Safety and Clinical Outcomes after Transverse Venous Sinus Stenting for Treatment of Refractory Idiopathic Intracranial Hypertension: Single Center Experience

Background—Idiopathic intracranial hypertension (IIH) is a syndrome of elevated intracranial pressure
of unknown etiology. Unilateral or bilateral transverse sinus (TS) or transverse-sigmoid junction stenosis is
present in about 30%–93% of these patients. There is an ongoing debate on whether venous sinus stenosis
is the cause of IIH or a result of it. The subset of IIH patients who continue to have clinical deterioration
despite maximum medical therapy is termed as “refractory IIH.” Traditionally, cerebrospinal fluid diversion
surgeries (ventriculoperitoneal shunt and lumboperitoneal shunt) and optic nerve sheath fenestration
(ONSF) were the mainstays of treatment for refractory IIH. In the last decade, venous sinus stenting (VSS)
has emerged as a safe and effective option for treating refractory IIH patients with venous sinus stenosis.
Through this study, we want to share our experience with venous stenting in refractory IIH patients with
venous sinus stenosis associated with a significant pressure gradient (≥10 mm Hg).
Methods—Retrospective chart review of all the patients diagnosed with refractory IIH who underwent
VSS or angioplasty at our comprehensive stroke center from November 2016 to March 2019.
Results—A total of seven refractory IIH patients underwent VSS or angioplasty within the specified
period. The mean age was 39 years. Eighty-five percent of the patients were women (n = 6). The mean
body mass index (BMI) was 37 kg/m2
. Headache was the most common symptom (85%, n = 6) followed
by transient visual obscurations (71%, n = 5) and pulsatile tinnitus (57%; n = 4). All patients had papille‐
dema. Fifty-seven percent of patients (n = 4) had impaired visual field. Mean lumbar opening pressure was
40.6 cm H2O (SD = 9.66; 95% CI = 33.5—47.7). All patients were on maximum doses of acetazolamide ±
furosemide. Six patients (85%) had dominant right transverse-sigmoid sinus. Fifty-seven percent of the
patients had severe right transverse ± sigmoid sinus stenosis (n = 4) and the rest (43%) had bilateral TS
stenosis (n = 3). Prestenting mean trans-stenosis pressure gradient was 18 mm Hg (SD = 6.16; 95% CI =
13.43–22.57). Six patients (85%) were treated with TS stenting and one (15%) with only angioplasty. Post‐
stenting mean trans-stenosis pressure gradient was 4.8 mm Hg (SD = 6.6; 95% CI = −0.1–9.7). All patients
were able to come off their medications with significant improvement in neurological and ophthalmological
signs and symptoms. No procedure-related complications occurred.
Conclusion—TS stenting ± angioplasty is a safe and effective means of treating refractory IIH with
venous sinus stenosis associated with a significant pressure gradient (≥10 mm Hg).