Idiopathic intracranial hypertension: 120-day clinical, radiological, and manometric outcomes after stent insertion into the dural venous sinus

Intravascular ultrasound characteristics of different types of stenosis in idiopathic intracranial hypertension with venous sinus stenosis

BACKGROUND

In this study, we analyzed the characteristics of different stenosis types in idiopathic intracranial hypertension (IIH) patients with venous sinus stenosis (VSS) using intravascular ultrasound (IVUS).

METHODS

We retrospectively reviewed data from patients who underwent IVUS evaluation during venography or stenting procedures between January 2014 and February 2022.

RESULTS

Among the 80 patients with intrinsic lesions, 47 cases were identified, including 41 single lesions and 6 multiple lesions. Single lesions consisted of 36 cases of AG, 3 cases of brain herniation, and 2 cases of septation. Multiple intrinsic lesions were found in 6 patients, with AG observed in the transverse sinus and sigmoid sinus. IVUS features varied depending on the anatomical variations of intrinsic stenosis. Additionally, among the 33 cases of extrinsic stenosis, two types were observed: unilateral compression (22 cases) and bilateral compression (11 cases), primarily affecting the transverse sinus.

CONCLUSION

IVUS effectively differentiated intrinsic and extrinsic types of stenosis and identified intraluminal and mural components of intrinsic stenosis.

Venous sinus stenting for idiopathic intracranial hypertension: An updated Meta-analysis

BACKGROUND

Idiopathic intracranial hypertension (IIH) is characterized by elevated intracranial pressure and primarily affects obese women of reproductive age. Venous sinus stenting (VSS) is a surgical procedure used to treat IIH, but its safety and efficacy are still controversial.

METHODS

A systematic review and meta-analysis were conducted following PRISMA guidelines. Multiple databases were searched for studies evaluating the safety and efficacy of VSS in IIH patients and meta-analysis was performed to pool the data.

RESULTS

A total of 36 studies involving 1066 patients who underwent VSS were included. After VSS, a significant reduction in trans-stenotic gradient pressure was observed. Patients also showed significantly lower cerebrospinal fluid (CSF) opening pressure. Clinical outcomes demonstrated improvement in tinnitus (95%), papilledema (89%), visual disturbances (88%), and headache (79%). However, 13.7% of patients experienced treatment failure or complications. The treatment failure rate was 8.35%, characterized by worsening symptoms and recurrence of IIH. The complications rate was 5.35%, including subdural hemorrhage, urinary tract infection, stent thrombus formation, and others.

CONCLUSION

VSS appears to be a safe and effective treatment option for IIH patients who are unresponsive to medical therapy or have significant visual symptoms. However, long-term outcomes and safety of the procedure require further investigation.

Stenting for Venous Sinus Stenosis in Patients With Idiopathic Intracranial Hypertension: An Updated Systematic Review and Meta-Analysis of the Literature

BACKGROUND AND OBJECTIVES

Although venous sinus stenting (VSS) improves cerebrospinal fluid reabsorption and decreases intracranial pressure in patients with idiopathic intracranial hypertension (IIH), the underlying pathophysiology of IIH is not well understood. We present a review and meta-analysis of the literature on VSS for IIH treatment, focusing on the rates of restenosis and symptom recurrence.

METHODS

We performed a systematic review of PubMed and Embase databases between January 1, 2011, and December 31, 2021. Articles including ≥5 patients with IIH and venous sinus stenosis treated with VSS and post-treatment rates of restenosis (de novo stenosis at a different anatomic location along the dural sinuses or restenosis within or adjacent to the stent) were selected. Demographic, procedural, and outcomes data were collected and analyzed. Mean values for variables collected were pooled, and a mean value was calculated with a 95% CI.

RESULTS

Twenty-four articles were included, comprising 694 patients and 781 VSS cases. The mean age was 33.9 (CI, 31.5-36.2) years. The mean body mass index was 35.3 (CI, 32.9-37.7) kg/m 2 . Before VSS, 98.8% (CI, 96.8%-100.0%) of patients experienced headaches, 87.7% (CI, 80.6%-95.5%) had visual acuity issues, 78.7% (CI, 69.9%-88.5%) had papilledema, 58.3% (CI, 46.0%-73.9%) had tinnitus, and 98.8% (96.4%-100.0%) had symptoms refractory to previous therapies. After VSS, 77.7% (CI, 71.1%-84.95%) experienced symptom improvement and 22.3% (CI, 15.1%-29.0%) had persistent or worsened symptoms. Pooled restenosis rate was 17.7% (CI, 14.9%-20.9%).

CONCLUSION

VSS is effective in alleviating IIH signs and symptoms, but the associated high rates of restenosis and persistent symptoms highlight the need for further investigation of this procedure and other adjunctive treatments for IIH.

Idiopathic Intracranial Venous Hypertension: Toward a Better Understanding of Venous Stenosis and the Role of Stenting in Idiopathic Intracranial Hypertension

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.

Zilver stent versus Carotid Wallstent for endovascular treatment of idiopathic intracranial hypertension

BACKGROUND

Venous sinus stenting (VSS) is a promising treatment option for medically refractory idiopathic intracranial hypertension (IIH). There are no published studies comparing the performance of different types of stents employed in VSS procedures. In this study we aimed to compare the safety and efficacy outcomes of the Zilver 518 (Cook Medical, Bloomington, Indiana, USA) and the Carotid Wallstent (Boston Scientific, Marlborough, Massachusetts, USA) devices.

METHODS

Records of patients with IIH who underwent VSS between January 2015 and February 2022 at a single referral center were retrospectively reviewed. Patients treated with the Zilver stent or Carotid Wallstent were included in the study. Stent model and size data, pre- and post-treatment pressure gradients, technical and safety outcomes, and pre- and post- stenting papilledema, headache, and tinnitus severity were collected. The χ2 and Fisher-Freeman-Halton tests were used for categorical data and the Student's t-test and Mann-Whitney U test were employed to examine the differences in non-categorical variables.

RESULTS

A total of 81 procedures (28 (34.5%) with the Zilver stent and 53 (65.5%) with the Carotid Wallstent) were performed in 76 patients. The mean procedure time was significantly shorter with the Zilver stent (22.56±10.2 vs 33.9±15 min, p=0.001). The papilledema improvement and resolution rates did not significantly differ between groups (94.7% vs 94.5%, p>0.99 for improvement; 78.9% vs 67.5%, p=0.37 for resolution). The tinnitus improvement and resolution rates in the Zilver stent group were significantly higher than those of the Carotid Wallstent group (100% vs 78.9%, p=0.041; 90% vs 63.1%, p=0.03, respectively). Additionally, the Zilver stent provided a significantly higher rate of headache resolution and improvement than the Carotid Wallstent (84.6% vs 27.6%, p=0.001 for resolution; 92.3% vs 72.3%, p=0.043 for improvement). One patient from the Carotid Wallstent group underwent re-stenting due to in-stent stenosis and refractory papilledema. No significant in-stent stenosis was observed in the Zilver stent group.

CONCLUSION

Stent choice may affect VSS outcomes. The Zilver stent provided better clinical outcomes than the Carotid Wallstent, with significantly shorter procedure times. Larger studies are needed to determine the efficacy of available venous stents for IIH.

Primary balloon angioplasty of venous Sinus stenosis in idiopathic intracranial hypertension

BACKGROUND

Venous sinus stenosis (VSS) stenting has emerged as an effective treatment for patients with Idiopathic Intracranial Hypertension (IIH). However, stenting carries risk of in-stent stenosis/thrombosis and cumulative bleeding risk from long-term dual antiplatelet (DAPT) use. Thus, we investigated the potential safety and efficacy of primary balloon angioplasty as an alternative to stenting in IIH.

METHODS

A prospectively maintained single-center registry of IIH patients undergoing endovascular procedures was queried. Inclusion criteria included patients with confirmed IIH and angiographically demonstrable VSS who underwent interventions from 2012- 2021. Patients were dichotomized into primary balloon angioplasty (Group A) and primary stenting (Group S), comparing clinical outcomes using bivariate analyses.

RESULTS

62 patients were included with median age of 33 [IQR 26-37], 74% females. Group A (9/62) and Group S (53/62) had similar baseline characteristics. Papilledema improvement was higher in Group S at 6 weeks and 6 months (44 vs. 93, p = 0.002 and 44 vs. 92%, p = 0.004), with similar improvements across all symptoms. Group S had higher mean post-procedure venous pressure gradient change (8 vs. 3 mmHg, p = 0.02) and a lower CSF opening pressure at 6 months (23 vs. 36 cmH2O, p < 0.001). VPS rescue rate was higher in Group A (44 vs. 2%, p = 0.001). There was only one procedural complications; a subdural hematoma in Group A.

CONCLUSIONS

Primary VSS balloon angioplasty provides a marginal and short-lived improvement of IIH symptoms compared to stenting. These findings suggest a cautious and limited role for short-term rescue angioplasty in poor shunting and stenting candidates with refractory IIH.

Current and emerging diagnostic and management approaches for idiopathic intracranial hypertension

INTRODUCTION

Idiopathic intracranial hypertension is characterized by raised intracranial pressure that triggers disabling headaches and can cause permanent visual loss. There is an increased incidence and prevalence of the condition linked to location-specific obesity rates. There are no licensed treatments for the condition. The majority of approaches to managing the disease prioritize resolution of papilledema. However, evidence is emerging that idiopathic intracranial hypertension is a systemic metabolic disease.

AREAS COVERED

The aim of this review is to present the emerging pathophysiology evidence which is leading to novel targeted therapeutics. The diagnostic pathway is outlined. The current and potential management approaches for idiopathic intracranial hypertension are also discussed.

EXPERT OPINION

Idiopathic intracranial hypertension is a condition with metabolic dysregulation with systemic manifestations that are present over and above what can be expl.ained by obesity alone. While most of the current management of this condition focuses on the eyes, future management needs to address the disabling headaches and the systemic risks of preeclampsia, gestational diabetes, and major cardiovascular events.

Venous Sinus Stenting for Low Pressure Gradient Stenoses in Idiopathic Intracranial Hypertension

BACKGROUND

Medically refractory idiopathic intracranial hypertension (IIH) is frequently treated with venous sinus stenosis stenting with high success rates. Patient selection has been driven almost exclusively by identification of supraphysiological venous pressure gradients across stenotic regions based on theoretical assessment of likelihood of response.

OBJECTIVE

To explore the possibility of benefit in low venous pressure gradient patients.

METHODS

Using a single-center, prospectively maintained registry of patients with IIH undergoing venous stenting, we defined treatment groups by gradient pressures of ≤4, 5 to 8, and >8 mmHg based on the most frequently previously published thresholds for stenting. Baseline demographics, clinical, and neuro-ophthalmological outcomes (including optical coherence tomography and Humphrey visual fields) were compared.

RESULTS

Among 53 patients, the mean age was 32 years and 70% female with a mean body mass index was 36 kg/m 2 . Baseline characteristics were similar between groups. The mean change in lumbar puncture opening pressure at 6 months poststenting was similar between the 3 groups (≤4, 5-8, and >8 mmHg; 13.4, 12.9, and 12.4 cmH 2 O, P = .47). Papilledema improvement was observed across groups at 6 months (100, 93, and 86, P = .7) as were all clinical symptoms. The mean changes in optical coherence tomography retinal nerve fiber layer (-30, -54, and -104, P = .5) and mean deviation in Humphrey visual fields (60, 64, and 67, P = .5) at 6 weeks were not significantly different.

CONCLUSION

Patients with IH with low venous pressure gradient venous sinus stenosis seem to benefit equally from venous stenting compared with their higher gradient counterparts. Re-evaluation of our restrictive criteria for this potentially vision sparing intervention is warranted. Future prospective confirmatory studies are needed.

Cerebral venous anatomy: implications for the neurointerventionalist

Meaningful contributions to neurointerventional practice may be possible by considering the dynamic aspects of angiography in addition to fixed morphologic information. The functional approach to venous anatomy requires integration of the traditional static anatomic features of the system-deep, superficial, posterior fossa, medullary veins, venous sinuses, and outflow routes into an overall appreciation of how a classic model of drainage is altered, embryologically, or pathologically, depending on patterns of flow-visualization made possible by angiography. In this review, emphasis is placed on balance between alternative venous networks and their redundancy, and the problems which arise when these systems are lacking. The role of veins in major neurovascular diseases, such as dural arteriovenous fistulae, arteriovenous malformations, pulsatile tinnitus, and intracranial hypertension, is highlighted, and deficiencies in knowledge emphasized.

Comparison of Dural Venous Sinus Volumes Before and After Flight in Astronauts With and Without Spaceflight-Associated Neuro-Ocular Syndrome

IMPORTANCE

Spaceflight-associated neuro-ocular syndrome (SANS) occurs in 40% to 60% of National Aeronautics and Space Administration (NASA) International Space Station (ISS) astronauts who present postflight with ophthalmological findings and elevated intracranial pressure. The etiology of SANS is unknown; it is hypothesized that venous outflow congestion from the head and neck occurs because of microgravity, which is supported by the finding of internal jugular vein stagnant flow and thrombosis in some astronauts, but the impact on intracranial dural venous sinus structures remains unknown.

OBJECTIVES

To clarify the potential risk of retrograde extension of clot intracranially among astronauts with internal jugular venous thrombosis by evaluating intracranial venous structures following spaceflight and to assess for any association between intracranial venous congestion and SANS.

DESIGN, SETTING, AND PARTICIPANTS

This retrospective cohort study of all NASA astronauts who had undergone magnetic resonance (MR) venography at the time of the study included quantitative and qualitative assessments of the intracranial venous system on preflight and postflight MR venograms. Data were collected a mean (SD) of 525.8 (187.5) days before spaceflight and 2.0 (1.5) days after return to Earth. A semiautomated segmentation of the venogram images was used, which was then compared with a neuroradiologist's assessment.

EXPOSURES

A mean (SD) 184.3 (66.0) days of ISS spaceflight missions.

MAIN OUTCOMES AND MEASURES

Dural venous sinus volumes before and after spaceflight.

RESULTS

A total of 12 astronauts (2 [16.67%] women; 10 [83.33%] men), with a mean (SD) age of 47.8 (5.8) years, were included. Overall, 4 astronauts (33.33%) met the diagnostic criteria for SANS. No dural venous sinus thrombosis was detected for any astronaut. Astronauts with SANS had significantly greater median (range) preflight to postflight increases in volume vs astronauts without SANS for all 3 venous sinus structures: superior sagittal sinus (13.40% [8.70% to 17.47%] vs -2.66% [-15.84% to 5.31%,]; P = .004), right transverse/sigmoid sinus (17.15% [7.63% to 30.08%] vs 0.77% [-14.98% to 15.12%]; P = .02), and left transverse/sigmoid sinus (9.40% [5.20% to 15.50%] vs -1.40% [-14.20% to 12.50%]; P = .03). There was a positive correlation between the neuroradiologist's evaluation and the semiautomated method for the superior sagittal sinus (rpb = 0.64; P = .02) and the right transverse/sigmoid sinus (rpb = 0.58; P = .050).

CONCLUSIONS AND RELEVANCE

These findings, in conjunction with the growing body of evidence of abnormal blood flow dynamics during spaceflight, suggest an association between intracranial venous congestion and SANS. Thus, there is an implication that individuals with increased venous sinus compliance may be at increased risk of developing SANS. These findings should be confirmed in a larger astronaut population and may contribute to understanding disorders of intracranial venous outflow on Earth.

Characteristics and Outcomes of the Idiopathic Intracranial Hypertension Treatment in Intrinsic and Extrinsic Stenosis: A Single-Center Experience in China

INTRODUCTION

This study aimed to explore the precipitating factors and evaluate the impact of different stenosis types on treatment outcomes in patients with idiopathic intracranial hypertension (IIH) and venous sinus stenosis (VSS).

METHODS

We recruited patients with IIH who presented with VSS, either intrinsic or extrinsic. We observed the clinical and laboratory findings, and we then compared the outcomes of stenting and medical treatment in different stenosis types.

RESULTS

Among 145 patients with IIH and VSS, 59 were of the intrinsic type and 86 were of the extrinsic type. Patients in the intrinsic group were older (42 vs. 34 years old, P < 0.001) and presented with higher pre-op gradient pressure (15 mmHg vs. 12 mmHg, P < 0.001). There was no significant difference between groups regarding other precipitating factors (P > 0.05). Stenting was significantly associated with complete resolution of the headache and impaired vision both in intrinsic (adjusted OR 0.017, 95% CI 0.001-0.35, P = 0.011; adjusted OR 0.056, 95% CI 0.004-0.697, P = 0.025, respectively) and extrinsic types of stenosis (adjusted OR 0.072, 95% CI 0.015-0.343, P = 0.001; adjusted OR 0.241, 95% CI 0.062-0.931, P = 0.039, respectively). Meanwhile, stenting was significantly associated with improvement of the papilledema in extrinsic-type stenosis compared with medical treatment (adjusted OR 0.017, 95% CI 0.002-0.135, P < 0.001).

CONCLUSION

Stenting may provide substantial clinical improvement in patients with IIH regardless of intrinsic or extrinsic stenosis type in our patient population, as noted in other series.

TRIAL REGISTRATION

Clinical trial registration number ChiCTR-ONN-17010421.

Dural venous sinus stenting in the treatment of idiopathic intracranial hypertension: A systematic review and critique of literature

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.

Major complications of dural venous sinus stenting for idiopathic intracranial hypertension: case series and management considerations

BACKGROUND

Venous sinus stenting (VSS) is a safe, effective, and increasingly popular treatment option for selected patients with idiopathic intracranial hypertension (IIH). Serious complications associated with VSS are rarely reported.

METHODS

Serious complications after VSS were identified retrospectively from multicenter databases. The cases are presented and management strategies are discussed.

RESULTS

Six major acute and chronic complications after VSS were selected from a total of 811 VSS procedures and 1466 venograms for IIH. These included an acute subdural hematoma from venous extravasation, cases of both intraprocedural and delayed stent thrombosis, an ultimately fatal cerebellar hemorrhage resulting in acute obstructive hydrocephalus, venous microcatheter perforation during venography and manometry, and a patient who developed subarachnoid hemorrhage and subdural hematoma after cerebellar cortical vein perforation. The six cases are reviewed and learning points regarding complication avoidance and management are presented.

CONCLUSION

We report on six rare, major complications after VSS for IIH. Familiarity with these potential complications and appropriate timely management may allow for good clinical outcomes.

Venous sinus stenting for intractable pulsatile tinnitus: A review of indications and outcomes

Background:

Pulsatile tinnitus presents as a unique variation of tinnitus in which a conscious perception of the heartbeat is localized to the ears in either unilateral or bilateral fashion. The sensation is typically caused by an increase in turbulent blood flow in the affected ear, in most cases, due to a structural abnormality of the venous sinuses – the most common of which being stenosis. Herein, we discuss the etiology of pulsatile tinnitus followed by indications for treatment of various pathologies which have been successfully treated with venous sinus stenting and have led to resolution of auditory symptoms.

Methods:

The authors queried PubMed database using combinations of the keywords “venous sinus stenting,” “endovascular treatment,” and “pulsatile tinnitus” to identify relevant studies published in English after 2001 and before December 1, 2020 and verified selected.

Results:

Our results corroborate those published in prior reviews reporting a high rate of pulsatile tinnitus resolution with venous sinus stenting.

Conclusion:

The success of venous sinus stenting is clinically relevant as an effective treatment option for patients suffering from pulsatile tinnitus. Future applications and studies are needed and are currently being developed to further demonstrate the effectiveness of stents in the treatment of pulsatile tinnitus.

Emerging themes in idiopathic intracranial hypertension

PURPOSE

Idiopathic intracranial hypertension (IIH) is a rare disorder characterised by raised intracranial pressure. The underlying pathophysiology is mostly unknown and effective treatment is an unmet clinical need in this disease. This review evaluates key emerging themes regarding disease characteristics, mechanisms contributing to raised intracranial pressure and advances in potential therapeutic targets.

FINDINGS

IIH is becoming more common, with the incidence rising in parallel with the global obesity epidemic. Current medical management remains centred around weight management, which is challenging. Metabolic investigations of patients have identified specific androgen profiles in cerebrospinal fluid (CSF), which suggest an endocrine dysfunction impacting CSF secretion in IIH. Glucagon-like peptide-1 (GLP-1) and 11β-hydroxysteroid dehydrogenase type 1 (11β-HSD1) have been found to play a role in CSF dynamics in IIH and have formed the basis of the first clinical trials looking at new treatments.

CONCLUSIONS

Identification of novel molecular targets thought to underlie IIH pathology is now being translated to clinical trials.

Styloidogenic jugular venous compression syndrome: a case report and review of the literature

BACKGROUND

Styloidogenic jugular venous compression syndrome (SJVCS) has been shown to present with a similar symptomatology to idiopathic intracranial hypertension (IIH) and is caused by compression of the internal jugular vein (IJV) between the lateral tubercle of C1 and the styloid process. Treatments including venous stenting and styloidectomy have been reported with good outcomes; however, treatment of a pediatric patient with SJVCS with styloidectomy has not previously been reported in the literature.

CASE REPORT

A 12-year-old male presented with refractory positional headaches, nausea, and vomiting, and after, workup including lumbar puncture (LP) and intracranial pressure (ICP) monitoring was found to have intracranial hypertension associated with contralateral neck turning. Computed tomography venogram (CTV) revealed severe bilateral compression of the IJV's between the styloid processes and C1 tubercle. The patient was successfully treated with unilateral right-sided styloidectomy with symptomatic relief.

CONCLUSIONS

This is the first reported pediatric case of SJVCS treated successfully with styloidectomy to our knowledge and adds to the limited literature that styloidectomy is a durable treatment option for SJVCS.

Styloidogenic Jugular Venous Compression Syndrome: Clinical Features and Case Series

BACKGROUND

Styloidogenic jugular venous compression syndrome (SJVCS) is a rare cause of idiopathic intracranial hypertension (IIH).

OBJECTIVE

To elucidate the pathophysiology and the hemodynamics of SJVCS.

METHODS

We conducted a retrospective review of medical records, clinical images, dynamic venography, and manometry for consecutive patients with SJVCS undergoing microsurgical decompression from April 2009 to October 2017. Patients with IIH with normal venography and manometry findings served as controls.

RESULTS

Data were analyzed for 10 patients with SJVCS who presented with headaches. Neck flexion exacerbated headaches in 7 patients. Eleven patients with IIH provided control data for normal intracranial venous pressure and styloid process anatomy. Patients with SJVCS had bilateral osseous compression of venous outflow. The styloid processes were significantly longer in patients with SJVCS than in those with IIH (mean [standard deviation (SD)] distance, 31.0 [10.6] vs 19.0 [14.1] mm; P < .01). The styloid process-C1 lateral tubercle distance was shorter in patients with SJVCS than in those with IIH (mean [SD] distance, 2.9 [1.0] vs 9.9 [2.8] mm; P < .01). Patients with SJVCS had significantly higher global venous pressure and a higher pressure gradient across the stenosis site than controls (mean [SD] pressure, 2.86 [2.61] vs 0.13 [1.09] cm H2O; P = .09). All 10 patients with SJVCS experienced venous pressure elevation during contralateral neck turning (mean [SD] pressure, 4.29 [2.50] cm H2O). All 10 patients with SJVCS underwent transcervical microsurgical decompression, and 9 experienced postoperative improvement or resolution of symptoms. One patient had transient postoperative dysphagia and facial drooping, and another patient reported jaw numbness.

CONCLUSION

SJVCS is a novel clinical entity causing IIH. Patients should be evaluated with dynamic venography with manometry. Surgical decompression with removal of osseous overgrowth is an effective treatment in select patients.

A systematic review of surgical treatments of idiopathic intracranial hypertension (IIH)

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.

Exploring The Current Management Idiopathic Intracranial Hypertension, And Understanding The Role Of Dural Venous Sinus Stenting

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.

Neuroendovascular Cerebral Sinus Stenting in Idiopathic Intracranial Hypertension

Idiopathic intracranial hypertension (IIH) is a rare, ill-understood disease of significant morbidity. Because the pathophysiology is poorly understood, treatment protocols are not uniform and are directed towards alleviating the most common symptoms: headache and visual loss. In this review, we analyze 25 case series, all of which included IIH patients (n = 408) who were treated with placement of a venous sinus stent. Among 342 patients who had headache, 240 patients (70.2%) had improvement or resolution of headache after the stent insertion. Of the 217 patients documented to have visual problems, visual acuity was improved or stabilized in 161 patients (74.2%). Of the 304 patients with papilledema, 257 showed resolution or improved (84.5%). Of the 124 patients who presented with pulsatile tinnitus, it was resolved in 110 patients (88.7%) after stent placement. Endovascular management of dural sinus stenosis is therefore clinically efficacious in patients with IIH who have failed medical and surgical therapy.

Stenting of symptomatic lateral sinus thrombosis refractory to mechanical thrombectomy

OBJECTIVE

Endovascular mechanical thrombectomy for the treatment of cerebral venous sinus thrombosis is not always successful. We present our experience of using self-expanding stents to facilitate effective recanalization of persistent lateral sinus thrombosis refractory to endovascular mechanical thrombectomy.

METHODS

Data from patients who underwent endovascular mechanical thrombectomy for the treatment of acute symptomatic cerebral venous sinus thrombosis between August 2015 and July 2018 were evaluated. Patient demographics, procedural techniques, devices used and follow-up outcomes were assessed.

RESULTS

A total of 14 patients underwent endovascular mechanical thrombectomy during the study period. Of these, stenting of the occluded sinus was performed in five patients with extensive sinus thrombosis after conventional endovascular mechanical thrombectomy. Three of the five patients had a variable degree of venous infarction and/or hemorrhage before treatment. The target lesion was located in the right lateral sinus in all five patients. Due to the length of the involved sinus, two stents were required in one patient and three stents in two patients. The only procedure-related complication was an asymptomatic tearing of the sinus wall in one patient. Stent patency could not be maintained in two patients due to stent buckling within the jugular foramen segment and an inability to maintain antiplatelet medication. Modified Rankin Scale scores at 2-16 months were zero in two patients, one in two patients, and five in one patient.

CONCLUSIONS

Stenting for the thrombotic occlusion of the lateral sinus is a feasible rescue method to overcome unsuccessful endovascular mechanical thrombectomy. However, currently available stenting systems may be unsuitable for use in the intracranial dural sinus system.

Headache attributed to cranial venous sinus stenting: A case series and literature review

Background

The diagnostic criteria for headache attributable to cranial venous sinus stenting were first formalized in the recently published third edition of the International Classification of Headache Disorders (ICHD-3). However, the diagnostic criteria for headache caused by cranial venous sinus stenting are based on very few data and the condition is poorly characterized.

Objectives

To validate the diagnostic criteria for cranial venous sinus stenting headache by retrospectively studying the characteristics of headache in patients with isolated pulsatile tinnitus who underwent curative cranial venous sinus stenting and who had not previously complained of headache.

Patients and methods

We retrospectively studied clinical, radiological, and manometric data from patients with isolated venous pulsatile tinnitus who had not previously reported headache. All patients underwent lateral sinus stenting in our institution between October 2010 and February 2018.

Results

Forty eight patients, 47 females and one male, were enrolled. The mean age at symptom onset was 36.2 ± 8.7 years and the mean body mass index was 24.0 ± 3.2 kg/m2. Lateral sinus stenosis was evident in 47 patients and a sigmoid diverticulum in one. Fourteen patients experienced headaches after recovering from general anesthesia. All were female, with a mean age of 35.5 ± 9.6 years. Headache persisted for less than 3 days in six patients (42.8%); for 3 days to 3 months in four (28.6%); and for longer than 3 months in four (28.6%). The headaches were located on the same sides as the cranial venous sinus stents in 13 patients (92.9%) and were principally occipital, being oppressive in nine patients (64.3%) and of moderate intensity in seven (50%). Age at onset of pulsatile tinnitus and body mass index were significantly associated with headache ( p < 0.05; t-test).

Conclusion

To the best of our knowledge, this is the first study to describe cranial venous sinus stenting headache in detail. We found that de novo headache developed after cranial venous sinus stenting, and was usually mild to moderate, unilateral, but oppressive; almost one-third of such headaches persisted for more than 3 months. Researchers and clinicians must become familiar with this headache spectrum; further prospective studies are required.

Reduced Jet Velocity in Venous Flow after CSF Drainage: Assessing Hemodynamic Causes of Pulsatile Tinnitus

BACKGROUND AND PURPOSE

Idiopathic intracranial hypertension is commonly associated with transverse sinus stenosis, a venous cause of pulsatile tinnitus. In patients with idiopathic intracranial hypertension, CSF drainage via lumbar puncture decreases intracranial pressure, which relieves the stenosis, and may provide at least temporary cessation of pulsatile tinnitus. The objective of this study was to evaluate changes in venous blood flow caused by lowered intracranial pressure in patients with pulsatile tinnitus to help identify the cause of pulsatile tinnitus.

MATERIALS AND METHODS

Ten patients with suspected transverse sinus stenosis as a venous etiology for pulsatile tinnitus symptoms underwent MR imaging before and after lumbar puncture in the same session. The protocol included flow assessment and rating of pulsatile tinnitus intensity before and after lumbar puncture and MR venography before lumbar puncture. Post-lumbar puncture MR venography was performed in 1 subject.

RESULTS

There was a lumbar puncture-induced reduction in venous peak velocity that correlated with the opening pressure (r = -0.72, P = .019) without a concomitant reduction in flow rate. Patients with flow jets had their peak velocity reduced by 0.30 ± 0.18 m/s (P = .002), correlating with a reduction in CSF pressure (r = 0.82, P = .024) and the reduction in subjectively scored pulsatile tinnitus intensity (r = 0.78, P = .023). The post-lumbar puncture MR venography demonstrated alleviation of the stenosis.

CONCLUSIONS

Our results show a lumbar puncture-induced reduction in venous peak velocity without a concomitant reduction in flow rate. We hypothesize that the reduction is caused by the expansion of the stenosis after lumbar puncture. Our results further show a correlation between the peak velocity and pulsatile tinnitus intensity, suggesting the flow jet to be instrumental in the development of sound.

Rebound high-pressure headache after treatment of spontaneous intracranial hypotension: MRV study

BACKGROUND

Rebound high-pressure headaches may complicate treatment of spontaneous intracranial hypotension (SIH), but no comprehensive study of such patients has been reported and little is known about its frequency and risk factors. We therefore studied patients undergoing treatment for SIH and performed magnetic resonance venography (MRV) to assess for cerebral venous sinus stenosis, a risk factor for idiopathic intracranial hypertension.

METHODS

We studied a consecutive group of patients who underwent treatment for SIH. Rebound high-pressure headache was defined as a reverse orthostatic headache responsive to acetazolamide. MRV was obtained in all patients and lateral sinus stenosis was scored according to the system published by Higgins et al., with 0 being normal and 4 signifying bilateral signal gaps.

RESULTS

The mean age of the 46 men and 67 women was 45.9 years (range 13-71 years) at the time of onset of SIH. Rebound high-pressure headache was diagnosed in 31 patients (27.4%); 14% of patients with an MRV score of 0, 24% with a score of 1, and 46% with a score of 2 or 3 (p = 0.0092). Also, compared to SIH patients who did not develop rebound high-pressure headaches (n = 82), those with rebound high-pressure headaches were younger, more often female, and more often had an extradural CSF collection on spinal imaging.

CONCLUSIONS

Rebound high-pressure headache occurs in about one-fourth of patients following treatment of SIH and is more common in those with restriction of cerebral venous outflow.

Stent Survival and Stent-Adjacent Stenosis Rates following Venous Sinus Stenting for Idiopathic Intracranial Hypertension: A Systematic Review and Meta-Analysis

Background

Idiopathic intracranial hypertension (IIH) is characterized by an elevated intracranial pressure without any identifiable causative factor such as an intracranial mass. Dural venous sinus stenosis (DVSS) has been suggested to be associated with IIH.

Objective

We performed an updated systematic review and meta-analysis to determine clinical outcomes as well as stent survival and stent-adjacent stenosis rates in patients undergoing DVSS for the management of medically refractory IIH.

Methods

We searched PubMed, Embase, and Cochrane databases to identify prospective or retrospective cohorts or case series of patients with IIH treated with DVSS between 2000 and 2017.

Results

A total of 473 patients were included from 24 studies. Headache was present in 429 (91.8%) patients and resolved or improved in 319/413 (77.2%) after the procedure. Headache, papilledema, visual acuity, and tinnitus improved in 256/330 (77.6%), 247/288 (85.8%), 121/172 (70.3%), and 93/110 (84.5%) patients following DVSS at the final follow-up (mean of 18.3 months). In a meta-analysis of 395 patients with available follow-up data on stenting outcome (mean of 18.9 months), the stent survival and stent-adjacent stenosis rates were 84% (95% confidence interval [CI] 79-87%) and 14% (95% CI 11-18%), respectively. The rate of major neurological complications was less than 2%.

Conclusion

Stent-adjacent stenosis is an important complication following venous stenting in patients with DVSS and IIH. Further studies are needed to identify determinants of stent-adjacent stenosis and stent nonsurvival.

Disease and Treatment-Related Sequelae in Patients with Complex Jugulotympanic Paraganglioma

Background: Jugulotympanic paraganglioma (JTP) are benign, high-vascularized lesions that frequently invade the jugular foramen, temporal bone, the upper neck, and the posterior fossa cavity, resulting in a wide variety of clinical symptoms. Methods: In this retrospective study, we assess the clinical symptoms and discuss the individual multidisciplinary treatment and outcome of 22 patients with JTP. Results: In 12 patients, a hearing deficit was the presenting symptom, whereas pulsatile tinnitus and otalgia were present in six and four patients respectively. Facial nerve involvement was seen in six patients (three HB Grade 1–2 and three HB Grade 4–6). Four patients presented with lower cranial nerve impairment. Rare symptoms were ataxia caused by brainstem compression and papilledema due to cerebral sinus obstruction. A new or worsening of the preoperative facial nerve or lower cranial nerve function occurred in two and four patients respectively. Conclusion: The treatment strategy and the surgical approach for JTP should be tailored to the tumor extension and the patient’s clinical symptoms.