Elsevier

World Neurosurgery

Volume 75, Issues 5–6, May–June 2011, Pages 648-652
World Neurosurgery

Peer-Review Report
Intracranial Venous Sinus Stenting for Benign Intracranial Hypertension: Clinical Indications, Technique, and Preliminary Results

https://doi.org/10.1016/j.wneu.2010.11.012Get rights and content

Objective

The cause of pseudotumor cerebri, or benign intracranial hypertension (BIH), is controversial. We report our results from 18 cases of venous sinus stenting (VSS), the largest series in the literature, with specific focus on the rate of technical success, amelioration of the subjective symptom of headache, attendant complications, and radiographic patency on follow-up.

Methods

Review of our prospectively maintained database identified 18 patients who had undergone 19 VSS procedures for the placement of 30 stents in the past 2.5 years. Indications for treatment included a clinical diagnosis of BIH with venographic demonstration of stenosis.

Results

VSS was technically successful in all patients (100%). No patient suffered a permanent complication. Three patients were lost to follow-up. The remaining 15 patients were followed clinically and asked to rate their headache severity on a scale of 1 to 10 both before and after VSS. Overall, 12 patients (80%) qualified their headaches as better after VSS, two stated that they were the same, and one patient said that they were worse. Of 14 patients who underwent follow-up angiography, all demonstrated normal patency of the stented segments. In one of these patients, stenosis was detected on follow-up in the unstented segment of the sigmoid sinus and jugular bulb.

Conclusions

VSS is highly effective (80%) in ameliorating headache associated with BIH. The procedure is associated with a high rate of technical success (100%), a low rate of permanent complications (0), and a high rate of stent patency on follow-up angiography (100%).

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.

Section snippets

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,

References (27)

  • Q. Chen et al.

    Lateral sinus thrombosis and intracranial hypertension associated with primary hypothyroidism: case report

    Neuro Endocrinol Lett

    (2008)
  • S. Couban et al.

    Cerebral venous sinus thrombosis presenting as idiopathic intracranial hypertension

    CMAJ

    (1991)
  • A. Donnet et al.

    Endovascular treatment of idiopathic intracranial hypertension: clinical and radiologic outcome of 10 consecutive patients

    Neurology

    (2008)
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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.

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