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Zhou C, Zhou Y, Liu L, Jiang H, Wei H, Zhou C, Ji X. Progress and recognition of idiopathic intracranial hypertension: A narrative review. CNS Neurosci Ther 2024; 30:e14895. [PMID: 39097911 PMCID: PMC11298205 DOI: 10.1111/cns.14895] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2024] [Revised: 06/03/2024] [Accepted: 07/19/2024] [Indexed: 08/06/2024] Open
Abstract
BACKGROUND Idiopathic intracranial hypertension (IIH) mainly affects obese young women, causing elevated intracranial pressure, headaches, and papilledema, risking vision loss and severe headaches. Despite weight loss as the primary treatment, the underlying mechanisms remain unclear. Recent research explores novel therapeutic targets. AIMS This review aimed to provide a comprehensive understanding of IIH's pathophysiology and clinical features to inform pathogenesis and improve treatment strategies. METHODS Recent publications on IIH were searched and summarized using PubMed, Web of Science, and MEDLINE. RESULTS The review highlights potential pathomechanisms and therapeutic advances in IIH. CONCLUSION IIH incidence is rising, with growing evidence linking it to metabolic and hormonal disturbances. Early diagnosis and treatment remain challenging.
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Affiliation(s)
- Chenxia Zhou
- Department of NeurologyXuanwu Hospital, Capital Medical UniversityBeijingChina
- Neurology and Intracranial Hypertension and Cerebral Venous Disease CenterNational Health Commission of China, Xuanwu Hospital, Capital Medical UniversityBeijingChina
| | - Yifan Zhou
- Laboratory of Brain Disorders, Ministry of Science and Technology, Collaborative Innovation Center for Brain DisordersBeijing Institute of Brain Disorders, Beijing Advanced Innovation Center for Big Data‐based Precision Medicine, Capital Medical UniversityBeijingChina
| | - Lu Liu
- Department of NeurologyXuanwu Hospital, Capital Medical UniversityBeijingChina
- Neurology and Intracranial Hypertension and Cerebral Venous Disease CenterNational Health Commission of China, Xuanwu Hospital, Capital Medical UniversityBeijingChina
- Zhongguancun Xirui Institute of Precision Medicine for Heart and Brain TumorsBeijingChina
| | - Huimin Jiang
- Laboratory of Brain Disorders, Ministry of Science and Technology, Collaborative Innovation Center for Brain DisordersBeijing Institute of Brain Disorders, Beijing Advanced Innovation Center for Big Data‐based Precision Medicine, Capital Medical UniversityBeijingChina
| | - Huimin Wei
- Beijing Advanced Innovation Center for Big Data‐Based Precision MedicineSchool of Biological Science and Medical Engineering, Beihang UniversityBeijingChina
| | - Chen Zhou
- Neurology and Intracranial Hypertension and Cerebral Venous Disease CenterNational Health Commission of China, Xuanwu Hospital, Capital Medical UniversityBeijingChina
- Laboratory of Brain Disorders, Ministry of Science and Technology, Collaborative Innovation Center for Brain DisordersBeijing Institute of Brain Disorders, Beijing Advanced Innovation Center for Big Data‐based Precision Medicine, Capital Medical UniversityBeijingChina
| | - Xunming Ji
- Neurology and Intracranial Hypertension and Cerebral Venous Disease CenterNational Health Commission of China, Xuanwu Hospital, Capital Medical UniversityBeijingChina
- Laboratory of Brain Disorders, Ministry of Science and Technology, Collaborative Innovation Center for Brain DisordersBeijing Institute of Brain Disorders, Beijing Advanced Innovation Center for Big Data‐based Precision Medicine, Capital Medical UniversityBeijingChina
- Department of NeurosurgeryXuanwu Hospital, Capital Medical UniversityBeijingChina
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Schuchardt FF, Krafft AJ, Miguel Telega L, Küchlin S, Lagrèze WA, Demerath T, Arnold P, Fung C, Kraus LM, Hennemuth A, Beck J, Urbach H, Weiller C, Harloff A. Interrelation Between Cerebrospinal Fluid Pressure, Intracranial Morphology and Venous Hemodynamics Studied by 4D Flow MRI. Clin Neuroradiol 2024; 34:391-401. [PMID: 38277058 PMCID: PMC11130051 DOI: 10.1007/s00062-023-01381-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2023] [Accepted: 12/26/2023] [Indexed: 01/27/2024]
Abstract
PURPOSE To quantify the effects of CSF pressure alterations on intracranial venous morphology and hemodynamics in idiopathic intracranial hypertension (IIH) and spontaneous intracranial hypotension (SIH) and assess reversibility when the underlying cause is resolved. METHODS We prospectively examined venous volume, intracranial venous blood flow and velocity, including optic nerve sheath diameter (ONSD) as a noninvasive surrogate of CSF pressure changes in 11 patients with IIH, 11 age-matched and sex-matched healthy controls and 9 SIH patients, before and after neurosurgical closure of spinal dural leaks. We applied multiparametric MRI including 4D flow MRI, time-of-flight (TOF) and T2-weighted half-Fourier acquisition single-shot turbo-spin echo (HASTE). RESULTS Sinus volume overlapped between groups at baseline but decreased after treatment of intracranial hypotension (p = 0.067) along with a significant increase of ONSD (p = 0.003). Blood flow in the middle and dorsal superior sagittal sinus was remarkably lower in patients with higher CSF pressure (i.e., IIH versus controls and SIH after CSF leak closure) but blood flow velocity was comparable cross-sectionally between groups and longitudinally in SIH. CONCLUSION We were able to demonstrate the interaction of CSF pressure, venous volumetry, venous hemodynamics and ONSD using multiparametric brain MRI. Closure of CSF leaks in SIH patients resulted in symptoms suggestive of increased intracranial pressure and caused a subsequent decrease of intracranial venous volume and of blood flow within the superior sagittal sinus while ONSD increased. In contrast, blood flow parameters from 4D flow MRI did not discriminate IIH, SIH and controls as hemodynamics at baseline overlapped at most vessel cross-sections.
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Affiliation(s)
- Florian F Schuchardt
- Department of Neurology and Neurophysiology, Medical Center-University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany.
- Department of Neurology and Neurophysiology, Medical Center-University of Freiburg, Faculty of Medicine, University of Freiburg, Breisacher Str. 64, 79106, Freiburg, Germany.
| | - Axel J Krafft
- Medical Physics, Department of Radiology, Medical Center-University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Lidia Miguel Telega
- Department of Neurology and Neurophysiology, Medical Center-University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
- Department of Neurosurgery, Medical Center-University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Sebastian Küchlin
- Department of Neuro-ophthalmology, Medical Center-University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Wolf A Lagrèze
- Department of Neuro-ophthalmology, Medical Center-University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Theo Demerath
- Department of Neuroradiology, Medical Center-University of Freiburg, Faculty of Medicine, University of Freiburg , Freiburg, Germany
| | - Philipp Arnold
- Department of Neuroradiology, Medical Center-University of Freiburg, Faculty of Medicine, University of Freiburg , Freiburg, Germany
| | - Christian Fung
- Department of Neurosurgery, Medical Center-University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Luisa M Kraus
- Department of Neurosurgery, Medical Center-University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Anja Hennemuth
- Institute for Cardiovascular Computer-assisted Medicine, Charité, Universitätsmedizin Berlin, Campus Virchow-Klinikum, Berlin, Germany
| | - Jürgen Beck
- Department of Neurosurgery, Medical Center-University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Horst Urbach
- Department of Neuroradiology, Medical Center-University of Freiburg, Faculty of Medicine, University of Freiburg , Freiburg, Germany
| | - Cornelius Weiller
- Department of Neurology and Neurophysiology, Medical Center-University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Andreas Harloff
- Department of Neurology and Neurophysiology, Medical Center-University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
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Fargen KM, Midtlien JP, Margraf C, Kiritsis NR, Chang E, Hui F. Dynamic internal jugular vein venography: a descriptive study in 89 patients with suspected cerebral venous outflow disorders. J Neurointerv Surg 2024:jnis-2024-021734. [PMID: 38782567 DOI: 10.1136/jnis-2024-021734] [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: 03/14/2024] [Accepted: 05/14/2024] [Indexed: 05/25/2024]
Abstract
BACKGROUND Internal jugular vein (IJV) stenosis has recently been recognized as a plausible source of symptom etiology in patients with cerebral venous outflow disorders (CVD). Diagnosis and determining surgical candidacy remains difficult due to a poor understanding of IJV physiology and positional symptom exacerbation often reported by these patients. METHODS A retrospective single-center chart review was conducted on adult patients who underwent diagnostic cerebral venography with rotational IJ venography from 2022 to 2024. Patients were divided into three groups for further analysis based on symptoms and diagnostic criteria: presumed jugular stenosis, near-healthy venous outflow, and idiopathic intracranial hypertension. RESULTS Eighty-nine patients were included in the study. Most commonly, ipsilateral rotation resulted in ipsilateral IJV stenosis and gradient development at C4-6 and contralateral stenosis and gradient appearance in the contralateral IJV at C1, with stenosis and gradient development in bilateral IJVs at C1-3 bilaterally during chin flexion. In all patients, 93.3% developed at least moderate dynamic stenosis of at least one IJV, more than two-thirds (69.7%) developed either severe or occlusive stenosis during rightward and leftward rotation, and 81.8% developed severe or occlusive stenosis with head flexion. Dynamic gradients of at least 4 mmHg were seen in 68.5% of patients, with gradients of at least 8 mmHg in 31.5% and at least 10 mmHg in 12.4%. CONCLUSION This study is the first to document dynamic changes in IJV caliber and gradients in different head positions, offering insights into the complex nature of venous outflow and its impact on CVD.
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Affiliation(s)
- Kyle M Fargen
- Department of Neurological Surgery and Radiology, Wake Forest University, Winston-Salem, North Carolina, USA
| | - Jackson P Midtlien
- Department of Neurological Surgery and Radiology, Wake Forest University, Winston-Salem, North Carolina, USA
| | - Connor Margraf
- Department of Neurological Surgery and Radiology, Wake Forest University, Winston-Salem, North Carolina, USA
| | - Nicholas R Kiritsis
- Department of Neurological Surgery and Radiology, Wake Forest University, Winston-Salem, North Carolina, USA
| | - Emily Chang
- Department of Neurological Surgery and Radiology, Wake Forest University, Winston-Salem, North Carolina, USA
| | - Ferdinand Hui
- Division of Neurointerventional Surgery, Neuroscience Institute, Queen's Medical Center, Honolulu, HI, USA
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Pandey A, Schreiber C, Garton ALA, Araveti N, Goldberg JL, Kocharian G, Carnevale JA, Boddu SR. Foundations of the Diagnosis and Management of Idiopathic Intracranial Hypertension and Pulsatile Tinnitus. World Neurosurg 2024; 184:361-371. [PMID: 38590070 DOI: 10.1016/j.wneu.2023.12.125] [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: 12/21/2023] [Accepted: 12/22/2023] [Indexed: 04/10/2024]
Abstract
Venous sinus stenosis has garnered increasing academic attention as a potential etiology of idiopathic intracranial hypertension (IIH) and pulsatile tinnitus (PT). The complex anatomy of the cerebral venous sinuses and veins plays a crucial role in the pathophysiology of these conditions. Venous sinus stenosis, often found in the superior sagittal or transverse sinus, can lead to elevated intracranial pressure (ICP) and characteristic IIH symptoms. Stenosis, variations in dural venous anatomy, and flow dominance patterns contribute to aberrant flow and subsequent PT. Accurate imaging plays a vital role in diagnosis, and magnetic resonance (MR) venography is particularly useful for detecting stenosis. Management strategies for IIH and PT focus on treating the underlying disease, weight management, medical interventions, and, in severe cases, surgical or endovascular procedures. Recently, venous sinus stenting has gained interest as a minimally invasive treatment option for IIH and PT. Stenting addresses venous sinus stenosis, breaking the feedback loop between elevated ICP and stenosis, thus reducing ICP and promoting cerebrospinal fluid outflow. The correction and resolution of flow aberrances can also mitigate or resolve PT symptoms. While venous sinus stenting remains an emerging field, initial results are promising. Further research is needed to refine patient selection criteria and evaluate the long-term efficacy of stenting as compared to traditional treatments.
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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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5
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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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Iyer AM, Midtlien JP, Kittel C, Fargen KM. Intensive care unit admission is not necessary after venous sinus stenting. J Neurointerv Surg 2024; 16:313-317. [PMID: 37197930 DOI: 10.1136/jnis-2023-020240] [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: 02/21/2023] [Accepted: 04/28/2023] [Indexed: 05/19/2023]
Abstract
BACKGROUND Venous sinus stenting (VSS) has emerged as a safe and effective treatment option for idiopathic intracranial hypertension. Many physicians routinely admit patients to the intensive care unit (ICU) for close monitoring, but little data exists on whether this is necessary. METHODS Electronic medical records of consecutive patients who underwent VSS by the senior author from 2016 to 2022 at a single center were reviewed. RESULTS 214 patients were included. The mean (SD) age was 35.5 (11.6) and 196 (91.6%) patients were female. A total of 166 (77.6%) patients underwent transverse sinus stenting alone; 9 (4.2%) underwent superior sagittal sinus (SSS) stenting alone, 37 (17.3) concomitant transverse and SSS stenting, and 2 (0.9%) underwent stenting at alternate sites. All patients were planned admission to the regular ward (27.6%) or day hospital (72.4%). Twenty (9.3%) patients were discharged to home the same day as the procedure and 182 (85%) patients were discharged the following day. Major periprocedural complications were identified in 2 (0.93%) patients and minor complications were identified in 16 (7.4%). Only one patient with a subdural hematoma identified in the post-anesthesia care unit (PACU) had care escalated to the ICU. No severe complications were identified after the PACU stay. During the next 48 hours after discharge, 4 (1.9%) patients returned to any emergency room to be evaluated without requiring readmission. CONCLUSION Routine ICU admission following uncomplicated VSS is unnecessary. Overnight admission to a low-acuity ward, or even same-day discharge in select patients, appears to be a safe and cost-effective strategy.
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Affiliation(s)
- Ankitha M Iyer
- Department of Neurological Surgery and Radiology, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
| | - Jackson P Midtlien
- Department of Neurological Surgery and Radiology, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
| | - Carol Kittel
- Division of Public Health Sciences, Wake Forest University, Winston-Salem, North Carolina, USA
| | - Kyle M Fargen
- Department of Neurological Surgery and Radiology, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
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7
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Midtlien JP, Curry BP, Chang E, Kiritsis NR, Aldridge JB, Fargen KM. Characterizing a new clinical phenotype: the co-existence of cerebral venous outflow and connective tissue disorders. Front Neurol 2024; 14:1305972. [PMID: 38269002 PMCID: PMC10806170 DOI: 10.3389/fneur.2023.1305972] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2023] [Accepted: 12/26/2023] [Indexed: 01/26/2024] Open
Abstract
Background There is increasing recognition of connective tissue disorders and their influence on disease in the general population. A conserved clinical phenotype involving connective tissue disorders and idiopathic intracranial hypertension (IIH) and associated cerebral venous outflow disorders (CVD) has not been previously described. Methods A single-institution retrospective review of a prospectively maintained database of patients with connective tissue disorders and CVD was performed. Results A total of 86 patients were identified. The majority of these patients carried a diagnosis of Ehlers-Danlos syndrome (55%) and most were non-obese (mean body mass index 29.7 kg/m2), Caucasian (90%) females (87%). Most prevalent presenting symptoms included pressure headache (98%), dizziness (90%), tinnitus (92%), and cognitive dysfunction (69%). Aside from CVD and IIH, the most common associated conditions were postural orthostatic tachycardia syndrome (POTS; 55.8%), cerebrospinal fluid (CSF) leaks (51.2%), dysautonomia (45.3%), cranio-cervical instability (37.2%), mast cell activation syndrome (25.6%), and tethered cord syndrome (23.3%). Allergies to medications (87.2%) and surgical tape (19.8%) were also frequent. Despite significantly lower opening pressures on lumbar puncture, headache severity and quality of life scores were reported with the same severity of classic IIH patients, suggesting an underlying hypersensitivity to intracranial pressures and cerebral venous congestion. Conclusion There is a rare but conserved clinical phenotype that has not been described previously that presents with severe IIH symptoms in predominantly young, non-obese Caucasian women with a high associated incidence of dysautonomia, POTS, craniocervical instability, and CSF leaks, among others.
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Affiliation(s)
- Jackson P. Midtlien
- Neurosurgery Department, Wake Forest School of Medicine, Winston-Salem, NC, United States
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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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Fargen KM, Wolfe SQ, Traunero JR, Iyer AM, Kittel C. A descriptive study of venous pressures and gradients while awake and both pre- and post-stent under anesthesia in patients with idiopathic intracranial hypertension. J Neurointerv Surg 2023; 15:1027-1033. [PMID: 36190942 DOI: 10.1136/jnis-2022-019337] [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: 06/30/2022] [Accepted: 08/23/2022] [Indexed: 11/04/2022]
Abstract
BACKGROUND This study aims to explore factors that affect venous sinus pressures and associated gradients while awake and under general anesthesia (GA) both before and after venous sinus stenting (VSS) in patients with idiopathic intracranial hypertension (IIH). METHODS A retrospective analysis was performed examining pressures and gradients in patients with IIH having undergone awake venography followed by VSS under GA. RESULTS 174 patients were included. Compared with awake, GA superior sagittal sinus (SSS) pressures were 2.6 mmHg lower (p=0.01) resulting in a total cranial gradient reduction of 2.5 mmHg (p=0.002). The transverse-sigmoid gradient, the most commonly stented segment, did not differ under the two conditions (p=0.30). Regression analyses demonstrated that body mass index, gender, blood pressure, and end-tidal carbon dioxide content significantly affected venous pressures (all p<0.05). After stenting, mean total cranial gradients decreased by 13.2 mmHg while skull base gradients increased by 0.8 mmHg. Stenting resulted in an 84% mean reduction in the target gradient and a mean decrease in SSS pressures by 78% of the target gradient. When cardiopulmonary and anesthetic factors were optimized, GA had a limited effect on the target gradient in most patients (p=0.88). CONCLUSIONS This study is the largest series to date to report on cerebral venous pressure measurements and gradients recorded while awake and under GA both before and after VSS for IIH. In a well-controlled cardiorespiratory and anesthetic setting, GA venography may provide information that is not substantially inequivalent to that obtained while awake.
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Affiliation(s)
- Kyle M Fargen
- 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
| | - Justin R Traunero
- Anesthesiology, Wake Forest University, Winston-Salem, North Carolina, USA
| | - Ankitha M Iyer
- Neurological Surgery and Radiology, Wake Forest University, Winston-Salem, North Carolina, USA
| | - Carol Kittel
- Division of Public Health Sciences, Wake Forest University, Winston-Salem, North Carolina, USA
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10
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Steinman DA, Gounis MJ, Levitt MR. You're so vein, you probably think this model's about you: opportunities and challenges for computational fluid dynamics in cerebral venous disease. J Neurointerv Surg 2023; 15:621-622. [PMID: 37328188 DOI: 10.1136/jnis-2023-020652] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/30/2023] [Indexed: 06/18/2023]
Affiliation(s)
- David A Steinman
- Mechanical & Industrial Engineering, University of Toronto, Toronto, Ontario, Canada
| | - Matthew J Gounis
- New England Center for Stroke Research, Department of Radiology, University of Massachusetts Chan Medical School, Worcester, Massachusetts, USA
| | - Michael R Levitt
- Neurological Surgery, University of Washington School of Medicine, Seattle, Washington, USA
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11
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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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12
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Marfoglio S, Kovarovic B, Fiorella DJ, Sadasivan C. A novel angiographic method to estimate arterial blood flow rates using contrast reflux: Effect of injection parameters. Med Phys 2023; 50:259-273. [PMID: 36030369 DOI: 10.1002/mp.15948] [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: 10/28/2021] [Revised: 07/20/2022] [Accepted: 08/10/2022] [Indexed: 01/25/2023] Open
Abstract
BACKGROUND Contrast reflux, which is the retrograde movement of contrast against flow direction, is commonly observed during angiography. Despite a vast body of literature on angiography, the hemodynamic factors affecting contrast reflux have not been studied. Numerous methods have been developed to extract flow from angiography, but the reliability of these methods is not yet sufficient to be of routine clinical use. PURPOSE To evaluate the effect of baseline blood flow rates and injection conditions on the extent of contrast reflux. To estimate arterial flow rates based on measurement of contrast reflux length. MATERIALS AND METHODS Iodinated contrast was injected into an idealized tube as well as a physiologically accurate model of the cervico-cerebral vasculature. A total of 194 high-speed angiograms were acquired under varying "blood" flow rates and injection conditions (catheter size, injection rate, and injection time). The length of contrast reflux was compared to the input variables and to dimensionless fluid dynamics parameters at the catheter-tip. Arterial blood flow rates were estimated using contrast reflux length as well as a traditional transit-time method and compared to measured flow rates. RESULTS Contrast reflux lengths were significantly affected by contrast injection rate (p < 0.0001), baseline blood flow rate (p = 0.0004), and catheter size (p = 0.04), but not by contrast injection time (p = 0.4). Reflux lengths were found to be correlated to dimensionless fluid dynamics parameters by an exponential function (R2 = 0.6-0.99). When considering the entire dataset in unison, flow estimation errors with the reflux-length method (39% ± 33%) were significantly higher (p = 0.003) than the transit-time method (33% ± 36%). However, when subgrouped by catheter, the error with the reflux-length method was substantially reduced and was significantly lower (14% ± 14%, p < 0.0001) than the transit-time method. CONCLUSION Results show correlations between contrast reflux length and baseline hemodynamic parameters that have not been reported previously. Clinically relevant blood flow rate estimation is feasible by simple measurement of reflux length. In vivo and clinical studies are required to confirm these correlations and to refine the methodology of estimating blood flow by reflux.
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Affiliation(s)
- Samantha Marfoglio
- Department of Biomedical Engineering, Stony Brook University, Stony Brook, New York, USA
| | - Brandon Kovarovic
- Department of Biomedical Engineering, Stony Brook University, Stony Brook, New York, USA
| | - David J Fiorella
- Department of Neurosurgery, Stony Brook University Medical Center, Stony Brook, New York, USA
| | - Chander Sadasivan
- Department of Neurosurgery, Stony Brook University Medical Center, Stony Brook, New York, USA
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13
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Seay MD, Digre KB. Idiopathic Intracranial Hypertension from Benign to Fulminant: Diagnostic and Management Issues. Ann Indian Acad Neurol 2022; 25:S59-S64. [PMID: 36589036 PMCID: PMC9795713 DOI: 10.4103/aian.aian_203_22] [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: 02/26/2022] [Revised: 03/01/2022] [Accepted: 03/05/2022] [Indexed: 01/04/2023] Open
Abstract
Idiopathic intracranial hypertension (IIH) primarrily affects obese women of childbearing years and is commonly associated with headaches, pulsatile tinnitus, and vision changes. Though most patients have a "benign" course, it can lead to significant morbidity, including blindness. The treatment approach is based on severity of visual impact and includes weight loss, intracranial pressure lowering medications, and sometimes surgery, such as spinal fluid diversion, optic nerve sheath fenestration, or venous sinus stenting. More studies are needed to determine when surgery is most appropriate and which surgical procedure provides maximal benefit with the least risk.
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Affiliation(s)
- Meagan D. Seay
- Department of Ophthalmology, Moran Eye Center, University of Utah, Salt Lake City, UT, United States,Department of Neurology, University of Utah, Salt Lake City, UT, United States,Address for correspondence: Dr. Meagan D. Seay, 65 Mario Capecchi Dr. Salt Lake City, UT, 84132, United States. E-mail:
| | - Kathleen B. Digre
- Department of Ophthalmology, Moran Eye Center, University of Utah, Salt Lake City, UT, United States,Department of Neurology, University of Utah, Salt Lake City, UT, United States
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14
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Robelin F, Lenfant M, Ricolfi F, Béjot Y, Comby PO. [Idiopathic intracranial hypertension: From physiopathological mechanisms to therapeutic decision]. Rev Med Interne 2022; 43:661-668. [PMID: 36114039 DOI: 10.1016/j.revmed.2022.08.012] [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: 06/20/2022] [Revised: 08/16/2022] [Accepted: 08/28/2022] [Indexed: 11/30/2022]
Abstract
Clinical features include visual disturbances, headaches, and pulsatile tinnitus that can be associated with reduced quality of life, and a risk of irreversible visual impairment in some cases. Obese women of childbearing age represent the main at-risk population, and the incidence of the disease is increasing because of rising prevalence of obesity worldwide. In addition, an imbalance in sex hormones is reported as a contributing risk factor. The pathophysiology of idiopathic intracranial hypertension involves a disturbance of the evacuation pathway of intracranial fluids caused by the increase in intracranial venous pressure. Brain imaging is useful for diagnosis with several signs including bilateral stenosis of the transverse sinuses that plays a major role in the pathogenesis of the disease by creating a positive feedback loop that increases intracranial venous hypertension and contributes to clinical manifestations. Treatment aims to relieve symptoms and prevent permanent visual impairment. Drug therapies including acetazolamide and topiramate have moderate effectiveness. Among invasive treatments, transverse sinus stenting seems to be the most interesting option to consider in drug-resistant patients. Weight loss remains essential to achieve a sustainable improvement by reducing central venous pressure. Future randomized trials are expected to reach a consensus on this treatment.
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Affiliation(s)
- F Robelin
- Service de neuroradiologie, CHU François Mitterrand Dijon, 14, rue Paul Gaffarel, 21000 Dijon, France.
| | - M Lenfant
- Service de neuroradiologie, CHU François Mitterrand Dijon, 14, rue Paul Gaffarel, 21000 Dijon, France
| | - F Ricolfi
- Service de neuroradiologie, CHU François Mitterrand Dijon, 14, rue Paul Gaffarel, 21000 Dijon, France; Université de Bourgogne, BP 27877-21078, Dijon Cedex, France
| | - Y Béjot
- Service de neurologie, CHU François Mitterrand Dijon, 14, rue Paul Gaffarel, 21000 Dijon, France; Université de Bourgogne, BP 27877-21078, Dijon Cedex, France
| | - P-O Comby
- Service de neuroradiologie, CHU François Mitterrand Dijon, 14, rue Paul Gaffarel, 21000 Dijon, France; Université de Bourgogne, BP 27877-21078, Dijon Cedex, France
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15
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Zhang Y, Ma C, Li C, Li X, Liu R, Liu M, Zhu H, Liang F, Wang Y, Dong K, Jiang C, Miao Z, Mo D. Prediction of the trans-stenotic pressure gradient with arteriography-derived hemodynamic features in patients with idiopathic intracranial hypertension. J Cereb Blood Flow Metab 2022; 42:1524-1533. [PMID: 35255760 PMCID: PMC9274861 DOI: 10.1177/0271678x221086408] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
The pathogenesis of idiopathic intracranial hypertension (IIH) is attributed to segmental stenosis of the venous sinus. The current treatment paradigm requires a trans-stenotic pressure gradient of ≥8 mmHg or ≥6 mmHg threshold. This study aimed to develop a machine learning screening method to identify patients with IIH using hemodynamic features. A total of 204 venous manometry instances (n = 142, training and validation; n = 62, test) from 135 patients were included. Radiomic features extracted from five arteriography perfusion parameter maps were selected using least absolute shrinkage and selection operator and then entered into support vector machine (SVM) classifiers. The Thr8-23-SVM classifier was created with 23 radiomic features to predict if the pressure gradient was ≥8 mmHg. On an independent test dataset, prediction sensitivity, specificity, accuracy, and AUC were 0.972, 0.846, 0.919, and 0.980, respectively (95% confidence interval: 0.980-1.000). For the 6 mmHg threshold, thr6-28-SVM incorporated 28 features, and its sensitivity, specificity, accuracy, and AUC were 0.923, 0.956, 0.935, and 0.969, respectively (95% confidence interval: 0.927-1.000). The trans-stenotic pressure gradient result was associated with perfusion pattern changes, and SVM classifiers trained with arteriography perfusion map-derived radiomic features could predict the 8 mmHg and 6 mmHg dichotomized trans-stenotic pressure gradients with favorable accuracy.
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Affiliation(s)
- Yupeng Zhang
- Interventional Neuroradiology Center, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,Beijing Neurosurgical Institute, Capital Medical University, Beijing, China
| | - Chao Ma
- Beijing Neurosurgical Institute, Capital Medical University, Beijing, China.,Department of Neurosurgery, Beijing Tsinghua Changgung Hospital, School of Clinical Medicine, Tsinghua University, Beijing, China
| | - Changxuan Li
- Department of Neurology, The First Affiliated Hospital of Hainan Medical University, Sanya, Hainan
| | - Xiaoqing Li
- Interventional Neuroradiology Center, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Raynald Liu
- Interventional Neuroradiology Center, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Minke Liu
- Department of Neurointerventional Surgery, Affiliated Hospital of Gansu University of Traditional Chinese Medicine, Lanzhou, Gansu
| | - Haoyu Zhu
- Beijing Neurosurgical Institute, Capital Medical University, Beijing, China
| | - Fei Liang
- Beijing Neurosurgical Institute, Capital Medical University, Beijing, China
| | - Yilong Wang
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Kehui Dong
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Chuhan Jiang
- Interventional Neuroradiology Center, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,Beijing Neurosurgical Institute, Capital Medical University, Beijing, China
| | - Zhongrong Miao
- Interventional Neuroradiology Center, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Dapeng Mo
- Interventional Neuroradiology Center, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
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16
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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] [MESH Headings] [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
| | - 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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17
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Fargen KM. Venous stenting for idiopathic intracranial hypertension: lessons learned from a high-volume practice. J Neurointerv Surg 2021; 14:528-532. [PMID: 34551993 DOI: 10.1136/neurintsurg-2021-018184] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/12/2021] [Indexed: 11/04/2022]
Affiliation(s)
- Kyle M Fargen
- Department of Neurological Surgery and Radiology, Wake Forest University, Winston-Salem, NC 27157, USA
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18
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Doron O, Zadka Y, Barnea O, Rosenthal G. Interactions of brain, blood, and CSF: a novel mathematical model of cerebral edema. Fluids Barriers CNS 2021; 18:42. [PMID: 34530863 PMCID: PMC8447530 DOI: 10.1186/s12987-021-00274-z] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2021] [Accepted: 08/20/2021] [Indexed: 12/02/2022] Open
Abstract
Background Previous models of intracranial pressure (ICP) dynamics have not included flow of cerebral interstitial fluid (ISF) and changes in resistance to its flow when brain swelling occurs. We sought to develop a mathematical model that incorporates resistance to the bulk flow of cerebral ISF to better simulate the physiological changes that occur in pathologies in which brain swelling predominates and to assess the model’s ability to depict changes in cerebral physiology associated with cerebral edema. Methods We developed a lumped parameter model which includes a representation of cerebral ISF flow within brain tissue and its interactions with CSF flow and cerebral blood flow (CBF). The model is based on an electrical analog circuit with four intracranial compartments: the (1) subarachnoid space, (2) brain, (3) ventricles, (4) cerebral vasculature and the extracranial spinal thecal sac. We determined changes in pressure and volume within cerebral compartments at steady-state and simulated physiological perturbations including rapid injection of fluid into the intracranial space, hyperventilation, and hypoventilation. We simulated changes in resistance to flow or absorption of CSF and cerebral ISF to model hydrocephalus, cerebral edema, and to simulate disruption of the blood–brain barrier (BBB). Results The model accurately replicates well-accepted features of intracranial physiology including the exponential-like pressure–volume curve with rapid fluid injection, increased ICP pulse pressure with rising ICP, hydrocephalus resulting from increased resistance to CSF outflow, and changes associated with hyperventilation and hypoventilation. Importantly, modeling cerebral edema with increased resistance to cerebral ISF flow mimics key features of brain swelling including elevated ICP, increased brain volume, markedly reduced ventricular volume, and a contracted subarachnoid space. Similarly, a decreased resistance to flow of fluid across the BBB leads to an exponential-like rise in ICP and ventricular collapse. Conclusions The model accurately depicts the complex interactions that occur between pressure, volume, and resistances to flow in the different intracranial compartments under specific pathophysiological conditions. In modelling resistance to bulk flow of cerebral ISF, it may serve as a platform for improved modelling of cerebral edema and blood–brain barrier disruption that occur following brain injury.
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Affiliation(s)
- Omer Doron
- Department of Neurosurgery, Hadassah-Hebrew University Medical Center, Kiryat Hadassah, 91120, Jerusalem, Israel.,Department of Biomedical Engineering, Tel Aviv University, Tel Aviv, Israel
| | - Yuliya Zadka
- Department of Biomedical Engineering, Tel Aviv University, Tel Aviv, Israel
| | - Ofer Barnea
- Department of Biomedical Engineering, Tel Aviv University, Tel Aviv, Israel
| | - Guy Rosenthal
- Department of Neurosurgery, Hadassah-Hebrew University Medical Center, Kiryat Hadassah, 91120, Jerusalem, Israel.
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19
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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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20
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Subacute vision loss after microvascular decompression for trigeminal neuralgia. Acta Neurochir (Wien) 2021; 163:1635-1638. [PMID: 33811522 DOI: 10.1007/s00701-021-04819-x] [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: 02/10/2021] [Accepted: 03/16/2021] [Indexed: 10/21/2022]
Abstract
Microvascular decompression is the surgery of choice for typical trigeminal neuralgia (TN) that fails conservative medical management. Visual loss after MVD is a rare complication that has not been reported. In this article, we present a patient who developed delayed visual loss and papilledema from transverse sinus stenosis resulting from bone wax compression after MVD for TN. While waxing the edges of a retrosigmoid craniotomy may seem mundane, meticulous care should be taken to ensure that there is no compression of the venous sinuses, as this could lead to intracranial hypertension.
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21
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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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22
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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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23
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Lee K, Kittel C, Aldridge JB, Wolfe SQ, Brown P, Fargen KM. Correlation between intracranial pressure and venous sinus pressures in patients undergoing cerebral venography and manometry. J Neurointerv Surg 2021; 13:1162-1166. [PMID: 33674395 DOI: 10.1136/neurintsurg-2020-017161] [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: 11/28/2020] [Revised: 01/08/2021] [Accepted: 01/09/2021] [Indexed: 11/04/2022]
Abstract
BACKGROUND The pathophysiology of idiopathic intracranial hypertension (IIH) is complex but is directly related to cerebral venous hypertension. Few studies have simultaneously recorded venous sinus pressures and lumbar puncture (LP) opening pressure (OP) to understand the relationship between these factors without temporal confounding. METHODS A retrospective review was performed of patients with a known or suspected diagnosis of IIH who underwent cerebral venography with manometry followed immediately by LP. RESULTS 47 patients aged 16-68 years met inclusion criteria. 91.5% were female. Mean body mass index (BMI) was 33.3 kg/m2. Of the included patients, median OP was 21 cm H2O (IQR (15.5, 26.5)). Mean (SD) recorded superior sagittal sinus (SSS) and torcular pressures were 25.5 (16.5) mm Hg and 23.8 (16.6) mm Hg, respectively. Twenty patients (42.6%) were discovered to have a trans-stenosis gradient of 8 mm Hg or greater. Transverse sinus, torcula, and SSS pressures were all significantly predicted by OP. On regression analysis, torcular pressures were best predicted by OP of the three measured sites. For 17 patients with OP <20 cm H2O (36.2%), mean (SD) SSS and torcular pressures were 13.5 (4.2) mm Hg and 15.4 (6.7) mm Hg, respectively, suggesting that normally SSS pressures should measure <18 mm Hg (80th percentile) in non-pathologic conditions. CONCLUSIONS This is the first study to correlate venous sinus pressures and OP in patients with IIH with LP performed directly after manometry. In 47 patients, LP OP significantly predicted transverse sinus, torcula, and SSS pressures. Torcular pressures (mm Hg) were most accurately predicted by OP (cm H2O) in a nearly one-to-one relationship.
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Affiliation(s)
- Katriel Lee
- Department of Neurosurgery, Wake Forest Baptist Medical Center, Winston-Salem, North Carolina, USA
| | - Carol Kittel
- Division of Public Health Sciences, Wake Forest University Health Sciences, Winston-Salem, NC, USA
| | | | - Stacey Q Wolfe
- Department of Neurosurgery, Wake Forest Baptist Medical Center, Winston-Salem, North Carolina, USA
| | - Patrick Brown
- Department of Radiology, Wake Forest Baptist Medical Center, Winston-Salem, North Carolina, USA
| | - Kyle M Fargen
- Department of Neurosurgery, Wake Forest Baptist Medical Center, Winston-Salem, North Carolina, USA
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24
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Marfoglio S, Kovarovic B, Hou W, Fiorella DJ, Sadasivan C. An in vitro study of pressure increases during contrast injections in diagnostic cerebral angiography. Interv Neuroradiol 2021; 27:695-702. [PMID: 33631993 DOI: 10.1177/1591019921996099] [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: 11/15/2022] Open
Abstract
BACKGROUND During diagnostic cerebral angiography, the contrast bolus injected into a vessel can cause substantial changes in baseline pressures and flows. One potential, and serious complication is the re-rupture of aneurysms due to these injections. The goals of this in vitro study were to evaluate the effect of injection conditions on intraneurysmal pressure changes during angiography. METHODS A silicone replica of a complete circle of Willis model with ophthalmic, anterior communicating, and basilar tip aneurysms was connected to a physiologically accurate flow pump. Contrast injections were performed under different conditions (carotid or vertebral vessel imaging, catheter diameter, injection rate, injection time, and arterial blood flow rate) and the pressure in each aneurysm was recorded before and during each injection. The effect of injection conditions on percentage increase in aneurysm pressures was statistically assessed. Additionally, the effect of the distance between the aneurysm and the catheter-tip on aneurysmal pressures was assessed. RESULTS Mean intraneurysmal pressures during injection (84.5 ± 10.8 mmHg) were significantly higher than pre-injection pressures (80.4 ± 10.6 mmHg, p < 0.0001). Only 3 of the 5 conditions - carotid injections, higher injection rates, and smaller catheter diameters - significantly increased intraneurysmal pressures. The catheter-tip distance showed no correlation to pressure increases. CONCLUSIONS Increasing contrast injection rates and decreasing catheter diameters are correlated to intraneurysmal pressure increases during angiography irrespective of the distance to the catheter tip. Future in vivo studies are required to confirm these findings and determine whether the amplitude of pressure increases with commonly used injection rates can be clinically detrimental.
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Affiliation(s)
- Samantha Marfoglio
- Department of Biomedical Engineering, Stony Brook University, Stony Brook, NY, USA
| | - Brandon Kovarovic
- Department of Biomedical Engineering, Stony Brook University, Stony Brook, NY, USA
| | - Wei Hou
- Family, Population and Preventive Medicine, Stony Brook University, Stony Brook, NY, USA
| | - David J Fiorella
- Department of Neurosurgery, Stony Brook University Medical Center, Stony Brook, NY, USA
| | - Chander Sadasivan
- Department of Neurosurgery, Stony Brook University Medical Center, Stony Brook, NY, USA
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Fargen KM. A unifying theory explaining venous sinus stenosis and recurrent stenosis following venous sinus stenting in patients with idiopathic intracranial hypertension. J Neurointerv Surg 2021; 13:587-592. [PMID: 33579755 DOI: 10.1136/neurintsurg-2020-017208] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/11/2021] [Indexed: 11/03/2022]
Affiliation(s)
- Kyle M Fargen
- Neurological Surgery and Radiology, Wake Forest University, Winston-Salem, North Carolina, USA
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26
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Kahan J, Sundararajan S, Brown K, Dinkin M, Oliveira C, Patsalides A. Predicting the need for retreatment in venous sinus stenting for idiopathic intracranial hypertension. J Neurointerv Surg 2020; 13:574-579. [PMID: 32895320 DOI: 10.1136/neurintsurg-2020-016550] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2020] [Revised: 08/14/2020] [Accepted: 08/18/2020] [Indexed: 11/04/2022]
Abstract
BACKGROUND Idiopathic intracranial hypertension is a disease of raised intra-cranial pressure of unknown etiology. Lateral cerebral venous sinus stenosis (VSS) has been increasingly reported in these patients, and stenting has emerged as an alternative treatment for medically refractory symptoms. Treatment efficacy on meta-analysis appears promising, but identifying which patients are likely to benefit most, and which are likely to require repeat procedures, is currently unclear. METHODS We retrospectively reviewed a prospectively collected database of 79 patients treated with venous sinus stenting at a single academic center with minimum follow-up of 18 months. We extracted baseline clinical data, as well as manometry at lumbar puncture and during angiography, and used logistic regression to identify parameters that could predict stent failure. RESULTS Retreatment rate after successful VSS was 13.9%. Lumbar puncture opening pressure (OP) was shown to significantly predict treatment failure (ß=0.06; OR=1.064 (1.003-1.135); P=0.039). This effect remained significant when age, sex and body mass index were added to the model (ß=0.06; OR=1.066 (1.002-1.140); P=0.043). OP was correlated with venous sinus manometry readings in the superior sagittal and transverse sinus pre-stent placement, as well trans-stenotic gradient (P<0.001). CONCLUSIONS Higher lumbar puncture OP was associated with an increased risk of stent failure in transverse sinus stenting for idiopathic intracranial hypertension, although the performance of this model as a linear discriminator was poor. Further studies are required to better assess which patients are at greatest risk of treatment failure.
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Affiliation(s)
- Joshua Kahan
- Department of Neurology, NewYork-Presbyterian Hospital/Weill Cornell Medical Center, New York, New York, USA
| | - Sri Sundararajan
- Department of Neurological Surgery, NewYork-Presbyterian Hospital/Weill Cornell Medical Center, New York, New York, USA
| | - Kenroy Brown
- Department of Neurological Surgery, NewYork-Presbyterian Hospital/Weill Cornell Medical Center, New York, New York, USA
| | - Marc Dinkin
- Department of Neurology, NewYork-Presbyterian Hospital/Weill Cornell Medical Center, New York, New York, USA
| | - Cristiano Oliveira
- Department of Neurology, NewYork-Presbyterian Hospital/Weill Cornell Medical Center, New York, New York, USA
| | - Athos Patsalides
- Department of Neurological Surgery, NewYork-Presbyterian Hospital/Weill Cornell Medical Center, New York, New York, USA
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Lee KE, Zehri A, Soldozy S, Syed H, Catapano JS, Maurer R, Albuquerque FC, Liu KC, Wolfe SQ, Brown S, Levitt MR, Fargen KM. Dural venous sinus stenting for treatment of pediatric idiopathic intracranial hypertension. J Neurointerv Surg 2020; 13:465-470. [PMID: 32732257 DOI: 10.1136/neurintsurg-2020-016183] [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] [Received: 04/17/2020] [Revised: 06/25/2020] [Accepted: 07/02/2020] [Indexed: 01/28/2023]
Abstract
BACKGROUND Dural venous sinus stenting (VSS) is an effective treatment for idiopathic intracranial hypertension (IIH) in adult patients. There are no published series to date evaluating safety and efficacy of VSS in pediatric patients. OBJECTIVE To report on procedural device selection and technique as well as safety and efficacy of VSS for pediatric patients with medically refractory IIH due to underlying venous sinus stenosis. METHODS A multi-institutional retrospective case series identified patients with medically refractory IIH aged less than 18 years who underwent VSS. RESULTS 14 patients were identified at four participating centers. Patient ages ranged from 10 to 17 years, and 10 patients (71.4%) were female. Mean body mass index was 25.7 kg/m2 (range 15.8-34.6 kg/m2). Stenting was performed under general endotracheal anesthesia in all except two patients. The average trans-stenotic gradient during diagnostic venography was 10.6 mm Hg. Patients had stents placed in the superior sagittal sinus, transverse sinus, sigmoid sinus, occipital sinus, and a combination. Average follow-up was 1.7 years after stenting. Six patients out of 10 (60%) had reduced medication dosing, 12 of 14 patients (85.7%) had improvements in headaches, two patients (100%) with pre-stent tinnitus had resolution of symptoms, and four (80%) of five patients with papilledema had improvement on follow-up ophthalmological examinations. Two patients (14.3%) developed postprocedural groin hematomas, one patient (7.1%) developed a groin pseudoaneurysm, and one patient (7.1%) had postprocedural groin bleeding. No other procedural complications occurred. Four patients (28.6%) required further surgical treatment (cerebrospinal shunting and/or stenting) after their first stenting procedure. CONCLUSIONS This series suggests that VSS is feasible in a pediatric population with IIH and has a low complication rate and good clinical outcomes.
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Affiliation(s)
- Katriel E Lee
- Department of Neurosurgery, Wake Forest Baptist Medical Center, Winston-Salem, North Carolina, USA
| | - Aqib Zehri
- Department of Neurosurgery, Wake Forest Baptist Medical Center, Winston-Salem, North Carolina, USA
| | - Sauson Soldozy
- Department of Neurosurgery, University of Virginia Medical Center, Charlottesville, Virginia, USA
| | - Hasan Syed
- Department of Neurosurgery, University of Virginia Medical Center, Charlottesville, Virginia, USA
| | - Joshua S Catapano
- Department of Neurosurgery, Barrow Neurological Institute, Phoenix, Arizona, USA
| | - Robert Maurer
- Penn State Health Neurosurgery, Hershey, Pennsylvania, USA
| | - Felipe C Albuquerque
- Department of Neurosurgery, Barrow Neurological Institute, Phoenix, Arizona, USA
| | - Kenneth C Liu
- Department of Neurological Surgery, University of Southern California Keck School of Medicine, Los Angeles, CA, USA
| | - Stacey Q Wolfe
- Department of Neurosurgery, Wake Forest Baptist Medical Center, Winston-Salem, North Carolina, USA
| | - Sandra Brown
- Cabarrus Eye Center, Concord, North Carolina, USA
| | - Michael R Levitt
- Department of Neurological Surgery, Radiology and Mechanical Engineering, University of Washington, Seattle, Washington, USA
| | - Kyle M Fargen
- Department of Neurosurgery, Wake Forest Baptist Medical Center, Winston-Salem, North Carolina, USA
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Garner RM, Aldridge JB, Wolfe SQ, Fargen KM. Quality of life, need for retreatment, and the re-equilibration phenomenon after venous sinus stenting for idiopathic intracranial hypertension. J Neurointerv Surg 2020; 13:79-85. [PMID: 32611623 DOI: 10.1136/neurintsurg-2020-016124] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2020] [Revised: 06/10/2020] [Accepted: 06/11/2020] [Indexed: 11/03/2022]
Abstract
BACKGROUND Long term failure rates after venous sinus stenting (VSS) for idiopathic intracranial hypertension (IIH) are poorly understood. METHODS Retrospective analysis was performed on a prospectively-maintained single center database to identify patients with medically refractory IIH who underwent VSS. Patients with persistent or severe recurrent symptoms after VSS undergo lumbar puncture (LP), therefore LP serves as a marker for treatment failure. RESULTS 81 patients underwent VSS with a mean follow-up of 10 months; 44 (54.3%) patients underwent LP after VSS due to persistent or recurrent symptoms at a mean of 12 months (median 7, range 2-43). There was a mean decrease in opening pressure (OP) on LP from pre- to post-VSS of 9.1 cm H2O (median 9.5). Overall, a total of 21 (25.9%) patients underwent further surgical intervention following VSS, including five who underwent repeat VSS (6.2% of total) and 18 who underwent cerebrospinal fluid shunting (22.2% of total). There was a non-significant (p=0.18) but overall increase in quality of life scores from pre-stenting (61.2) to last follow-up (71.2), and a significant decrease in Headache Impact Test-6 (HIT-6) scores (p=0.03) with mean pre-stenting and last follow-up scores of 62.7 and 55.8, respectively. CONCLUSIONS VSS is an effective treatment for venous sinus stenosis in IIH; however, this study found higher rates of symptomatic recurrence and need for further surgical intervention (26%) than previously reported in the literature. Recurrence of symptoms occurred at a median of 7 months, even though OP remained lower at follow-up LP, suggestive of a re-equilibration phenomenon.
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Affiliation(s)
- Rebecca M Garner
- Neurological Surgery, Wake Forest University, Winston-Salem, North Carolina, USA
| | | | - Stacey Q Wolfe
- Neurological Surgery, Wake Forest University, Winston-Salem, North Carolina, USA
| | - Kyle M Fargen
- Neurological Surgery, Wake Forest University, Winston-Salem, North Carolina, USA
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Levitt M. Another version of the truth. J Neurointerv Surg 2020; 12:335-336. [PMID: 32161165 DOI: 10.1136/neurintsurg-2020-015935] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/19/2020] [Indexed: 11/04/2022]
Affiliation(s)
- Michael Levitt
- Departments of Neurological Surgery, Radiology, Mechanical Engineering, Stroke & Applied Neuroscience Center, University of Washington, Seattle, WA 98195, USA
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Tschoe C, Garner RM, Kittel C, Traunero JR, Wolfe SQ, Fargen KM. Changes in mean arterial pressure and end-tidal carbon dioxide content affect venous sinus pressures in patients with idiopathic intracranial hypertension: a randomized study. J Neurointerv Surg 2020; 12:906-910. [DOI: 10.1136/neurintsurg-2019-015741] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2019] [Revised: 02/07/2020] [Accepted: 02/08/2020] [Indexed: 02/03/2023]
Abstract
IntroductionLittle is known about how changes in physiologic parameters affect venous sinus pressure measurements, waveforms, or gradients associated with sinus stenosis.ObjectiveTo evaluate the effect of changes in cardiovascular and respiratory physiologic parameters on venous sinus pressure and caliber measurements in patients with idiopathic intracranial hypertension (IIH) undergoing venous sinus stenting.MethodsIn a prospective, randomized pilot study, eight patients with IIH undergoing venous sinus stenting were randomized to one of two groups. Under general anesthesia, patients underwent venous manometry and waveform recordings twice in succession based on assigned physiologic groups immediately before stenting. The mean arterial pressure (MAP) group maintained normocapnia but modified MAPs in two arms to control for temporal confounding: group A1 (MAP 60-80 mm Hg then 100–110 mm Hg) and group A2 (MAP 100-110 mm Hg then 60–80 mm Hg). The end-tidal carbon dioxide (EtCO2) group maintained a high-normal MAP similar to standard neuroanesthesia goals and modified EtCO2: group B1 (EtCO2 24–26 mm Hg then 38–40 mm Hg) and B2 (EtCO2 28–40 mm Hg then 24–26 mm Hg).ResultsIn group A, superior sagittal sinus (SSS) pressures (ranging from 8 to 76 mm Hg) and trans-stenotic pressure gradients (TSPGs) (ranging from 2 to 67 mm Hg) were seen at MAP of 100–110 mm Hg compared with SSS pressures (4–38 mm Hg) and TSPGs (3–31 mm Hg) at 60–80 mm Hg. In group B, SSS pressures and TSPGs were considerably higher at EtCO2 levels of 38–40 mm Hg (15–57 mm Hg and 3–44 mm Hg, respectively) than at 24–26 mm Hg (8–26 mm Hg and 1–8 mm Hg, respectively).ConclusionsDespite the small sample size, this pilot study demonstrates a dramatic effect of both MAP and EtCO2 on venous sinus pressures obtained during venography. These findings underscore the importance of maintaining normal physiologic cardiovascular and respiratory parameters during venous sinus manometry.
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Fargen KM. Idiopathic intracranial hypertension is not idiopathic: proposal for a new nomenclature and patient classification. J Neurointerv Surg 2019; 12:110-114. [DOI: 10.1136/neurintsurg-2019-015498] [Citation(s) in RCA: 29] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/10/2019] [Indexed: 11/04/2022]
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