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Unilateral Transverse Sinus Stenting of Patients with Idiopathic Intracranial Hypertension - AJNR News Digest
June 2014
Interventional

Unilateral Transverse Sinus Stenting of Patients with Idiopathic Intracranial Hypertension

David Pelz

David Pelz

Idiopathic intracranial hypertension (IIH) is a syndrome caused by raised intracranial CSF pressure (ICP) without an underlying mass lesion, hydrocephalus, or cerebral edema. Patients typically present with intractable headaches (90%), papilledema (89%), visual changes (62%), and pulsatile tinnitus (48%). In North American women, it has a prevalence of 15–19/100,000. If left untreated, it can result in blindness. Since first described by Walter Dandy in 1937, who believed it was related to increased blood or CSF production, the etiology has been and remains controversial. Traditional treatments include medication (acetazolamide), weight loss, CSF diversion surgery, and optic nerve fenestration. There is up to a 45% recurrence rate with medical therapy and significant complication rates with surgery.

With the advent of modern CT and MR imaging, it has been shown that 30–93% of these patients have either unilateral or bilateral transverse sinus (TS) stenosis. It is still unknown whether this is the cause or consequence of raised ICP. Our interest in the topic was stimulated by the initial report of Higgins et al1 that IIH symptoms could be relieved by balloon angioplasty and stenting of the TS stenosis. In our series of 10 patients who had failed medical therapy, unilateral TS stenting resulted in dramatic clinical improvement in all patients. This was one of the largest case series at the time, and led to more interest in the topic. Subsequent case series2,3 showed similar findings, and included mathematical models postulating pathophysiologic mechanisms for the sinus stenosis and clinical responses to stenting.2 A recent review of the literature,3 including 143 patients, has shown a technical success rate of 99% and a complication rate of 6%. Mean follow-up of 22 months has shown improvement in headaches in 88% of patients, resolution of papilledema in 97%, of visual changes in 87%, and of tinnitus in 93% of patients.

TS stenting is now an accepted treatment option for IIH in patients who fail medical management. It is seen as an effective and less invasive alternative to CSF diversion surgery. Although one randomized controlled

trial (RCT) comparing acetazolamide to placebo for IIH has been completed,4 there has been no RCT comparing stenting to other medical or surgical therapies. We would be very interested to participate in such an investigation. Despite the efficacy of venous sinus stenting, the underlying pathophysiology of IIH remains a mystery.

References

  1. Higgins JNP, Owler BK, Cousins C et al. Venous sinus stenting for refractory benign intracranial hypertension. Lancet 2002;359:228–30, 10.1016/S0140-6736(02)07440-8
  2. Ahmed RM, Wilkinson M, Parker GD et al. Transverse sinus stenting for idiopathic intracranial hypertension: a review of 52 patients and of model predictions. AJNR Am J Neuroradiol 2011;32:1408–14, 10.3174/ajnr.A2575
  3. Puffer RC, Mustafa W, Lanzino G. Venous sinus stenting for idiopathic intracranial hypertension: a review of the literature. J Neurointervent Surg 2013;5:483–86, 10.1136/neurintsurg-2012-010468
  4. Wall M, McDermott MP, Kieburtz KD et al. Effect of acetazolamide on visual function in patients with idiopathic intracranial hypertension and mild visual loss: the idiopathic intracranial hypertension trial. JAMA 2014:311:1641–51, 10.1001/jama.2014.3312

 

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