Venous sinus stenting in idiopathic intracranial hypertension

IIDIOPATHIC INTRACRANIAL HYPERTENSION (IIH)

Mostly affects obese women. Men are twice likely to experience severe vision loss.

Its pathophysiology remains unclear, but has been related to cerebral venous outflow abnormalities, such as dural venous hypertension and dural venous sinus stenosis - cause or consequence?

Symptoms consist of frontal or retro-orbital headaches (+++), nausea, tinnitus, and visual loss (due to papilledema and optic nerve damage).

IIH is a diagnosis of exclusion.

MRI and Veno-RM are highly recommended to:

• exclude secondary causes of increased ICP 
• look for suggestive findings: empty sella turca, enlarged Meckel cave, dural   venous sinus stenosis, flattening of the posterior sclera, distension of the optic   nerve sheaths…

Treatment:

• Weigh loss;
• Medical: Acetazolamide, Topiramate, Furosemide;
• Surgical: Optic nerve sheath fenestration, CSF diversion with ventriculo-  peritoneal shunt, and venous sinus stenting.

CASE REPORT 

A 23-year-old man (BMI 21) presented with headache, tinnitus and bilateral visual obscuration that increased with Valsalva maneuver.

MRI and VENO-MRI

• Secondary causes excluded;
• Hypoplasia/stenosis of the internal 2/3 of the right transverse sinus;
• No other ICH suggestive findings.

DSA

PRESSURE MEASUREMENT

PROCEDURE

Right ICA: Select 5F catheter

Right IJV: NeuronMax catheter w/Select 5F.

• NeuroMax in the sigmoid sinus
• Precise stent (5x30mm) w/ Terumo 0.14 microguide
• Overcome stenosis with the microguide
• Stent deployment in the transverse sinus w/proper patency and caliber

AFTER PROCEDURE & FOLLOW-UP

After the procedure:

• AAS 150 mg + Clopidogrel 75 mg for 3 months and AAS 150 mg for 12 months

Ophthalmology evaluation 2 weeks after the procedure:

• no visual complaints;
• refers disappearance of symptoms;
• no change with Valsalva maneuver;
• resolution of the bilateral papilledema;
• significant bilateral recovery of the visual fields deficit, particularly on   the left eye.

1 YEAR FOLLOW-UP

• No symptoms reported;
• Significant recovery of the visual fields deficit;
• Veno-CT reveals patent right transverse venous sinus.

DISCUSSION & CONCLUSION

Venous stenosis as cause or consequence of IIH?

Challenging management and multidisciplinary discussion

Importance of imaging and pressure measurement (gradient)

Venous stenting as a very effective treatment in this case, however:

• Venous intervention inherent risks
• Follow-up strategy?
• Few long-term studies available