Dural Venous Stenting for Idiopathic Intracranial Hypertension- Our

experiences and literature review.

S Saipriya1, C Miranda2, S Chettri2, H Sonwalker2,

S Wuppalapatti2

1 - Central Manchester University Hospitals, Manchester, United Kingdom

2- Royal Preston Hospital, Preston, United Kingdom

EP-33

No disclosures.

Background and Purpose

Idiopathic intracranial hypertension (IIH) is a rare condition which

can lead to visual loss due to chronic papilledema and

secondary optic atrophy if left untreated.

Most of these patients are treated medically but nearly 20%

eventually require surgery1.

A sizeable subset of patients have been shown to have

abnormalities in the venous sinuses, when compared to control

subjects in a study by Farb et al2.

Background and Purpose

Hypotheses have been put forth

suggesting that the stenoses

lead to alterations in the

pressure gradient required for

normal CSF absorption, and

derangements in the feedback

loop mechanism resulting in

increasing CSF production,

decreased absorption and raised

intracranial pressure3,4.

Venous Sinus Stenosis

Altered Pressure Gradient

Reduced CSF Absorption

Increased CSF Pressure

There remains continuous

debate over whether the

association of venous stenoses

is a cause of BIH or is merely a

consequence.

Background and Purpose

Venous Sinus Stenosis

Altered Pressure Gradient

Reduced CSF Absorption

Increased CSF Pressure

Background and PurposeVenous sinus stenting (VSS) is a new, albeit controversial treatment option which aims to reduce the pressure gradient across the stenosis.

A few case series so far have shown promising results with significant clinical improvement in a majority of the patients.

Complications of VSS include perforation of the vessels, stent migration, increased risk of thrombus formation, and restenosis. 5,6

This report outlines our experience with venous sinus stenting in a cohort of patients chosen via a strict selection criteria.

Methods

Patients were selected using a patient selection pathway

based on current evidence as of Jan 2012, after peer

review at a departmental level. 

Selection criteria

Patients had to meet all the below criteria to proceed to diagnostic intracranial

venography.

- Progressive headache as defined by the International headache society

(version 1) Section 7.1.17

- Raised intracranial pressure (ICP)> 250 mmH20

- Normal cerebro-spinal fluid chemistry

- No intracranial disease

- Temporal relation of the headache to raised ICP

- Improvement of symptoms following therapeutic lumbar puncture

- Papilledema/ visual defect/ 6th nerve palsy

Methods

• Selected patients underwent angiography.

• If a significant focal venous stenosis was identified, a stent

was placed across the focal venous sinus stenosis.

• Patients were followed up at 3 and 12 month intervals.

• Post treatment visual fields were compared to pre treatment

figures to assess for improvement.

Results

• A total of 28 patients were referred to our hospital with IIH.

• 27 of these were female with an average age of 42.5 and

average BMI of 28.8.

• 18 patients met the criteria and proceeded to have direct

retrograde cerebral venography (DRCV).

Procedure

• Following vascular access under general anesthesia,

pre-stenosis and post-stenosis pressures were

measured.

The above images depict intravenous catheter tip (arrowed) measuring pre- (Image A) and post- (Image B) stenotic pressures.

A B

Procedure

Following a road map of the stenosis, an intravascular stent was placed (EV3 Protégé or Cordis Precis) was placed.

A B

Image A- Oblique view showing the stenosis, involving the right transverse sinus. Image B- Catheter and guidewire in place for placement of stent.

Procedure

The pressures are reassessed to confirm the absence of a pressure gradient.

A B

Image A shows a digital subtraction images showing a deployed stent. Image B is an oblique view taken post stenting, with a normal caliber of the transverse sinus.

ResultsThe patients were followed up at 3, 6 and 12 months.

Condition Significance

Gradient across stenosis (Pre- and Post- stent)

12 (1-62) 3 (0-16) <0.05

Proceeded for stenting 19

No stenosis identified 1

Post procedure complications within 24 hours

1

Symptom improvement at 3 months 17

Symptom improvement at 6 months 14

Symptom improvement at 12 months 14

Results

• All but 1 of our patients had demonstrable venous sinus

stenoses.

• All of the stenoses involved the transverse sinus, with 11

patients having bilateral transverse sinus stenoses.

• 1 of our patients who was stented had a serious complication-

hemorrhagic stroke with post procedural disability.

Results

• 14/18 patients (78%) had sustained symptomatic

improvement of visual acuity even 12 months after the

procedure.

• 12/ 18 patients (67%) also noted relief of headache.

• 6 patients needed further CSF drainage to relieve headache

and 3 of these went on to require a lumbar peritoneal CSF

shunt

Results

• Of the remaining 10 patients who did not qualify for DRCV:

– 4 underwent lumbar peritoneal CSF shunt insertion

– 1 continues to be treated by intermittent CSF drainage

– 5 were lost to follow up

Conclusion

• The pathophysiology of BIH is still not fully understood.

• There is a strong association between the presence of venous

stenoses, esp. transverse sinus stenosis, and BIH.

• There is continued debate over whether this causes BIH or is

merely a consequence of BIH.

• Recent studies have shown cerebral venous sinus stenting

(VSS) to be a treatment modality in some patients with BIH.

Conclusion

• A review article published in the Lancet analyzed a total of 31

patients, and documented similar outcomes8.

• In our study, 78% of the patients who were stented showed

sustained symptomatic improvement at 12 months.

• Further controlled prospective studies are required to evaluate

this new treatment option.

References

1. Burgett RA, Purvin VA, Kawasaki A: Lumboperitoneal shunting for pseudotumor cerebri. Neurology

1997;49:734–739

2. Farb R, Vanek I, Scott J, Mikulis D, Willinsky R, Tomlinson G, Brugge K. Idiopathic intracranial

hypertension: the prevalence and morphology of sinovenous stenosis. Neurology. 2003;60:1418–24

3. Bateman GA. Idiopathic intracranial hypertension: priaprism of the brain? Medical Hypotheses.

2004;63:549–52

4. Davson H, Hollingworth G, Segai M. The mechanism of drainage of the cerebrospinal fluid. Brain.

1970;93:665–78.

5. Thrombus formation- Malek AM, Higashida RT, Balousek PA, Phatouros CC, Smith WS, Dowd CF:

Endovascular recanalization with balloon angioplasty and stenting of an occluded occipital sinus for

treatment of intracranial venous hypertension: technical case report. Neurosurgery 1999;44:896–901

6. Tsumoto T, Miyamoto T, Shimizu M, Inui Y, Nakakita K, Hayashi S, et al: Restenosis of the sigmoid

sinus after stenting for treatment of intracranial venous hypertension: case report. Neuroradiology

2003;45:911–915

7. Headache classification committee of the International Headache Society (HIS) Version 1.

8. Higgins JN, Owler BK, Cousins C, Pickard JD. Venous sinus stenting for refractory benign

intracranial hypertension.Lancet Jan 2002;19;359(9302):228-30