Dural venous sinus stenting for treatment of pediatric idiopathic intracranial hypertension

Adjunctive venous sinus stenting in transvenous embolization of vein of Galen malformations

BACKGROUND

Vein of Galen malformations are congenital arteriovenous malformations primarily treated by endovascular embolization via transarterial or transvenous approaches. transvenous embolization can be utilized to close the malformation but may be difficult in patients with venous stenosis or blockages, which drive venous hypertension and lead to significant neurologic consequences. Here, we illustrate the atypical placement of an intracranial venous sinus stent to improve outflow after transvenous embolization in pediatric patients with the vein of Galen malformation.

METHODS

A retrospective review of clinical databases at two high-volume endovascular centers from January 2018 to March 2023 identified all vein of Galen malformation patients who received a venous sinus stent during transvenous embolization. Clinical data, imaging, angioarchitecture, operative details, postoperative management, and follow-up were reviewed.

RESULTS

Three patients presented for transvenous embolization after multiple staged transarterial embolizations of their vein of Galen malformation. Transvenous access was complicated by lateral sinus stenosis, which was temporarily relieved by balloon angioplasty. After transvenous embolization by pressure cooker technique, the dural sinuses were stented using the existing venous guide catheter. Venous angiography demonstrated improved flow across the stenosed areas and post-embolization angiography demonstrated normalized venous drainage with widely patent stents. One patient experienced postoperative oculomotor nerve palsy unrelated to the stent placement. All patients demonstrated a complete cure of their vein of Galen malformations with patent venous sinus stents on follow-up.

CONCLUSION

In patients with the vein of Galen malformation and venous hypertension receiving transvenous embolization, venous sinus stenting may be a safe and effective option to reduce aberrant cortical venous drainage and improve normal outflow. Further studies are warranted to investigate its benefit in high-flow vascular malformations.

Outcomes of Pulsatile Tinnitus After Cerebral Venous Sinus Stenting: Systematic Review and Pooled Analysis of 616 Patients

BACKGROUND

Pulsatile tinnitus (PT) is a debilitating condition with substantial morbidity related to quality of life. Cerebral venous sinus stenosis has recently emerged as a noninfrequent cause of PT, either in the setting of concurrent idiopathic intracranial hypertension (IIH) or due to primary venous stenosis. Venous sinus stenting (VSS) is an endovascular technique that can be used to treat venous stenosis. However, it is unclear if outcomes are different between patients with primary venogenic PT and IIH associated PT.

METHODS

A systematic literature review and pooled analysis was completed to evaluate the clinical outcomes of PT in patients undergoing cerebral VSS. Outcome measures included: Improved PT, complete resolution of PT, and PT recurrence at follow-up. Subgroup analysis between patients with IIH and primary PT was completed.

RESULTS

In total, 28 studies were identified with 616 patients. The proportion of improved PT symptoms after VSS had an overall pooled rate of 91.7% (confidence interval [CI]:88.1%-95.2%; I2 = 65%) and no difference between subgroups (P = 0.12). Complete resolution after VSS had an overall pooled rate of 88.6% (CI: 84.0%-93.3%; I2 = 68%) and no significant difference between subgroups (P = 0.35). Recurrent PT after stenting occurred in 6.5% of cases (CI: 1.7%-11.3%; I2 = 62%). Furthermore, subgroup analysis demonstrated that IIH patients had a significantly higher recurrence rate (10.6%; CI: 5.2%-16.1%; I2 = 26%) compared to patients treated with venous stenting for PT as the primary indication (2.0%; CI: 0.8%-4.7%; I2 = 0%) (P < 0.0001).

CONCLUSIONS

Venous stenting in patients with PT results in a substantial decrease and often complete resolution of symptoms. PT is more likely to recur in patients with IIH-associated PT.

Selective iliofemoral stent placement for complex pediatric cases: a decade of institutional experience

BACKGROUND

Pediatric iliofemoral venous thromboembolism that is resistant to conventional treatments poses significant management challenges. Stent placement represents a potentially underutilized strategy in children when stenosis or thrombosis persists intraprocedurally or recurs postoperatively, despite treatments such as venoplasty, lysis, and thrombectomy.

OBJECTIVE

This study aims to report our institutional experience with iliofemoral stenting in 17 pediatric patients with recurrent iliofemoral venous thromboembolism or stenosis.

MATERIALS AND METHODS

We performed an IRB-approved retrospective review of pediatric patients (<18 years of age) who underwent iliofemoral venous stenting for recurrent stenosis or thrombosis between January 2012 and December 2022 at a single tertiary care institution. Patient demographics, risk factors for venous thromboembolism, presenting symptoms, and procedural characteristics were recorded. The primary outcome was stent patency rates at interval imaging follow-up.

RESULTS

Seventeen patients with mean age of 14.6 years (range 7-17) and mean BMI of 27.7 were stented during the study period. Sixteen of 17 patients presented with evidence of May-Thurner anatomy. 14/17 patients presented with acute iliofemoral venous thromboembolism, 2/17 with chronic venous thromboembolism, and 1/17 with left lower extremity swelling without thrombosis. Seventy-three total angiographic procedures were performed, which included angioplasty, lysis, and thrombectomy, and 23 stent placements. Patients underwent an average of 3 procedures (range 1-9) over a mean of 2.8 months (range 0-17 months) prior to undergoing stent placement. Stents were deployed successfully in all patients. The median follow-up was 18 months (range, 1-77 months). Primary and secondary patency rates were 13/17 (76%) and 14/14 (100%) at 12 months and 12/17 (71%) and 14/14 (100%) at 24 months, respectively.

CONCLUSION

In our experience of 17 patients, stent placement appears to be a durable option for children with iliofemoral venous thromboembolism following failure to establish vessel patency or development of recurrent thrombosis/stenosis postoperatively.

Venous sinus stenting for idiopathic intracranial hypertension: An updated Meta-analysis

BACKGROUND

Idiopathic intracranial hypertension (IIH) is characterized by elevated intracranial pressure and primarily affects obese women of reproductive age. Venous sinus stenting (VSS) is a surgical procedure used to treat IIH, but its safety and efficacy are still controversial.

METHODS

A systematic review and meta-analysis were conducted following PRISMA guidelines. Multiple databases were searched for studies evaluating the safety and efficacy of VSS in IIH patients and meta-analysis was performed to pool the data.

RESULTS

A total of 36 studies involving 1066 patients who underwent VSS were included. After VSS, a significant reduction in trans-stenotic gradient pressure was observed. Patients also showed significantly lower cerebrospinal fluid (CSF) opening pressure. Clinical outcomes demonstrated improvement in tinnitus (95%), papilledema (89%), visual disturbances (88%), and headache (79%). However, 13.7% of patients experienced treatment failure or complications. The treatment failure rate was 8.35%, characterized by worsening symptoms and recurrence of IIH. The complications rate was 5.35%, including subdural hemorrhage, urinary tract infection, stent thrombus formation, and others.

CONCLUSION

VSS appears to be a safe and effective treatment option for IIH patients who are unresponsive to medical therapy or have significant visual symptoms. However, long-term outcomes and safety of the procedure require further investigation.

Idiopathic Intracranial Venous Hypertension: Toward a Better Understanding of Venous Stenosis and the Role of Stenting in Idiopathic Intracranial Hypertension

BACKGROUND

Venous sinus stenosis, typically at the junction of the transverse and sigmoid sinus, is increasingly recognized as a contributor to the pathophysiology of idiopathic intracranial hypertension (IIH), whether it be the intrinsic type that does not reverse with normalization of intracranial pressure or the extrinsic type, which does. Efforts to treat the stenosis and reduce the associated transstenotic gradient through placement of a stent at the site of stenosis have been studied over the past 2 decades, primarily through retrospective studies, with variable emphasis on formal visual testing and direct assessment of poststent opening pressure. Most studies have presented evidence for utilization of stenting as an alternative to cerebrospinal fluid shunting or optic nerve sheath fenestration in patients with IIH who harbor the stenosis and are refractory to or intolerant of intracranial pressure-lowering medications, but an assessment of the current data is needed to better understand the role of stenting for this patient population.

EVIDENCE ACQUISITION

A search in PubMed was made for "IIH," "papilledema," and "venous stenting." Data pre and post stenting, including symptoms attributable to IIH, intracranial pressure, papilledema, retinal nerve fiber layer thickening on optical coherence tomography, and visual field assessment (mean deviation), were collected. Need for retreatment and complications were assessed among all studies. Studies using stenting for special circumstances, such as cerebrospinal leaks or for stenosis along anomalous vessels, were reviewed.

RESULTS

In total, 49 studies (45 retrospective and 4 prospective) and 18 case reports (with 3 or less patients) were found and included in the analysis, for a total of 1,626 patients. In 250 patients in whom poststent intracranial pressure was measured, the mean value was 19.7 cm H 2 O, reduced from a mean of 33 cm H 2 O. Transient visual obscurations resolved in 79.6% of 201 patients who complained of it, pulsatile tinnitus resolved in 84.7% of 515, diplopia resolved in 93% of 86 patients, and nonspecific visual symptoms such as "blurry vision" improved in 76.2% of 537 patients. Headaches resolved in 36% and improved in a further 40.7% of 1,105 patients in whom they were documented before stenting. Of 1,116 with papilledema, 40.8% demonstrated resolution and 38.2% improvement. The mean retinal nerve fiber layer thickness improved from 170.2 µm to 89.2 µm among 402 eyes in which optical coherence tomography was used to measure it. Among 135 eyes in which formal visual fields were performed pre and post stenting, the prestent average mean deviation of -7.35 dB improved to -4.72 dB after stenting. Complications associated with stenting included in-stent stenosis or thrombosis, subdural hematoma, intracerebral hematoma, cerebral edema, stent migration, and death. A recurrence of symptoms requiring a follow-up surgical intervention occurred in 9%.

CONCLUSIONS

A growing body of evidence supports the use of venous sinus stenting as a viable option for medically refractory IIH, especially when papilledema threatens visual function. Complication and failure rates seem to be similar to alternative surgical approaches, although serious neurological sequalae can rarely occur. Emerging studies evaluating stent type, including novel stents designed for use in the venous system, may help improve ease of the procedure and long-term success rates. Prospective head-to-head studies are needed to better understand the performance of stenting compared with other interventions.

Long-term safety and efficacy of stenting on correcting internal jugular vein and cerebral venous sinus stenosis

OBJECTIVES

To compare the long-term safety and efficacy of stenting in correcting cerebral venous sinus stenosis (CVSS) and internal jugular venous stenosis (IJVS).

METHODS

Patients confirmed with CVSS or IJVS by imaging were enrolled in this real-world study from 2014 through 2021. Clinical characteristics and long-term outcomes of these two diseases entities post-stenting were followed up and compared.

RESULTS

Three hundred and nineteen patients were enrolled in this study, with a mean age of 48.83 years and a BMI of 25.08 on average. In which, 144 patients underwent stenting, the stenotic segments were corrected and the venous blood flow was restored immediately post-stenting. At 6.15 ± 1.67 days follow-up, significant improvement was observed in headache, tinnitus, insomnia, ICP, and mean pressure gradient in both groups (all p < 0.05). At 30.53 ± 4.41 months follow-up post-stenting, the headache, tinnitus, visual loss, papilledema, and insomnia were attenuated remarkably or even completely disappeared. The Frisen papilledema grade scores declined from 2 (0-4) to 1 (0-3) in IJVS group and from 4 (1-5) to 1 (0-4) in CVSS group compared to the baseline. One hundred and twenty-seven out of the 144 patients (95.5%) maintained sufficient blood flow verified by followed up computed tomographic venography or contrast-enhanced magnetic resonance angiography. Adverse events related to stenting included three cases of intraluminal restenosis and three cases of in-stent thrombosis, no intracranial hemorrhage, venous thromboembolisms, stent-adjacent stenosis, and stent displacement occurred.

INTERPRETATION

Using stents to correct IH and related neurological issues has shown to be a safe and effective approach for both IJVS and CVSS.

Coronary Stent for Right Transverse Venous Sinus Stenosis in a Patient With Symptomatic Idiopathic Intracranial Hypertension

A 59-year-old woman was referred to the neuro-interventional team with complaints of headache, papilledema, and visual disturbances. Imaging and Lumbar puncture revealed signs consistent with idiopathic intracranial hypertension with stenosis of the right transverse venous sinus. The neurosurgery board chose to treat her with an endovascular approach and stenting. During the procedure, the right jugular vein revealed decreased blood flow. This led to a left jugular vein access through the confluence of venous dural sinuses. However, an incomplete confluence required the catheter to ascend the superior sagittal sinus before descending to the right transverse sinus. The carotid catheter system kept herniating up the SSS, risking rupture. Given the intraoperative findings and the available equipment, a more flexible coronary catheter system was chosen. This catheter device allowed plasty and successful stent deployment. A lumbar puncture was performed, and the patient was discharged. A follow-up MRI at five weeks showed signs of intracranial hypertension improvement and the patient reported Improvement in symptoms. To our knowledge, this is the first time this type of device has been used in this anatomical location for this pathology.

Life-threatening idiopathic intracranial hypertension: the role of venous sinus stenting

BACKGROUND

Idiopathic intracranial hypertension (IIH) is a clinical syndrome characterised by raised intracranial pressure with no discernible aetiology. It is relatively rare in children and its demographic features may differ from those of adults. The relationship between IIH and venous sinus stenosis (VSS) is well known. As VSS plays an important role in the pathophysiology, treatments have been developed aimed at improving venous blood outflow in refractory IIH. In the last two decades, venous sinus stenting has emerged as a treatment option in cases where stenosis is documented.

METHODS AND RESULTS

The scientific literature on paediatric cases of IIH and its treatment with venous sinus stenting was analysed. We present the case of a 6-year-old girl with a life-threatening presentation of IIH, who was treated with transverse sinus stenting and a lumboperitoneal shunt. We summarise the characteristic of paediatric stenting cases reported and review the literature focusing on the main aspects of venous sinus stenting.

CONCLUSION

VSS stenting could be a treatment tool for the acute presentation of IIH with severe symptoms and VSS plus an elevated trans-stenotic pressure gradient. However, in some cases, additional surgical treatment may be necessary.

Sensorineural Hearing Loss and Tinnitus Characteristics in Patients With Idiopathic Intracranial Hypertension

OBJECTIVES

To characterize patterns of sensorineural hearing loss (SNHL) and tinnitus in patients with idiopathic intracranial hypertension (IIH).

STUDY DESIGN

Retrospective chart review.

SETTING

Tertiary referral center.

PATIENTS

Adult patients diagnosed with IIH via lumbar puncture (LP) between 2010 and 2020 who had available audiograms. The study included a total of 40 patients; 33 women, and 7 men with a median age of 43.

INTERVENTIONS

Diagnostic LP and audiogram.

MAIN OUTCOME MEASURES

Otologic symptoms, ophthalmologic signs, hearing thresholds, cerebrospinal fluid opening pressures.

RESULTS

The most commonly reported symptoms were tinnitus in 28 (70%, 23 pulsatile and 5 tonal), aural fullness in 11 (28%), and vertigo in 10 (25%). Twenty-nine patients had ophthalmologic examinations and 18 had evidence of papilledema. Twenty-five (63%) patients had hearing loss in at least one ear at one frequency range. Patients presented with both unilateral and bilateral hearing loss across low, middle, and high frequency ranges. No significant association was observed between hearing loss threshold and LP opening pressure except for 250 Hz in the left ear. After stratification by tinnitus group (pulsatile, tonal, and no tinnitus), no significant difference was found between mean hearing loss threshold at different frequencies. In addition, no significant mean age difference was identified in patients within each tinnitus group.

CONCLUSIONS

There was no classic pattern or presentation for hearing loss in our IIH patients. They developed sudden, unilateral, or bilateral SNHL in low, middle, or high frequency range. The degree of hearing loss did not correlate with CSF opening pressure.

Management of idiopathic intracranial hypertension in children utilizing venous sinus stenting

BACKGROUND

Venous sinus stenting (VSS) is an accepted and minimally invasive treatment for adult idiopathic intracranial hypertension (IIH) associated with lateral sinus stenosis (LSS). The efficacy and safety of venous sinus stenting (VSS) in children with IIH has not been established.

METHODS

This is a retrospective analysis of IIH patients 18 years of age or younger with LSS treated with VSS at our institution. Included patients have fulminant disease course or are refractory or intolerant to medical management.

RESULTS

Eight patients were identified; 4 males and 4 females. Mean age is 13.4 years (range 4-18). All patients had severe headaches, 5 had blurred vision, 3 had diplopia and 3 had pulsatile tinnitus. Papilledema was present in 4 patients. Three patients had prior surgical procedures. Four patients were intolerant to medical management, 3 were refractory and 1 had fulminant course. Cerebral venography demonstrated severe stenosis of the dominant sinus in 6 patients and of bilateral co-dominant sinuses in 2 patients. Six patients had intrinsic stenosis and 2 had extrinsic stenosis. Venous sinus stenting (VSS) resulted in improvement of symptoms, papilledema and normalization of CSF opening pressure in 7 patients. No immediate complications were observed. Mean follow-up period is 21 months (range 6-42). Two patients required re-stenting; one responded well and the other had persistent symptoms and underwent subsequent surgical procedures of CSF diversion, suboccipital decompression and duraplasty which were also ineffective.

CONCLUSION

VSS may provide a viable option for pediatric IIH patients who are intolerant to medication, have failed conservative management or prior surgical interventions, or present with fulminant disease.