenting has emerged as a treatment option in cases where stenosis is documented. METHODS AND RESULTS The scientific literature on paediatric cases of IIH and its treatment with venous sinus stenting was analysed. We present the case of a 6-year-old girl with a life-threatening presentation of IIH, who was treated with transverse sinus stenting and a lumboperitoneal shunt. We summarise the characteristic of paediatric stenting cases reported and review the literature focusing on the main aspects of venous sinus stenting. CONCLUSION VSS stenting could be a treatment tool for the acute presentation of IIH with severe symptoms and VSS plus an elevated trans-stenotic pressure gradient. However, in some cases, additional surgical treatment may be necessary.
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Affiliation(s)
- Estrella Barrero Ruiz
- Neurosurgery Department, Hospital Regional Universitario de Málaga, Málaga, Spain. .,Neurosurgery Department, Hospital Universitario Ramón Y Cajal, Ctra. de Colmenar Viejo km. 9, 28034, Madrid, Spain.
| | - Sara Iglesias Moroño
- Neurosurgery Department, Hospital Regional Universitario de Málaga, Málaga, Spain
| | - Bienvenido Ros López
- Neurosurgery Department, Hospital Regional Universitario de Málaga, Málaga, Spain
| | | | - Teresa Díaz
- Neurointerventional Radiology Department, Hospital Regional Universitario de Málaga, Málaga, Spain
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Cerebral angiography as a tool for diagnosis and management of idiopathic intracranial hypertension syndrome. Clin Imaging 2022; 88:53-58. [DOI: 10.1016/j.clinimag.2022.04.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2022] [Revised: 04/21/2022] [Accepted: 04/26/2022] [Indexed: 11/19/2022]
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Souza MNP, Costa BDAL, Santos FRDR, Fortini I. Update on Idiopathic Intracranial Hypertension Management. ARQUIVOS DE NEURO-PSIQUIATRIA 2022; 80:227-231. [PMID: 35976300 PMCID: PMC9491417 DOI: 10.1590/0004-282x-anp-2022-s110] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/15/2022] [Accepted: 04/29/2022] [Indexed: 06/15/2023]
Abstract
BACKGROUND Idiopathic Intracranial Hypertension (IIH) is a secondary headache with a steadily growing incidence. Currently, there is little evidence to guide the treatment of IIH. OBJECTIVE To review the pathophysiology of IIH, with focus on the role of obesity as a risk factor, and the implications for new therapeutic perspectives. METHODS in this narrative review, we summarized the current knowledge on treatment options highlighting available evidence for managing intracranial hypertension, obesity, and headache. RESULTS Clinical Presentation: headache is the most common symptom and a significant cause of quality-of-life impairment. Visual loss is common in the diagnosis. Pathophysiology: there is no unified theory able to explain all symptoms and the evolution of the disease. There is growing data pointing to metabolic changes and obesity with a central role in IIH pathophysiology. Treatment: most published data on IIH treatment is related to pressure control and protection from visual loss. Acetazolamide and cerebrospinal fluid diversion are the best options available. Optic nerve sheath fenestration might be useful to temporally control the pressure over the optic nerve and thus protect from visual deterioration. Recently, venous sinus stenting has proven to be a safe option in selected cases. Finally, bariatric surgery has proven to effectively control elevated intracranial pressure. CONCLUSION IIH is a potential cause of high disability. Early recognition is important, and treatment should be tailored to the needs of each case. There is a lack of research on headache management, which might persist after ICP control.
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Affiliation(s)
| | | | | | - Ida Fortini
- Universidade de São Paulo, Faculdade de Medicina, Hospital das Clínicas, São Paulo SP, Brazil
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13
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Uesugi S, Karukaya T, Nakayama H. The Case of a Patient with Idiopathic Intracranial Hypertension Who Required Additional Stenting for Stent-Adjacent Stenosis. JOURNAL OF NEUROENDOVASCULAR THERAPY 2021; 16:211-217. [PMID: 37502447 PMCID: PMC10370996 DOI: 10.5797/jnet.cr.2021-0073] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/28/2021] [Accepted: 07/08/2021] [Indexed: 07/29/2023]
Abstract
Objective We report the case of a patient with recurred idiopathic intracranial hypertension (IIH) with transverse sinus (TS) stenosis after initial stenting, which was treated with additional stent placed in tandem to the secondarily occurred stent-adjacent stenosis (SAS). Case Presentation A 41-year-old woman complained of reduced visual acuity and blurred vision, and presented with papilledema. Lumbar puncture revealed an opening pressure of 36 cmH2O. MRI revealed no space-occupying lesions, and the patient was diagnosed with IIH based on the modified Dandy criteria. MR venography revealed stenosis in the right and hypoplastic left TS. The patient complained of headache and neck pain after each lumbar puncture for examination. Venous sinus stenting (VSS) was performed in the right TS. One month after stenting, follow-up angiography revealed stenosis in the remaining parts of TS. Five months after stenting, IIH recurred, and SAS was detected on angiography. An additional stenting procedure was performed. Three months after the second treatment, her symptoms disappeared and cerebrospinal fluid pressure was normalized. Conclusion Patients with post-VSS recurrent IIH may develop restenosis in the remaining parts of TS at variable progression speeds. In this case, angiography revealed gradually advancing stenosis that seemed to form SAS at the time of recurrence. If the initial VSS is effective for IIH, SAS can also be treated effectively and less invasively with a second stent placement covering the entire TS length.
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Affiliation(s)
- Seiji Uesugi
- Department of Neurosurgery, Oita San-ai Medical Center, Oita, Oita, Japan
| | - Takashi Karukaya
- Department of Neurosurgery, Oita San-ai Medical Center, Oita, Oita, Japan
| | - Hisato Nakayama
- Department of Neurosurgery, Oita San-ai Medical Center, Oita, Oita, Japan
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14
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Mollan SP, Grech O, Sinclair AJ. Headache attributed to idiopathic intracranial hypertension and persistent post-idiopathic intracranial hypertension headache: A narrative review. Headache 2021; 61:808-816. [PMID: 34106464 DOI: 10.1111/head.14125] [Citation(s) in RCA: 34] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2021] [Accepted: 04/12/2021] [Indexed: 01/01/2023]
Abstract
OBJECTIVE Headache is a near-universal sequela of idiopathic intracranial hypertension (IIH). The aim of this paper is to report current knowledge of headache in IIH and to identify therapeutic options. BACKGROUND Disability in IIH is predominantly driven by headache; thus, headache management is an urgent and unmet clinical need. At present, there is currently no scientific evidence for the directed use of abortive or preventative headache therapy. METHODS A detailed search of the scientific literature and narrative review was performed. RESULTS Headache in IIH is driven by raised intracranial pressure (ICP) and reduction of ICP has been reported in some studies to reduce headache. Despite resolution of papilledema and normalization of raised ICP, a majority suffer persistent post-IIH headache. The lack of evidence-based management approaches leaves many untreated. Where clinicians attempt to manage IIH headache, they use off-label therapies to target the prevailing headache phenotype. A recent prospective open-label study demonstrated the effective use of a calcitonin gene-related peptide monoclonal antibody therapy in IIH for persistent post-IIH headache. CONCLUSIONS There is overwhelming evidence of the headache burden in IIH. Studies are required to investigate the biological foundations of headache related to ICP and to develop treatments specifically directed to manage headache in IIH.
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Affiliation(s)
- Susan P Mollan
- Birmingham Neuro-Ophthalmology, Queen Elizabeth Hospital, Birmingham, UK
| | - Olivia Grech
- Metabolic Neurology, Institute of Metabolism and Systems Research, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK.,Centre for Endocrinology, Diabetes and Metabolism, Birmingham Health Partners, Birmingham, UK
| | - Alexandra J Sinclair
- Birmingham Neuro-Ophthalmology, Queen Elizabeth Hospital, Birmingham, UK.,Metabolic Neurology, Institute of Metabolism and Systems Research, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK.,Centre for Endocrinology, Diabetes and Metabolism, Birmingham Health Partners, Birmingham, UK.,Department of Neurology, University Hospitals Birmingham NHS Foundation Trust, Queen Elizabeth Hospital, Birmingham, UK
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15
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Schwarz J, Al Balushi A, Sundararajan S, Dinkin M, Oliveira C, Greenfield JP, Patsalides A. Management of idiopathic intracranial hypertension in children utilizing venous sinus stenting. Interv Neuroradiol 2021; 27:257-265. [PMID: 33236688 PMCID: PMC8050535 DOI: 10.1177/1591019920976234] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2020] [Revised: 09/21/2020] [Accepted: 10/01/2020] [Indexed: 02/05/2023] Open
Abstract
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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Affiliation(s)
- Justin Schwarz
- Department of Neurological Surgery, Weill Cornell Medical Center/New York Presbyterian Hospital, New York, NY, USA
| | - Ali Al Balushi
- Department of Neurological Surgery, Weill Cornell Medical Center/New York Presbyterian Hospital, New York, NY, USA
| | - Sri Sundararajan
- Department of Neurological Surgery, Weill Cornell Medical Center/New York Presbyterian Hospital, New York, NY, USA
| | - Marc Dinkin
- Department of Ophthalmology, Weill Cornell Medical Center/New York Presbyterian Hospital, New York, NY, USA
| | - Cristiano Oliveira
- Department of Ophthalmology, Weill Cornell Medical Center/New York Presbyterian Hospital, New York, NY, USA
| | - Jeffrey P Greenfield
- Department of Neurological Surgery, Weill Cornell Medical Center/New York Presbyterian Hospital, New York, NY, USA
| | - Athos Patsalides
- Department of Neurological Surgery, North Shore University Hospital, Northwell Health, Manhasset, NY, USA
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16
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Venous Sinus Stenosis Treatment in Pediatric Idiopathic Intracranial Hypertension: Illustrative Case and Literature Review. World Neurosurg 2021; 149:2-7. [PMID: 33476783 DOI: 10.1016/j.wneu.2021.01.029] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2020] [Revised: 01/07/2021] [Accepted: 01/08/2021] [Indexed: 11/20/2022]
Abstract
OBJECTIVE To review the literature of venous sinus stenosis (VSS) treatment in children for idiopathic intracranial hypertension (IIH) and present our own institutional case. METHODS A literature review was conducted using the PubMed and MEDLINE databases up to June 2020. From 134 studies that were screened, 6 studies were chosen for analysis that included patients <18 years old, a diagnosis of IIH that fit Dandy diagnostic criteria, and angiogram obtained to assess for VSS. IIH symptoms experienced in the pediatric population and efficacy of venous sinus stenting were analyzed. RESULTS Eleven patients identified in the literature and 1 patient from our institution were included in the analysis. There was no statistically significant difference in pressure gradient response to stenting between male and female patients (P = 0.424) or patients with body mass index >90th percentile (P = 0.626). Larger decreases in pressure gradient after stent placement correlated with headache resolution (P = 0.0005). Patients who underwent unilateral stenting showed greater reduction in pressure gradient compared with patients who underwent bilateral stenting (average change 24 mm Hg vs. 5.75 mm Hg, P = 0.003). CONCLUSIONS Our analysis showed that VSS treatment has the potential to be a safe option for IIH in pediatric patients. VSS treatment has shown similar results to traditional cerebrospinal fluid diversion procedures, with a lower complication rate and need for revision. More studies should be conducted to analyze the long-term efficacy and safety of VSS treatment in pediatric patients with IIH.
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17
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Sundararajan SH, Ramos AD, Kishore V, Michael M, Doustaly R, DeRusso F, Patsalides A. Dural Venous Sinus Stenosis: Why Distinguishing Intrinsic-versus-Extrinsic Stenosis Matters. AJNR Am J Neuroradiol 2021; 42:288-296. [PMID: 33414231 DOI: 10.3174/ajnr.a6890] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2020] [Accepted: 09/04/2020] [Indexed: 12/17/2022]
Abstract
BACKGROUND AND PURPOSE Dural venous sinus stenosis has been associated with idiopathic intracranial hypertension and isolated venous pulsatile tinnitus. However, the utility of characterizing stenosis as intrinsic or extrinsic remains indeterminate. The aim of this retrospective study was to review preprocedural imaging of patients with symptomatic idiopathic intracranial hypertension and pulsatile tinnitus, classify the stenosis, and assess a trend between stenosis type and clinical presentation while reviewing the frequencies of other frequently seen imaging findings in these conditions. MATERIALS AND METHODS MRVs of 115 patients with idiopathic intracranial hypertension and 43 patients with pulsatile tinnitus before venous sinus stent placement were reviewed. Parameters recorded included the following: intrinsic or extrinsic stenosis, prominent emissary veins, optic nerve tortuosity, cephalocele, sella appearance, poststenotic fusiform enlargement versus saccular venous aneurysm, and internal jugular bulb diverticula. χ2 cross-tabulation statistics were calculated and recorded for all data. RESULTS Most patients with idiopathic intracranial hypertension (75 of 115 sinuses, 65%) had extrinsic stenosis, and most patients with pulsatile tinnitus (37 of 45 sinuses, 82%) had intrinsic stenosis. Marked optic nerve tortuosity was more common in idiopathic intracranial hypertension. Cephaloceles were rare in both cohorts, with an increased trend toward the presence in idiopathic intracranial hypertension. Empty sellas were more common in idiopathic intracranial hypertension. Cerebellar tonsils were similarly located at the foramen magnum level in both cohorts. Saccular venous aneurysms were more common in pulsatile tinnitus. Internal jugular bulb diverticula were similarly common in both cohorts. CONCLUSIONS In this cohort, most patients with idiopathic intracranial hypertension had extrinsic stenosis, and most patients with pulsatile tinnitus had intrinsic stenosis. Awareness and reporting of these subtypes may reduce the underrecognition of potential contributory stenoses in a given patient's idiopathic intracranial hypertension or pulsatile tinnitus.
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Affiliation(s)
- S H Sundararajan
- From the Department of Neurosurgery (S.H.S., A.D.R., M.M., F.D.), Division of Interventional NeuroRadiology, NY Presbyterian Hospital Weill Cornell Medicine, New York, New York
| | - A D Ramos
- From the Department of Neurosurgery (S.H.S., A.D.R., M.M., F.D.), Division of Interventional NeuroRadiology, NY Presbyterian Hospital Weill Cornell Medicine, New York, New York
| | - V Kishore
- GE Healthcare (V.K., R.D.), Buc, France
| | - M Michael
- From the Department of Neurosurgery (S.H.S., A.D.R., M.M., F.D.), Division of Interventional NeuroRadiology, NY Presbyterian Hospital Weill Cornell Medicine, New York, New York
| | | | - F DeRusso
- From the Department of Neurosurgery (S.H.S., A.D.R., M.M., F.D.), Division of Interventional NeuroRadiology, NY Presbyterian Hospital Weill Cornell Medicine, New York, New York
| | - A Patsalides
- Department of Neuro-Interventional Surgery (A.P.), North Shore University Hospital, Northwell Health, Manhasset, New York
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18
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Hu W, Wang C, Wu Q, Chen Y, Gao W, Ying G, Zhu Y, Yan W. Intracranial hypertension due to spinal cord tumor misdiagnosed as pseudotumor cerebri syndrome: case report. BMC Neurol 2020; 20:420. [PMID: 33213405 PMCID: PMC7677777 DOI: 10.1186/s12883-020-02000-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2020] [Accepted: 11/12/2020] [Indexed: 11/10/2022] Open
Abstract
Background Isolated onset of intracranial hypertension due to spinal cord tumor is rare, thus, easily leading to misdiagnosis and delay in effective treatment. Case presentation Herein, we describe a 45-year-old female patient who manifested isolated symptoms and signs of intracranial hypertension and whose condition was initially diagnosed as idiopathic intracranial hypertension and transverse sinus stenosis. The patient received a stent implantation; however, no improvements were observed. One year later her symptoms exacerbated, and during rehospitalization a spinal imaging examination revealed a lumbar tumor. Pathologic evaluation confirmed schwannoma, and tumor resection significantly improved her symptoms, except for poor vision. Conclusions Space-occupying lesions of the spine should be considered in the differential diagnosis of idiopathic intracranial hypertension, even in the absence of spine-localized signs or symptoms.
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Affiliation(s)
- Wanglu Hu
- Department of Neurosurgery, the Second Affiliated Hospital, Zhejiang University School of Medicine, 88 Jiefang Rd, Hangzhou, 310009, China
| | - Chun Wang
- Department of Neurosurgery, the Second Affiliated Hospital, Zhejiang University School of Medicine, 88 Jiefang Rd, Hangzhou, 310009, China
| | - Qun Wu
- Department of Neurosurgery, the Second Affiliated Hospital, Zhejiang University School of Medicine, 88 Jiefang Rd, Hangzhou, 310009, China
| | - Yike Chen
- Department of Neurosurgery, the Second Affiliated Hospital, Zhejiang University School of Medicine, 88 Jiefang Rd, Hangzhou, 310009, China
| | - Wei Gao
- Department of Neurosurgery, the Second Affiliated Hospital, Zhejiang University School of Medicine, 88 Jiefang Rd, Hangzhou, 310009, China
| | - Guangyu Ying
- Department of Neurosurgery, the Second Affiliated Hospital, Zhejiang University School of Medicine, 88 Jiefang Rd, Hangzhou, 310009, China
| | - Yongjian Zhu
- Department of Neurosurgery, the Second Affiliated Hospital, Zhejiang University School of Medicine, 88 Jiefang Rd, Hangzhou, 310009, China
| | - Wei Yan
- Department of Neurosurgery, the Second Affiliated Hospital, Zhejiang University School of Medicine, 88 Jiefang Rd, Hangzhou, 310009, China.
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Kishore V, Sundararajan SH, Doustaly R, Michael M, Xuan D, Link T, Rapoport B, Patsalides A. Magnetic resonance venography for 3-dimensional live guidance during venous sinus stenting. CVIR Endovasc 2020; 3:66. [PMID: 32915317 PMCID: PMC7486350 DOI: 10.1186/s42155-020-00158-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2020] [Accepted: 09/03/2020] [Indexed: 12/03/2022] Open
Abstract
Purpose The purpose of this study was to report the technique for intraprocedural guidance of endovascular Venous Sinus Stenting procedures using 3-Dimensional (3D) Magnetic Resonance Venography (MRV) as an overlay on live biplanar fluoroscopy. Materials and methods Venous sinus stenting procedures performed between April and December, 2017 with 3D MRV fusion for live guidance were reviewed in this study. A thin-slice, contrast-enhanced MR Venogram was used to create 2 3D models – vessels and skull – for procedural guidance via augmented fluoroscopy (Vessel ASSIST, GE Healthcare, Chicago, IL). The skull model was used in the registration of the 3D overlay on both the frontal and lateral planes, which required 1–2 min of procedural time. The vessel model was used to mark landmarks such as the cortical vein ostia and stenosis on the 3D overlay fused with biplanar fluoroscopy. The retrospective imaging review was conducted by 3 neurointerventionalists and relied on a consensus confidence ranking on a 3-point Likert scale from 1- low confidence to 3- high confidence. The neurointerventionalists first reviewed the conventional 2-dimensional pre-stent deployment fluoroscopy images and then reviewed the corresponding images with the 3D MRV overlay. They ranked their confidence in their understanding of cortical venous anatomy for each group. Statistical analysis was performed using a Paired T Test at a 99% confidence interval. Results Ten cases were included in the retrospective image review. Operator confidence regarding the location of cortical veins was significantly increased using 3D MRV fusion during venous sinus stenting procedures (1.9 vs 2.9, p = .001). Conclusion 3-Dimensional MRV fusion is feasible and helpful in understanding the venous sinus anatomy and location of important cortical veins during venous sinus stenting procedures.
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Affiliation(s)
| | - Sri Hari Sundararajan
- Department of Neurosurgery, New York Presbyterian Hospital/Weill Cornell Medical Center, 525 East 68th St, New York, NY, 10065, USA.
| | | | - Marissa Michael
- Department of Neurosurgery, New York Presbyterian Hospital/Weill Cornell Medical Center, 525 East 68th St, New York, NY, 10065, USA
| | - Dwight Xuan
- Department of Aerospace Medicine, Los Angeles Air Force Base, 483 North Aviation Boulevard, Los Angeles, CA, 90245, USA
| | - Thomas Link
- Department of Neurosurgery, New York Presbyterian Hospital/Weill Cornell Medical Center, 525 East 68th St, New York, NY, 10065, USA
| | - Benjamin Rapoport
- Department of Neurosurgery, New York Presbyterian Hospital/Weill Cornell Medical Center, 525 East 68th St, New York, NY, 10065, USA
| | - Athos Patsalides
- Department of Neurosurgery, New York Presbyterian Hospital/Weill Cornell Medical Center, 525 East 68th St, New York, NY, 10065, USA
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20
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Virdee J, Larcombe S, Vijay V, Sinclair AJ, Dayan M, Mollan SP. Reviewing the Recent Developments in Idiopathic Intracranial Hypertension. Ophthalmol Ther 2020; 9:767-781. [PMID: 32902722 PMCID: PMC7708542 DOI: 10.1007/s40123-020-00296-0] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2019] [Indexed: 02/07/2023] Open
Abstract
There is increasing evidence and appreciation of idiopathic intracranial hypertension (IIH) in medicine. The pathological processes underlying raised intracranial pressure are being studied, with new insights found in both hormonal dysregulation and the metabolic neuroendocrine axis. These will potentially lead to novel therapeutic targets for IIH. The first consensus guidelines have been published on the investigation and management of adult IIH, and the International Headache Society criteria for headache attributable to IIH have been modified to reflect our evolving understanding of IIH. Randomized clinical trials have been published, and a number of studies in this disease area are ongoing.
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Affiliation(s)
- Jasvir Virdee
- Ophthalmology, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | | | - Vivek Vijay
- Metabolic Neurology, Institute of Metabolism and Systems Research, University of Birmingham, Birmingham, UK.,Centre for Endocrinology, Diabetes and Metabolism, Birmingham Health Partners, Birmingham, UK
| | - Alex J Sinclair
- Metabolic Neurology, Institute of Metabolism and Systems Research, University of Birmingham, Birmingham, UK.,Centre for Endocrinology, Diabetes and Metabolism, Birmingham Health Partners, Birmingham, UK.,Birmingham Neuro-Ophthalmology, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Margaret Dayan
- Newcastle Eye Centre, The Newcastle Upon Tyne Hospitals NHS Foundation Trust, Royal Victoria Infirmary, Newcastle upon Tyne, UK
| | - Susan P Mollan
- Birmingham Neuro-Ophthalmology, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK.
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21
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Al Balushi A, Oliveira C, Patsalides A. Idiopathic intracranial hypertension with stenosis of a solitary occipital venous sinus treated with stenting. Interv Neuroradiol 2020; 26:664-667. [PMID: 32757674 DOI: 10.1177/1591019920949094] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
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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Affiliation(s)
- Ali Al Balushi
- Department of Neurological Surgery, New York-Presbyterian Hospital, Weill Cornell Medical College, New York, NY, USA
| | - Cristiano Oliveira
- Department of Ophthalmology, New York-Presbyterian Hospital, Weill Cornell Medical College, New York, NY, USA
| | - Athos Patsalides
- Department of Neurological Surgery, New York-Presbyterian Hospital, Weill Cornell Medical College, New York, NY, USA
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22
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Ghali MGZ, Marchenko V, Yaşargil MG, Ghali GZ. Structure and function of the perivascular fluid compartment and vertebral venous plexus: Illumining a novel theory on mechanisms underlying the pathogenesis of Alzheimer's, cerebral small vessel, and neurodegenerative diseases. Neurobiol Dis 2020; 144:105022. [PMID: 32687942 DOI: 10.1016/j.nbd.2020.105022] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2020] [Revised: 06/13/2020] [Accepted: 07/15/2020] [Indexed: 01/14/2023] Open
Abstract
Blood dynamically and richly supplies the cerebral tissue via microvessels invested in pia matter perforating the cerebral substance. Arteries penetrating the cerebral substance derive an investment from one or two successive layers of pia mater, luminally apposed to the pial-glial basal lamina of the microvasculature and abluminally apposed to a series of aquaporin IV-studded astrocytic end feet constituting the soi-disant glia limitans. The full investment of successive layers forms the variably continuous walls of the periarteriolar, pericapillary, and perivenular divisions of the perivascular fluid compartment. The pia matter disappears at the distal periarteriolar division of the perivascular fluid compartment. Plasma from arteriolar blood sequentially transudates into the periarteriolar division of the perivascular fluid compartment and subarachnoid cisterns in precession to trickling into the neural interstitium. Fluid from the neural interstitium successively propagates into the venules through the subarachnoid cisterns and perivenular division of the perivascular fluid compartment. Fluid fluent within the perivascular fluid compartment flows gegen the net direction of arteriovenular flow. Microvessel oscillations at the central tendency of the cerebral vasomotion generate corresponding oscillations of within the surrounding perivascular fluid compartment, interposed betwixt the abluminal surface of the vessels and internal surface of the pia mater. The precise microanatomy of this most fascinating among designable spaces has eluded the efforts of various investigators to interrogate its structure, though most authors non-consensusly concur the investing layers effectively and functionally segregate the perivascular and subarachnoid fluid compartments. Enlargement of the perivascular fluid compartment in a variety of neurological disorders, including senile dementia of the Alzheimer's type and cerebral small vessel disease, may alternately or coordinately constitute a correlative marker of disease severity and a possible cause implicated in the mechanistic pathogenesis of these conditions. Venular pressures modulating oscillatory dynamic flow within the perivascular fluid compartment may similarly contribute to the development of a variety among neurological disorders. An intimate understanding of subtle features typifying microanatomy and microphysiology of the investing structures and spaces of the cerebral microvasculature may powerfully inform mechanistic pathophysiology mediating a variety of neurovascular ischemic, neuroinfectious, neuroautoimmune, and neurodegenerative diseases.
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Affiliation(s)
- Michael George Zaki Ghali
- Department of Neurological Surgery, University of California San Francisco, 505 Parnassus Street, San Francisco, CA 94143, United States; Department of Neurobiology and Anatomy, 2900 W. Queen Lane, Philadelphia, PA 19129, United States.
| | - Vitaliy Marchenko
- Department of Neurobiology and Anatomy, 2900 W. Queen Lane, Philadelphia, PA 19129, United States; Department of Neurophysiology, Bogomoletz Institute, Kyiv, Ukraine; Department of Neuroscience, Московский государственный университет имени М. В., Ломоносова GSP-1, Leninskie Gory, Moscow 119991, Russian Federation
| | - M Gazi Yaşargil
- Department of Neurosurgery, University Hospital Zurich Rämistrasse 100, 8091 Zurich, Switzerland
| | - George Zaki Ghali
- United States Environmental Protection Agency, Arlington, Virginia, USA; Emeritus Professor of Toxicology, Purdue University, West Lafayette, Indiana, USA
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23
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Transverse venous sinus stenosis in idiopathic intracranial hypertension: a prospective pilot study. Can J Ophthalmol 2020; 55:401-405. [PMID: 32589917 DOI: 10.1016/j.jcjo.2020.05.008] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2019] [Revised: 04/23/2020] [Accepted: 05/17/2020] [Indexed: 11/23/2022]
Abstract
OBJECTIVE Whether transverse venous sinus stenosis (TVSS) causes idiopathic intracranial hypertension (IIH) or is an effect of the increased intracranial pressures is controversial. The purpose of this study was to assess the feasibility of serial imaging in patients with IIH on medical management. DESIGN AND PARTICIPANTS Patients found to have IIH and TVSS on contrast-enhanced magnetic resonance venography (CEMRV) were recruited in a prospective cohort study. Patients were medically managed and followed with a CEMRV immediately after lumbar puncture, 3-6 months after diagnosis with resolution of IIH symptoms, and 1 year after diagnosis. Ophthalmological data were collected at the time of diagnosis, 3-6 months after diagnosis, and 1 year after diagnosis. Feasibility data, including patient recruitment rate, barriers, and logistical issues, were recorded. RESULTS Twenty patients with suspected IIH were screened, and 5 of 7 (71.4%; 95% confidence interval: 36.21-100) eligible patients were enrolled in 1 year, at completion. All recruited patients had clinical resolution of their IIH on medical therapy, and none of them had any obvious change in their TVSS. CONCLUSIONS Prospective examination of TVSS with serial magnetic resonance imaging in patients with IIH is feasible. TVSS in patients with IIH did not show any change, despite clinical improvement on medical management in all participants.
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Larson A, Rinaldo L, Chen JJ, Cutsforth-Gregory J, Theiler AR, Brinjikji W. Reductions in bilateral transverse sinus pressure gradients with unilateral transverse venous sinus stenting for idiopathic intracranial hypertension. J Neurointerv Surg 2020; 13:187-190. [PMID: 32482835 DOI: 10.1136/neurintsurg-2020-016170] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2020] [Revised: 04/29/2020] [Accepted: 04/30/2020] [Indexed: 11/04/2022]
Abstract
BACKGROUND Venous 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. METHODS Consecutive 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. RESULTS Sixteen 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). CONCLUSIONS The use of a single stent provides some venous decompression of the contralateral non-stented stenosis in most cases of IIH treated with endovascular therapy.
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Affiliation(s)
- Anthony Larson
- Radiology, Mayo Clinic, Rochester, MN, USA.,Neurosurgery, Mayo Clinic, Rochester, MN, USA
| | | | - John J Chen
- Neurology, Mayo Clinic, Rochester, Minnesota, USA
| | | | | | - Waleed Brinjikji
- Radiology, Mayo Clinic, Rochester, MN, USA .,Neurosurgery, Mayo Clinic, Rochester, MN, USA
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Touzé R, Bonnin S, Houdart E, Nicholson P, Bodaghi B, Shotar E, Clarençon F, Lenck S, Touitou V. Long-term Kinetic Papilledema Improvement After Venous Sinus Stenting in Idiopathic Intracranial Hypertension. Clin Neuroradiol 2020; 31:483-490. [PMID: 32399641 DOI: 10.1007/s00062-020-00908-z] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2020] [Accepted: 04/15/2020] [Indexed: 11/30/2022]
Abstract
BACKGROUND AND PURPOSE The aim of this study was to assess the safety and effectiveness of lateral sinus stenosis (LSS) stenting in patients with idiopathic intracranial hypertension (IIH) who are refractory to medical treatment, particularly focusing on visual outcomes including papilledema. MATERIAL AND METHODS Retrospective study of consecutive patients with IIH refractory to medical treatment who underwent LSS stenting. Clinical features, visual fields and optical coherence tomography (OCT) retinal nerve fiber layer (RNFL) and ganglion cell layer (GCL) thicknesses were assessed before stenting, at 1 month poststenting and at last follow-up. Complications were also recorded. RESULTS A total of 16 women were included, with a mean age of 39 ± 11 years. All patients had papilledema while 15/16 (94%) had headaches. Mean visual acuity was 0.036 logMAR, range (+0.4 to +0.0 logMAR). The mean RNFL thickness prior to stenting was 121.7 µm (±34.7 µm) and mean GCL thickness was 80.2 µm (±8.9 µm). Mean follow-up was 19.7 months (±11.8 months). After stenting, acetazolamide was discontinued in 15/16 (94%) patients. Papilledema improved in 14/16 (88%) of patients. The mean RNFL thickness was significantly decreased 1 month after stenting (96.3 ± 15.6 µm; p < 0.001) and at last visit (93.4 ± 15.3 µm; p < 0.001). The GCL thickness after LSS stenting was moderately decreased at the last visit examination: 80.2 ± 8.9 µm vs. 78.0 ± 10.7 µm; (p < 0.01). No stent-related complication occurred, while there was one case of restenosis. CONCLUSION Improvement of papilledema appears to occur relatively rapidly after the LSS stenting. The results further support the role of LSS stenting in the treatment of IIH, especially with respect to visual symptoms.
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Affiliation(s)
- Romain Touzé
- Department of Ophthalmology, Pitié-Salpêtrière Hospital, APHP, 47, Bd de l'Hôpital, 75013, Paris, France.
| | - Sophie Bonnin
- Department of Ophthalmology, Pitié-Salpêtrière Hospital, APHP, 47, Bd de l'Hôpital, 75013, Paris, France.,Department of Ophthalmology, Lariboisière Hospital, APHP, Paris, France
| | - Emmanuel Houdart
- Department of Neuroradiology, Lariboisière Hospital, APHP, Paris, France
| | - Patrick Nicholson
- Joint Division of Medical Imaging, Department of Medical Imaging, UHN, University of Toronto, Toronto, Ontario, Canada
| | - Bahram Bodaghi
- Department of Ophthalmology, Pitié-Salpêtrière Hospital, APHP, 47, Bd de l'Hôpital, 75013, Paris, France.,Paris VI University, Sorbonne University, Paris, France
| | - Eimad Shotar
- Department of Neuroradiology, Pitié-Salpêtrière Hospital, APHP, Paris, France
| | - Frédéric Clarençon
- Paris VI University, Sorbonne University, Paris, France.,Department of Neuroradiology, Pitié-Salpêtrière Hospital, APHP, Paris, France
| | - Stéphanie Lenck
- Department of Neuroradiology, Pitié-Salpêtrière Hospital, APHP, Paris, France
| | - Valérie Touitou
- Department of Ophthalmology, Pitié-Salpêtrière Hospital, APHP, 47, Bd de l'Hôpital, 75013, Paris, France.,Paris VI University, Sorbonne University, Paris, France
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Ramos AD, Sundararajan S, Santillan A, Schwarz JT, Patsalides A. Single arm access venous sinus stenting (SAVeS) technique: Technical note. Interv Neuroradiol 2020; 26:501-505. [PMID: 32340513 DOI: 10.1177/1591019920920992] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Intracranial venous sinus stenting is gaining acceptance as an effective treatment for idiopathic intracranial hypertension (IIH). The typical approach is via femoral venous and arterial access for transvenous stenting with simultaneous angiography. These patients are at an above average risk for groin complications considering obesity is typically associated with IIH and the need for heparinization and dual antiplatelet therapy. Here, we describe cerebral venography, angiography, and venous sinus stenting via a single upper extremity. We utilize a transradial approach for angiography and a venous access via the brachial or basilic vein. Over a series of 28 consecutive procedures, we were able to successfully access the intracranial venous sinuses via the arm without access site complications. This method offers the advantages of immediate patient mobilization after the procedure and more easily monitored and compressible access sites for easier post-procedural care.
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Affiliation(s)
- Alexander D Ramos
- Division of Interventional Neuroradiology, Department of Neurological Surgery, New York Presbyterian Hospital/Weill Cornell Medical Center, New York, NY, USA
| | - Sri Sundararajan
- Division of Interventional Neuroradiology, Department of Neurological Surgery, New York Presbyterian Hospital/Weill Cornell Medical Center, New York, NY, USA
| | - Alejandro Santillan
- Division of Interventional Neuroradiology, Department of Neurological Surgery, New York Presbyterian Hospital/Weill Cornell Medical Center, New York, NY, USA
| | - Justin T Schwarz
- Division of Interventional Neuroradiology, Department of Neurological Surgery, New York Presbyterian Hospital/Weill Cornell Medical Center, New York, NY, USA
| | - Athos Patsalides
- Division of Interventional Neuroradiology, Department of Neurological Surgery, New York Presbyterian Hospital/Weill Cornell Medical Center, New York, NY, USA
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Custom Shunt System for Increased Baseline Intracranial Pressure in a Patient with Idiopathic Intracranial Hypertension. World Neurosurg 2020; 136:318-322. [PMID: 31996337 DOI: 10.1016/j.wneu.2020.01.142] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2019] [Revised: 01/16/2020] [Accepted: 01/18/2020] [Indexed: 11/20/2022]
Abstract
BACKGROUND Standard treatment of idiopathic intracranial hypertension (IIH) involves reduction of intracranial pressure (ICP) to normal range, often via a ventriculoperitoneal shunt (VPS). We describe a case of a middle-aged man who presented with symptoms consistent with IIH. After ICP was normalized with a VPS, the patient had neurologic deterioration into a coma. He completely recovered after a month when his ICP was allowed to increase and remain above the normal range. CASE DESCRIPTION A 50-year-old man presented with daily headaches, visual loss (right > left), and increased lumbar opening pressure consistent with IIH. A VPS was inserted using a Strata II valve with a pressure setting of 1.5, lowering ICP into the normal range. The patient initially had a normal postoperative course, but then became comatose and developed imaging signs consistent with intracranial hypotension. A Codman Certas valve was placed at a setting of 7 and a distal slit-cut peritoneal catheter was used (as opposed to standard open output). This custom system drained at pressure >26 mm Hg based on intraoperative manometry. The patient tolerated this well and is currently planned for a gradual reduction in ICP with valve setting adjustments as an outpatient. CONCLUSIONS In patients with chronic IIH, reduction to normal ICP may unexpectedly lead to encephalopathic changes. Personalized shunts may facilitate reduction of ICP to still elevated but tolerable levels in these patients.
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Gurney SP, Ramalingam S, Thomas A, Sinclair AJ, Mollan SP. Exploring The Current Management Idiopathic Intracranial Hypertension, And Understanding The Role Of Dural Venous Sinus Stenting. Eye Brain 2020; 12:1-13. [PMID: 32021528 PMCID: PMC6969694 DOI: 10.2147/eb.s193027] [Citation(s) in RCA: 33] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2019] [Accepted: 11/05/2019] [Indexed: 12/12/2022] Open
Abstract
Idiopathic Intracranial Hypertension (IIH) is a debilitating disorder characterised by raised intracranial pressure (ICP), papilloedema with the potential risk of permanent visual loss, and headaches that are profoundly disabling and reduce the quality of life. The first consensus guidelines have been published on investigation and management of adult IIH and one key area of uncertainty is the utility of dural venous sinus stenting for the management of headache and visual loss. There are an increasing number of series published and to help understand the successes and complications. During a patient physician priority setting, the understanding of the best type of intervention to treat IIH was assigned to the top 10 of most desired research questions for the disease. Ultimately randomised clinical trials (RCTs) in neurovascular stenting for IIH would be instructive, as the literature to date may suffer from publication bias. Due to the increasing incidence of IIH, there is no better time to systematically investigate interventions that may reverse the disease process and achieve remission. In this review we discuss the pathophysiology of IIH in relation to venous sinus stenosis, the role of venous sinus stenting with a review of the relevant literature, the advantages and disadvantages of stenting compared with other surgical interventions, and the future of stenting in the treatment of IIH.
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Affiliation(s)
- Sam P Gurney
- Birmingham Neuro-Ophthalmology, Queen Elizabeth Hospital, University Hospitals Birmingham, BirminghamB15 2WB, UK
| | - Sateesh Ramalingam
- Neuroradiology Department, Queen Elizabeth Hospital, University Hospitals Birmingham, BirminghamB15 2WB, UK
| | - Alan Thomas
- Neuroradiology Department, Queen Elizabeth Hospital, University Hospitals Birmingham, BirminghamB15 2WB, UK
| | - Alex J Sinclair
- Metabolic Neurology, Institute of Metabolism and Systems Research, College of Medical and Dental Sciences, University of Birmingham, BirminghamB15 2TT, UK
- Centre for Endocrinology, Diabetes and Metabolism, Birmingham Health Partners, BirminghamB15 2TH, UK
- Department of Neurology, University Hospitals Birmingham NHS Foundation Trust, Queen Elizabeth Hospital, BirminghamB15 2WB, UK
| | - Susan P Mollan
- Birmingham Neuro-Ophthalmology, Queen Elizabeth Hospital, University Hospitals Birmingham, BirminghamB15 2WB, UK
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Almadidy Z, Brunozzi D, Nelson J, Baumgart J, Atwal G, Alaraj A. Intracranial venous sinus stenosis: hemodynamic assessment with two-dimensional parametric parenchymal blood flow software on digital subtraction angiography. J Neurointerv Surg 2019; 12:311-314. [DOI: 10.1136/neurintsurg-2019-015582] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2019] [Revised: 11/05/2019] [Accepted: 11/07/2019] [Indexed: 11/03/2022]
Abstract
ObjectiveIntracranial venous sinus stenosis (IVSS) is the most common finding associated with idiopathic intracranial hypertension. A pressure gradient >8–10 mm Hg across the stenosis is considered hemodynamically significant, and typically responds to endovascular stent treatment. Here we assess the venous hemodynamics with two-dimensional (2D) parametric parenchymal blood flow software (Siemens-Healthineers, Forchheim, Germany) and its ability to predict significant IVSS.MethodsPatients with IVSS treated at our institution between 2013 and 2018 were retrospectively reviewed. Measurements of contrast transit time on DSA were calculated with 2D parametric parenchymal blood flow software. Values were obtained proximally and distally to the stenotic region. Venous Stenosis Index (VSI) was defined as the ratio of the area under the curve (AUC) in the pre-stenotic vessel to the AUC in the post-stenotic vessel. VSI was compared between the stenotic and control groups at baseline, and before and after stent deployment in the stenotic group. The accuracy of VSI was assessed using the non-parametric receiver operating characteristic (ROC) curve.Results11 patients with IVSS treated with venous stent deployment were included. Patients in the control group were similar in age, gender, and absence of major comorbidities. VSI in the IVSS group was significantly higher at baseline compared with the control group (1.42 vs 0.97, p=0.01). Area under the ROC was 0.82. After stent deployment, VSI decreased significantly compared with baseline (1.04 vs 1.42, p<0.01).Conclusion2D parametric parenchymal blood flow software is a useful tool which can accurately evaluate significant hemodynamic venous stenosis without intracranial catheterization, added radiation exposure, additional contrast injection, and periprocedural risks.
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Yu CW, Kwok JM, Micieli JA. Resolution of papilledema associated with cyclosporine use after change to tacrolimus. BMJ Case Rep 2019; 12:12/11/e232725. [PMID: 31748372 DOI: 10.1136/bcr-2019-232725] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Use of medications including vitamin A derivatives and tetracyclines have been associated with papilledema and raised intracranial pressure. A 46-year-old woman was referred to neuro-ophthalmology for bilateral optic disc oedema and had a 7-year history of cyclosporine use after renal transplantation. She had preserved visual function and moderate bilateral optic disc oedema. Magnetic resonance imaging and magnetic resonance venography of the brain were normal apart from signs of raised intracranial pressure. Lumbar puncture revealed an elevated opening pressure of 40 cm of water with normal cerebrospinal fluid contents. Nephrology was consulted and cyclosporine was switched to tacrolimus and she was treated with acetazolamide. The papilledema resolved within 1 month of her initial visit. It is important to recognise the role that cyclosporine plays in raising intracranial pressure, especially in patients requiring immunosuppression, such as transplant patients. Tacrolimus is a suitable alternative in these cases.
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Affiliation(s)
- Caberry W Yu
- School of Medicine, Faculty of Health Sciences, Queen's University, Kingston, Ontario, Canada
| | - Jason M Kwok
- Department of Ophthalmology of Vision Sciences, University of Toronto, Toronto, Ontario, Canada
| | - Jonathan A Micieli
- Department of Ophthalmology of Vision Sciences, University of Toronto, Toronto, Ontario, Canada
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Giridharan N, Patel SK, Ojugbeli A, Nouri A, Shirani P, Grossman AW, Cheng J, Zuccarello M, Prestigiacomo CJ. Understanding the complex pathophysiology of idiopathic intracranial hypertension and the evolving role of venous sinus stenting: a comprehensive review of the literature. Neurosurg Focus 2019; 45:E10. [PMID: 29961379 DOI: 10.3171/2018.4.focus18100] [Citation(s) in RCA: 33] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Idiopathic intracranial hypertension (IIH) is a disease defined by elevated intracranial pressure without established etiology. Although there is now consensus on the definition of the disorder, its complex pathophysiology remains elusive. The most common clinical symptoms of IIH include headache and visual complaints. Many current theories regarding the etiology of IIH focus on increased secretion or decreased absorption of cerebrospinal fluid (CSF) and on cerebral venous outflow obstruction due to venous sinus stenosis. In addition, it has been postulated that obesity plays a role, given its prevalence in this population of patients. Several treatments, including optic nerve sheath fenestration, CSF diversion with ventriculoperitoneal or lumboperitoneal shunts, and more recently venous sinus stenting, have been described for medically refractory IIH. Despite the availability of these treatments, no guidelines or standard management algorithms exist for the treatment of this disorder. In this paper, the authors provide a review of the literature on IIH, its clinical presentation, pathophysiology, and evidence supporting treatment strategies, with a specific focus on the role of venous sinus stenting.
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Affiliation(s)
| | | | | | | | - Peyman Shirani
- Departments of1Neurosurgery and.,2Neurology, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Aaron W Grossman
- Departments of1Neurosurgery and.,2Neurology, University of Cincinnati College of Medicine, Cincinnati, Ohio
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Hady-Cohen R, Maharshak I, Michelson M, Yosovich K, Lev D, Constantini S, Leiba H, Lerman-Sagie T, Blumkin L. Familial Intracranial Hypertension in 2 Brothers With PTEN Mutation: Expansion of the Phenotypic Spectrum. J Child Neurol 2019; 34:506-510. [PMID: 31046523 DOI: 10.1177/0883073819842970] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
PTEN (Phosphatase and Tensin Homolog on chromosome TEN) encodes a vastly expressed tumor suppressor protein that antagonizes the PI3 K signaling pathway and alters the MTOR pathway. Mutations in PTEN have been described in association with a number of syndromes including PTEN hamartoma-tumor syndrome, macrocephaly/autism, and juvenile polyposis of infancy. Although there is a wide variability in the clinical and radiologic presentations of PTEN-related phenotypes, the most consistent features include macrocephaly and increased tumorigenesis. Intracranial hypertension may be idiopathic or secondary to multiple etiologies. We describe 2 siblings harboring a PTEN mutation who presented with macrocephaly and intracranial hypertension. Repeat brain MRIs were normal in both. Acetazolamide treatment normalized intracranial pressure, but several trials of medication tapering led to recurrence of intracranial hypertension symptoms. The clinical presentation of our patients expands the PTEN-related phenotypes. We discuss the possible pathophysiology in view of PTEN function.
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Affiliation(s)
- Ronen Hady-Cohen
- 1 Metabolic Neurogenetic Service, Wolfson Medical Center, Holon, Israel.,2 Pediatric Neurology Unit, Wolfson Medical Center, Holon, Israel.,3 Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Idit Maharshak
- 3 Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel.,4 Neuro-Ophthalmology Clinic, Ophthalmology Department, Wolfson Medical Center, Holon, Israel
| | - Marina Michelson
- 1 Metabolic Neurogenetic Service, Wolfson Medical Center, Holon, Israel.,3 Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel.,5 The Rina Mor Institute of Medical Genetics, Wolfson Medical Center, Holon, Israel
| | - Keren Yosovich
- 1 Metabolic Neurogenetic Service, Wolfson Medical Center, Holon, Israel.,5 The Rina Mor Institute of Medical Genetics, Wolfson Medical Center, Holon, Israel.,6 Molecular Genetics Laboratory, Wolfson Medical Center, Holon, Israel
| | - Dorit Lev
- 1 Metabolic Neurogenetic Service, Wolfson Medical Center, Holon, Israel.,3 Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel.,5 The Rina Mor Institute of Medical Genetics, Wolfson Medical Center, Holon, Israel
| | - Shlomi Constantini
- 3 Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel.,7 Peditric Neurosurgery Department, Tel-Aviv Medical Center, Tel-Aviv, Israel
| | - Hana Leiba
- 8 Ophthalmology Department, Kaplan Medical Center, Rehovot, Israel.,9 Hadassah Medical School, the Hebrew University, Jerusalem, Israel
| | - Tally Lerman-Sagie
- 1 Metabolic Neurogenetic Service, Wolfson Medical Center, Holon, Israel.,2 Pediatric Neurology Unit, Wolfson Medical Center, Holon, Israel.,3 Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Lubov Blumkin
- 1 Metabolic Neurogenetic Service, Wolfson Medical Center, Holon, Israel.,2 Pediatric Neurology Unit, Wolfson Medical Center, Holon, Israel.,3 Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel
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Endovascular Stenting in a Transgender Patient With Idiopathic Intracranial Hypertension. J Neuroophthalmol 2019; 39:247-248. [DOI: 10.1097/wno.0000000000000752] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Daggubati LC, Liu KC. Intracranial Venous Sinus Stenting: A Review of Idiopathic Intracranial Hypertension and Expanding Indications. Cureus 2019; 11:e4008. [PMID: 31001462 PMCID: PMC6450594 DOI: 10.7759/cureus.4008] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2019] [Accepted: 02/04/2019] [Indexed: 02/04/2023] Open
Abstract
Idiopathic intracranial hypertension (IIH) is a functionally limiting disorder secondary to increased intracranial pressures (ICPs) with a prevalence of one per 100,000 persons. It is estimated to cost >$400 million per year in productively. Symptoms classically consist of chronic headaches, papilledema, and visual loss. The pathophysiology is unknown but postulated to involve increased resistance to cerebrospinal fluid (CSF) absorption. Traditional treatments involve weight loss, acetazolamide, CSF diversion, or optic nerve fenestration. More recent technology has allowed exploration of venous sinus stenosis. Through venous sinus stenting (VSS), the ICPs and venous sinus pressures decrease. After treatment, >75% exhibit an improvement in headaches, ~50% improvement in tinnitus, and ~50 % improvement in ophthalmologic testing. Complications are rare but involve stent stenosis, femoral pseudoaneurysm, and hemorrhages. Future studies will look into controlled studies for VSS as well as expansion to other venous structures of the intracranial circulation.
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Affiliation(s)
- Lekhaj C Daggubati
- Neurosurgery, Penn State Health Milton S. Hershey Medical Center, Hershey, USA
| | - Kenneth C Liu
- Neurosurgery, Penn State Milton Health S. Hershey Medical Center, Hershey, USA
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36
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Zhao T, Wang G, Dai J, Liu Y, Wang Y, Li S. Cases of visual impairment caused by cerebral venous sinus occlusion-induced intracranial hypertension in the absence of headache. BMC Neurol 2018; 18:159. [PMID: 30268100 PMCID: PMC6162896 DOI: 10.1186/s12883-018-1156-7] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2018] [Accepted: 09/14/2018] [Indexed: 11/10/2022] Open
Abstract
Background Cerebral venous sinus thrombosis or stenosis (here collectively referred to as cerebral venous sinus occlusion, CVSO) can cause chronically-elevated intracranial pressure (ICP). Patients may have no neurological symptoms other than visual impairment, secondary to bilateral papilledema. Correctly recognizing these conditions, through proper ophthalmological examination and brain imaging, is very important to avoid delayed diagnosis and treatment. Case presentation We report a case series of 3 patients with chronic CVSO, who were admitted to an ophthalmological department in Chongqing, China, from 2015 March to 2017 February. All patients presented with decreased vision and bilateral papilledema, but had no headache or other neurological symptoms. The visual fields of all patients were impaired. Flash visual evoked potentials (VEPs) in two patients showed essentially normal peak time of P2 wave, and pattern VEPs in one patient displayed decreased P100 amplitude in one eye, while a normal P100 wave in the other eye. In all patients, lumbar puncture (LP) revealed significantly elevated ICP. And magnetic resonance venography (MRV) demonstrated cerebral venous sinus abnormalities in every patient: one right sigmoid sinus thrombosis, one superior sagittal sinus thrombosis, and one right transverse sinus stenosis. Conclusions CVSO can cause chronically-elevated ICP, leading to bilateral papilledema and visual impairment. A considerable amount of patients have no apparent neurological symptoms other than visual loss. Unlike other optic nerve lesions, such as neuritis or ischemic optic neuropathy, the optic disc edema in CVSO is usually bilateral, the flash or pattern VEP is often normal or only mildly affected, and patients are often not sensitive to steroid therapy. CVSO should be suspected in such patients when unenhanced brain imaging is normal. Further investigations, such as LP and contrast-enhanced imaging (MRV and digital subtraction angiography), should be performed to diagnose or exclude CVSO.
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Affiliation(s)
- Tongtao Zhao
- Department of Ophthalmology, Southwest Hospital, The Third Military Medical University (Army Medical University), Chongqing, China
| | - Gang Wang
- Department of Ophthalmology, Southwest Hospital, The Third Military Medical University (Army Medical University), Chongqing, China
| | - Jiaman Dai
- Department of Ophthalmology, Southwest Hospital, The Third Military Medical University (Army Medical University), Chongqing, China
| | - Yong Liu
- Department of Ophthalmology, Southwest Hospital, The Third Military Medical University (Army Medical University), Chongqing, China
| | - Yi Wang
- Department of Ophthalmology, Southwest Hospital, The Third Military Medical University (Army Medical University), Chongqing, China.,Aier Eye Hospital, Chongqing, China
| | - Shiying Li
- Department of Ophthalmology, Southwest Hospital, The Third Military Medical University (Army Medical University), Chongqing, China.
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Boddu SR, Gobin YP, Dinkin M, Oliveira C, Patsalides A. Impaired drainage of vein of Labbé following venous sinus stenting for idiopathic intracranial hypertension. J Neurointerv Surg 2018; 11:300-306. [PMID: 30219791 DOI: 10.1136/neurintsurg-2018-014153] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2018] [Revised: 07/30/2018] [Accepted: 07/30/2018] [Indexed: 11/03/2022]
Abstract
PURPOSE The 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 METHODS Institutional 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. RESULTS 70 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. CONCLUSION Impaired 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 REGISTRATION NCT01407809.
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Affiliation(s)
- Srikanth R Boddu
- Division of Interventional Neuroradiology, Department of Neurological Surgery, New York Presbyterian Hospital/Weill Cornell Medical Center, New York, USA.,Interventional Neuroradiology, New York Presbyterian Queens Hospital, New York, USA
| | - Y Pierre Gobin
- Division of Interventional Neuroradiology, Department of Neurological Surgery, New York Presbyterian Hospital/Weill Cornell Medical Center, New York, USA
| | - Marc Dinkin
- Department of Ophthalmology, New York Presbyterian Hospital, Weill Cornell Medical College, New York, USA
| | - Cristiano Oliveira
- Department of Ophthalmology, New York Presbyterian Hospital, Weill Cornell Medical College, New York, USA
| | - Athos Patsalides
- Division of Interventional Neuroradiology, Department of Neurological Surgery, New York Presbyterian Hospital/Weill Cornell Medical Center, New York, USA
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Diffusion tensor imaging of the optic disc in idiopathic intracranial hypertension. Neuroradiology 2018; 60:1159-1166. [DOI: 10.1007/s00234-018-2078-1] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2018] [Accepted: 08/07/2018] [Indexed: 12/11/2022]
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Cappuzzo JM, Hess RM, Morrison JF, Davies JM, Snyder KV, Levy EI, Siddiqui AH. Transverse venous stenting for the treatment of idiopathic intracranial hypertension, or pseudotumor cerebri. Neurosurg Focus 2018; 45:E11. [DOI: 10.3171/2018.5.focus18102] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
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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Affiliation(s)
- Justin M. Cappuzzo
- Departments of 1Neurosurgery,
- 6Department of Neurosurgery, Gates Vascular Institute at Kaleida Health
| | - Ryan M. Hess
- 5Jacobs School of Medicine at the University at Buffalo
| | - John F. Morrison
- Departments of 1Neurosurgery,
- 6Department of Neurosurgery, Gates Vascular Institute at Kaleida Health
| | - Jason M. Davies
- Departments of 1Neurosurgery,
- 2Biomedical Informatics,
- 6Department of Neurosurgery, Gates Vascular Institute at Kaleida Health
- 8Jacobs Institute, Buffalo, New York
| | - Kenneth V. Snyder
- Departments of 1Neurosurgery,
- 3Neurology, and
- 6Department of Neurosurgery, Gates Vascular Institute at Kaleida Health
- 7Canon Stroke and Vascular Research Center at the University at Buffalo; and
| | - Elad I. Levy
- Departments of 1Neurosurgery,
- 4Radiology,
- 6Department of Neurosurgery, Gates Vascular Institute at Kaleida Health
- 7Canon Stroke and Vascular Research Center at the University at Buffalo; and
| | - Adnan H. Siddiqui
- Departments of 1Neurosurgery,
- 4Radiology,
- 6Department of Neurosurgery, Gates Vascular Institute at Kaleida Health
- 8Jacobs Institute, Buffalo, New York
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Koovor JM, Lopez GV, Riley K, Tejada J. Transverse venous sinus stenting for idiopathic intracranial hypertension: Safety and feasibility. Neuroradiol J 2018; 31:513-517. [PMID: 29882475 DOI: 10.1177/1971400918782320] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
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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Affiliation(s)
- Jerry Me Koovor
- Indiana University Department of Radiology and Imaging Sciences, Indianapolis, USA
| | - Gloria V Lopez
- Indiana University Department of Radiology and Imaging Sciences, Indianapolis, USA
| | - Kalen Riley
- Indiana University Department of Radiology and Imaging Sciences, Indianapolis, USA
| | - Juan Tejada
- Indiana University Department of Radiology and Imaging Sciences, Indianapolis, USA
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Boddu SR, Gobin P, Oliveira C, Dinkin M, Patsalides A. Anatomic measurements of cerebral venous sinuses in idiopathic intracranial hypertension patients. PLoS One 2018; 13:e0196275. [PMID: 29856739 PMCID: PMC5983447 DOI: 10.1371/journal.pone.0196275] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2017] [Accepted: 04/07/2018] [Indexed: 11/24/2022] Open
Abstract
Purpose Magnetic resonance venography (MRV) has not been validated in pre-operative planning of the dural venous sinus stenting (VSS) among idiopathic intracranial hypertension (IIH) patients. We aim to prospectively evaluate dural venous sinus measurement in IIH patient population on two-dimensional time-of-flight (2D-TOF) MRV and Three-dimensional contrast-enhanced (3D-CE) MRV acquisitions and compare them against real-time endoluminal measurements with intravascular ultrasound (IVUS), served as the reference. Materials and methods The study has been approved by the Weill Cornell Medicine institutional review board. All patients signed written informed consent approved by IRB. Prospective evaluation of forty-five consecutive IIH patients treated with VSS at our institution were evaluated. Patients with pre-stent magnetic resonance venography (MRV) ≤ 6-months of VSS and intravascular ultrasound (IVUS) during VSS constituted the study population. Maximum diameter (in mm), Area (in cm2) and Perimeter (in cm) were measured at posterior 1/3rd of superior sagittal sinus (SSS), proximal transverse sinus (PTS), proximal sigmoid sinus (PSS) and mid sigmoid sinus (MSS) on 2D-TOF-MRV, 3D-CE-MRV and IVUS. Statistical analysis performed using box and whisker plots, Bland-Altman analysis and paired sample t-test. Results Twenty (n = 20) patients constituted our study population. The mean age was 30±11 years (7–59 years) and 18 out of 20 were female patients. Mean weight and BMI (range) were 86.3±18.3 kilograms (30.8–107.5 kgs) and 32.9±6.8 kg/M2 (16.4–48.3kg/M2) respectively. The CE-MRV significantly oversized the cerebral venous sinuses compared to TOF-MRV (Dmax: +2.0±1.35 mm, p<0.001; Area: +13.31±10.92 mm2, p<0.001 and Perimeter: +4.79±3.4 mm, p<0.001) and IVUS (Dmax: +1.52±2.16 mm, p<0.001; Area: +10.03±21.5 mm2, p<0.001 and Perimeter: +4.15±3.27 mm, p<0.001). The TOF-MRV sinus measurements were in good agreement with the IVUS measurements with no significant variation (Dmax: +.21±2.23 mm, p = 0.49; Area: +2.51±20.41mm2, p = 0.347 and Perimeter: +.001±1.11 mm, p = 0.991). Conclusion We report baseline cerebral venous sinus measurements (maximum diameter, area and perimeter) in patients with idiopathic intracranial hypertension. In our experience, TOF-MRV is a reliable representation of endoluminal cerebral venous sinus dimensions, and CE-MRV measurements reflected an overestimation of the endoluminal sinus dimensions when compared against the real time IVUS measurements.
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Affiliation(s)
- Srikanth R Boddu
- Division of Interventional Neuroradiology, Department of Neurological surgery, New York Presbyterian Hospital / Weill Cornell Medical Center, New York, NY, United States of America.,Interventional Neuroradiology, New York Presbyterian Queens Hospital, Flushing, NY, United States of America
| | - Pierre Gobin
- Division of Interventional Neuroradiology, Department of Neurological surgery, New York Presbyterian Hospital / Weill Cornell Medical Center, New York, NY, United States of America
| | - Cristiano Oliveira
- Department of Ophthalmology, New York Presbyterian Hospital, Weill Cornell Medical College, New York, NY, United States of America
| | - Marc Dinkin
- Department of Ophthalmology, New York Presbyterian Hospital, Weill Cornell Medical College, New York, NY, United States of America
| | - Athos Patsalides
- Division of Interventional Neuroradiology, Department of Neurological surgery, New York Presbyterian Hospital / Weill Cornell Medical Center, New York, NY, United States of America
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Boddu SR, Gobin P, Oliveria C, Dinkin M, Patsalides A. Pressure variations in cerebral venous sinuses of idiopathic intracranial hypertension patients. JOURNAL OF VASCULAR AND INTERVENTIONAL NEUROLOGY 2018; 10:25-30. [PMID: 29922401 PMCID: PMC5999300] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Abstract
PURPOSE To evaluate the alteration of pressure characteristics in the cerebral venous sinuses before and after venous sinus stenting (VSS) using mean sinus pressures (MSPs), sinus pressure gradient (SPG), and sinus pressure pulsatility (SPP) parameters among the idiopathic intracranial hypertension (IIH) patients. MATERIALS AND METHODS Prospective evaluation of 45 consecutive IIH patients who underwent VSS at our institution. A written informed consent approved by the Weill Cornell Institutional Review Board was signed by the study participants. All patients (n = 45) were evaluated for MSPs and SPG. In a subgroup of 12 (n = 12) consecutive patients, SPP was measured. MSP was measured using microcatheter at superior sagittal sinus (SSS), transverse sinus (TS), and sigmoid sinus (SS). SPG was measured as trans-stenotic gradient and trans-torcular gradient. SPP was recorded in the dominant TS with a six French intermediate catheter. Statistical analysis was performed using paired student t-test and two sample t-tests tested for both equal and unequal variances. P values below 0.05 were considered significant. RESULTS The mean age of the study population was 30.6 ± 10 years (7-59 years) and 43 out of 45 are female patients. The mean weight and BMI of the study population were 96 ± 24.7 kg (30.8-144 kg) and 35.6 ± 8.3 kg/M2 (16.4-51.4 kg/M2), respectively. VSS in IIH patients resulted in immediate reduction of MSP in the SSS {Δ Mean: -8.1 mm Hg [95% confidence interval (CI): -5.0-11.7 mm Hg], p < 0.001} and TS [Δ Mean: -11.8 mm Hg (95% CI: -7.5 to 13.4 mm Hg), p < 0.001] and increase of MSP in SS [Δ Mean: 7.5 mm Hg (95% CI: 6-10.1 mm Hg), p < 0.001]. Significant reduction of trans-stenotic SPG reduction [Δ Mean: -15.7 mm Hg (95% CI: -13.6-17.8 mm Hg), p < 0.001] and SPP [Δ Mean: -8 mm Hg (95% CI: -2.5-13.4 mm Hg), p < 0.05] was observed following VSS. CONCLUSION VSS resulted in immediate alteration of the cerebral venous sinus pressure measurements in patients with IIH.
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Affiliation(s)
- Srikanth R. Boddu
- Division of Interventional Neuroradiology, Department of Neurological surgery, New York Presbyterian Hospital/Weill Cornell Medical Center, New York, NY, USA
- Department of Interventional Neuroradiology, New York Presbyterian Queens Hospital, Flushing, NY, USA
| | - Pierre Gobin
- Division of Interventional Neuroradiology, Department of Neurological surgery, New York Presbyterian Hospital/Weill Cornell Medical Center, New York, NY, USA
| | - Cristiano Oliveria
- Department of Ophthalmology, New York Presbyterian Hospital, Weill Cornell Medical College, New York, NY, USA
| | - Marc Dinkin
- Department of Ophthalmology, New York Presbyterian Hospital, Weill Cornell Medical College, New York, NY, USA
| | - Athos Patsalides
- Division of Interventional Neuroradiology, Department of Neurological surgery, New York Presbyterian Hospital/Weill Cornell Medical Center, New York, NY, USA
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Boddu SR, Gobin P, Oliveira C, Dinkin M, Patsalides A. Contrast enhanced magnetic resonance venography in the follow-up evaluation of idiopathic intracranial hypertension patients with cerebral venous sinus stenting. Clin Imaging 2018; 50:330-335. [PMID: 29754068 DOI: 10.1016/j.clinimag.2018.04.016] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2018] [Revised: 04/05/2018] [Accepted: 04/16/2018] [Indexed: 10/17/2022]
Abstract
PURPOSE Role of contrast-enhanced magnetic resonance venography (CE-MRV) in the follow-up of venous sinus stenting (VSS) among the idiopathic intracranial hypertension (IIH) patients. MATERIALS AND METHODS Prospective evaluation of VSS patients with CE-MRV, DRCV and DSA for follow-up of clinically suspected recurrent stenosis. CE-MRV was evaluated against DRCV and DSA. RESULTS Ten patients with twelve episodes of recurrent symptoms. Sensitivity, specificity, PPV, NPV and accuracy of the CE-MRV for the detection of recurrent stenosis were: 100%, 33.33%, 81.82%, 100% and 83.3% respectively. CONCLUSION CE-MRV was a reliable first-line investigation for the detection of recurrent stenosis following VSS.
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Affiliation(s)
- Srikanth R Boddu
- Division of Interventional Neuroradiology, Department of Neurological Surgery, New York Presbyterian Hospital/Weill Cornell Medical Center, 525 East, 68th Street, New York, NY 10065, United States; Interventional Neuroradiology, New York Presbyterian Queens Hospital, Flushing, NY 11355, United States.
| | - Pierre Gobin
- Division of Interventional Neuroradiology, Department of Neurological Surgery, New York Presbyterian Hospital/Weill Cornell Medical Center, 525 East, 68th Street, New York, NY 10065, United States.
| | - Cristiano Oliveira
- Department of Ophthalmology, New York Presbyterian Hospital, Weill Cornell Medical College, New York, NY 10021, United States.
| | - Marc Dinkin
- Department of Ophthalmology, New York Presbyterian Hospital, Weill Cornell Medical College, New York, NY 10021, United States.
| | - Athos Patsalides
- Division of Interventional Neuroradiology, Department of Neurological Surgery, New York Presbyterian Hospital/Weill Cornell Medical Center, 525 East, 68th Street, New York, NY 10065, United States.
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Long-term management and outcomes after repair of cerebrospinal fluid rhinorrhea related to idiopathic intracranial hypertension. Curr Opin Otolaryngol Head Neck Surg 2018; 26:46-51. [DOI: 10.1097/moo.0000000000000424] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Young CC, Morton RP, Ghodke BV, Levitt MR. Retrograde 3D rotational venography (3DRV) for venous sinus stent placement in idiopathic intracranial hypertension. J Neurointerv Surg 2017; 10:777-779. [DOI: 10.1136/neurintsurg-2017-013533] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2017] [Revised: 11/07/2017] [Accepted: 11/07/2017] [Indexed: 11/04/2022]
Abstract
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.
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