Peer-Review ReportIntracranial Venous Sinus Stenting for Benign Intracranial Hypertension: Clinical Indications, Technique, and Preliminary Results
Introduction
Pseudotumor cerebri or benign intracranial hypertension (BIH) refers to a state of increased intracranial pressure (ICP) in the absence of primary cerebral disease on conventional imaging. Patients usually become symptomatic with severe headache, papilledema, and even vision loss. These patients are extremely difficult to manage and often require multiple shunting operations and protracted courses of narcotics or other analgesic medications. Venous sinus stenosis may play a role in the pathogenesis of BIH, but the exact mechanism remains a topic of widespread debate. Specifically, venous sinus stenosis, which is present in more than 90% of patients with BIH, is variously considered both the etiology and the sequella of BIH (15). Venous sinus stenosis and the resultant elevated intrasinus pressure may produce BIH by impeding cerebrospinal fluid absorption within the arachnoid granulations. Conversely, elevated ICP may produce compression and stenosis of the dural venous sinuses.
Venous sinus stenting is a recent phenomenon, made possible by the introduction of flexible stents capable of navigating the intracranial venous circulation. Preliminary evidence from a handful of small case series has shown promising results when sinus stenting has been used for the treatment of BIH. We report the largest experience with venous sinus stenting for the treatment of BIH to date.
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Materials and Methods
During the past 2.5 years, we performed 19 venous sinus stenting procedures in 18 patients with BIH (15 women, 3 men, mean age 31 years, age range 12–51 years). Indications for venous sinus stenting were a clinical diagnosis of BIH with venographic demonstration of venous sinus stenosis. Only patients demonstrating more than 50% stenosis were included in the study. All patients presented with headache and either elevated intracranial pressure or papilledema. Conventional angiography,
Results
All patients underwent unilateral stent placement, including one patient who required additional stenting in a second setting (Table 1). Stenting was successful in all patients (100%). There was one temporary, procedurally related complication, a retroperitoneal hematoma that resulted in a decrease in the hematocrit without the need for transfusion. No patient suffered a permanent complication as a result of treatment. Potential complications from venous sinus stenting include sinus perforation
Discussion
BIH often occurs in young, overweight women between the ages of 20 and 50 years. The disease phenotype consists of severe headache, papilledema, and even vision loss. These patients are difficult to manage and often require multiple cerebrospinal fluid (CSF) shunting operations with poor pain control. The etiology and pathophysiology of BIH is poorly understood. Proposed etiologies include reaction to certain drugs, CSF overproduction, decreased intracranial compliance, endocrine abnormalities,
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Conflict of interest statement: The authors declare that the article content was composed in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.