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Mamikoglu B, Cooper J, Stidham KR, Al-Muhti F, Gandhi CD. What should otolaryngologists know about dural venous sinus stenting? Eur Arch Otorhinolaryngol 2024:10.1007/s00405-024-08806-7. [PMID: 39042170 DOI: 10.1007/s00405-024-08806-7] [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: 02/22/2024] [Accepted: 06/24/2024] [Indexed: 07/24/2024]
Abstract
Dural venous sinus stenting is an emerging and exciting area in otolaryngology in collaboration with neurosurgeons and neuroradiologists. The first cases were reported 20 years ago. It is now considered part of the routine treatment of increased intracranial pressure due to transverse sinus stenosis. ENT doctors are the first to see these patients in their clinics, as sinus headaches, pulsating tinnitus, and dizziness are the most common symptoms. Previously, with limited success, high-dose diuretics and intracranial shunts had been the only options for treating these patients. Other methods, such as covering the sigmoid sinuses with graft material, appear to cause a sudden increase in intracranial pressure that can lead to blindness and even death. This overview summarizes the clinical and imaging characteristics of patients who will benefit from endovascular sinus stenting for elevated intracranial pressure.
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Affiliation(s)
- Bulent Mamikoglu
- Department of Otolaryngology-Head and Neck Surgery, Westchester Medical Center Health Network, New York Medical College, 100 Woods Road, Macy Pavilion, 1331, Valhalla, NY, 10595, USA.
| | - Jared Cooper
- Department of Neurosurgery, Westchester Medical Center Health Network, New York Medical College, 100 Woods Road, Valhalla, NY, 10595, USA
| | - Katrina R Stidham
- Director of Otology/Neurotology Section, Department of Otolaryngology-Head and Neck Surgery, Westchester Medical Center Health Network, New York Medical College, 100 Woods Road, Valhalla, NY, 10595, USA
| | - Fawaz Al-Muhti
- Neuroendovascular Surgery, Department. of Neurology Westchester Medical Center, 100 Woods Road, Valhalla, NY, 10595, USA
| | - Chirag D Gandhi
- Department of Neurosurgery Director, Brain and Spine Institute, Westchester Medical Center Health Network New York Medical College, 100 Woods Road, Macy Pavilion, 1331, Valhalla, NY, 10595, USA
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2
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Elsaid N, Razek A, Batouty NM, Elmokadem AH, Tawfik AM, Saied A. Combined Conduit Score in Contrast-Enhanced Magnetic Resonance Venography in Patients with Idiopathic Intracranial Hypertension : Neuro-interventionalists' vs. Radiologists' Assessment. Clin Neuroradiol 2023; 33:695-700. [PMID: 36799990 PMCID: PMC10450004 DOI: 10.1007/s00062-023-01263-5] [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: 10/17/2022] [Accepted: 01/11/2023] [Indexed: 02/18/2023]
Abstract
BACKGROUND Based on increased understanding of the idiopathic intracranial hypertension (IIH) pathophysiology, venous sinus stenting (VSS) has emerged as an effective treatment for patients with transverse sinus stenosis (TSS). The presence of a reliable TSS screening tool is warranted. The combined conduit score (CCS) is the most widely used score for evaluation of the cerebral sinovenous stenosis in contrast-enhanced magnetic resonance venography (CE-MRV). PURPOSE OF THE STUDY To evaluate the interobserver agreement between neuro-interventionalists and radiologists with respect to the CCS in evaluation of transverse sinus stenosis in patients with idiopathic intracranial hypertension using CE-MRV. METHODS A retrospective study was conducted on 26 consecutive patients diagnosed with IIH and underwent CE-MRV. The 2 neuro-interventionalists and 2 radiologists separately evaluated the cerebral venous sinuses using the CCS. RESULTS The mean CCS was significantly different between the neuro-interventionalists and radiologists (p < 0.001), higher for the radiologists. The inter-rater reliability was excellent (ICC = 0.954, 95% CI: 0.898-0.979) between the 2 neuro-interventionalists, good between the 2 radiologists (ICC = 0.805, 95% CI: 0.418-0.921), but was not acceptable between the neuro-interventionalists and the radiologists (ICC 0.47 95% CI:-2.2-0.782). CONCLUSION Despite the excellent agreement between the neuro-interventionists and the good agreement between the radiologists, there was no agreement between the neuro-interventionists and the radiologists. Our finding suggests that there is a gap between the 2 specialties but does not favor any of them. Factors related to the observers, the venous sinus system, the MRV or the CCS score may have resulted in this discrepancy. Automatic or semi-automatic feature extractions to produce quantifiable biomarkers for IIH are warranted. The clinical decisions should not depend only on strongly observer-dependent scores with training and/or experience-dependent influences.
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Affiliation(s)
- Nada Elsaid
- Department of Neurology, Faculty of Medicine, Mansoura University, Mansoura, Egypt.
| | - Ahmed Razek
- Department of Diagnostic and interventional Radiology, Faculty of Medicine, Mansoura University, Mansoura, Egypt
| | - Nihal M Batouty
- Department of Diagnostic and interventional Radiology, Faculty of Medicine, Mansoura University, Mansoura, Egypt
| | - Ali H Elmokadem
- Department of Diagnostic and interventional Radiology, Faculty of Medicine, Mansoura University, Mansoura, Egypt
| | - Ahmed M Tawfik
- Department of Diagnostic and interventional Radiology, Faculty of Medicine, Mansoura University, Mansoura, Egypt
| | - Ahmed Saied
- Department of Neurology, Faculty of Medicine, Mansoura University, Mansoura, Egypt
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3
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Gorjian M, Andrada JE, Sitko KR, Sorte DE, Taylor CL, Eliyas JK, Carlson AP. Dural venous sinus stenting technique for idiopathic intracranial hypertension in patients with tortuous venous anatomy. Neurosurg Rev 2023; 46:177. [PMID: 37462792 DOI: 10.1007/s10143-023-02087-0] [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: 05/12/2023] [Revised: 06/27/2023] [Accepted: 07/09/2023] [Indexed: 07/21/2023]
Abstract
Venous sinus stenting (VSS) for medically refractory idiopathic intracranial hypertension (IIH) is emerging as a safe and effective alternative to shunting. However, stent navigation past the jugular bulb with commonly used carotid stenting systems via femoral access in cases with tortuous venous anatomy can present a challenge, leading to procedural failure. We present a technical refinement using a cervical access and peripheral vascular stent with a more stable 0.035-in. delivery platform as an alternative to the traditional approach to simplify the procedure and overcome the technical difficulties in cases with tortuous venous anatomy. Our institutional database for patients who had IIH and undergone VSS using the peripheral vascular stent between 2013 and 2023 was retrospectively reviewed. Data on 36 patients (33 women, 3 men, mean age 32 years) was collected. VSS was technically successful in all patients (100%) without major complications or thrombosis. There was one case of minor neck cellulitis treated with oral antibiotics. Three patients underwent repeat stenting, and 2 patients had ventriculoperitoneal shunt placement after stenting due to persistent or recurrent symptoms. All patients (100%) had improvement or resolution of papilledema; however, six patients had evidence of optic atrophy and persistent vision loss. Headache was resolved or improved in 91% of patients. In the presence of tortuous venous anatomy, VSS using cervical access and a peripheral vascular stent with a more stable 0.035-in. delivery platform can be considered as a safe and effective alternative approach with shorter procedure time. This approach is particularly advantageous in situations where the procedure is prolonged or high dose of contrast has been administered due to the technical challenges associated with the traditional use of carotid systems via femoral access for stent delivery.
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Affiliation(s)
| | | | - Kevin R Sitko
- University of New Mexico, Albuquerque, NM, 87131, USA
| | | | | | | | - Andrew P Carlson
- Department of Neurosurgery, University of New Mexico, 1 University of New Mexico, Albuquerque, NM, 87131, USA.
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4
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Aksu Y, Tiryaki Ş. Evaluation of Clinical Findings with MRI Venography in Patients with Idiopatic Intracranial Hypertension. Curr Med Imaging 2022; 18:1378-1383. [PMID: 35578860 DOI: 10.2174/1573405618666220516121352] [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: 12/18/2021] [Revised: 02/01/2022] [Accepted: 02/18/2022] [Indexed: 01/25/2023]
Abstract
OBJECTIVES To evaluate clinical data and Magnetic Resonance Venography (MRV) findings together in patients with idiopathic intracranial hypertension (IIH). MATERIALS AND METHODS In this retrospective study between January 2009 and February 2021, conventional MRI and MRV examinations were performed on 30 patients who were admitted to the neurology service of Erciyes University Medical Faculty with the pre-diagnosis of IIH, cerebrospinal fluid (CSF) pressure was measured in these patients to confirm the diagnosis of IIH. Transverse Sinus Stenosis Ratio (TS SR), Superior Sagittal Sinus (SSS) diameter, Sinus Rectus (SR) diameter, Stenosis Segment Length (SSL) were studied. RESULTS High CSF pressure was detected in 22 of 30 patients with IIH pre-diagnosis. CSF pressure was normal in 8 cases. TS SR was compared in all groups, right TS SR 0.63 ± 0.16, Left TS SR 0.55 ± 0.16 in the patient group with IIH, right TS SR 0.55 ±0.16 in the CSF pressure normal patient group, Right TS SR 0.28 ± 0.07 Left TS SR 0.31 ± 0.07 in the control group Right TS SR It was 0.28 ± 0.09, Sol TS SR was 0.30 ± 0.07. CONCLUSION Before LP, the cranial venous system must be monitored. TS SR and CSF pressure are directly proportional. The stenosis rate is important for IIH rather than SSL.
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Affiliation(s)
- Yusuf Aksu
- Nevşehir State Hospital, Department of Radiology, Nevşehir, Turkey
| | - Şaban Tiryaki
- Kırşehir Ahi Evran University Medical Faculty, Department of Radiology, Kırşehir, Turkey
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5
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Byth LA, Lust K, Jeffree RL, Paine M, Voldanova L, Craven AM. Management of idiopathic intracranial hypertension in pregnancy. Obstet Med 2022; 15:160-167. [PMID: 36262821 PMCID: PMC9574447 DOI: 10.1177/1753495x211021333] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2021] [Accepted: 05/11/2021] [Indexed: 09/03/2023] Open
Abstract
Idiopathic intracranial hypertension is more common among women of reproductive age and is often encountered in pregnancy, either pre-existing and exacerbated by pregnancy-associated weight gain and hormonal changes or arising de novo. We report the case of a 33-year-old woman with progressive visual loss and intractable headache from 20 weeks' gestation requiring ventriculoperitoneal shunting during pregnancy. The risk of permanent maternal vision loss raises complex management dilemmas, when this must be balanced with the fetal and neonatal risks of treatment and possible premature delivery.
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Affiliation(s)
- Lachlan Andrew Byth
- Department of Obstetric Medicine, Royal Brisbane and Women’s
Hospital, Herston, Australia
- Griffith University School of Medicine, Southport,
Australia
| | - Karin Lust
- Department of Obstetric Medicine, Royal Brisbane and Women’s
Hospital, Herston, Australia
- University of Queensland School of Medicine, Herston,
Australia
| | - Rosalind L Jeffree
- Department of Neurosurgery, Royal Brisbane and Women’s Hospital,
Herston, Australia
- University of Queensland School of Medicine, Herston,
Australia
| | - Mark Paine
- Department of Neurology, Royal Brisbane and Women’s Hospital,
Herston, Australia
| | - Lucie Voldanova
- Department of Anaesthesia, Royal Brisbane and Women’s Hospital,
Herston, Australia
| | - Ann-Maree Craven
- Department of Obstetric Medicine, Royal Brisbane and Women’s
Hospital, Herston, Australia
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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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Shim T, Chillakuru Y, Moncada P, Kim S, Sabetrasekh P, Sparks A, Mulcahy CF, Monfared A. Sensorineural Hearing Loss and Tinnitus Characteristics in Patients With Idiopathic Intracranial Hypertension. Otol Neurotol 2021; 42:1323-1328. [PMID: 34172653 DOI: 10.1097/mao.0000000000003213] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES To characterize patterns of sensorineural hearing loss (SNHL) and tinnitus in patients with idiopathic intracranial hypertension (IIH). STUDY DESIGN Retrospective chart review. SETTING Tertiary referral center. PATIENTS Adult patients diagnosed with IIH via lumbar puncture (LP) between 2010 and 2020 who had available audiograms. The study included a total of 40 patients; 33 women, and 7 men with a median age of 43. INTERVENTIONS Diagnostic LP and audiogram. MAIN OUTCOME MEASURES Otologic symptoms, ophthalmologic signs, hearing thresholds, cerebrospinal fluid opening pressures. RESULTS The most commonly reported symptoms were tinnitus in 28 (70%, 23 pulsatile and 5 tonal), aural fullness in 11 (28%), and vertigo in 10 (25%). Twenty-nine patients had ophthalmologic examinations and 18 had evidence of papilledema. Twenty-five (63%) patients had hearing loss in at least one ear at one frequency range. Patients presented with both unilateral and bilateral hearing loss across low, middle, and high frequency ranges. No significant association was observed between hearing loss threshold and LP opening pressure except for 250 Hz in the left ear. After stratification by tinnitus group (pulsatile, tonal, and no tinnitus), no significant difference was found between mean hearing loss threshold at different frequencies. In addition, no significant mean age difference was identified in patients within each tinnitus group. CONCLUSIONS There was no classic pattern or presentation for hearing loss in our IIH patients. They developed sudden, unilateral, or bilateral SNHL in low, middle, or high frequency range. The degree of hearing loss did not correlate with CSF opening pressure.
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Affiliation(s)
- Timothy Shim
- Division of Otolaryngology-Head and Neck Surgery, George Washington University School of Medicine & Health Sciences, Washington, DC
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Essibayi MA, Oushy SH, Lanzino G, Brinjikji W. Venous Causes of Pulsatile Tinnitus: Clinical Presentation, Clinical and Radiographic Evaluation, Pathogenesis, and Endovascular Treatments: A Literature Review. Neurosurgery 2021; 89:760-768. [PMID: 34392338 DOI: 10.1093/neuros/nyab299] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2021] [Accepted: 06/09/2021] [Indexed: 12/19/2022] Open
Abstract
Tinnitus is an abnormal perception of a sound without external stimulation. Venous pulsatile tinnitus (VPT) is a specific form of tinnitus characterized by an objective and often subjective bruit that occurs as a result of localized venous abnormalities. Clinical evaluation relies on sound quality, duration, and precipitating factors. Idiopathic intracranial hypertension (IIH) and transverse sinus stenosis (TSS) are among the most common causes of VPT. Other causes include sigmoid sinus wall abnormalities (SSWAs), jugular vein anomalies (JVAs), and emissary veins anomalies. These anomalies can be detected on magnetic resonance imaging, magnetic resonance angiography/magnetic resonance venography, and high-resolution temporal bone computed tomography. The pathogenesis behind the VPT includes turbulent blood flow as a result of luminal stenosis or abnormal dilation, amplification of internal sound due to temporal bone defects, and abnormal position of the venous sinus system structures adjacent to the bony structures of the auditive apparatus. Based on these theories, different interventional treatment modalities can be applied to treat the underlying causes. Endovascular treatments have shown high efficacy and safety among those treatments which include stenting of the lateral sinus stenosis in IIH and TSS, coiling of the SSWA and JVA, and embolization of emissary veins anomalies. Further studies are needed to understand the natural history of these anomalies and the efficacy of treatments of VPT, which-unlike other types of tinnitus-can be cured with proper treatment.
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Affiliation(s)
| | - Soliman H Oushy
- Department of Neurosurgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Giuseppe Lanzino
- Department of Neurosurgery, Mayo Clinic, Rochester, Minnesota, USA.,Department of Radiology, Mayo Clinic, Rochester, Minnesota, USA
| | - Waleed Brinjikji
- Department of Neurosurgery, Mayo Clinic, Rochester, Minnesota, USA.,Department of Radiology, Mayo Clinic, Rochester, Minnesota, USA
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Domingo RA, Ravindran K, Kulakova K, Tawk RG. Intracranial Access: Dural Venous Sinus Stenting: 2-Dimensional Operative Video. Oper Neurosurg (Hagerstown) 2021; 21:E113-E114. [PMID: 33891009 DOI: 10.1093/ons/opab120] [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: 12/23/2020] [Accepted: 02/21/2021] [Indexed: 11/13/2022] Open
Abstract
Cerebral venous sinus stenting has gained popularity in recent years as a safe and efficacious treatment of selected patients with idiopathic intracranial hypertension (IIH) and focal venous sinus stenosis.1-3 The main goal of treatment is to prevent visual loss, and often patients report resolution of headache and visual symptoms within 21 mo of mean follow-up.4-8 We present the case of a 57-yr-old woman with medically refractory IIH, bilateral sinus stenosis, and a mass lesion causing stenosis on the left. Venous angiogram with pressure monitoring was completed with the patient awake, which showed a significant pressure gradient on the right (19 mm Hg) and borderline gradient on the left (8 mm Hg). Options were reviewed and decision was made to proceed with the treatment of the right-sided stenosis with stenting and continue with the observation of the lesion on the left to prevent further visual deterioration. The patient consented for the procedure, and she tolerated the procedure well. Neurological exam remained at baseline, and she was discharged home on post-operative day #1. At 2 mo's follow-up, the patient reported improvement in headaches and remained intact neurologically.
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Affiliation(s)
- Ricardo A Domingo
- Department of Neurologic Surgery, Mayo Clinic, Jacksonville, Florida, USA
| | - Krishnan Ravindran
- Department of Neurologic Surgery, Mayo Clinic, Jacksonville, Florida, USA
| | - Katya Kulakova
- Department of Neurologic Surgery, Mayo Clinic, Jacksonville, Florida, USA.,Sechenov First Moscow State Medical University, Moscow, Russia
| | - Rabih G Tawk
- Department of Neurologic Surgery, Mayo Clinic, Jacksonville, Florida, USA
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Mollan SP, Grech O, Sinclair AJ. Headache attributed to idiopathic intracranial hypertension and persistent post-idiopathic intracranial hypertension headache: A narrative review. Headache 2021; 61:808-816. [PMID: 34106464 DOI: 10.1111/head.14125] [Citation(s) in RCA: 34] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2021] [Accepted: 04/12/2021] [Indexed: 01/01/2023]
Abstract
OBJECTIVE Headache is a near-universal sequela of idiopathic intracranial hypertension (IIH). The aim of this paper is to report current knowledge of headache in IIH and to identify therapeutic options. BACKGROUND Disability in IIH is predominantly driven by headache; thus, headache management is an urgent and unmet clinical need. At present, there is currently no scientific evidence for the directed use of abortive or preventative headache therapy. METHODS A detailed search of the scientific literature and narrative review was performed. RESULTS Headache in IIH is driven by raised intracranial pressure (ICP) and reduction of ICP has been reported in some studies to reduce headache. Despite resolution of papilledema and normalization of raised ICP, a majority suffer persistent post-IIH headache. The lack of evidence-based management approaches leaves many untreated. Where clinicians attempt to manage IIH headache, they use off-label therapies to target the prevailing headache phenotype. A recent prospective open-label study demonstrated the effective use of a calcitonin gene-related peptide monoclonal antibody therapy in IIH for persistent post-IIH headache. CONCLUSIONS There is overwhelming evidence of the headache burden in IIH. Studies are required to investigate the biological foundations of headache related to ICP and to develop treatments specifically directed to manage headache in IIH.
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Affiliation(s)
- Susan P Mollan
- Birmingham Neuro-Ophthalmology, Queen Elizabeth Hospital, Birmingham, UK
| | - Olivia Grech
- Metabolic Neurology, Institute of Metabolism and Systems Research, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK.,Centre for Endocrinology, Diabetes and Metabolism, Birmingham Health Partners, Birmingham, UK
| | - Alexandra J Sinclair
- Birmingham Neuro-Ophthalmology, Queen Elizabeth Hospital, Birmingham, UK.,Metabolic Neurology, Institute of Metabolism and Systems Research, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK.,Centre for Endocrinology, Diabetes and Metabolism, Birmingham Health Partners, Birmingham, UK.,Department of Neurology, University Hospitals Birmingham NHS Foundation Trust, Queen Elizabeth Hospital, Birmingham, UK
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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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12
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Hong CS, Kundishora AJ, Elsamadicy AA, Vining EM, Manes RP, Omay SB. A Unique Subset: Idiopathic Intracranial Hypertension Presenting as Spontaneous CSF Leak of the Anterior Skull Base. Skull Base Surg 2021; 83:105-115. [DOI: 10.1055/s-0040-1716898] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2020] [Accepted: 08/09/2020] [Indexed: 10/22/2022]
Abstract
Abstract
Introduction Spontaneous cerebrospinal fluid (CSF) leaks represent a unique clinical presentation of idiopathic intracranial hypertension (IIH), lacking classical features of IIH, including severe headaches, papilledema, and markedly elevated opening pressures.
Methods Following a single-institution retrospective review of patients undergoing spontaneous CSF leak repair, we performed a literature review of spontaneous CSF leak in patients previously undiagnosed with IIH, querying PubMed.
Results Our literature review yielded 26 studies, comprising 716 patients. Average age was 51 years with 80.8% female predominance, and average body mass index was 35.5. Presenting symptoms included headaches (32.5%), visual disturbances (4.2%), and a history of meningitis (15.3%). Papilledema occurred in 14.1%. An empty sella was present in 77.7%. Slit ventricles and venous sinus stenosis comprised 7.7 and 31.8%, respectively. CSF leak most commonly originated from the sphenoid sinus (41.1%), cribriform plate (25.4%), and ethmoid skull base (20.4%). Preoperative opening pressures were normal at 22.4 cm H2O and elevated postoperatively to 30.8 cm H2O. 19.1% of patients underwent shunt placement. CSF leak recurred after repair in 10.5% of patients, 78.6% involving the initial site. A total of 85.7% of these patients were managed with repeat surgical intervention, and 23.2% underwent a shunting procedure.
Conclusion Spontaneous CSF leaks represent a distinct variant of IIH, distinguished by decreased prevalence of headaches, lack of visual deficits, and normal opening pressures. Delayed measurement of opening pressure after leak repair may be helpful to diagnose IIH. Permanent CSF diversion may be indicated in patients exhibiting significantly elevated opening pressures postoperatively, refractory symptoms of IIH, or recurrent CSF leak.
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Affiliation(s)
- Christopher S. Hong
- Department of Neurosurgery, Yale School of Medicine, Yale University, New Haven, Connecticut, United States
| | - Adam J. Kundishora
- Department of Neurosurgery, Yale School of Medicine, Yale University, New Haven, Connecticut, United States
| | - Aladine A. Elsamadicy
- Department of Neurosurgery, Yale School of Medicine, Yale University, New Haven, Connecticut, United States
| | - Eugenia M. Vining
- Division of Otolaryngology, Department of Surgery, Yale School of Medicine, Yale University, New Haven, Connecticut, United States
| | - R. Peter Manes
- Division of Otolaryngology, Department of Surgery, Yale School of Medicine, Yale University, New Haven, Connecticut, United States
| | - Sacit Bulent Omay
- Department of Neurosurgery, Yale School of Medicine, Yale University, New Haven, Connecticut, United States
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Hamedani AG, Thibault DP, Revere KE, Lee JYK, Grady MS, Willis AW, Liu GT. Trends in the Surgical Treatment of Pseudotumor Cerebri Syndrome in the United States. JAMA Netw Open 2020; 3:e2029669. [PMID: 33320265 PMCID: PMC7739135 DOI: 10.1001/jamanetworkopen.2020.29669] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
IMPORTANCE Optic nerve sheath fenestration (ONSF) and cerebrospinal fluid shunting are sometimes used to treat pseudotumor cerebri syndrome (PTCS), but their use patterns are unknown. OBJECTIVES To investigate the frequency of surgical PTCS treatment in the United States and to compare patients undergoing ONSF with those treated with shunting. DESIGN, SETTING, AND PARTICIPANTS This was a retrospective longitudinal cross-sectional study. Inpatient data were obtained from the National Inpatient Sample (NIS), and outpatient surgical center data were obtained from the National Survey of Ambulatory Surgery (NSAS) and National Hospital Ambulatory Medical Care Survey (NHAMCS). Included in the analysis were 10 720 patients aged 18 to 65 years with a diagnosis code for PTCS, excluding venous thrombosis and other causes of intracranial hypertension. Time trends were explored and logistic regression was used to measure differences according to age, race/ethnicity, sex, Elixhauser comorbidity index, and other patient and hospital characteristics. Data analysis was performed from March 31 to October 7, 2020. EXPOSURE Treatment for PTCS, excluding venous thrombosis and other causes of intracranial hypertension. MAIN OUTCOMES AND MEASURES Annual number of PTCS-related admissions, ONSFs, and shunt procedures from 2002-2016. Patient and hospital-level characteristics of patients with PTCS undergoing ONSF or shunting were compared. RESULTS Between 2010 and 2016, 297 ONSFs were performed and 10 423 shunts were placed as treatment for PTCS. The procedures were most commonly performed in individuals aged 26 to 35 years (39.4%), and 9920 (92.4%) of the surgically treated patients were women. ONSF was more common among younger patients (eg, adjusted odds ratio [AOR] for patients ≥46 years vs those 18-25 years, 0.22; 95% CI, 0.08-0.61) and in Black, Hispanic, or other minority populations (AOR, 2.37; 95% CI, 1.31-4.30) and less common in the South (AOR, 0.34; 95% CI, 0.13-0.88) and West (AOR, 0.15; 95% CI, 0.04-0.58) compared with the Northeast. Total PTCS-related hospitalizations increased from 6081 (95% CI, 5137-7025) in 2002 to 18 020 (95% CI, 16 607-19 433) in 2016. Shunting increased from 2002 to 2011 and subsequently plateaued and declined. ONSF was used much less frequently, and use has not increased. No instances of outpatient ONSF or shunting for PTCS were recorded in the NSAS or NHAMCS databases. CONCLUSIONS AND RELEVANCE This study's findings suggest that shunting is more common than ONSF and that the use gap has widened as shunting has increased. However, because overall PTCS-related hospitalizations have increased even more rapidly, the percentage of inpatients with PTCS undergoing surgery has decreased. These trends may reflect changes in medical treatment practices and outcomes or growing limitations in access to ophthalmic surgical expertise.
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Affiliation(s)
- Ali G. Hamedani
- Department of Neurology, Perelman School of Medicine, University of Pennsylvania, Philadelphia
- Translational Center of Excellence for Neuroepidemiology and Neurology Outcomes Research, University of Pennsylvania, Philadelphia
- Department of Biostatistics, Epidemiology, and Informatics, Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania, Philadelphia
| | - Dylan P. Thibault
- Department of Neurology, Perelman School of Medicine, University of Pennsylvania, Philadelphia
- Translational Center of Excellence for Neuroepidemiology and Neurology Outcomes Research, University of Pennsylvania, Philadelphia
| | - Karen E. Revere
- Department of Ophthalmology, Perelman School of Medicine, University of Pennsylvania, Philadelphia
- Division of Ophthalmology, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - John Y. K. Lee
- Department of Neurosurgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - M. Sean Grady
- Department of Neurosurgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Allison W. Willis
- Department of Neurology, Perelman School of Medicine, University of Pennsylvania, Philadelphia
- Translational Center of Excellence for Neuroepidemiology and Neurology Outcomes Research, University of Pennsylvania, Philadelphia
- Department of Biostatistics, Epidemiology, and Informatics, Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania, Philadelphia
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia
| | - Grant T. Liu
- Department of Neurology, Perelman School of Medicine, University of Pennsylvania, Philadelphia
- Department of Ophthalmology, Perelman School of Medicine, University of Pennsylvania, Philadelphia
- Division of Ophthalmology, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
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