Venous Sinus Pulsatility and the Potential Role of Dural Incompetence in Idiopathic Intracranial Hypertension

*Department of Neurology, Medical College of Wisconsin and Froedtert Hospital, Milwaukee, Wisconsin ‡Department of Ophthalmology, Medical College of Wisconsin and Froedtert Hospital, Milwaukee, Wisconsin §Clement Zablocki VA Medical Center, Milwaukee, Wisconsin ¶Arrowhead Neurosurgery, Desert Regional Medical Center, Palm Springs, California ‖Department of Neurosurgery, Medical College of Wisconsin and Froedtert Hospital, Milwaukee, Wisconsin #Department of Radiology, Medical College of Wisconsin and Froedtert Hospital, Milwaukee, Wisconsin.
Neurosurgery (Impact Factor: 3.62). 10/2012; 71(4):877-884. DOI: 10.1227/NEU.0b013e318267a8f9
Source: PubMed


BACKGROUND:: Idiopathic intracranial hypertension (IIH) remains a poorly understood and therapeutically challenging disease. Enthusiasm has emerged for endovascular therapy with stent reconstruction of dural sinus narrowing; however, a complete understanding of the hydrodynamic dysequilibrium is lacking. OBJECTIVE:: To review and characterize catheter manometry findings including pulsatility changes within the venous sinuses in IIH. METHODS:: Cases of venous sinus stent implantation for IIH were retrospectively reviewed. RESULTS:: Three cases of venous sinus stent implantation for treatment of IIH are reported. All cases demonstrated severe narrowing (>70%) within the transverse sinus and a high pressure gradient across the lesion (>30 mm Hg). Stent implantation resulted in pulsatility attenuation, correction of pressure gradient, and improvement of flow. CONCLUSION:: We report the finding of high venous sinus pulsatility attenuation after stent implantation for dural sinus narrowing and propose the hypothesis that this finding is a marker of advanced dural sinus incompetence. This characteristic may be useful in identifying patients who would benefit from endovascular stent remodeling. ABBREVIATIONS:: DSN, dural sinus narrowingDSV, digital subtraction venographyICP, intracranial pressureIIH, idiopathic intracranial hypertensionMRV, magnetic resonance venography.

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    ABSTRACT: Background: Idiopathic intracranial hypertension (IIH) is a disorder characterized by signs and symptoms of increased intracranial pressure without structural cause seen on conventional imaging. Hallmark treatment after failed medical management, has been CSF shunting or optic nerve fenestration with the goal of treatment being preservation of vision. Recently, there have been multiple case reports and case series on dural sinus stenting for this disorder. Objective: We aim to review all published cases and case series of dural sinus stenting for IIH, with analysis of patient presenting symptoms, objective findings (CSF pressures, papilledema, pressure gradients across dural sinuses), follow-up of objective findings, and complications. Methods: A Medline search was performed to identify studies meeting pre-specified criteria of a case report or case series of patients treated with dural sinus stent placement for IIH. The manuscripts were reviewed and data was extracted. Results: A total of 22 studies were identified, of which 19 studies representing 207 patients met criteria and were included in the analysis. Only 3 major complications related to procedure were identified. Headaches resolved or improved in 81% of patients. Papilledema improved the (172/189) 90%. Sinus pressure decreased from an average of 30.3 to 15 mm Hg. Sinus pressure gradient decreased from 18.5 (n=185) to 3.2 mm Hg (n=172). Stenting had an overall symptom improvement rate of 87%. Conclusion: Although all published case reports and case series are nonrandomized, the low complication and high symptom improvement rate make dural sinus stenting for IIH a potential alternative surgical treatment. Standardized patient selection and randomization trials or registry are warranted.
    Full-text · Article · Jan 2013
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    ABSTRACT: BACKGROUND Previous studies have demonstrated that cerebral dural sinus stenosis (DSS) may be a potential patho-physiological cause of idiopathic intracranial hypertension (IIH). Endovascular therapy for DSS is emerging as a potential alternative to treat IIH. Here, we present the results of our case series. METHOD We prospectively collected angiographic and manometric data on patients that underwent angioplasty/stenting for IIH. All patients had failed maximal medical therapy (MMT) and had confirmed sinus stenosis. Demographic, clinical and radiological presentation, and outcomes were collected retrospectively. RESULTSA total of 18 patients underwent 25 procedures. Demographics revealed a mean age of 30 (range 15-59), 83% (15/18) were female, 72% (13/18) were white, and mean body mass index of 36 (range 23-59.2). All patients presented with classic IIH. Symptom improvement or resolution was reported in 94% (17/18) of patients. All patients had resolution and/or stabilization/improvement of their papilledema. Headaches related to increased pressure improved in 56% (10/18). Re-stenosis and retreatment occurred in 33% (6/18). No procedural related complications were reported. CONCLUSION Dural sinus angioplasty and stenting is relatively safe, feasible, and clinically efficacious for patients with symptomatic sinus stenosis who have failed standard therapy. The long-term durability of patency and clinical improvement remains unknown.
    Full-text · Article · Nov 2013 · Journal of neuroimaging: official journal of the American Society of Neuroimaging
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    ABSTRACT: Idiopathic intracranial hypertension (IIH) is a potentially blinding disease and may require surgical management when maximal medical treatment has failed. The purpose of this review is to discuss the current literature on surgical and endovascular treatments for IIH. The most commonly performed surgical treatments for IIH are cerebrospinal fluid diversion procedures (e.g. ventriculo- and lumbo-peritoneal shunts) and optic nerve sheath fenestration. Controversy still exists about which is the preferred initial surgical treatment for IIH. Emerging procedures include venous sinus stenting in cases with venous sinus stenosis, and bariatric surgery for weight loss. Cranial (suboccipital or subtemporal) decompression was a more popular surgical procedure in the past, but can still have a role in selected cases with impaired cerebrospinal flow dynamics (e.g. Chiari malformation) or after multiple failed conventional surgical procedures. This review compares and contrasts the surgical management options for IIH.
    No preview · Article · Nov 2013 · Current opinion in neurology
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