1
|
Pandey A, Schreiber C, Garton ALA, Jung B, Goldberg JL, Kocharian G, Carnevale JA, Boddu SR. Challenges in the use of Venous Sinus Stenting in the Treatment of Idiopathic Intracranial Hypertension and Pulsatile Tinnitus. World Neurosurg 2024; 184:372-386. [PMID: 38590071 DOI: 10.1016/j.wneu.2023.12.164] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2023] [Accepted: 12/30/2023] [Indexed: 04/10/2024]
Abstract
Although numerous case series and meta-analyses have shown the efficacy of venous sinus stenting (VSS) in the treatment of idiopathic intracranial hypertension and idiopathic intracranial hypertension-associated pulsatile tinnitus, there remain numerous challenges to be resolved. There is no widespread agreement on candidacy; pressure gradient and failed medical treatment are common indications, but not all clinicians require medical refractoriness as a criterion. Venous manometry, venography, and cerebral angiography are essential tools for patient assessment, but again disagreements exist regarding the best, or most appropriate, diagnostic imaging choice. Challenges with the VSS technique also exist, such as stent choice and deployment. There are considerations regarding postprocedural balloon angioplasty and pharmacologic treatment, but there is insufficient evidence to formalize postoperative decision making. Although complications of VSS are relatively rare, they include in-stent stenosis, hemorrhage, and subdural hematoma, and the learning curve for VSS presents specific challenges in navigating venous anatomy, emphasizing the need for wider availability of high-quality training. Recurrence of symptoms, particularly stent-adjacent stenosis, poses challenges, and although restenting and cerebrospinal fluid-diverting procedures are options, there is a need for clearer criteria for retreatment strategies. Despite these challenges, when comparing VSS with traditional cerebrospinal fluid-diverting procedures, VSS emerges as a favorable option, with strong clinical outcomes, lower complication rates, and cost-effectiveness. Further research is necessary to refine techniques and indications and address specific aspects of VSS to overcome these challenges.
Collapse
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.
| |
Collapse
|
2
|
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.
Collapse
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
| | | |
Collapse
|
3
|
Thanki S, Guerrero W, Mokin M. Treatment of Pseudotumor Cerebri (Sinus Stenosis). Neurosurg Clin N Am 2022; 33:207-214. [DOI: 10.1016/j.nec.2021.11.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
|
4
|
Rohit W, Rajesh A, Mridula R, Jabeen SA. Idiopathic Intracranial Hypertension - Challenges and Pearls. Neurol India 2022; 69:S434-S442. [PMID: 35103000 DOI: 10.4103/0028-3886.332276] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
Idiopathic intracranial hypertension (IIH) is defined as a syndrome of raised intracranial pressure with normal imaging of the brain and cerebrospinal fluid (CSF) composition. There is a rising incidence and prevalence of this disease related to the increased prevalence of obesity. It typically affects women of working age, and headache is the predominant morbidity in over 90%. The disease is also more prevalent in young males. There are many controversies and myths that surround IIH. There are currently few treatment options for IIH, management is typically medical with those experiencing progressive visual loss undergoing surgical procedures. Weight loss and venous sinus stenting are a few therapies directed at the etiology.
Collapse
Affiliation(s)
- Wadikhaye Rohit
- RVM Institute of Medical Science and Research Centre, Hyderabad, Telangana, India
| | - Alugolu Rajesh
- Department of Neurosurgery, Nizam's Institute of Medical Sciences, Hyderabad, Telangana, India
| | - Rukmini Mridula
- Department of Neurology, Nizam's Institute of Medical Sciences, Hyderabad, Telangana, India
| | - Shaik A Jabeen
- Department of Neurology, Nizam's Institute of Medical Sciences, Hyderabad, Telangana, India
| |
Collapse
|
5
|
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.
Collapse
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
| |
Collapse
|
6
|
Dural venous sinus stenting in the treatment of idiopathic intracranial hypertension: A systematic review and critique of literature. Surv Ophthalmol 2021; 67:271-287. [PMID: 34004224 DOI: 10.1016/j.survophthal.2021.05.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2020] [Revised: 04/23/2021] [Accepted: 05/03/2021] [Indexed: 12/19/2022]
Abstract
Idiopathic intracranial hypertension (IIH) is increased intracranial pressure without a known cause. Dural venous sinus stenting (DVSS) is a relatively new intervention for treatment of IIH refractory to medical therapy and lifestyle modifications. In this review, we outline various hypotheses of IIH pathogenesis and describe the role of venous sinus stenosis and the technical details of DVSS. We also present a summary and critique of the available evidence describing the outcomes of DVSS in IIH and review the evidence-based guidelines for this procedure. We conclude that, although many studies have shown generally favorable outcomes of DVSS in patients with IIH, most have serious limitations, the most common one being paucity of pre- and postprocedure ophthalmological data. Thus, there is not enough available evidence to conclude whether DVSS is an effective procedure for treatment of IIH. We also present the most commonly used indications for DVSS as described in the literature and stress the importance of neuro-ophthalmological assessment before and after the procedure to monitor response and potential complications.
Collapse
|
7
|
Intracranial Venous Sinus Stenting in Idiopathic Intracranial Hypertension: A Case Report and Review of the Literature. Brain Sci 2021; 11:brainsci11030382. [PMID: 33802706 PMCID: PMC8002446 DOI: 10.3390/brainsci11030382] [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: 01/21/2021] [Revised: 02/22/2021] [Accepted: 03/11/2021] [Indexed: 11/17/2022] Open
Abstract
We describe a case of severe headaches, double vision, and progressive vision loss secondary to a ruptured intracranial cyst (IAC) in a 31-year-old woman with no relevant past medical history. The case is peculiar because drainage of the subdural hygroma led to a minimal improvement in vision with persistent elevated intracranial pressure (ICP). Further exploration revealed transverse sinus stenosis necessitating stenting. Evaluation post-stenting showed marked reduction of ICP and improvement in symptoms. This report underscores the importance of comprehensive work-up and suspicion of multiple underlying etiologies that may be crucial to complete resolution of presenting symptoms in some cases. We provide an overview of the clinical indications and evidence for venous sinus stenting in treating idiopathic intracranial hypertension (IIH).
Collapse
|
8
|
Kishore V, Sundararajan SH, Doustaly R, Michael M, Xuan D, Link T, Rapoport B, Patsalides A. Magnetic resonance venography for 3-dimensional live guidance during venous sinus stenting. CVIR Endovasc 2020; 3:66. [PMID: 32915317 PMCID: PMC7486350 DOI: 10.1186/s42155-020-00158-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2020] [Accepted: 09/03/2020] [Indexed: 12/03/2022] Open
Abstract
Purpose The purpose of this study was to report the technique for intraprocedural guidance of endovascular Venous Sinus Stenting procedures using 3-Dimensional (3D) Magnetic Resonance Venography (MRV) as an overlay on live biplanar fluoroscopy. Materials and methods Venous sinus stenting procedures performed between April and December, 2017 with 3D MRV fusion for live guidance were reviewed in this study. A thin-slice, contrast-enhanced MR Venogram was used to create 2 3D models – vessels and skull – for procedural guidance via augmented fluoroscopy (Vessel ASSIST, GE Healthcare, Chicago, IL). The skull model was used in the registration of the 3D overlay on both the frontal and lateral planes, which required 1–2 min of procedural time. The vessel model was used to mark landmarks such as the cortical vein ostia and stenosis on the 3D overlay fused with biplanar fluoroscopy. The retrospective imaging review was conducted by 3 neurointerventionalists and relied on a consensus confidence ranking on a 3-point Likert scale from 1- low confidence to 3- high confidence. The neurointerventionalists first reviewed the conventional 2-dimensional pre-stent deployment fluoroscopy images and then reviewed the corresponding images with the 3D MRV overlay. They ranked their confidence in their understanding of cortical venous anatomy for each group. Statistical analysis was performed using a Paired T Test at a 99% confidence interval. Results Ten cases were included in the retrospective image review. Operator confidence regarding the location of cortical veins was significantly increased using 3D MRV fusion during venous sinus stenting procedures (1.9 vs 2.9, p = .001). Conclusion 3-Dimensional MRV fusion is feasible and helpful in understanding the venous sinus anatomy and location of important cortical veins during venous sinus stenting procedures.
Collapse
Affiliation(s)
| | - Sri Hari Sundararajan
- Department of Neurosurgery, New York Presbyterian Hospital/Weill Cornell Medical Center, 525 East 68th St, New York, NY, 10065, USA.
| | | | - Marissa Michael
- Department of Neurosurgery, New York Presbyterian Hospital/Weill Cornell Medical Center, 525 East 68th St, New York, NY, 10065, USA
| | - Dwight Xuan
- Department of Aerospace Medicine, Los Angeles Air Force Base, 483 North Aviation Boulevard, Los Angeles, CA, 90245, USA
| | - Thomas Link
- Department of Neurosurgery, New York Presbyterian Hospital/Weill Cornell Medical Center, 525 East 68th St, New York, NY, 10065, USA
| | - Benjamin Rapoport
- Department of Neurosurgery, New York Presbyterian Hospital/Weill Cornell Medical Center, 525 East 68th St, New York, NY, 10065, USA
| | - Athos Patsalides
- Department of Neurosurgery, New York Presbyterian Hospital/Weill Cornell Medical Center, 525 East 68th St, New York, NY, 10065, USA
| |
Collapse
|
9
|
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.
Collapse
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
| |
Collapse
|
10
|
Kalyvas A, Neromyliotis E, Koutsarnakis C, Komaitis S, Drosos E, Skandalakis GP, Pantazi M, Gobin YP, Stranjalis G, Patsalides A. A systematic review of surgical treatments of idiopathic intracranial hypertension (IIH). Neurosurg Rev 2020; 44:773-792. [PMID: 32335853 DOI: 10.1007/s10143-020-01288-1] [Citation(s) in RCA: 66] [Impact Index Per Article: 16.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2019] [Revised: 03/10/2020] [Accepted: 03/17/2020] [Indexed: 01/28/2023]
Abstract
Idiopathic intracranial hypertension denotes raised intracranial pressure in the absence of an identifiable cause and presents with symptoms relating to elevated ICP, namely headaches and visual deterioration. Treatment of IIH aims at reducing intracranial pressure, relieving headache and salvaging patients' vision. Surgical interventions are recommended for medically refractory IIH and include CSF diversion techniques, optic nerve sheath fenestration, bariatric surgery and venous sinus stenting. Prospective studies on the surgical options for IIH are scant and no evidence-based guidelines for the surgical management of medically refractory IIH have been established. A search in Cochrane Library, MEDLINE and EMBASE from 1 January 1985 to 19 April 2019 for controlled or observational studies on the surgical treatment of IIH (defined in accordance with the modified Dandy or the modified Friedman criteria) in adults yielded 109 admissible studies. VSS improved papilledema, visual fields and headaches in 87.1%, 72.7% and 72.1% of the patients respectively, with a 2.3% severe complication rate and 11.3% failure rate. CSF diversion techniques diminished papilledema, visual field deterioration and headaches in 78.9%, 66.8% and 69.8% of the cases and are associated with a 9.4 severe complication rate and a 43.4% failure rate. ONSF ameliorated papilledema, visual field defects and headaches in 90.5, 65.2% and 49.3% of patients. Severe complication rate was 2.2% and failure rate was 9.4%. This is currently the largest systematic review for the available operative modalities for IIH. VSS provided the best results in headache resolution and visual outcomes, with low failure rates and a very favourable complication profile. In light of this, VSS ought to be regarded as the first-line surgical modality for the treatment of medically refractory IIH.
Collapse
Affiliation(s)
- Aristotelis Kalyvas
- Division of Neurosurgery, Toronto Western Hospital/University Health Network, University of Toronto, Toronto, ON, Canada. .,Department of Neurosurgery, Evangelismos Hospital, National and Kapodistrian University of Athens, Athens, Greece.
| | - Eleftherios Neromyliotis
- Department of Neurosurgery, Evangelismos Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Christos Koutsarnakis
- Department of Neurosurgery, Evangelismos Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Spyridon Komaitis
- Department of Neurosurgery, Evangelismos Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Evangelos Drosos
- Department of Neurosurgery, Evangelismos Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Georgios P Skandalakis
- Department of Anatomy, Medical School, National and Kapodistrian University of Athens, Athens, Greece
| | - Mantha Pantazi
- Department of Pediatrics, Hatzikosta General Hospital, Ioannina, Greece
| | - Y Pierre Gobin
- Department of Neurological Surgery, New York Presbyterian Hospital/Weill Cornell Medical Center, New York, NY, USA
| | - George Stranjalis
- Department of Neurosurgery, Evangelismos Hospital, National and Kapodistrian University of Athens, Athens, Greece.,Hellenic Center for Neurosurgical Research, "Petros Kokkalis", Athens, Greece
| | - A Patsalides
- Department of Neurological Surgery, New York Presbyterian Hospital/Weill Cornell Medical Center, New York, NY, USA
| |
Collapse
|
11
|
Gurney SP, Ramalingam S, Thomas A, Sinclair AJ, Mollan SP. Exploring The Current Management Idiopathic Intracranial Hypertension, And Understanding The Role Of Dural Venous Sinus Stenting. Eye Brain 2020; 12:1-13. [PMID: 32021528 PMCID: PMC6969694 DOI: 10.2147/eb.s193027] [Citation(s) in RCA: 33] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2019] [Accepted: 11/05/2019] [Indexed: 12/12/2022] Open
Abstract
Idiopathic Intracranial Hypertension (IIH) is a debilitating disorder characterised by raised intracranial pressure (ICP), papilloedema with the potential risk of permanent visual loss, and headaches that are profoundly disabling and reduce the quality of life. The first consensus guidelines have been published on investigation and management of adult IIH and one key area of uncertainty is the utility of dural venous sinus stenting for the management of headache and visual loss. There are an increasing number of series published and to help understand the successes and complications. During a patient physician priority setting, the understanding of the best type of intervention to treat IIH was assigned to the top 10 of most desired research questions for the disease. Ultimately randomised clinical trials (RCTs) in neurovascular stenting for IIH would be instructive, as the literature to date may suffer from publication bias. Due to the increasing incidence of IIH, there is no better time to systematically investigate interventions that may reverse the disease process and achieve remission. In this review we discuss the pathophysiology of IIH in relation to venous sinus stenosis, the role of venous sinus stenting with a review of the relevant literature, the advantages and disadvantages of stenting compared with other surgical interventions, and the future of stenting in the treatment of IIH.
Collapse
Affiliation(s)
- Sam P Gurney
- Birmingham Neuro-Ophthalmology, Queen Elizabeth Hospital, University Hospitals Birmingham, BirminghamB15 2WB, UK
| | - Sateesh Ramalingam
- Neuroradiology Department, Queen Elizabeth Hospital, University Hospitals Birmingham, BirminghamB15 2WB, UK
| | - Alan Thomas
- Neuroradiology Department, Queen Elizabeth Hospital, University Hospitals Birmingham, BirminghamB15 2WB, UK
| | - Alex J Sinclair
- Metabolic Neurology, Institute of Metabolism and Systems Research, College of Medical and Dental Sciences, University of Birmingham, BirminghamB15 2TT, UK
- Centre for Endocrinology, Diabetes and Metabolism, Birmingham Health Partners, BirminghamB15 2TH, UK
- Department of Neurology, University Hospitals Birmingham NHS Foundation Trust, Queen Elizabeth Hospital, BirminghamB15 2WB, UK
| | - Susan P Mollan
- Birmingham Neuro-Ophthalmology, Queen Elizabeth Hospital, University Hospitals Birmingham, BirminghamB15 2WB, UK
| |
Collapse
|
12
|
Schwarz J, Santillan A, Patsalides A. Safely traversing venous sinus stenosis: The "Cobra" technique. Interv Neuroradiol 2019; 26:231-234. [PMID: 31856648 DOI: 10.1177/1591019919894802] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
Abstract
Venous sinus stenting is an accepted and minimally invasive treatment for idiopathic intracranial hypertension associated with significant venous sinus stenosis. There is inherent difficulty in navigating past the region of venous stenosis in order to safely deliver and deploy a stent. We have developed the "Cobra" technique, which allows for the safe and efficient navigation past regions of high-grade venous sinus stenosis.
Collapse
Affiliation(s)
- Justin Schwarz
- Department of Neurological Surgery, New York-Presbyterian Hospital, Weill Cornell Medical Center, New York, NY, USA
| | - Alejandro Santillan
- Department of Neurological Surgery, New York-Presbyterian Hospital, Weill Cornell Medical Center, New York, NY, USA
| | - Athos Patsalides
- Department of Neurological Surgery, New York-Presbyterian Hospital, Weill Cornell Medical Center, New York, NY, USA
| |
Collapse
|
13
|
Daggubati LC, Liu KC. Intracranial Venous Sinus Stenting: A Review of Idiopathic Intracranial Hypertension and Expanding Indications. Cureus 2019; 11:e4008. [PMID: 31001462 PMCID: PMC6450594 DOI: 10.7759/cureus.4008] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2019] [Accepted: 02/04/2019] [Indexed: 02/04/2023] Open
Abstract
Idiopathic intracranial hypertension (IIH) is a functionally limiting disorder secondary to increased intracranial pressures (ICPs) with a prevalence of one per 100,000 persons. It is estimated to cost >$400 million per year in productively. Symptoms classically consist of chronic headaches, papilledema, and visual loss. The pathophysiology is unknown but postulated to involve increased resistance to cerebrospinal fluid (CSF) absorption. Traditional treatments involve weight loss, acetazolamide, CSF diversion, or optic nerve fenestration. More recent technology has allowed exploration of venous sinus stenosis. Through venous sinus stenting (VSS), the ICPs and venous sinus pressures decrease. After treatment, >75% exhibit an improvement in headaches, ~50% improvement in tinnitus, and ~50 % improvement in ophthalmologic testing. Complications are rare but involve stent stenosis, femoral pseudoaneurysm, and hemorrhages. Future studies will look into controlled studies for VSS as well as expansion to other venous structures of the intracranial circulation.
Collapse
Affiliation(s)
- Lekhaj C Daggubati
- Neurosurgery, Penn State Health Milton S. Hershey Medical Center, Hershey, USA
| | - Kenneth C Liu
- Neurosurgery, Penn State Milton Health S. Hershey Medical Center, Hershey, USA
| |
Collapse
|
14
|
Dinkin M, Kesler A. Venous Stenting for Idiopathic Intracranial Hypertension. Neuroophthalmology 2019. [DOI: 10.1007/978-3-319-98455-1_7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022] Open
|
15
|
Li K, Ren M, Meng R, Ding Y, Rajah GB, Wang F, Ji X. Efficacy of stenting in patients with cerebral venous sinus thrombosis-related cerebral venous sinus stenosis. J Neurointerv Surg 2018; 11:307-312. [PMID: 30389898 DOI: 10.1136/neurintsurg-2018-014328] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2018] [Revised: 10/05/2018] [Accepted: 10/08/2018] [Indexed: 01/22/2023]
Abstract
BACKGROUND Venous stenting has been proven to be a safe and effective therapeutic option for patients with idiopathic intracranial hypertension (IIH) and cerebral venous sinus stenosis (CVSS). However, its use in patients with cerebral venous sinus thrombosis-related CVSS has been less reported. PURPOSE To explore the safety and efficacy of stenting for patients with cerebral venous sinus thrombosis (CVST)-related CVSS. METHODS The clinical presentation, treatment, and outcome of patients with CVST-related CVSS received venous stenting in the chronic stage after failed medical treatment were retrospectively evaluated. RESULTS A total of 17 patients with CVST-related CVSS were included. Mean pressure gradient across the CVSS decreased from 11.5±4.2 mmHg prior to stenting to 2.1±1.1 mmHg post- stenting. Mean CSF opening pressure decreased from 33.1±5.5 cmH2O to 18.7±1.7 cmH2O. Both headache and visual disturbance improved or resolved in 78% and 92% of the patients, respectively. Complications included lethal cerebellar hematoma in one case and bilateral occipital epidural hematoma in another case. One of the patients received retreatment with ventriculo-peritoneal shunting due to recurrent headache. CONCLUSION Restoring the patency of stenotic sinuses with stents in patients of CVST-related CVSS unresponsive to medical therapy in the chronic stage may improve symptoms in the majority of the patients. However, a relatively higher cerebral hemorrhage rate was observed and may be related to this pathology. Stenting in this subgroup of CVSS patients may require further evaluation with a larger and long-term study, and should be used with caution at this time.
Collapse
Affiliation(s)
- Ke Li
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China.,Department of Interventional Radiology, The First Affiliated Hospital of Dalian Medical University, Dalian, China
| | - Ming Ren
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Ran Meng
- Department of Neurology, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Yuchuan Ding
- Department of Neurosurgery, Wayne State University School of Medicine, Detroit, Michigan, USA
| | - Gary B Rajah
- Department of Neurosurgery, Wayne State University School of Medicine, Detroit, Michigan, USA
| | - Feng Wang
- Department of Interventional Radiology, The First Affiliated Hospital of Dalian Medical University, Dalian, China
| | - Xunming Ji
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China
| |
Collapse
|
16
|
Boddu SR, Gobin YP, Dinkin M, Oliveira C, Patsalides A. Impaired drainage of vein of Labbé following venous sinus stenting for idiopathic intracranial hypertension. J Neurointerv Surg 2018; 11:300-306. [PMID: 30219791 DOI: 10.1136/neurintsurg-2018-014153] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2018] [Revised: 07/30/2018] [Accepted: 07/30/2018] [Indexed: 11/03/2022]
Abstract
PURPOSE The impact of venous sinus stenting (VSS) on vein of Labbé (VOL) drainage is poorly understood. The purpose of the study is to examine the incidence and potential high risk factors of impaired VOL drainage among idiopathic intracranial hypertension (IIH) patients following VSS. MATERIALS AND METHODS Institutional review board approved prospective evaluation of all IIH patients who underwent VSS over a 5 year period (January 2012 to December 2017) at Weill Cornell Medical Center constituted the study population. Patient demographics, procedural details (laterality of stenting, balloon angioplasty, number of stents, and stent diameters), morphology of the VOL and changes in the flow in the VOL, type of sinus stenosis, and transverse sinus symmetry were evaluated. We used χ2 analysis to evaluate impaired VOL drainage against other variables. Statistical significance was set at 0.05. RESULTS 70 consecutive patients (67 women, 3 men) with a mean age of 31±9.8 years underwent VSS. Stenosis was extrinsic in 63% (n=44) and intrinsic in 37% (n=26) of patients. Impaired drainage of the VOL was detected in 9/70 (13%) patients. Ipsilateral VOL was recognized as dominant in 20% (n=14), co-dominant in 51% (n=36), and non-dominant in 29% (n=20) of patients. Impaired VOL drainage was significantly associated with ipsilateral VOL dominance (P=0.001) and stent diameter of ≥9 mm (P=0.042). All patients demonstrated widely patent VOL on follow-up contrast enhanced MR venography at 3 months and 24 months. CONCLUSION Impaired drainage of the ipsilateral VOL is a potential consequence of VSS with 13% incidence, and has significant association with ipsilateral superficial cortical venous drainage via dominant VOL and stent diameter of ≥9 mm. CLINICAL TRIAL REGISTRATION NCT01407809.
Collapse
Affiliation(s)
- Srikanth R Boddu
- Division of Interventional Neuroradiology, Department of Neurological Surgery, New York Presbyterian Hospital/Weill Cornell Medical Center, New York, USA.,Interventional Neuroradiology, New York Presbyterian Queens Hospital, New York, USA
| | - Y Pierre Gobin
- Division of Interventional Neuroradiology, Department of Neurological Surgery, New York Presbyterian Hospital/Weill Cornell Medical Center, New York, USA
| | - Marc Dinkin
- Department of Ophthalmology, New York Presbyterian Hospital, Weill Cornell Medical College, New York, USA
| | - Cristiano Oliveira
- Department of Ophthalmology, New York Presbyterian Hospital, Weill Cornell Medical College, New York, USA
| | - Athos Patsalides
- Division of Interventional Neuroradiology, Department of Neurological Surgery, New York Presbyterian Hospital/Weill Cornell Medical Center, New York, USA
| |
Collapse
|