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White TG, Chen A, Dalal S, Mehta SH, Turpin J, Papadimitriou K, Link T, Patsalides A. Treatment of tumor-induced cerebral venous sinus stenosis: Technical note and review of the literature. Interv Neuroradiol 2024:15910199241267341. [PMID: 39094581 DOI: 10.1177/15910199241267341] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/04/2024] Open
Abstract
INTRODUCTION Tumors that invade or compress the venous sinuses have the potential to impair venous drainage. Rarely, this may be so severe as to induce intracranial hypertension. Other studies have previously described venous sinus stenting (VSS) for the treatment of these symptomatic lesions. In this report, we present our series of eight cases of VSS for symptomatic tumor-induced venous sinus stenosis and review the existing literature. CASES Eight patients with mostly intracranial tumors were found to have symptomatic venous sinus stenosis with the most common presenting symptom being elevated intracranial pressure. Six of the eight (75%) patients presented with papilledema on neuro-ophthalmological exam. The most affected locations were the transverse and sigmoid sinuses in four patients, followed by the superior sagittal sinus in three patients. All eight patients underwent VSS with no adverse events. In total, 6 out of 8 (75%) of patients had complete resolution of their symptoms, while the remaining patients experienced at least partial improvement. CONCLUSION Tumors that cause symptomatic venous sinus stenosis may be successfully managed with VSS to improve venous drainage. This may facilitate continued conservative management of meningiomas or allow for treatment with noninvasive means, such as stereotactic radiosurgery. Depending on the size of the target stenosis, balloon-mounted coronary stents may be a suitable option to treat these lesions.
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Affiliation(s)
- Timothy G White
- Department of Neurological Surgery, North Shore University Hospital/Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Manhasset, NY, USA
| | - Adrian Chen
- Department of Neurological Surgery, North Shore University Hospital/Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Manhasset, NY, USA
| | - Sidd Dalal
- Department of Neurological Surgery, North Shore University Hospital/Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Manhasset, NY, USA
- Department of Neurology, North Shore University Hospital/Long Island Jewish Hospital/Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Manhasset, NY, USA
| | - Shyle H Mehta
- Department of Neurological Surgery, North Shore University Hospital/Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Manhasset, NY, USA
| | - Justin Turpin
- Department of Neurological Surgery, North Shore University Hospital/Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Manhasset, NY, USA
| | - Kyriakos Papadimitriou
- Department of Neurological Surgery, North Shore University Hospital/Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Manhasset, NY, USA
| | - Thomas Link
- Department of Neurological Surgery, North Shore University Hospital/Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Manhasset, NY, USA
| | - Athos Patsalides
- Department of Neurological Surgery, North Shore University Hospital/Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Manhasset, NY, USA
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Subramanian PS. Novel Approaches to the Treatment of Idiopathic Intracranial Hypertension. Curr Neurol Neurosci Rep 2024; 24:265-272. [PMID: 38864967 DOI: 10.1007/s11910-024-01347-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] [Accepted: 05/30/2024] [Indexed: 06/13/2024]
Abstract
PURPOSE OF REVIEW Idiopathic intracranial hypertension (IIH) typically affects women of childbearing age, is associated with recent weight gain, and can result in debilitating headache as well as papilledema that can cause vision loss. There have been advances in the medical and surgical treatment of affected patients with IIH that can improve outcomes and tolerability of therapy. RECENT FINDINGS Medical treatment with agents that lower intracranial pressure through pathways other than carbonic anhydrase inhibition are being developed, and medically-directed weight loss as well as bariatric surgery now may be considered as primary therapy. New surgical options including venous sinus stenting have shown efficacy even with cases of severe vision loss. Our treatment options for IIH patients are becoming more diverse, and individualized treatment decisions are now possible to address specific components of the patient's disease manifestations and to lead to IIH remission.
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Affiliation(s)
- Prem S Subramanian
- Department of Ophthalmology, Neurology, and Neurosurgery, University of Colorado School of Medicine, Sue Anschutz-Rodgers University of Colorado Eye Center, Aurora, CO, USA.
- Department of Surgery (Division of Ophthalmology), Uniformed Services University of the Health Sciences, Bethesda, MD, USA.
- UCHealth Eye Center, 1675 Aurora Ct Mail Stop F731, 80045, Aurora, CO, USA.
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3
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Hladky SB, Barrand MA. Regulation of brain fluid volumes and pressures: basic principles, intracranial hypertension, ventriculomegaly and hydrocephalus. Fluids Barriers CNS 2024; 21:57. [PMID: 39020364 PMCID: PMC11253534 DOI: 10.1186/s12987-024-00532-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2023] [Accepted: 03/21/2024] [Indexed: 07/19/2024] Open
Abstract
The principles of cerebrospinal fluid (CSF) production, circulation and outflow and regulation of fluid volumes and pressures in the normal brain are summarised. Abnormalities in these aspects in intracranial hypertension, ventriculomegaly and hydrocephalus are discussed. The brain parenchyma has a cellular framework with interstitial fluid (ISF) in the intervening spaces. Framework stress and interstitial fluid pressure (ISFP) combined provide the total stress which, after allowing for gravity, normally equals intracerebral pressure (ICP) with gradients of total stress too small to measure. Fluid pressure may differ from ICP in the parenchyma and collapsed subarachnoid spaces when the parenchyma presses against the meninges. Fluid pressure gradients determine fluid movements. In adults, restricting CSF outflow from subarachnoid spaces produces intracranial hypertension which, when CSF volumes change very little, is called idiopathic intracranial hypertension (iIH). Raised ICP in iIH is accompanied by increased venous sinus pressure, though which is cause and which effect is unclear. In infants with growing skulls, restriction in outflow leads to increased head and CSF volumes. In adults, ventriculomegaly can arise due to cerebral atrophy or, in hydrocephalus, to obstructions to intracranial CSF flow. In non-communicating hydrocephalus, flow through or out of the ventricles is somehow obstructed, whereas in communicating hydrocephalus, the obstruction is somewhere between the cisterna magna and cranial sites of outflow. When normal outflow routes are obstructed, continued CSF production in the ventricles may be partially balanced by outflow through the parenchyma via an oedematous periventricular layer and perivascular spaces. In adults, secondary hydrocephalus with raised ICP results from obvious obstructions to flow. By contrast, with the more subtly obstructed flow seen in normal pressure hydrocephalus (NPH), fluid pressure must be reduced elsewhere, e.g. in some subarachnoid spaces. In idiopathic NPH, where ventriculomegaly is accompanied by gait disturbance, dementia and/or urinary incontinence, the functional deficits can sometimes be reversed by shunting or third ventriculostomy. Parenchymal shrinkage is irreversible in late stage hydrocephalus with cellular framework loss but may not occur in early stages, whether by exclusion of fluid or otherwise. Further studies that are needed to explain the development of hydrocephalus are outlined.
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Affiliation(s)
- Stephen B Hladky
- Department of Pharmacology, Tennis Court Rd, Cambridge, CB2 1PD, UK.
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Schartz D, Finkelstein A, Bender M, Kessler A, Zhong J. Association of Extent of Transverse Sinus Stenosis With Cerebral Glymphatic Clearance in Patients With Idiopathic Intracranial Hypertension. Neurology 2024; 103:e209529. [PMID: 38833652 DOI: 10.1212/wnl.0000000000209529] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/06/2024] Open
Abstract
BACKGROUND AND OBJECTIVES Idiopathic intracranial hypertension (IIH) is a neurologic disorder characterized by symptoms of elevated intracranial pressure in the absence of a clear cause. There is a developing theory that IIH may, in part, be related to abnormal cerebral glymphatic clearance. In addition, transverse sinus stenosis (TSS) is a common finding in IIH of unclear pathophysiologic significance. Similarly, whether or not TSS is associated with glymphatic outflow in IIH is unknown. The aim of this investigation was to explore the possible association between glymphatic outflow and extent of TSS in patients with IIH. METHODS The study cohort consisted of patients with IIH and healthy controls who were retrospectively identified from our tertiary care institution located in upstate New York from 2016 to 2023. Patients with IIH were included if they had brain MRIs completed with sufficient sequences for analysis. Brain MRIs were computationally analyzed using diffusion tensor imaging analysis along the perivascular space technique to quantify the glymphatic function in patients with IIH. Glymphatic clearance, the primary outcome, was then correlated with the degree of TSS on MR venography using 2 different scoring systems, the 'Farb score' and 'Carvalho score.' RESULTS Overall, 81 patients with IIH (70 [86%] female, mean age 29.8 years [SD: 8.2 years], mean BMI 41 [SD: 8.4]) and 10 normal controls were identified with sufficient imaging. Based on the Carvalho TSS score, IIH patients without TSS had significantly lower glymphatic clearance than healthy controls (mean ALPS index: 1.196 [SD: 0.05] vs 1.238 [SD: 0.04], respectively; p = 0.018). Furthermore, IIH patients with TSS had significantly lower glymphatic outflow than healthy controls (1.129 [SD: 0.07] vs 1.238 [SD: 0.04], respectively; p < 0.0001) and IIH patients without TSS (1.129 [SD: 0.07] vs 1.196 [SD: 0.05], respectively; p < 0.0001). In addition, there was a significant association between increasing extent of TSS and declining glymphatic clearance (p < 0.0001, R = 0.62). Finally, IIH patients with severe TSS had significantly lower glymphatic flow than IIH patients with mild stenosis (1.121 [SD: 0.07] vs 1.178 [SD: 0.05], respectively; p < 0.0001). These findings were similarly recapitulated using the Farb TSS scoring system. DISCUSSION These preliminary findings suggest that the extent of TSS is associated with the degree of glymphatic clearance in IIH, providing novel insights into IIH pathophysiology. Further research is required to clarify the possible causal relationship between TSS and impaired glymphatic clearance in IIH.
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Affiliation(s)
- Derrek Schartz
- From the Department of Imaging Sciences (D.S., A.K., J.Z.), University of Rochester Medical Center; Department of Biomedical Engineering (A.F.), University of Rochester; and Department of Neurosurgery (M.B.), University of Rochester Medical Center, NY
| | - Alan Finkelstein
- From the Department of Imaging Sciences (D.S., A.K., J.Z.), University of Rochester Medical Center; Department of Biomedical Engineering (A.F.), University of Rochester; and Department of Neurosurgery (M.B.), University of Rochester Medical Center, NY
| | - Matthew Bender
- From the Department of Imaging Sciences (D.S., A.K., J.Z.), University of Rochester Medical Center; Department of Biomedical Engineering (A.F.), University of Rochester; and Department of Neurosurgery (M.B.), University of Rochester Medical Center, NY
| | - Alex Kessler
- From the Department of Imaging Sciences (D.S., A.K., J.Z.), University of Rochester Medical Center; Department of Biomedical Engineering (A.F.), University of Rochester; and Department of Neurosurgery (M.B.), University of Rochester Medical Center, NY
| | - Jianhui Zhong
- From the Department of Imaging Sciences (D.S., A.K., J.Z.), University of Rochester Medical Center; Department of Biomedical Engineering (A.F.), University of Rochester; and Department of Neurosurgery (M.B.), University of Rochester Medical Center, NY
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Schartz D, Finkelstein A, Akkipeddi SMK, Kessler A, Williams Z, Vates E, Hauck EF, Fargen KM, Bender MT. Total brain volume is associated with severity of transverse sinus stenosis in idiopathic intracranial hypertension. J Neurointerv Surg 2024:jnis-2024-021938. [PMID: 38960700 DOI: 10.1136/jnis-2024-021938] [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: 05/03/2024] [Accepted: 06/13/2024] [Indexed: 07/05/2024]
Abstract
BACKGROUND Idiopathic intracranial hypertension (IIH) is a complex neurological condition characterized by symptoms of increased intracranial pressure of unclear etiology. While transverse sinus stenosis (TSS) is often present in patients with IIH, how and why it occurs remains unclear. METHODS IIH patients and a set of age-matched normal controls were identified from our single-center tertiary care institution from 2016 to 2024. Brain MRIs before treatment were computationally segmented and parcellated using FreeSurfer software. Extent of TSS on MR venograms was graded using the Farb scoring system. Relationship between normalized brain volume, normalized brain-to-CSF volume, and TSS was investigated. Multiple linear regression was conducted to investigate the association between continuous variables, accounting for the covariates body mass index, sex, and age. RESULTS In total, 84 IIH patients (mean age, 29.8 years; 87% female) and 15 normal controls (mean age, 28.1 years) were included. Overall, increasing/worsening TSS was found to be significantly associated with normalized total brain volume (p=0.018, R=0.179) and brain-to-CSF ratio volume (p=0.026, R=0.184). Additionally, there was a significant difference between controls and IIH patients with mild and severe stenosis regarding normalized total brain volume (ANCOVA, p=0.023) and brain-to-CSF ratio volume (ANCOVA, p=0.034). Likewise, IIH patients with severe TSS had a significantly higher brain-to-CSF volume compared with controls (p=0.038) and compared with IIH patients with mild TSS (p=0.038). CONCLUSIONS These findings suggest that total brain volume is associated with extent of TSS, which may reflect extramural venous compression due to enlarged brain and/or venous hypertension with associated cerebral congestion/swelling.
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Affiliation(s)
- Derrek Schartz
- Imaging Sciences, University of Rochester Medical Center, Rochester, New York, USA
| | - Alan Finkelstein
- Imaging Sciences, University of Rochester Medical Center, Rochester, New York, USA
| | | | - Alex Kessler
- Imaging Sciences, University of Rochester Medical Center, Rochester, New York, USA
| | - Zoe Williams
- Ophthalmology, University of Rochester Medical Center, Rochester, New York, USA
| | - Edward Vates
- Neurosurgery, University of Rochester Medical Center, Rochester, New York, USA
| | - Erik F Hauck
- Neurosurgery, Duke University Medical Center, Durham, North Carolina, USA
| | - Kyle M Fargen
- Neurological Surgery and Radiology, Wake Forest University, Winston-Salem, North Carolina, USA
| | - Matthew T Bender
- Neurosurgery, University of Rochester Medical Center, Rochester, New York, USA
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6
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Ahmed G, Abou-Foul M, Sage W, McConachie N. Endovascular stenting for cerebral venous sinus stenosis secondary to meningioma invasion. Neuroradiology 2024; 66:817-824. [PMID: 38429544 DOI: 10.1007/s00234-024-03321-2] [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: 10/10/2023] [Accepted: 02/20/2024] [Indexed: 03/03/2024]
Abstract
INTRODUCTION Symptomatic intracranial hypertension (IH) due to venous outflow obstruction secondary to dural venous sinus (DVS) tumoral invasion affects up to 3% of intracranial meningioma patients. The literature regarding endovascular therapies of such patients is limited to a few case reports and a recent single-centre case series. PURPOSE We describe our single-centre experience of endovascular therapy in patients with clinically symptomatic IH secondary to DVS meningioma invasion. METHODS We performed a retrospective review of clinical and radiological data of all patients with refractory IH and meningiomas invading the DVS who were referred for possible DVS venoplasty and stenting. Seven endovascular procedures in six female patients were done. Presumed secondarily induced lateral transverse sinus stenosis was also stented in four patients as part of the primary intervention. RESULTS All patients experienced complete symptomatic resolution at 6-month follow-up. Five patients had no symptom recurrence over a mean follow-up period of 3.5 years. One patient with multiple meningiomas developed recurrent IH 2 years following stenting secondary to in-stent tumour re-invasion. This was re-stented with consequent 6 months post-retreatment symptomatic relief at the time of writing. No procedure-related complications occurred. CONCLUSION In the setting of DVS stenosis secondary to meningioma invasion, endovascular therapy is a safe and successful therapeutic option with promising mid-term results. The procedure should be considered in cases where complete surgical tumour resection is unlikely or carries a significant risk. If present, secondarily induced stenoses at the lateral ends of the transverse sinuses should also be considered for treatment.
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Affiliation(s)
- Gasim Ahmed
- Department of Imaging, Queens Medical Centre, Nottingham University Hospitals NHS Trust, Nottingham, UK.
| | - Mahmoud Abou-Foul
- Department of Imaging, Queens Medical Centre, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - William Sage
- Department of Neurosurgery, Queens Medical Centre, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Norman McConachie
- Department of Imaging, Queens Medical Centre, Nottingham University Hospitals NHS Trust, Nottingham, UK
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7
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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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8
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Jijeh AMZ, Fatima A, Faraji MA, Hamadah HK, Shaath GA. Intracranial Pressure and Cerebral Hemodynamics in Infants Before and After Glenn Procedure. Crit Care Explor 2024; 6:e1083. [PMID: 38694846 PMCID: PMC11057806 DOI: 10.1097/cce.0000000000001083] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/04/2024] Open
Abstract
OBJECTIVES This prospective cohort study aimed to investigate changes in intracranial pressure (ICP) and cerebral hemodynamics in infants with congenital heart disease undergoing the Glenn procedure, focusing on the relationship between superior vena cava pressure and estimated ICP. DESIGN A single-center prospective cohort study. SETTING The study was conducted in a cardiac center over 4 years (2019-2022). PATIENTS Twenty-seven infants with congenital heart disease scheduled for the Glenn procedure were included in the study, and detailed patient demographics and primary diagnoses were recorded. INTERVENTIONS Transcranial Doppler (TCD) ultrasound examinations were performed at three time points: baseline (preoperatively), postoperative while ventilated (within 24-48 hr), and at discharge. TCD parameters, blood pressure, and pulmonary artery pressure were measured. MEASUREMENTS AND MAIN RESULTS TCD parameters included systolic flow velocity, diastolic flow velocity (dFV), mean flow velocity (mFV), pulsatility index (PI), and resistance index. Estimated ICP and cerebral perfusion pressure (CPP) were calculated using established formulas. There was a significant postoperative increase in estimated ICP from 11 mm Hg (interquartile range [IQR], 10-16 mm Hg) to 15 mm Hg (IQR, 12-21 mm Hg) postoperatively (p = 0.002) with a trend toward higher CPP from 22 mm Hg (IQR, 14-30 mm Hg) to 28 mm Hg (IQR, 22-38 mm Hg) postoperatively (p = 0.1). TCD indices reflected alterations in cerebral hemodynamics, including decreased dFV and mFV and increased PI. Intracranial hemodynamics while on positive airway pressure and after extubation were similar. CONCLUSIONS Glenn procedure substantially increases estimated ICP while showing a trend toward higher CPP. These findings underscore the intricate interaction between venous pressure and cerebral hemodynamics in infants undergoing the Glenn procedure. They also highlight the remarkable complexity of cerebrovascular autoregulation in maintaining stable brain perfusion under these circumstances.
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Affiliation(s)
- Abdulraouf M Z Jijeh
- Department of Cardiology, Division of Pediatric Cardiac Intensive Care, Ministry of National Guard-Health Affairs, Riyadh, Saudi Arabia
- King Abdullah International Medical Research Center, Riyadh, Saudi Arabia
- King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
| | - Anis Fatima
- Department of Cardiology, Division of Pediatric Cardiac Intensive Care, Ministry of National Guard-Health Affairs, Riyadh, Saudi Arabia
| | - Mohammad A Faraji
- Department of Radiology, Ministry of National Guard-Health Affairs, Riyadh, Saudi Arabia
| | - Hussam K Hamadah
- Department of Cardiology, Division of Pediatric Cardiac Intensive Care, Ministry of National Guard-Health Affairs, Riyadh, Saudi Arabia
| | - Ghassan A Shaath
- Department of Cardiology, Division of Pediatric Cardiac Intensive Care, Ministry of National Guard-Health Affairs, Riyadh, Saudi Arabia
- King Abdullah International Medical Research Center, Riyadh, Saudi Arabia
- King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
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Azzam AY, Mortezaei A, Morsy MM, Essibayi MA, Ghozy S, Elamin O, Azab MA, Elswedy A, Altschul D, Kadirvel R, Brinjikji W, Kallmes DF. Venous sinus stenting for idiopathic intracranial hypertension: An updated Meta-analysis. J Neurol Sci 2024; 459:122948. [PMID: 38457956 DOI: 10.1016/j.jns.2024.122948] [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: 09/19/2023] [Revised: 02/11/2024] [Accepted: 03/04/2024] [Indexed: 03/10/2024]
Abstract
BACKGROUND Idiopathic intracranial hypertension (IIH) is characterized by elevated intracranial pressure and primarily affects obese women of reproductive age. Venous sinus stenting (VSS) is a surgical procedure used to treat IIH, but its safety and efficacy are still controversial. METHODS A systematic review and meta-analysis were conducted following PRISMA guidelines. Multiple databases were searched for studies evaluating the safety and efficacy of VSS in IIH patients and meta-analysis was performed to pool the data. RESULTS A total of 36 studies involving 1066 patients who underwent VSS were included. After VSS, a significant reduction in trans-stenotic gradient pressure was observed. Patients also showed significantly lower cerebrospinal fluid (CSF) opening pressure. Clinical outcomes demonstrated improvement in tinnitus (95%), papilledema (89%), visual disturbances (88%), and headache (79%). However, 13.7% of patients experienced treatment failure or complications. The treatment failure rate was 8.35%, characterized by worsening symptoms and recurrence of IIH. The complications rate was 5.35%, including subdural hemorrhage, urinary tract infection, stent thrombus formation, and others. CONCLUSION VSS appears to be a safe and effective treatment option for IIH patients who are unresponsive to medical therapy or have significant visual symptoms. However, long-term outcomes and safety of the procedure require further investigation.
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Affiliation(s)
- Ahmed Y Azzam
- Montefiore-Einstein Cerebrovascular Research Lab, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA; Faculty of Medicine, October 6 University, Giza, Egypt; Department of Radiology, Mayo Clinic, Rochester, MN, USA.
| | - Ali Mortezaei
- Montefiore-Einstein Cerebrovascular Research Lab, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Mahmoud M Morsy
- Montefiore-Einstein Cerebrovascular Research Lab, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA; Faculty of Medicine, October 6 University, Giza, Egypt
| | - Muhammed Amir Essibayi
- Montefiore-Einstein Cerebrovascular Research Lab, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA; Department of Neurological Surgery, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Sherief Ghozy
- Department of Radiology, Mayo Clinic, Rochester, MN, USA; Department of Neurologic Surgery, Mayo Clinic, Rochester, MN, USA
| | - Osman Elamin
- Department of Neurosurgery, Jordan Hospital, Amman, Jordan
| | - Mohammed A Azab
- Department of Neurosurgery, Cleveland Clinic Foundation, OH, USA
| | - Adam Elswedy
- Faculty of Medicine, October 6 University, Giza, Egypt; Biomedicinskt Centrum BMC, Uppsala University, Husargatan 3, Uppsala 752 37, Sweden
| | - David Altschul
- Montefiore-Einstein Cerebrovascular Research Lab, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA; Department of Neurological Surgery, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Ramanathan Kadirvel
- Department of Radiology, Mayo Clinic, Rochester, MN, USA; Department of Neurologic Surgery, Mayo Clinic, Rochester, MN, USA
| | - Waleed Brinjikji
- Department of Radiology, Mayo Clinic, Rochester, MN, USA; Department of Neurologic Surgery, Mayo Clinic, Rochester, MN, USA
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10
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Pandey A, Schreiber C, Garton ALA, Jung B, Goldberg JL, Kocharian G, Carnevale JA, Boddu SR. Challenges in the use of Venous Sinus Stenting in the Treatment of Idiopathic Intracranial Hypertension and Pulsatile Tinnitus. World Neurosurg 2024; 184:372-386. [PMID: 38590071 DOI: 10.1016/j.wneu.2023.12.164] [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: 12/29/2023] [Accepted: 12/30/2023] [Indexed: 04/10/2024]
Abstract
Although numerous case series and meta-analyses have shown the efficacy of venous sinus stenting (VSS) in the treatment of idiopathic intracranial hypertension and idiopathic intracranial hypertension-associated pulsatile tinnitus, there remain numerous challenges to be resolved. There is no widespread agreement on candidacy; pressure gradient and failed medical treatment are common indications, but not all clinicians require medical refractoriness as a criterion. Venous manometry, venography, and cerebral angiography are essential tools for patient assessment, but again disagreements exist regarding the best, or most appropriate, diagnostic imaging choice. Challenges with the VSS technique also exist, such as stent choice and deployment. There are considerations regarding postprocedural balloon angioplasty and pharmacologic treatment, but there is insufficient evidence to formalize postoperative decision making. Although complications of VSS are relatively rare, they include in-stent stenosis, hemorrhage, and subdural hematoma, and the learning curve for VSS presents specific challenges in navigating venous anatomy, emphasizing the need for wider availability of high-quality training. Recurrence of symptoms, particularly stent-adjacent stenosis, poses challenges, and although restenting and cerebrospinal fluid-diverting procedures are options, there is a need for clearer criteria for retreatment strategies. Despite these challenges, when comparing VSS with traditional cerebrospinal fluid-diverting procedures, VSS emerges as a favorable option, with strong clinical outcomes, lower complication rates, and cost-effectiveness. Further research is necessary to refine techniques and indications and address specific aspects of VSS to overcome these challenges.
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Affiliation(s)
- Abhinav Pandey
- Department of Neurological Surgery, Weill Cornell Medicine/NewYork-Presbyterian Hospital, New York, New York, USA
| | - Craig Schreiber
- Department of Neurological Surgery, Weill Cornell Medicine/NewYork-Presbyterian Hospital, New York, New York, USA
| | - Andrew L A Garton
- Department of Neurological Surgery, Weill Cornell Medicine/NewYork-Presbyterian Hospital, New York, New York, USA
| | | | - Jacob L Goldberg
- Department of Neurological Surgery, Weill Cornell Medicine/NewYork-Presbyterian Hospital, New York, New York, USA
| | - Gary Kocharian
- Department of Neurological Surgery, Weill Cornell Medicine/NewYork-Presbyterian Hospital, New York, New York, USA
| | - Joseph A Carnevale
- Department of Neurological Surgery, Weill Cornell Medicine/NewYork-Presbyterian Hospital, New York, New York, USA
| | - Srikanth R Boddu
- Department of Neurological Surgery, Weill Cornell Medicine/NewYork-Presbyterian Hospital, New York, New York, USA.
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11
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Colman BD, Boonstra F, Nguyen MN, Raviskanthan S, Sumithran P, White O, Hutton EJ, Fielding J, van der Walt A. Understanding the pathophysiology of idiopathic intracranial hypertension (IIH): a review of recent developments. J Neurol Neurosurg Psychiatry 2024; 95:375-383. [PMID: 37798095 DOI: 10.1136/jnnp-2023-332222] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/17/2023] [Accepted: 09/15/2023] [Indexed: 10/07/2023]
Abstract
Idiopathic intracranial hypertension (IIH) is a condition of significant morbidity and rising prevalence. It typically affects young people living with obesity, mostly women of reproductive age, and can present with headaches, visual abnormalities, tinnitus and cognitive dysfunction. Raised intracranial pressure without a secondary identified cause remains a key diagnostic feature of this condition, however, the underlying pathophysiological mechanisms that drive this increase are poorly understood. Previous theories have focused on cerebrospinal fluid (CSF) hypersecretion or impaired reabsorption, however, the recent characterisation of the glymphatic system in many other neurological conditions necessitates a re-evaluation of these hypotheses. Further, the impact of metabolic dysfunction and hormonal dysregulation in this population group must also be considered. Given the emerging evidence, it is likely that IIH is triggered by the interaction of multiple aetiological factors that ultimately results in the disruption of CSF dynamics. This review aims to provide a comprehensive update on the current theories regarding the pathogenesis of IIH.
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Affiliation(s)
- Blake D Colman
- Department of Neuroscience, Monash University Faculty of Medicine Nursing and Health Sciences, Clayton, Victoria, Australia
- Department of Neurology, Alfred Hospital, Melbourne, Victoria, Australia
| | - Frederique Boonstra
- Department of Neuroscience, Monash University Faculty of Medicine Nursing and Health Sciences, Clayton, Victoria, Australia
| | - Minh Nl Nguyen
- Department of Neuroscience, Monash University Faculty of Medicine Nursing and Health Sciences, Clayton, Victoria, Australia
- Department of Neurology, Alfred Hospital, Melbourne, Victoria, Australia
| | | | - Priya Sumithran
- Department of Surgery, Monash University Faculty of Medicine Nursing and Health Sciences, Clayton, Victoria, Australia
- Department of Endocrinology, Alfred Hospital, Melbourne, Victoria, Australia
| | - Owen White
- Department of Neurology, Alfred Hospital, Melbourne, Victoria, Australia
- Department of Neuroscience, Monash University Central Clinical School, Clayton, Victoria, Australia
| | - Elspeth J Hutton
- Department of Neuroscience, Monash University Faculty of Medicine Nursing and Health Sciences, Clayton, Victoria, Australia
- Department of Neurology, Alfred Hospital, Melbourne, Victoria, Australia
| | - Joanne Fielding
- Department of Neuroscience, Monash University Faculty of Medicine Nursing and Health Sciences, Clayton, Victoria, Australia
| | - Anneke van der Walt
- Department of Neuroscience, Monash University Faculty of Medicine Nursing and Health Sciences, Clayton, Victoria, Australia
- Department of Neurology, Alfred Hospital, Melbourne, Victoria, Australia
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12
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Kemerdere R, Vergili E, Bas G, Kafadar AM, Tanriover N. Surgical management of pseudotumor cerebri syndrome: A single center experience with endoscopic optic nerve decompression and CSF diversion procedures. Clin Neurol Neurosurg 2024; 236:108088. [PMID: 38176216 DOI: 10.1016/j.clineuro.2023.108088] [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: 11/08/2023] [Revised: 12/13/2023] [Accepted: 12/15/2023] [Indexed: 01/06/2024]
Abstract
OBJECTIVES Pseudotumor cerebri syndrome (PTC) is a chronic disorder, which is initially treated by conservative measures, yet surgery is inevitable in case of progressive worsening of vision or headache despite medical treatment. The surgical management is controversial including CSF diversion procedures and optic decompression. The purpose of this study was to evaluate the efficacy of different surgeries in PTC and to present surgical outcomes in a single center. METHODS This retrospective study included the patients with PTC who were operated by endoscopic optic nerve decompression (EOND), ventriculoperitoneal (VP) and lumboperitoneal (LP) shunting. Surgical outcomes, i.e. visual acuity, visual field, papilledema and headache were compared according to type of surgery. Surgical complications were noted. RESULTS Seventeen of 36 patients were treated with shunting, 14 with EOND and 5 patients with both EOND and shunting. No statistical significance was observed between CSF diversion procedures and EOND concerning clinical outcomes. The improvement rate of papilledema was higher with VPS (p = 0574) while more patients benefitted from LPS regarding visual field and acuity (p = 0471 and p = 0718, respectively). The best treatment response for headache was in shunt implemented patients (VPS and LPS) with a rate of 88.2% followed by EOND (78.6%) and both surgeries (60%)(p = 0.294). Gender and BMI were significant predictors of improved papilledema (p = 0.034). CONCLUSIONS Our study demonstrated comparable results between shunting and EOND, regarding the efficacy on surgical outcomes. EOND is quite effective for headache besides its advantage on treatment-refractory visual loss. Shunting may offer sustained relief of symptoms when compared with EOND.
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Affiliation(s)
- Rahsan Kemerdere
- Department of Neurosurgery, Istanbul University-Cerrahpasa, Cerrahpasa Medical Faculty, Istanbul, Turkey.
| | - Ender Vergili
- Department of Neurosurgery, Istanbul University-Cerrahpasa, Cerrahpasa Medical Faculty, Istanbul, Turkey
| | - Gulcin Bas
- Department of Neurosurgery, Istanbul University-Cerrahpasa, Cerrahpasa Medical Faculty, Istanbul, Turkey
| | - Ali Metin Kafadar
- Department of Neurosurgery, Istanbul University-Cerrahpasa, Cerrahpasa Medical Faculty, Istanbul, Turkey
| | - Necmettin Tanriover
- Department of Neurosurgery, Istanbul University-Cerrahpasa, Cerrahpasa Medical Faculty, Istanbul, Turkey
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Dinkin MJ, Patsalides A. Idiopathic Intracranial Venous Hypertension: Toward a Better Understanding of Venous Stenosis and the Role of Stenting in Idiopathic Intracranial Hypertension. J Neuroophthalmol 2023; 43:451-463. [PMID: 37410913 DOI: 10.1097/wno.0000000000001898] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/08/2023]
Abstract
BACKGROUND Venous sinus stenosis, typically at the junction of the transverse and sigmoid sinus, is increasingly recognized as a contributor to the pathophysiology of idiopathic intracranial hypertension (IIH), whether it be the intrinsic type that does not reverse with normalization of intracranial pressure or the extrinsic type, which does. Efforts to treat the stenosis and reduce the associated transstenotic gradient through placement of a stent at the site of stenosis have been studied over the past 2 decades, primarily through retrospective studies, with variable emphasis on formal visual testing and direct assessment of poststent opening pressure. Most studies have presented evidence for utilization of stenting as an alternative to cerebrospinal fluid shunting or optic nerve sheath fenestration in patients with IIH who harbor the stenosis and are refractory to or intolerant of intracranial pressure-lowering medications, but an assessment of the current data is needed to better understand the role of stenting for this patient population. EVIDENCE ACQUISITION A search in PubMed was made for "IIH," "papilledema," and "venous stenting." Data pre and post stenting, including symptoms attributable to IIH, intracranial pressure, papilledema, retinal nerve fiber layer thickening on optical coherence tomography, and visual field assessment (mean deviation), were collected. Need for retreatment and complications were assessed among all studies. Studies using stenting for special circumstances, such as cerebrospinal leaks or for stenosis along anomalous vessels, were reviewed. RESULTS In total, 49 studies (45 retrospective and 4 prospective) and 18 case reports (with 3 or less patients) were found and included in the analysis, for a total of 1,626 patients. In 250 patients in whom poststent intracranial pressure was measured, the mean value was 19.7 cm H 2 O, reduced from a mean of 33 cm H 2 O. Transient visual obscurations resolved in 79.6% of 201 patients who complained of it, pulsatile tinnitus resolved in 84.7% of 515, diplopia resolved in 93% of 86 patients, and nonspecific visual symptoms such as "blurry vision" improved in 76.2% of 537 patients. Headaches resolved in 36% and improved in a further 40.7% of 1,105 patients in whom they were documented before stenting. Of 1,116 with papilledema, 40.8% demonstrated resolution and 38.2% improvement. The mean retinal nerve fiber layer thickness improved from 170.2 µm to 89.2 µm among 402 eyes in which optical coherence tomography was used to measure it. Among 135 eyes in which formal visual fields were performed pre and post stenting, the prestent average mean deviation of -7.35 dB improved to -4.72 dB after stenting. Complications associated with stenting included in-stent stenosis or thrombosis, subdural hematoma, intracerebral hematoma, cerebral edema, stent migration, and death. A recurrence of symptoms requiring a follow-up surgical intervention occurred in 9%. CONCLUSIONS A growing body of evidence supports the use of venous sinus stenting as a viable option for medically refractory IIH, especially when papilledema threatens visual function. Complication and failure rates seem to be similar to alternative surgical approaches, although serious neurological sequalae can rarely occur. Emerging studies evaluating stent type, including novel stents designed for use in the venous system, may help improve ease of the procedure and long-term success rates. Prospective head-to-head studies are needed to better understand the performance of stenting compared with other interventions.
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Affiliation(s)
- Marc J Dinkin
- Department of Ophthalmology and Neurology (MJD), Weill Cornell Medicine, New York Presbyterian Hospital, New York, NY; and Department of Neurosurgery (AP), North Shore University Hospital, Northwell Health, Great Neck, NY
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Rozen TD, Devcic Z, Lewis AR, Sandhu SJS, Erben Y, Toskich BB. A secondary daily persistent headache from onset with underlying nutcracker physiology and spinal epidural venous congestion: case series with lumbar vein embolization as a therapeutic approach. Ther Adv Neurol Disord 2023; 16:17562864231213243. [PMID: 38021477 PMCID: PMC10666676 DOI: 10.1177/17562864231213243] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2023] [Accepted: 10/24/2023] [Indexed: 12/01/2023] Open
Abstract
The authors have published on a unique subset of patients whose headaches worsened in the Trendelenburg position and who on time-resolved MR angiography demonstrated left renal vein compression (nutcracker physiology) with retrograde left second lumbar vein (L2LV) flow and regional spinal epidural venous plexus (EVP) congestion. We hypothesized that the spinal EVP congestion subsequently causes a secondary congestion of the cerebral venous system, which then leads to an elevation of CSF pressure above that individuals CSF pressure set point. This results in a daily headache from onset. Thus, eliminating the spinal EVP could conceivably improve or eliminate the manifested headache syndrome. We now present a case series of four patients with long-term follow-up utilizing lumbar vein coil embolization as a new therapeutic approach. In each patient, the MR angiography findings were verified by catheter-based venography. Treatment consisted of endovascular embolization of the second lumbar vein. Four patients have had coil embolization of which three are 1 year or longer from their procedure while one is 10 months posttreatment. All patients were women. Duration of daily headache prior to embolization ranged from 4 to 8 years. Post-embolization: Three patients are either headache free or 90-95% improved with substantial pain free time. There were no procedure-related complications. Our results suggest that embolization of L2LV in a specific patient population with nutcracker physiology may substantially improve head pain issues. This is a minimally invasive outpatient technique with no apparent side effects.
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Affiliation(s)
- Todd D. Rozen
- Division of Neurology, Mayo Clinic Jacksonville, 4500 San Pablo Road, Jacksonville, FL 32224, USA
| | - Zlatko Devcic
- Division of Interventional Radiology, Mayo Clinic Florida, Jacksonville, FL, USA
| | - Andrew R. Lewis
- Division of Interventional Radiology, Mayo Clinic Florida, Jacksonville, FL, USA
| | | | - Young Erben
- Division of Vascular and Endovascular Surgery, Mayo Clinic Florida, Jacksonville, FL, USA
| | - Beau B. Toskich
- Division of Interventional Radiology, Mayo Clinic Florida, Jacksonville, FL, USA
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15
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Levitt MR. Point:Dural venous sinus stenting should be considered a first-line treatment option for select patients with idiopathic intracranial hypertension. J Neurointerv Surg 2023; 15:1061-1062. [PMID: 37344175 DOI: 10.1136/jnis-2023-020597] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/10/2023] [Indexed: 06/23/2023]
Affiliation(s)
- Michael R Levitt
- Neurological Surgery, University of Washington School of Medicine, Seattle, Washington, USA
- Radiology, University of Washington, Seattle, WA, USA
- Mechanical Engineering, University of Washington, Seattle, WA, USA
- Stroke & Applied Neuroscience Center, University of Washington, Seattle, WA, USA
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Raynald, Yang H, Tong X, Huo X, Li X, Liu L, Sui B, Qu H, Dong K, Wang Y, Wang S, Miao Z, Mo D. Stenting versus medical treatment for idiopathic intracranial hypertension: a matched-control study. J Neurointerv Surg 2023; 15:1021-1026. [PMID: 36202600 DOI: 10.1136/jnis-2022-019191] [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: 05/29/2022] [Accepted: 09/13/2022] [Indexed: 11/03/2022]
Abstract
BACKGROUND This prospective cohort study compared the outcomes of stenting and medical treatment for patients with idiopathic intracranial hypertension (IIH) and venous sinus stenosis (VSS). METHODS In this single-center cohort study, patients with IIH and VSS were evaluated between January 2014 and December 2019 with follow-up periods of 1, 3, and 6 months. The patients received either stenting or medical treatment. The two groups underwent 1:1 matching using propensity score analysis, and the clinical outcomes were compared. RESULTS Following 1:1 matching, 36 patients who underwent stenting and 36 who underwent medical treatment were matched. The median improvements in the papilledema Frisén grade were greater in the stenting group at 1 month (-2 vs 0), 3 months (-3 vs -1), and 6 months (-3 vs -1) than in the medical treatment group. Patients who received stenting treatment had a significantly higher prevalence of complete resolution of their respective symptoms (headache, tinnitus, or visual disturbances) at 3 months (58.3% vs 13.9%, OR 8.68, 95% CI 2.74 to 27.52) and 6 months (80.6% vs 22.2%, OR 14.50, 95% CI 4.64 to 45.32) than those receiving medical treatment. CONCLUSIONS This matched-control study shows that stenting has a greater efficacy rate and rapid resolution of papilledema and its respective symptoms compared with medical treatment.
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Affiliation(s)
- Raynald
- Department of Interventional Neuroradiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Hongchao Yang
- Department of Neurosurgery, Beijing ChaoYang Hospital, Capital Medical University, Beijing, China
| | - Xu Tong
- Department of Interventional Neuroradiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Xiaochuan Huo
- 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
| | - Binbin Sui
- Department of Radiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Hui Qu
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Kehui Dong
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Yilong Wang
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Shuran Wang
- Department of Ophthalmology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Zhongrong Miao
- 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
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Carlos Martinez-Gutierrez J, Kole MJ, Lopez-Rivera V, Inam ME, Tang R, Al-Zubidi N, Adesina OO, Lekka E, Engstrom AC, Sheth S, Pedroza C, Day AL, Chen PR. Primary balloon angioplasty of venous Sinus stenosis in idiopathic intracranial hypertension. Interv Neuroradiol 2023; 29:358-362. [PMID: 35323053 PMCID: PMC10399507 DOI: 10.1177/15910199221089446] [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: 01/04/2022] [Revised: 03/01/2022] [Accepted: 03/03/2022] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND Venous sinus stenosis (VSS) stenting has emerged as an effective treatment for patients with Idiopathic Intracranial Hypertension (IIH). However, stenting carries risk of in-stent stenosis/thrombosis and cumulative bleeding risk from long-term dual antiplatelet (DAPT) use. Thus, we investigated the potential safety and efficacy of primary balloon angioplasty as an alternative to stenting in IIH. METHODS A prospectively maintained single-center registry of IIH patients undergoing endovascular procedures was queried. Inclusion criteria included patients with confirmed IIH and angiographically demonstrable VSS who underwent interventions from 2012- 2021. Patients were dichotomized into primary balloon angioplasty (Group A) and primary stenting (Group S), comparing clinical outcomes using bivariate analyses. RESULTS 62 patients were included with median age of 33 [IQR 26-37], 74% females. Group A (9/62) and Group S (53/62) had similar baseline characteristics. Papilledema improvement was higher in Group S at 6 weeks and 6 months (44 vs. 93, p = 0.002 and 44 vs. 92%, p = 0.004), with similar improvements across all symptoms. Group S had higher mean post-procedure venous pressure gradient change (8 vs. 3 mmHg, p = 0.02) and a lower CSF opening pressure at 6 months (23 vs. 36 cmH2O, p < 0.001). VPS rescue rate was higher in Group A (44 vs. 2%, p = 0.001). There was only one procedural complications; a subdural hematoma in Group A. CONCLUSIONS Primary VSS balloon angioplasty provides a marginal and short-lived improvement of IIH symptoms compared to stenting. These findings suggest a cautious and limited role for short-term rescue angioplasty in poor shunting and stenting candidates with refractory IIH.
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Affiliation(s)
| | - Matthew J Kole
- Department of Neurosurgery, University of Texas McGovern Medical School, Houston, Texas, United States
| | - Victor Lopez-Rivera
- Department of Neurosurgery, Boston University, Boston, Massachusetts, United States
| | - Mehmet Enes Inam
- Texas Institute for Restorative Neurotechnologies, School of Biomedical Informatics, University of Texas Health Science Center at Houston, Houston, Texas, United States
| | - Rosa Tang
- Eye Wellness Center, Houston, Texas, United States
| | - Nagham Al-Zubidi
- Department of Ophthalmology, MD Anderson Cancer Center, Houston, Texas, United States
| | - Ore-Ofeoluwatomi Adesina
- Department of Ophthalmology, University of Texas McGovern Medical School, Houston, Texas, United States
| | - Elvira Lekka
- Department of Neurosurgery, University of Texas McGovern Medical School, Houston, Texas, United States
| | - Allison C. Engstrom
- Department of Neurosurgery, University of Texas McGovern Medical School, Houston, Texas, United States
| | - Sunil Sheth
- Department of Neurology, University of Texas McGovern Medical School, Houston, Texas, United States
| | - Claudia Pedroza
- Department of Pediatrics, University of Texas McGovern Medical School, Houston, Texas, United States
| | - Arthur L. Day
- Department of Neurosurgery, University of Texas McGovern Medical School, Houston, Texas, United States
| | - Peng Roc Chen
- Department of Neurosurgery, University of Texas McGovern Medical School, Houston, Texas, United States
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18
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Fargen KM, Coffman S, Torosian T, Brinjikji W, Nye BL, Hui F. "Idiopathic" intracranial hypertension: An update from neurointerventional research for clinicians. Cephalalgia 2023; 43:3331024231161323. [PMID: 36924237 DOI: 10.1177/03331024231161323] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/18/2023]
Abstract
BACKGROUND The recognition of venous sinus stenosis as a contributing factor in the majority of patients with idiopathic intracranial hypertension coupled with increasing cerebral venography and venous sinus stenting experience have dramatically improved our understanding of the pathophysiologic mechanisms driving this disease. There is now a dense, growing body of research in the neurointerventional literature detailing anatomical and physiological mechanisms of disease which has not been widely disseminated among clinicians. METHODS A literature search was conducted, covering the most recent neurointerventional literature on idiopathic intracranial hypertension, the pathophysiology of idiopathic intracranial hypertension, and management strategies (including venous sinus stenting), and subsequently summarized to provide a comprehensive review of the most recently published studies on idiopathic intracranial hypertension pathophysiology and management. CONCLUSION Recent studies in the neurointerventional literature have greatly improved our understanding of the pathophysiologic mechanisms causing idiopathic intracranial hypertension and its associated conditions. The ability to make individualized, patient-specific treatment approaches has been made possible by advances in our understanding of how venous sinus stenosis and cerebral venous hypertension fundamentally contribute to idiopathic intracranial hypertension.
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Affiliation(s)
- Kyle M Fargen
- Neurological Surgery, Atrium Health Wake Forest Baptist, Winston-Salem, NC, USA
| | - Stephanie Coffman
- Neurological Surgery, Atrium Health Wake Forest Baptist, Winston-Salem, NC, USA
| | - Taron Torosian
- Neurological Surgery, Atrium Health Wake Forest Baptist, Winston-Salem, NC, USA
| | | | - Barbara L Nye
- Neurology, Atrium Health Wake Forest Baptist, Winston-Salem, NC, USA
| | - Ferdinand Hui
- Interventional Radiology, John Hopkins Hospital, Baltimore, MD, USA
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Estimation of venous sinus pressure drop in patients with idiopathic intracranial hypertension using 4D-flow MRI. Eur Radiol 2023; 33:2576-2584. [PMID: 36287270 DOI: 10.1007/s00330-022-09199-z] [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: 05/01/2022] [Revised: 07/28/2022] [Accepted: 09/23/2022] [Indexed: 01/25/2023]
Abstract
OBJECTIVE We aimed to explore a non-invasive estimate of pressure drop in patients who undergo venous sinus stenting to treat idiopathic intracranial hypertension (IIH). METHODS This prospective study included 28 IIH patients scheduled for venous stenting. 4D-flow MRI was acquired 24-48 h before venous manometry. Manometry-obtained pressure drop (Mp) was dichotomized into low (Lp: 0-8 mmHg) and high (Hp: 8-30 mmHg) groups. Hemodynamic indices were compared between Lp and Hp. Trans-stenotic pressure drop was estimated by work-energy equation, simplified Bernoulli equation, vorticity magnitude, and velocity difference between inlet and outlet and was compared with Mp. Measurement agreement, correlation, and accuracy were evaluated using the κ coefficient, Pearson's r, and confusion matrix-derived accuracy. RESULTS Among 28 patients (mean age 38.8 ± 12.7), 19 (67.9%) were female. Work-energy equation-estimated pressure drop (WEp) had strong correlation (r = 0.91, 95% confidence interval [CI]: 0.81-0.96, p < 0.001) and high agreement (intraclass correlation coefficient = 0.90, 95% CI: 0.78-0.95, p < 0.001) with Mp. WEp classified Lp and Hp with an accuracy of 0.96. The κ value between WEp and Mp was 0.92 (95% CI: 0.78-1.00). In the work-energy equation, the viscosity energy term (Ve) had the largest weights, and the ratio of Ve to the summation of the three energy terms was 0.93 ± 0.07. Ve had strong correlation with mVort (r = 0.93, 95% CI: 0.85-0.97, p < 0.001), and mean vorticity magnitude was significantly elevated in Hp compared to that in Lp (259.8 vs. 174.9 mL/s, p < 0.001). CONCLUSION Trans-stenotic pressure drop in IIH can be estimated using the work-energy equation with favorable accuracy. KEY POINTS • Trans-stenotic pressure drop in patients with idiopathic intracranial hypertension can be estimated accurately with the work-energy equation using the 4D-flow MRI full velocity field. • Compared with traditional venous sinus manometry, the 4D-flow MRI-derived pressure drop is totally non-invasive and cost-saving. • 4D-flow MRI may help neurointerventionalist to select IIH patients suitable for venous sinus stenting.
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Abstract
PURPOSE OF REVIEW Idiopathic intracranial hypertension (IIH) is a disorder of raised intracranial pressure (ICP). Although the majority of patients with IIH present classically with headache and papilledema, some patients may have unusual presentations or manifestations. Recent advancements in neuroimaging have facilitated the identification of other presentations associated with IIH. This review provides an overview of the expanding clinical spectrum of IIH. RECENT FINDINGS Presentations of IIH that are considered unusual include highly asymmetric or unilateral papilledema, IIH without papilledema, and IIH associated with cranial nerve involvement. These presentations likely reflect differences in the way cerebrospinal fluid (CSF) pressure is transmitted intracranially. Radiological signs of intracranial hypertension are increasingly recognized in patients with IIH and provide further insights into the effects of raised ICP on intracranial structures. Osseous changes in the skull base leading to formation of meningoceles and encephaloceles have been identified in patients with IIH, spontaneous skull base CSF leak, and drug-resistant temporal lobe epilepsy, suggesting a possible association. SUMMARY Clinicians should be familiar with the expanding clinical spectrum of IIH and the implications for the management of these presentations.
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Affiliation(s)
- Benson S. Chen
- John van Geest Centre for Brain Repair and MRC Mitochondrial Biology Unit, Department of Clinical Neurosciences, University of Cambridge
- Cambridge Eye Unit, Addenbrooke's Hospital, Cambridge University Hospitals, Cambridge, United Kingdom
| | - John O.T. Britton
- John van Geest Centre for Brain Repair and MRC Mitochondrial Biology Unit, Department of Clinical Neurosciences, University of Cambridge
- Cambridge Eye Unit, Addenbrooke's Hospital, Cambridge University Hospitals, Cambridge, United Kingdom
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Idiopathic Intracranial Hypertension and Vascular Anomalies in Chiari I Malformation. Neurosurg Clin N Am 2023; 34:175-183. [DOI: 10.1016/j.nec.2022.09.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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22
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Kole MJ, Martinez-Gutierrez JC, Sanchez F, Tang R, Chen PR. Dural venous sinus stenting in patients with idiopathic intracranial hypertension: report of outcomes from a single-center prospective database and literature review. EXPERT REVIEW OF OPHTHALMOLOGY 2022. [DOI: 10.1080/17469899.2022.2139678] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Affiliation(s)
- Matthew J Kole
- Department of Neurosurgery, University of Texas Health Science Center at Houston, Houston, Texas, USA
| | | | | | - Rosa Tang
- Eye Wellness Center, Houston, Texas, USA
| | - P Roc Chen
- Department of Neurosurgery, University of Texas Health Science Center at Houston, Houston, Texas, USA
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Inam ME, Martinez-Gutierrez JC, Kole MJ, Sanchez F, Lekka E, Truong VTT, Lopez-Rivera V, Sheriff FG, Zima LA, Pedroza C, Tang R, Adesina OO, Engstrom A, Sheth SA, Chen PR. Venous Sinus Stenting for Low Pressure Gradient Stenoses in Idiopathic Intracranial Hypertension. Neurosurgery 2022; 91:734-740. [PMID: 35960743 PMCID: PMC10553007 DOI: 10.1227/neu.0000000000002095] [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: 12/13/2021] [Accepted: 06/05/2022] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Medically refractory idiopathic intracranial hypertension (IIH) is frequently treated with venous sinus stenosis stenting with high success rates. Patient selection has been driven almost exclusively by identification of supraphysiological venous pressure gradients across stenotic regions based on theoretical assessment of likelihood of response. OBJECTIVE To explore the possibility of benefit in low venous pressure gradient patients. METHODS Using a single-center, prospectively maintained registry of patients with IIH undergoing venous stenting, we defined treatment groups by gradient pressures of ≤4, 5 to 8, and >8 mmHg based on the most frequently previously published thresholds for stenting. Baseline demographics, clinical, and neuro-ophthalmological outcomes (including optical coherence tomography and Humphrey visual fields) were compared. RESULTS Among 53 patients, the mean age was 32 years and 70% female with a mean body mass index was 36 kg/m 2 . Baseline characteristics were similar between groups. The mean change in lumbar puncture opening pressure at 6 months poststenting was similar between the 3 groups (≤4, 5-8, and >8 mmHg; 13.4, 12.9, and 12.4 cmH 2 O, P = .47). Papilledema improvement was observed across groups at 6 months (100, 93, and 86, P = .7) as were all clinical symptoms. The mean changes in optical coherence tomography retinal nerve fiber layer (-30, -54, and -104, P = .5) and mean deviation in Humphrey visual fields (60, 64, and 67, P = .5) at 6 weeks were not significantly different. CONCLUSION Patients with IH with low venous pressure gradient venous sinus stenosis seem to benefit equally from venous stenting compared with their higher gradient counterparts. Re-evaluation of our restrictive criteria for this potentially vision sparing intervention is warranted. Future prospective confirmatory studies are needed.
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Affiliation(s)
- Mehmet Enes Inam
- Department of Neurosurgery, University of Texas Health Science Center at Houston, McGovern Medical School, Houston, Texas, USA
- Center for Precision Health, UTHealth Science Center at Houston, School of Biomedical Informatics, Houston, Texas, USA
| | - Juan Carlos Martinez-Gutierrez
- Department of Neurosurgery, University of Texas Health Science Center at Houston, McGovern Medical School, Houston, Texas, USA
| | - Matthew J. Kole
- Department of Neurosurgery, University of Texas Health Science Center at Houston, McGovern Medical School, Houston, Texas, USA
| | | | - Elvira Lekka
- Department of Neurosurgery, University of Texas Health Science Center at Houston, McGovern Medical School, Houston, Texas, USA
| | - Van Thi Thanh Truong
- Department of Pediatrics, University of Texas Health Science Center at Houston, McGovern Medical School, Houston, Texas, USA
| | | | - Faheem G. Sheriff
- Neurology Department, Texas Tech University Health Science Center, El-Paso, Texas, USA
| | - Laura A. Zima
- Department of Neurosurgery, University of Texas Health Science Center at Houston, McGovern Medical School, Houston, Texas, USA
| | - Claudia Pedroza
- Department of Pediatrics, University of Texas Health Science Center at Houston, McGovern Medical School, Houston, Texas, USA
| | - Rosa Tang
- Eye Wellness Center, Houston, Texas, USA
| | - Ore-Ofe Adesina
- Department of Neurology, University of Texas Health Science Center at Houston, McGovern Medical School, Houston, Texas, USA
- Department of Ophthalmology, University of Texas Health Science Center at Houston, McGovern Medical School, Houston, Texas, USA
| | - Allison Engstrom
- Department of Neurosurgery, University of Texas Health Science Center at Houston, McGovern Medical School, Houston, Texas, USA
| | - Sunil A. Sheth
- Department of Neurology, University of Texas Health Science Center at Houston, McGovern Medical School, Houston, Texas, USA
| | - Peng Roc Chen
- Department of Neurosurgery, University of Texas Health Science Center at Houston, McGovern Medical School, Houston, Texas, USA
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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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25
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Reid K, Winters HS, Ang T, Parker GD, Halmagyi GM. Transverse Sinus Stenting Reverses Medically Refractory Idiopathic Intracranial Hypertension. FRONTIERS IN OPHTHALMOLOGY 2022; 2:885583. [PMID: 38983575 PMCID: PMC11182310 DOI: 10.3389/fopht.2022.885583] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 02/28/2022] [Accepted: 04/06/2022] [Indexed: 07/11/2024]
Abstract
Aim To characterise the ophthalmic indications for, and ophthalmic efficacy of, transverse sinus stenting in adults with medically refractory idiopathic intracranial hypertension. Methods A retrospective cohort study was undertaken on a single-author database of 226 successive patients with confirmed idiopathic intracranial hypertension (IIH). A total of 32 patients were identified who received a transverse sinus stent for medically refractory disease. This which was defined as visual threat and/or intolerance of maximal medical therapy. Patients with medically refractory disease proceeded to stenting, if found to have a significant transverse sinus stenosis gradient at catheter venography. Visual threat was quantified via the degree of papilledema on optical coherence tomography of the retinal nerve fibre layer, and via the visual field mean deviation. CSF opening pressure at lumbar puncture and cerebral venous sinus pressure measurements from catheter venography were correlated with the ophthalmic data, noting also intolerance of maximal medical therapy. Complications of stenting were fully assessed. Results Medically refractory IIH was found in 18% of the total cohort of IIH patients. 90% of those with medically refractory disease had a significant transverse sinus stenosis pressure gradient, and 80% proceeded to stenting. The intervention eliminated papilledema in 96% of stented patients, and allowed 81% to cease acetazolamide. The need for a further procedure was low at 6%, and the safety profile was favourable. Conclusions Medically refractory disease in IIH is common (18%), and nearly always associated with a significant transverse sinus stenosis pressure gradient (90%). Endovascular stenting of the stenosis deserves wider uptake as a highly effective, safe, and usually definitive treatment. It safeguards vision by eliminating papilledema (96%), and allows most patients to cease acetazolamide (81%). By analogy with glaucoma, if acetazolamide is the prostaglandin of IIH and CSF diversion the emergency glaucoma filter, stenting is the minimally invasive glaucoma surgery.
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Affiliation(s)
- Kate Reid
- Neuro-Ophthalmology Service, Ophthalmology Department, Canberra Hospital, Canberra, ACT, Australia
- Medical School, Australian National University, Canberra, ACT, Australia
| | - H Stephen Winters
- Medical Imaging Department, Royal Prince Alfred Hospital, Sydney, NSW, Australia
| | - Timothy Ang
- Medical Imaging Department, Royal Prince Alfred Hospital, Sydney, NSW, Australia
| | - Geoffrey D Parker
- Medical Imaging Department, Royal Prince Alfred Hospital, Sydney, NSW, Australia
| | - G Michael Halmagyi
- Neurology Department, Royal Prince Alfred Hospital, Sydney, NSW, Australia
- Central Clinical School, University of Sydney, Sydney, NSW, Australia
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26
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Zhao K, Gu W, Liu C, Kong D, Zheng C, Chen W, Li X, Liang Y, Zhou H. Advances in the Understanding of the Complex Role of Venous Sinus Stenosis in Idiopathic Intracranial Hypertension. J Magn Reson Imaging 2022; 56:645-654. [PMID: 35357056 PMCID: PMC9541264 DOI: 10.1002/jmri.28177] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2021] [Revised: 02/26/2022] [Accepted: 02/28/2022] [Indexed: 11/16/2022] Open
Abstract
Idiopathic intracranial hypertension (IIH) is a disorder characterized by elevated intracranial pressure (ICP) that predominantly affects young obese women. IIH is a diagnosis of exclusion. That is, if increased ICP is suspected, magnetic resonance imaging and magnetic resonance venography of the brain are recommended to exclude secondary causes. Imaging findings, such as empty sella, orbital findings, meningocele, and encephalocele, are not diagnostic of ICP, nor does their absence exclude ICP either. Therefore, venous manometry is recommended as the gold standard for evaluation, regardless of previous anatomic imaging results. Venous manometry is an invasive examination that is frequently applied to derive physiologic information concerning the nature of the pressure gradient. However, the pathogenesis of IIH has not been fully elucidated. The presence of venous sinus stenosis in a subset of patients has provided some support for the potential mechanisms underlying this condition. Hence, this review provides an up‐to‐date discussion on the potential pathogenic mechanisms of IIH with a special focus on venous sinus stenosis.
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Affiliation(s)
- Kexin Zhao
- Department of Radiology, The First Hospital of Jilin University, Changchun, China
| | - Wenjing Gu
- Department of Otorlaryngology, The First Hospital of Jilin University, Changchun, China
| | - Chunmei Liu
- Department of Gynecology, Changchun Obstetrics Gynecology Hospital, Changchun, China
| | - Derui Kong
- Department of Radiology, The First Hospital of Jilin University, Changchun, China
| | - Chong Zheng
- Department of Radiology, The First Hospital of Jilin University, Changchun, China
| | - Wei Chen
- Department of Radiology, The First Hospital of Jilin University, Changchun, China
| | - Xuewei Li
- Department of Radiology, The First Hospital of Jilin University, Changchun, China
| | - Yuchen Liang
- Department of Radiology, The First Hospital of Jilin University, Changchun, China
| | - Hongwei Zhou
- Department of Radiology, The First Hospital of Jilin University, Changchun, China
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27
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Falardeau J. New Options (or not) for Treatment of Idiopathic Intracranial Hypertension. Curr Neurol Neurosci Rep 2022; 22:257-264. [PMID: 35332515 DOI: 10.1007/s11910-022-01188-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/24/2022] [Indexed: 11/30/2022]
Abstract
PURPOSE OF REVIEW Idiopathic intracranial hypertension (IIH) is a disorder primarily affecting obese women of childbearing age and, if left untreated, can lead to irreversible vision loss. No consensus exists on the best management strategy for IIH. Weight loss is advocated and few useful medical options exist. There is an unmet need to discover new treatment options for this increasingly prevalent condition. This article reviews the recent advances and research on the treatment of IIH. RECENT FINDINGS Venous sinus stenting (VSS) is now performed in many experienced centers, and there is growing interest in bariatric surgery as a treatment modality. Newly approved anti-obesity drugs are showing effectiveness in weight loss, and novel targeted disease-modifying IIH therapies are being explored. Further evaluation of these novel therapeutic strategies as well as studies exploring the use of anti-obesity drugs in IIH is needed. While VSS is gaining popularity due to its efficacy and low complication rate, there is insufficient evidence to support any surgical procedure over another. Bariatric surgery is appealing for patients with non-sight-threatening IIH and needs to be further explored.
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Affiliation(s)
- Julie Falardeau
- Department of Ophthalmology, Oregon Health and Science University, 3303 S Bond Avenue, 11th floor, Portland, OR, 97239, USA.
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28
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Arun A, Amans MR, Higgins N, Brinjikji W, Sattur M, Satti SR, Nakaji P, Luciano M, Huisman TAGM, Moghekar A, Pereira VM, Meng R, Fargen K, Hui FK. A proposed framework for cerebral venous congestion. Neuroradiol J 2022; 35:94-111. [PMID: 34224274 PMCID: PMC8826290 DOI: 10.1177/19714009211029261] [Citation(s) in RCA: 17] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023] Open
Abstract
BACKGROUND While venous congestion in the peripheral vasculature has been described and accepted, intracranial venous congestion remains poorly understood. The characteristics, pathophysiology, and management of cerebral venous stasis, venous hypertension and venous congestion remain controversial, and a unifying conceptual schema is absent. The cerebral venous and lymphatic systems are part of a complex and dynamic interaction between the intracranial compartments, with interplay between the parenchyma, veins, arteries, cerebrospinal fluid, and recently characterized lymphatic-like systems in the brain. Each component contributes towards intracranial pressure, occupying space within the fixed calvarial volume. This article proposes a framework to consider conditions resulting in brain and neck venous congestion, and seeks to expedite further study of cerebral venous diagnoses, mechanisms, symptomatology, and treatments. METHODS A multi-institution retrospective review was performed to identify unique patient cases, complemented with a published case series to assess a spectrum of disease states with components of venous congestion affecting the brain. These diseases were organized according to anatomical location and purported mechanisms. Outcomes of treatments were also analyzed. Illustrative cases were identified in the venous treatment databases of the authors. CONCLUSION This framework is the first clinically structured description of venous pathologies resulting in intracranial venous and cerebrospinal fluid hypertension. Our proposed system highlights unique clinical symptoms and features critical for appropriate diagnostic work-up and potential treatment. This novel schema allows clinicians effectively to approach cases of intracranial hypertension secondary to venous etiologies, and furthermore provides a framework by which researchers can better understand this developing area of cerebrovascular disease.
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Affiliation(s)
- Anirudh Arun
- Department of Radiology and
Radiological Science, Johns Hopkins University School of Medicine, USA,Anirudh Arun, Department of Radiology and
Radiological Science, Johns Hopkins University School of Medicine, 600 North
Wolfe Street, Baltimore, MD 21287, USA.
| | - Matthew R Amans
- Department of Radiology and
Biomedical Imaging, University of California San Francisco, USA
| | | | | | - Mithun Sattur
- Department of Neurosurgery, Medical
University of South Carolina, USA
| | - Sudhakar R Satti
- Department of Neurointerventional
Surgery, ChristianaCare Christiana Hospital, USA
| | - Peter Nakaji
- Department of Neurosurgery, Banner
University Medical Center, USA
| | - Mark Luciano
- Department of Neurosurgery, Johns
Hopkins University School of Medicine, USA
| | | | - Abhay Moghekar
- Department of Neurology, Johns
Hopkins University School of Medicine, USA
| | - Vitor M Pereira
- Department of Medical Imaging,
Toronto Western Hospital, Canada
| | - Ran Meng
- Department of Neurology, Xuanwu
Hospital, China
| | - Kyle Fargen
- Department of Neurosurgery, Wake
Forest School of Medicine, USA
| | - Ferdinand K Hui
- Department of Radiology and
Radiological Science, Johns Hopkins University School of Medicine, USA
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29
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Nutcracker phenomenon with a daily persistent headache as the primary symptom: Case series and a proposed pathogenesis model based on a novel MRI technique to evaluate for spinal epidural venous congestion. J Neurol Sci 2022; 434:120170. [DOI: 10.1016/j.jns.2022.120170] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2021] [Revised: 12/30/2021] [Accepted: 01/21/2022] [Indexed: 11/20/2022]
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30
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Kedra A, Lahlouh M, Shotar E, Chenoune Y, Boistard L, Boussac A, Shor N, Savatovsky J, Hage R, Touitou V, Nicholson P, Clarençon F, Piotin M, Blanc R, Lenck S. Global collapse of the dural sinuses after venous stenting in idiopathic intracranial hypertension. J Neurol Neurosurg Psychiatry 2021; 92:1363-1364. [PMID: 34168084 DOI: 10.1136/jnnp-2020-325717] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/22/2020] [Accepted: 06/10/2021] [Indexed: 11/03/2022]
Affiliation(s)
- Alice Kedra
- Neuroradiology, Fondation Ophtalmologique Adolphe de Rothschild, Paris, Île-de-France, France
| | - Mounir Lahlouh
- CReSTIC EA 3804, Université de Reims Champagne Ardenne, Reims, Grand Est, France.,Ecole ESME Sudria, Ivry-sur-Seine, France
| | - Eimad Shotar
- Neuroradiology, Groupe Hospitalier La Pitié Salpêtrière-Charles Foix, Paris, Île-de-France, France.,GRC E-HTIC, Sorbonne University, Paris, Île-de-France, France
| | - Yasmina Chenoune
- Ecole ESME Sudria, Ivry-sur-Seine, France.,LISSI (EA 3956), UPEC, Creteil, Île-de-France, France
| | - Lucas Boistard
- Neuroradiology, Fondation Ophtalmologique Adolphe de Rothschild, Paris, Île-de-France, France.,Ecole ESME Sudria, Ivry-sur-Seine, France
| | - Alizée Boussac
- Neuroradiology, Fondation Ophtalmologique Adolphe de Rothschild, Paris, Île-de-France, France.,Ecole ESME Sudria, Ivry-sur-Seine, France
| | - Natalia Shor
- Neuroradiology, Groupe Hospitalier La Pitié Salpêtrière-Charles Foix, Paris, Île-de-France, France.,GRC E-HTIC, Sorbonne University, Paris, Île-de-France, France
| | - Julien Savatovsky
- Neuroradiology, Fondation Ophtalmologique Adolphe de Rothschild, Paris, Île-de-France, France
| | - Rabih Hage
- Ophtalmology, Fondation Ophtalmologique Adolphe de Rothschild, Paris, Île-de-France, France
| | - Valérie Touitou
- GRC E-HTIC, Sorbonne University, Paris, Île-de-France, France.,Ophtalmology, Groupe Hospitalier La Pitié Salpêtrière-Charles Foix, Paris, Île-de-France, France.,Sorbonne University, Paris, France
| | | | - Frédéric Clarençon
- Neuroradiology, Groupe Hospitalier La Pitié Salpêtrière-Charles Foix, Paris, Île-de-France, France.,Sorbonne University, Paris, France.,GRC BioFast, Paris VI University, Paris, France
| | - Michel Piotin
- Neuroradiology, Fondation Ophtalmologique Adolphe de Rothschild, Paris, Île-de-France, France
| | - Raphaël Blanc
- Neuroradiology, Fondation Ophtalmologique Adolphe de Rothschild, Paris, Île-de-France, France
| | - Stephanie Lenck
- Neuroradiology, Groupe Hospitalier La Pitié Salpêtrière-Charles Foix, Paris, Île-de-France, France .,GRC E-HTIC, Sorbonne University, Paris, Île-de-France, France.,Sorbonne University, Paris, France
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31
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Horev A, Lorber D, Vardi-Dvash N, Zlotnik Y, Biederko R, Ifergane G, Shelef I, Zvenigorodsky V, Horev A. A Comparison Between Pressure Wire and Microcatheter Measurements for Evaluating the Cerebral Venous Pressure Gradient. Front Neurol 2021; 12:711870. [PMID: 34721256 PMCID: PMC8554017 DOI: 10.3389/fneur.2021.711870] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2021] [Accepted: 09/10/2021] [Indexed: 11/13/2022] Open
Abstract
Introduction: A pressure gradient of over 8 mm Hg across the stenosis (usually located in the transverse-sigmoid junction) is one of the criteria for cerebral venous stenting in idiopathic intracranial hypertension (IIH) patients. The possible inaccuracy of the traditional microcatheter-based pressure measurements has been discussed in previous studies. In the cardiology field, a dual-sensor pressure wire is routinely used for the evaluation of stenotic lesions. Using a pressure wire for cerebral vasculature was previously discussed in a small case series and case reports. In this study, we compared venous pressure measurements obtained using both a microcatheter and a pressure wire in patients who were candidates for stenting. Methods: A retrospective study was conducted, comparing the two methods of pressure measurements in 26 patients with venous stenosis. Altogether, 120 measurements were performed using both methods. Demographic characteristics, medical history, procedural details, medications, indications for the procedure, and complications were collected from the patient charts. Results: Based on an 8-mm Hg pressure gradient cutoff indication, 19 patients were found eligible to go through unilateral venous stenting based on catheter measurements alone. The wire results corroborated the catheter results in detecting all cases indicated for a stent. This finding implies a sensitivity equal to 100% for the wire measurements. There were no wire-related complications, demonstrating its safety. Conclusions: We conclude that the pressure wire is as safe as the microcatheter and can identify cases requiring intervention. A larger-scale study is needed to assess the measurement accuracy of the pressure wire in brain vasculature.
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Affiliation(s)
- Anat Horev
- Neurology Department, Soroka University Medical Center, Beersheba, Israel.,Faculty of Health Sciences, Ben-Gurion University of the Negev, Beersheba, Israel
| | - Dana Lorber
- Department of Molecular Genetics, Weizmann Institute of Science, Rehovot, Israel
| | - Noa Vardi-Dvash
- Neurology Department, Soroka University Medical Center, Beersheba, Israel
| | - Yair Zlotnik
- Neurology Department, Soroka University Medical Center, Beersheba, Israel
| | - Ron Biederko
- Clinical Research Center, Soroka University Medical Center, Beersheba, Israel
| | - Gal Ifergane
- Neurology Department, Soroka University Medical Center, Beersheba, Israel.,Faculty of Health Sciences, Ben-Gurion University of the Negev, Beersheba, Israel
| | - Ilan Shelef
- Faculty of Health Sciences, Ben-Gurion University of the Negev, Beersheba, Israel.,Radiology Department, Soroka University Medical Center, Beersheba, Israel
| | | | - Amir Horev
- Faculty of Health Sciences, Ben-Gurion University of the Negev, Beersheba, Israel.,Pediatric Division, Soroka University Medical Center, Beersheba, Israel
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32
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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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33
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Brown PA, Wolfe SQ, Fargen KM. Perspective: Correlation Between Intracranial Pressure and Venous Sinus Pressures in Idiopathic Intracranial Hypertension. World Neurosurg 2021; 152:235-236. [PMID: 34340283 DOI: 10.1016/j.wneu.2021.05.040] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Affiliation(s)
- Patrick A Brown
- Neurological Surgery and Radiology, Wake Forest University, Winston-Salem, North Carolina, USA
| | - Stacey Q Wolfe
- Neurological Surgery and Radiology, Wake Forest University, Winston-Salem, North Carolina, USA
| | - Kyle M Fargen
- Neurological Surgery and Radiology, Wake Forest University, Winston-Salem, North Carolina, USA
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34
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Mugge L, Dang D, Curry B, Whiting R, Crimmins M. Superior Ophthalmic Vein Flow Patterns as a Marker of Venous Sinus Stenosis and Hypertension in Idiopathic Intracranial Hypertension: A Case of Emergent Transverse Sinus Stenting as Treatment of Fulminant Idiopathic Intracranial Hypertension. World Neurosurg 2021; 161:170-178. [PMID: 34224883 DOI: 10.1016/j.wneu.2021.06.126] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2021] [Revised: 06/23/2021] [Accepted: 06/24/2021] [Indexed: 10/21/2022]
Affiliation(s)
- Luke Mugge
- Inova Neuroscience and Spine Institute, Department of Neurosurgery, Inova Neuroscience and Spine Institute, Falls Church, VA, USA.
| | - Danielle Dang
- Inova Neuroscience and Spine Institute, Department of Neurosurgery, Inova Neuroscience and Spine Institute, Falls Church, VA, USA
| | - Brian Curry
- Walter Reed National Military Medical Center, Department of Neurosurgery, National Capital Consortium Walter Reed National Military Medical Center, Bethesda, MD, USA
| | - Ryan Whiting
- Walter Reed National Military Medical Center, Department of Radiology, National Capital Consortium Walter Reed National Military Medical Center, Bethesda, MD, USA
| | - Michael Crimmins
- Walter Reed National Military Medical Center, Department of Neurology, National Capital Consortium Walter Reed National Military Medical Center, Bethesda, MD, USA
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35
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Labeyrie MA, Fantoni M, Vever U, Guedon A, Bonnin S, Bernat AL, Verillaud B, Houdart E. Intracranial venous sinus stenting for the treatment of lateral sinus stenoses: An analysis of 200 patients. Diagn Interv Imaging 2021; 102:619-627. [PMID: 34127434 DOI: 10.1016/j.diii.2021.05.008] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2021] [Revised: 05/22/2021] [Accepted: 05/24/2021] [Indexed: 12/14/2022]
Abstract
PURPOSE The purpose of this study was to analyze the long-term efficacy and safety of intracranial venous sinus stenting in a large cohort of patients with any type of presentation of primary lateral venous sinus stenosis (VSS). MATERIALS AND METHODS A retrospective cohort study was performed including patients treated by venous sinus stenting for symptomatic VSS from 2012 to 2019. Successful primary resolution of symptoms without adjunctive treatment or recurrence, and complications after stenting were analyzed at the last follow-up time point. RESULTS Two-hundred patients were included. There were 14 men and 186 women with a mean age of 39±14 (SD) years (age range: 13-75 years). Presenting symptoms included venous pulsatile tinnitus in 168 patients (168/200; 84%), idiopathic intracranial hypertension in 100 patients (100/200; 50%) and/or spontaneous cerebrospinal fluid leak in 35 patients (35/200; 17%). The overall rate of successful primary resolution of any typical presenting symptoms was 79% (95% CI: 73-85%). This rate ranged from 74% to 93% depending on the symptom with no significant difference between patients with and those without idiopathic intracranial hypertension (P=0.08). Recurrence rate was 10% (95% CI: 6-14%). No death or permanent morbidity were observed during a median follow-up of 2.2 years (Q1, Q3: 1.4, 3.3; range: 1-7.7 years). CONCLUSION Our study shows that venous sinus stenting has a low morbidity and high success rate at long-term follow-up for the treatment of idiopathic intracranial hypertension, venous pulsatile tinnitus or spontaneous cerebrospinal fluid leak associated with VSS. The excellent safety suggests considering this treatment as first-line treatment when medical management is ineffective or poorly tolerated.
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Affiliation(s)
- Marc-Antoine Labeyrie
- Department of Interventional Neuroradiology, Hôpital Lariboisière, Assistance Publique-Hôpitaux de Paris, Université de Paris, 75010 Paris, France.
| | - Matteo Fantoni
- Department of Interventional Neuroradiology, Hôpital Lariboisière, Assistance Publique-Hôpitaux de Paris, Université de Paris, 75010 Paris, France
| | - Ursula Vever
- Department of Neurology, Hôpital Lariboisière, Assistance Publique-Hôpitaux de Paris, Université de Paris, 75010 Paris, France
| | - Alexis Guedon
- Department of Interventional Neuroradiology, Hôpital Lariboisière, Assistance Publique-Hôpitaux de Paris, Université de Paris, 75010 Paris, France
| | - Sophie Bonnin
- Department of Neuroophtalmology, Hôpital Lariboisière, Assistance Publique-Hôpitaux de Paris, Université de Paris, 75010 Paris, France
| | - Anne-Laure Bernat
- Department of Neurosurgery, Hôpital Lariboisière, Assistance Publique-Hôpitaux de Paris, Université de Paris, 75010 Paris, France
| | - Benjamin Verillaud
- Department of Otorhinolaryngology, Hôpital Lariboisière, Assistance Publique-Hôpitaux de Paris Université de Paris, 75010 Paris, France
| | - Emmanuel Houdart
- Department of Interventional Neuroradiology, Hôpital Lariboisière, Assistance Publique-Hôpitaux de Paris, Université de Paris, 75010 Paris, France
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36
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Intracranial Venous Hypertension and Venous Sinus Stenting in the Modern Management of Idiopathic Intracranial Hypertension. Life (Basel) 2021; 11:life11060508. [PMID: 34073077 PMCID: PMC8227267 DOI: 10.3390/life11060508] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2021] [Revised: 05/15/2021] [Accepted: 05/28/2021] [Indexed: 12/20/2022] Open
Abstract
Idiopathic intracranial hypertension (IIH) is a debilitating condition that has traditionally been difficult to treat. In recent years, there has been increasing focus on the role of intracranial venous hypertension in the pathophysiology of IIH. Based on increased understanding of this pathophysiology, venous sinus stenting (VSS) has emerged as a safe and reliable treatment for a certain population of patients with IIH. Stratifying patients with IIH based on the status of their venous outflow can provide insight into which patients may enjoy reduction in their symptoms after VSS and provides information regarding why some patients may have symptom recurrence. The traditional view of IIH as a disease due to obesity in young women has been cast into doubt as the understanding of the role of intracranial venous hypertension has improved.
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Belachew NF, Baschung S, Almiri W, Encinas R, Kaesmacher J, Dobrocky T, Schankin CJ, Abegg M, Piechowiak EI, Raabe A, Gralla J, Mordasini P. Casper Versus Precise Stent for the Treatment of Patients with Idiopathic Intracranial Hypertension. Clin Neuroradiol 2021; 31:853-862. [PMID: 34003319 PMCID: PMC8463398 DOI: 10.1007/s00062-021-01024-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2021] [Accepted: 04/15/2021] [Indexed: 11/29/2022]
Abstract
Purpose We hypothesized that due to its specific characteristics, the CasperTM RX carotid stent (CP) might be particularly suitable for venous sinus stenting (VSS) in patients with idiopathic intracranial hypertension (IIH). To test this theory, we compared it to the commonly used Precise Pro RXTM stent (PP). Methods A total of 15 patients with IIH (median age 28.7 years) were reviewed retrospectively. Technical aspects as well as peri- and postinterventional complication rates were examined in patients treated with CP (n = 10) and the PP (n = 5). Improvements in cerebrospinal fluid opening pressure (CSF OP), transstenotic pressure gradient (TSPG) and clinical symptoms were also assessed. Results Stent delivery was easier and more successful with the CP than the PP (difficult/failed stent delivery 0.0% versus 57.1%) and consequently achieved with less attempts (≥ 2: 0.0% versus 40.0%). No severe peri- or postinterventional complications or instances of in-stent thrombosis and/or stenosis were observed during follow-up. Improvement of CSF OP and TSPG immediately after VSS as well as at 6‑month follow-up was comparable between the CP and PP group. Both groups showed substantial and similar decreases in intensity and frequency of headache. Almost all patients with other IIH-related symptoms showed either improvement or complete resolution of those symptoms after VSS. All patients who were available for interview (n = 12/15) reported a substantial improvement in quality of life. Conclusion VSS using the CP seems to be safe and effective. The CP may reduce the risk of difficult or failed stent delivery in patients with challenging intracranial venous anatomy. Supplementary Information The online version of this article (10.1007/s00062-021-01024-2) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Nebiyat F Belachew
- Department of Diagnostic and Interventional Neuroradiology, Inselspital, Bern University Hospital, and University of Bern, Freiburgstraße 18, 3010, Bern, Switzerland.
| | | | - William Almiri
- Department of Diagnostic and Interventional Neuroradiology, Inselspital, Bern University Hospital, and University of Bern, Freiburgstraße 18, 3010, Bern, Switzerland
| | - Ruben Encinas
- Department of Diagnostic and Interventional Neuroradiology, Inselspital, Bern University Hospital, and University of Bern, Freiburgstraße 18, 3010, Bern, Switzerland
| | - Johannes Kaesmacher
- Department of Diagnostic and Interventional Neuroradiology, Inselspital, Bern University Hospital, and University of Bern, Freiburgstraße 18, 3010, Bern, Switzerland.,Department of Diagnostic, Interventional and Pediatric Radiology, Inselspital, Bern University Hospital, and University of Bern, Bern, Switzerland
| | - Tomas Dobrocky
- Department of Diagnostic and Interventional Neuroradiology, Inselspital, Bern University Hospital, and University of Bern, Freiburgstraße 18, 3010, Bern, Switzerland
| | - Christoph J Schankin
- Department of Neurology, Inselspital, Bern University Hospital, and University of Bern, Bern, Switzerland
| | - Mathias Abegg
- Department of Ophthalmology, Inselspital, Bern University Hospital, and University of Bern, Bern, Switzerland
| | - Eike I Piechowiak
- Department of Diagnostic and Interventional Neuroradiology, Inselspital, Bern University Hospital, and University of Bern, Freiburgstraße 18, 3010, Bern, Switzerland
| | - Andreas Raabe
- Department of Neurosurgery, Inselspital, Bern University Hospital, and University of Bern, Bern, Switzerland
| | - Jan Gralla
- Department of Diagnostic and Interventional Neuroradiology, Inselspital, Bern University Hospital, and University of Bern, Freiburgstraße 18, 3010, Bern, Switzerland
| | - Pasquale Mordasini
- Department of Diagnostic and Interventional Neuroradiology, Inselspital, Bern University Hospital, and University of Bern, Freiburgstraße 18, 3010, Bern, Switzerland
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Dural venous sinus stenting in the treatment of idiopathic intracranial hypertension: A systematic review and critique of literature. Surv Ophthalmol 2021; 67:271-287. [PMID: 34004224 DOI: 10.1016/j.survophthal.2021.05.002] [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: 09/13/2020] [Revised: 04/23/2021] [Accepted: 05/03/2021] [Indexed: 12/19/2022]
Abstract
Idiopathic intracranial hypertension (IIH) is increased intracranial pressure without a known cause. Dural venous sinus stenting (DVSS) is a relatively new intervention for treatment of IIH refractory to medical therapy and lifestyle modifications. In this review, we outline various hypotheses of IIH pathogenesis and describe the role of venous sinus stenosis and the technical details of DVSS. We also present a summary and critique of the available evidence describing the outcomes of DVSS in IIH and review the evidence-based guidelines for this procedure. We conclude that, although many studies have shown generally favorable outcomes of DVSS in patients with IIH, most have serious limitations, the most common one being paucity of pre- and postprocedure ophthalmological data. Thus, there is not enough available evidence to conclude whether DVSS is an effective procedure for treatment of IIH. We also present the most commonly used indications for DVSS as described in the literature and stress the importance of neuro-ophthalmological assessment before and after the procedure to monitor response and potential complications.
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Townsend RK, Jost A, Amans MR, Hui F, Bender MT, Satti SR, Maurer R, Liu K, Brinjikji W, Fargen KM. Major complications of dural venous sinus stenting for idiopathic intracranial hypertension: case series and management considerations. J Neurointerv Surg 2021; 14:neurintsurg-2021-017361. [PMID: 33911014 DOI: 10.1136/neurintsurg-2021-017361] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2021] [Revised: 04/13/2021] [Accepted: 04/14/2021] [Indexed: 12/18/2022]
Abstract
BACKGROUND Venous sinus stenting (VSS) is a safe, effective, and increasingly popular treatment option for selected patients with idiopathic intracranial hypertension (IIH). Serious complications associated with VSS are rarely reported. METHODS Serious complications after VSS were identified retrospectively from multicenter databases. The cases are presented and management strategies are discussed. RESULTS Six major acute and chronic complications after VSS were selected from a total of 811 VSS procedures and 1466 venograms for IIH. These included an acute subdural hematoma from venous extravasation, cases of both intraprocedural and delayed stent thrombosis, an ultimately fatal cerebellar hemorrhage resulting in acute obstructive hydrocephalus, venous microcatheter perforation during venography and manometry, and a patient who developed subarachnoid hemorrhage and subdural hematoma after cerebellar cortical vein perforation. The six cases are reviewed and learning points regarding complication avoidance and management are presented. CONCLUSION We report on six rare, major complications after VSS for IIH. Familiarity with these potential complications and appropriate timely management may allow for good clinical outcomes.
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Affiliation(s)
- Robert Kyle Townsend
- Neurological Surgery, Wake Forest University, Winston-Salem, North Carolina, USA
| | - Alec Jost
- Wake Forest School of Medicine, Wake Forest University School of Medicine, Winston-Salem, North Carolina, USA
| | - Matthew R Amans
- Radiology and Biomedical Imaging, UCSF, San Francisco, California, USA
| | - Ferdinand Hui
- Radiology, Johns Hopkins University, Baltimore, Maryland, USA
| | - Matthew T Bender
- Neurosurgery, University of Rochester Medical Center, Rochester, New York, USA
| | | | - Robert Maurer
- Neurosurgery, Penn State Health Neurosurgery, Hershey, Pennsylvania, USA
| | - Kenneth Liu
- Neurosurgery, University of Southern California, Los Angeles, California, USA
| | | | - Kyle M Fargen
- Neurosurgery, Wake Forest University, Winston-Salem, North Carolina, USA
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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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Memon MZ, Nisar T, Gupta G, Singla A, Khandelwal P. Single Arm Access for Combined Transarterial and Transvenous Neurointerventional Procedures. World Neurosurg 2021; 150:121-126. [PMID: 33812065 DOI: 10.1016/j.wneu.2021.03.123] [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: 02/07/2021] [Revised: 03/23/2021] [Accepted: 03/24/2021] [Indexed: 11/18/2022]
Abstract
A concurrent arterial and venous access is routinely obtained for diagnosis and treatment of various neurovascular diseases. Traditionally, venous access is obtained by accessing the femoral vein or through direct internal jugular puncture. Although complication rates are low, life-threatening severe complications have been reported. Moreover, venous access can be challenging in large body habitus patients through these traditional routes. There is a growing trend of utilizing radial artery access for neuroendovascular procedures. Nevertheless, the use of upper limb veins in neurointerventional procedures is rare. We present 3 cases of the concurrent arterial and venous approach through the radial artery and cephalic or basilic vein of the forearm for diagnostic cerebral arteriography and venography. Radial access was obtained by using the standard technique, and venous access was obtained by cannulating cephalic or basilic vein using ultrasound guidance, and a 5F or 6F short sheath was placed. Venous angiography and catheterization of right and left internal jugular veins were then performed using a Simmons (SIM) 2 catheter alone or using 6F Envoy guide catheter coaxially over the SIM 2 catheter if an additional support for microcatheter was needed. Procedures were successfully completed with no adverse effects, and patients were discharged home the same day. We also describe the technique for the reformation of the SIM 2 catheter in the venous system for catheterization of right and left internal jugular veins through the arm access.
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Affiliation(s)
- Muhammad Zeeshan Memon
- Department of Neurological Surgery, Rutgers New Jersey Medical School, Newark, New Jersey, USA.
| | - Taha Nisar
- Department of Neurological Surgery, Rutgers New Jersey Medical School, Newark, New Jersey, USA
| | - Gaurav Gupta
- Department of Neurological Surgery, Rutgers New Jersey Medical School, Newark, New Jersey, USA
| | - Amit Singla
- Department of Neurological Surgery, Rutgers New Jersey Medical School, Newark, New Jersey, USA
| | - Priyank Khandelwal
- Department of Neurological Surgery, Rutgers New Jersey Medical School, Newark, New Jersey, USA
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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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Altafulla JJ, Prickett J, Iwanaga J, Dumont AS, Tubbs RS. Intraluminal anatomy of the transverse sinus: implications for endovascular therapy. Anat Cell Biol 2020; 53:393-397. [PMID: 32647072 PMCID: PMC7769094 DOI: 10.5115/acb.20.041] [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: 02/26/2020] [Revised: 04/01/2020] [Accepted: 04/27/2020] [Indexed: 11/27/2022] Open
Abstract
Trabeculae or septations in the transverse sinus can have potentially life-threatening clinical significance. The current study demonstrates trabecula/septum patterning within the transverse sinus with measurements and distribution data supplemented by imaging, and describes the possible etiology of idiopathic intracranial hypertension and turbulent blood flow in the transverse sinus. Twenty-four sides from 12 cadaveric heads, all fresh-frozen, were used (five males, seven females; age at death 65–91 years, mean 79.1 years). The length and diameter of the transverse sinus were measured along with the number and locations of septations/trabeculae and their tensile strength. The mean length of the transverse sinus was 68.43 mm on the right side and 74.31 mm on the left. A total of 42 septations were found in the 24 transverse sinuses. The number of septations per side ranged from zero to four with a mean of 1.75. The septations were located in the proximal 1/3 in 54.8% (23/42), the middle 1/3 in 21.4% (9/42), and the distal 1/3 in 23.8% (10/42). The work presented here furthers our understanding of transverse sinus anatomy, including its detailed internal architecture. The measurements can provide a technical guide for neurosurgeons and influence instrument selection when a large thrombus forms or anchors in one of these trabeculae or septa and necessitates treatment.
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Affiliation(s)
- Juan J Altafulla
- Department of Neurosurgery, Hospital Santo Tomas, Panamá, Panama, USA
| | | | - Joe Iwanaga
- Department of Neurosurgery, Tulane Center for Clinical Neurosciences, Tulane University School of Medicine, New Orleans, LA, USA.,Division of Gross and Clinical Anatomy, Department of Anatomy, Kurume University School of Medicine, Kurume, Japan
| | - Aaron S Dumont
- Department of Neurosurgery, Tulane Center for Clinical Neurosciences, Tulane University School of Medicine, New Orleans, LA, USA
| | - R Shane Tubbs
- Department of Neurosurgery, Tulane Center for Clinical Neurosciences, Tulane University School of Medicine, New Orleans, LA, USA.,Department of Anatomical Sciences, St. George's University, St. George's, Grenada, USA.,Department of Neurosurgery and Ochsner Neuroscience Institute, Ochsner Health System, New Orleans, LA, USA.,Department of Structural and Cellular Biology, Tulane University School of Medicine, New Orleans, LA, USA
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Headache in idiopathic intracranial hypertension. A CGRP-dependent head pain? Neurol Sci 2020; 41:417-421. [DOI: 10.1007/s10072-020-04641-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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Abstract
Idiopathic intracranial hypertension is a syndrome of increased intracranial pressure of unknown cause that most often occurs in women of childbearing age. Most patients are overweight or obese with a history of recent weight gain. Following a brief review of the symptoms and signs, we discuss the approach to assessment and monitoring of this condition. We then present a practical approach to treatment. Because patients frequently struggle with weight loss and can also have refractory headaches and coexisting psychosocial issues, we emphasize the importance of a multidisciplinary approach to the management of this common condition.
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Affiliation(s)
- Matthew J Thurtell
- Department of Ophthalmology and Visual Sciences, University of Iowa, Iowa City, IA 52242, USA; Department of Neurology, University of Iowa, Iowa City, IA 52242, USA
| | - Aki Kawasaki
- University of Lausanne, Hôpital Ophtalmique Jules Gonin, Avenue de France 15, Lausanne 1004, Switzerland.
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Drocton GT, Copelan A, Eisenmenger L, Villanueva-Meyer JE, Dillon WP, Shah VN, Meisel K, Amans M. Venous sinus stenting as a treatment approach in patients with idiopathic intracranial hypertension and encephaloceles. Interv Neuroradiol 2020; 27:129-136. [PMID: 32954924 DOI: 10.1177/1591019920956860] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Stenosis of a dural venous sinus is the most common cause of idiopathic intracranial hypertension (IIH) and can be classified as either intrinsic or extrinsic. Intrinsic stenoses are characterized by a focal filling defect within the sinus secondary to an enlarged arachnoid granulation or fibrous septa while extrinsic stenoses tend to be long and smooth-tapered and are most commonly secondary to external compression from the adjacent brain parenchyma. Brain herniations, or encephaloceles, into arachnoid granulations in dural venous sinuses have rarely been reported in the literature in patients with IIH. We propose that dural venous sinus stenting (VSS) may be a safe and effective treatment approach in patients with an encephalocele and IIH. METHODS We retrospectively analyze three cases of patients with encephalocele who underwent VSS for treatment of medically refractory IIH at our institution. RESULTS One patient underwent stenting ipsilateral and two patients underwent stenting contralateral to the side of their encephaloceles. No technical related issues or complications occurred during either of the three stenting procedures. Two out of the three patients had complete resolution in their IIH-related symptoms and normalization of cerebrospinal (CSF) pressures shortly after stenting. We await clinical follow-up in the third patient. CONCLUSIONS Our results suggest that VSS is a technically feasible and effective approach in treating patients with medically refractory IIH and encephaloceles.
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Affiliation(s)
- Gerald T Drocton
- Radiology and Biomedical Imaging, UCSF Medical Center, San Francisco, CA, USA
| | - Alexander Copelan
- Radiology and Biomedical Imaging, UCSF Medical Center, San Francisco, CA, USA
| | - Laura Eisenmenger
- Radiology and Biomedical Imaging, UW Health University Hospital, Madison, WI, USA
| | | | - William P Dillon
- Radiology and Biomedical Imaging, UCSF Medical Center, San Francisco, CA, USA
| | - Vinil N Shah
- Radiology and Biomedical Imaging, UCSF Medical Center, San Francisco, CA, USA
| | - Karl Meisel
- Department of Neurology, UCSF Medical Center, San Francisco, CA, USA
| | - Matthew Amans
- Radiology and Biomedical Imaging, UCSF Medical Center, San Francisco, CA, USA
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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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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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Mondejar V, Patsalides A. The Role of Arachnoid Granulations and the Glymphatic System in the Pathophysiology of Idiopathic Intracranial Hypertension. Curr Neurol Neurosci Rep 2020; 20:20. [DOI: 10.1007/s11910-020-01044-4] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
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