Venous Sinus Stenting: Safety and Health Care Resource Evaluation for Optimal Recovery in an Evolving Health Care Environment

Introduction/purpose Evaluate the role of intravascular ultrasound (IVUS) in the cerebral venous sinus angioplasty and stenting. Materials and methods The study population included all patients treated with dural venous sinus stenting (DVS) at our institution over a 3-year period (January 2012–December 2014). Depending on age and presence of visual symptoms at presentation, the patients were either enrolled in the FDA approved prospective clinical trial of “Venous sinus stenting in patients with idiopathic intracranial hypertension (IIH) refractory to medical therapy” or were enrolled in a prospective patient registry, both approved by our Institutional Review Board. Patient demographics, clinical presentation, imaging findings and procedural details were obtained from the institutional prospective database (RedCap). Eagle Eye ST (Short Tip) intravenous ultrasound (IVUS) device (Volcano Corporation) was used to measure the maximum luminal diameter of the superior sagittal sinus, proximal transverse sinus, distal transverse sinus stenosis and the sigmoid sinus beyond the stenosis. Similar measurements at identical locations were made on preprocedural MR venography (phase contrast-INHANCE) and digital subtraction angiography (DSA). DSA measurements are obtained under both, the conscious sedation (venous manometry) and general anesthesia (venous sinus stenting). Feasibility of IVUS and technical complications were documented for each procedure. Statistical analysis performed using student t-Test. Results Twenty patients with 21 procedures of DVS of distal transverse sinus constituted the study population. The mean age of the study population was 27.1 ± 7 years (16–39 years) and 19 out of 20 are female patients. Sixteen patients (n = 16) had DVS on the right side and four patients (n = 4) on the left side. The measured venous sinus diameters on IVUS are: 6.6 ± 1.5 mm for superior sagittal sinus, 6.3 ± 1.7 mm for proximal transverse sinus, 2.7 ± 0.6 mm for distal transverse stenosis and 7.5 ± 2.5 mm for post stenotic sigmoid sinus. Venous sinus measurements including the stenosis on MR venography (6.7 ± 1.0 mm, 6.2 ± 1.5 mm, 3.1 ± 0.9 mm and 7.7 ± 1.2 mm respectively) are concordant to the IVUS (p = 0.74). The maximum diameter of the stenosis measured on DSA is significantly higher than IVUS, at venous manometry (3.3 ± 1.1 mm; p Successful DVS was confirmed significant increase in the diameter of the stenosis from 4.4 ± 1.8 mm to 6.8 ± 0.9 mm (p IVUS was feasible in all our patients, except one where the IVUS probe failed to advance across a severe stenosis from a large arachnoid granulation. IVUS confirmed the accurate localization of the stenosis in all the feasible patients. No technical or procedural complications were encountered in our study cohort. One patient developed re-stenosis at the distal aspect of the initial stent and required re-stenting. Conclusion In our experience, intravascular ultrasound is a feasible, safe and reliable diagnostic tool; provides valuable supplemental information in the diagnosis and treatment planning of cerebral dural venous sinus stenosis under general anesthesia. Disclosures S. Boddu: None. M. Crimmins: None. M. Dinkin: None. A. Patsalides: None.

The pathogenesis and treatment paradigm for idiopathic intracranial hypertension (IIH) is controversial. The goal of this article is to review the current literature addressing a relatively new and controversial therapeutic approach for a subset of IIH patients: dural venous sinus stenting. The debate continues as to whether transverse sinus stenosis is a primary or secondary process relative to raised intracranial pressure (ICP). Transverse sinus stenosis is seen in the majority of patients with IIH and appears to play some role in the disease process. Recent case reports and case series that looked at patients treated with venous sinus stents show encouraging results in decreasing ICP and its related signs and symptoms. Venous sinus stenting could be a treatment option for many patients with IIH. Exactly where in the treatment paradigm endovascular venous sinus stenting falls is unknown. Additional work, preferably controlled prospective studies, needs to be performed to prove its safety and efficacy. Finally, venous sinus stenting should be compared in head-to-head trials with optic nerve sheath fenestration and cerebrospinal fluid diversion surgeries to address its superiority or inferiority relative to these more traditional surgical options.

Background: Cerebrospinal fluid (CSF)-diversion procedures have traditionally been the standard of treatment for patients with medically refractive idiopathic intracranial hypertension (IIH). However, dural venous sinus stent (VSS) placement has been described as a safe and effective procedure for the management of medically refractive IIH. We performed a meta-analysis comparing outcomes and complications of CSF-diversion procedures, VSS and optic nerve sheath fenestration (ONSF) for the treatment of medically refractive IIH. Methods: Electronic searches were performed using six databases from 1988 to January 2017. Data was extracted and meta-analysed from the identified studies. Results: From 55 pooled studies, there were 538 CSF-diversion cases, 224 dural venous stent placements, and 872 ONSF procedures. Similar improvements were found in terms of postoperative headaches (CSF vs . VSS vs . ONSF: 84% vs . 78% vs . 62%, P=0.223), papilledema (CSF vs . VSS vs . ONSF: 71% vs . 86% vs . 77%, P=0.192), whilst visual acuity changes favored venous stenting (CSF vs . VSS vs . ONSF: 55% vs . 69% vs . 44%, P=0.037). There was a significantly lower rate of subsequent procedures with venous stent placement (CSF vs . VSS vs . ONSF: 37% vs . 13% vs . 18%, P vs . VSS vs . ONSF: 13% vs . 8% vs . 14%, P=0.28). Subgroup analysis of lumbar-peritoneal vs . ventriculoperitoneal shunts found no differences in symptom improvements, complications and subsequent procedure rates. Conclusions: Our findings suggest that dural venous sinus stenting may be a viable alternative to traditional surgical interventions in patients who are refractory to medical treatment.

Introduction/Purpose Intra‐operative vascular imaging is essential in neuroendovascular procedures, such as flow diversion and venous sinus stenting, where 3D digital subtraction angiography (3D‐DSA) is frequently used to map patient anatomy and guide interventions. Typically, patients undergo a full 4s 3D‐DSA acquisition both before and after procedures, leading to significant radiation exposure. The aim of this study is to present a novel 2D‐3D fusion technique, which merges pre‐intervention 3D‐DSA with 2D‐DSA or single‐shot X‐ray images, allowing for procedure guidance and pre‐procedural planning without requiring an additional 3D‐DSA spin. The premise of this technique is that it could reduce overall radiation exposure by eliminating the need for a second 4s 3D‐DSA acquisition. Materials/Methods This is a retrospective review of 37 patients who underwent either flow diversion or venous sinus stenting, where a 3D‐DSA acquisition was fused with 2D imaging for stent placement confirmation or follow‐up. Demographic data, procedural characteristics, and radiation exposure metrics—including dose area product (DAP) and radiation dose (RP)—were recorded. The primary goal was to descriptively assess the radiation exposure for the 4s 3D‐DSA acquisition and the index procedures (whether flow diversion or venous stenting), using this data to highlight the theoretical reduction in radiation exposure achieved through the 2D‐3D fusion technique. Results Among the 37 patients (mean age 44.4 years, with 19% of procedures performed on the same day), the radiation exposure associated with the 4s 3D‐DSA acquisition was substantial, with an average DAP of 1408.93 µGym 2 and a mean radiation dose of 65.84 mGy. For the index procedures, including both flow diversion and venous stenting, the radiation exposure averaged 12435.29 µGym 2 for DAP and 1323.77 mGy for radiation dose, with a maximum skin entrance dose of 590.00 mGy. These values demonstrate the significant radiation burden associated with both the 3D‐DSA acquisition and the procedures themselves. Conclusion The data presented here underscore the significant radiation exposure involved in both 4s 3D‐DSA acquisitions and index procedures like flow diversion and venous stenting. The 2D‐3D fusion technique presents a promising method for reducing radiation exposure by eliminating the need for additional 3D‐DSA spins, potentially improving efficiency and patient safety. image

Idiopathic intracranial hypertension (IIH) is characterised by an increased intracranial pressure (ICP) in the absence of any central nervous system disease or structural abnormality and by normal CSF composition. Management becomes complicated once surgical intervention is required. Venous sinus stenosis has been suggested as a possible aetiology for IIH. Venous sinus stenting has emerged as a possible interventional option. Evidence for venous sinus stenting is based on elimination of the venous pressure gradient and clinical response. There have been no studies demonstrating the immediate effect of venous stenting on ICP. Patients with a potential or already known diagnosis of IIH were investigated according to departmental protocol. ICP monitoring was performed for 24h. When high pressures were confirmed, CT venogram and catheter venography were performed to look for venous stenosis to demonstrate a pressure gradient. If positive, venous stenting would be performed and ICP monitoring would continue for a further 24h after deployment of the venous stent. Ten patients underwent venous sinus stenting with concomitant ICP monitoring. Nine out of ten patients displayed an immediate reduction in their ICP that was maintained at 24h. The average reduction in mean ICP and pulsatility was significant (p=0.003). Six out of ten patients reported a symptomatic improvement within the first 2weeks. Venous sinus stenting results in an immediate reduction in ICP. This physiological response to venous stenting has not previously been reported. Venous stenting could offer an alternative treatment option in correctly selected patients with IIH.

ObjectAlthough venous sinus stenting is an established treatment for medically refractory idiopathic intracranial hypertension (IIH), a subset of patients do not sustain improvement in symptoms post-procedurally. While many physicians perform...

Idiopathic intracranial hypertension (IIH) is characterized by headache, papilledema, visual field changes and tinnitus with elevated cerebral spinal fluid opening pressures on lumbar puncture. Left untreated, this condition can lead...

Dural Venous Sinus Stenting in Pediatric Refractory Idiopathic Intracranial Hypertension: A Case Series and Literature Review.

Based on their clinical and radiological patterns, idiopathic CSF rhinorrhea and idiopathic intracranial hypertension can represent different clinical expressions of the same underlying pathological process. Transverse sinus stenoses are associated with both diseases, resulting in eventual restriction of the venous CSF outflow pathway. While venous sinus stenting has emerged as a promising treatment for idiopathic intracranial hypertension, its efficiency on idiopathic CSF leaks has not been very well addressed in the literature so far. The purpose of this study was to report the results of transverse sinus stenting in patients with spontaneous CSF rhinorrhea associated with transverse sinus stenoses. From a prospectively collected database, the authors retrospectively collected the clinical and radiological features of the patients with spontaneous CSF leakage who were treated with venous sinus stenting. Five female patients were included in this study. Transverse sinus stenoses were present in all patients, and other radiological signs of idiopathic intracranial hypertension were present in 4 patients. The median transstenotic pressure gradient was 6.5 mm Hg (range 3-9 mm Hg). Venous stenting resulted in the disappearance of the leak in 4 patients with no recurrence and no subsequent meningitis during the follow-up (median 12 months, range 6-63 months). According to the authors' results, venous sinus stenting may result in the disappearance of the leak in many cases of idiopathic CSF rhinorrhea. Larger comparative studies are needed to assess the efficiency and safety of venous stenting as a first-line approach in patients with spontaneous CSF rhinorrhea associated with transverse sinus stenoses.

Objective: Patients with chronic idiopathic intracranial hypertension (IIH) commonly experience a high level of disability and low satisfaction with medical treatment. We aim to evaluate long-term functional improvement and patient satisfaction in IIH patients with similar symptoms by comparing venous sinus stenting (VSS) to standard medical therapy. Methods: We conducted a cross-sectional questionnaire study of 111 IIH patients, comparing 37 adult female patients who underwent venous sinus stenting with 74 patients treated medically. Propensity score matching was used to balance age and presence of papilledema at presentation between groups. Headache-related disability was evaluated using the Migraine Disability Assessment Scale (MIDAS), while general function and treatment satisfaction were assessed using custom questionnaires. Electronic medical records and the results of imaging upon diagnosis were reviewed retrospectively. Results: The stented group reported significantly better outcomes in physical well-being (median 4.0 vs. 1.0, p < 0.001), task completion (4.0 vs. 1.0, p < 0.001), work/school persistence (5.0 vs. 1.0, p < 0.001), and mental well-being (4.0 vs. 1.0, p < 0.001). Additionally, the stented group had a lower proportion of patients with severe MIDAS (MIDAS > 4, 24.3% vs. 47.9%, p = 0.017). Logistic regression suggested venous stenting as a protective factor against severe MIDAS scores (OR = 0.174, p = 0.004). Conclusion: Cerebral venous stenting in patients with IIH is associated with lower disability and higher patient satisfaction from medical treatment compared to those treated with medications only. These findings suggest that venous sinus stenting may be a valuable treatment option for selected IIH patients. However, larger prospective studies are needed to further validate our results.

<h3>Introduction</h3> Idiopathic Intracranial Hypertension (IIH) is a disorder of elevated intracranial pressure, often treated by venous sinus stenting. The eShunt transdural implant is deployed via the inferior petrosal sinus (IPS) to drain CSF from the cerebellopontine angle cistern (CPAC) into the internal jugular vein. We analyzed the morphometrics of cisternal, venous, and skull base anatomy in adult patients with IIH-associated transverse sinus stenosis to assess for minimum required dimensions needed in eShunt deployment. <h3>Methods</h3> High-resolution T1-weighted Gadolinium-enhanced brain MRIs of IIH patients collected on post-op day 1 following venous sinus stenting at Tufts Medical Center (Boston, MA) were retrospectively analyzed to measure CPAC depth, IPS diameter, IPS angle, and descent of cerebellar tonsils, with history and demographic assessment. <h3>Results</h3> Sixty adult patients (ages 18-77, 50 females) were included. Median CPAC depth was 4.5 mm and 4.4 mm, while median IPS diameter was 4.1 mm and 3.8 mm, for right and left sides, respectively. CPAC depth trended higher in older and male patients, though not significantly. Endovascular placement of the eShunt System was possible (IPS diameter &gt; 2mm) with stringent (CPAC depth &gt; 5mm) and permissive (CPAC depth &gt; 3mm) feasibility criteria in 55% and 78% of analyzed patients, respectively. Importantly, cerebellar tonsillar descent, such as seen in Chiari I patients, was identified be inversely correlated with CPAC depth (P&lt;0.005) and thus a predictor of eShunt eligibility. Excluding patients with positive tonsillar ectopia, increases eShunt eligibility to 64% (ns) and 91% (P&lt;0.01) using stringent and permissive criteria, respectively. <h3>Conclusions</h3> A significant proportion of patients with IIH currently treated with venous stenting may be suitable candidates for the eShunt System, especially when favoring patients without evidence of tonsillar descent. These preliminary results, coupled with eShunt’s lack of anti-coagulant and anti-platelet requirement, warrant further clinical investigation for treatment of patients with IIH. <h3>Disclosures</h3> <b>D. Vajipayajula:</b> None. <b>C. Heilman:</b> 2; C; CereVasc Inc. 4; C; Cerevasc Inc. <b>A. Malek:</b> 2; C; CereVasc Inc., Stryker Inc. 4; C; Cerevasc Inc.

Objective. To evaluate the cerebral autoregulation (CA) in idiopathic intracranial hypertension (IIH) patients with transfer function analysis, and to explore its improvement after venous sinus stenting. Approach. In total, 15 consecutive IIH patients with venous sinus stenosis and 15 controls were recruited. All the patients underwent digital subtraction angiography and venous manometry. Venous sinus stenting was performed for IIH patients with a trans-stenosis pressure gradient ≥8 mmHg. CA was assessed before and after the operation with transfer function analysis, by using the spontaneous oscillations of the cerebral blood flow velocity in the bilateral middle cerebral artery and blood pressure. Main results. Compared with controls, the autoregulatory parameters, phase shift and rate of recovery, were both significantly lower in IIH patients [(57.94° ± 23.22° versus 34.59° ± 24.15°, p < 0.001; (39.87 ± 21.95) %/s versus (20.56 ± 46.66) %/s, p = 0.045, respectively). In total, six patients with bilateral transverse or sigmoid sinus stenosis received venous sinus stenting, in whom, the phase shift significantly improved after venous sinus stenting (39.62° ± 20.26° versus 22.79° ± 19.96°, p = 0.04). Significance. The study revealed that dynamic CA was impaired in IIH patients and was improved after venous sinus stenting. CA assessment has the potential to be used for investigating the hemodynamics in IIH patients.

IntroductionIdiopathic intracranial hypertension (IIH) is a neurological disorder of unknown etiology characterized by increased intracranial pressure, resulting in headaches, pulsatile tinnitus, and papilledema. A major risk factor for IIH is...

INTRODUCTION: Idiopathic intracranial hypertension (IIH) is a debilitating disease that can present with severe vision loss. Although medical management is the first-line treatment, these cases commonly require intervention by either ventriculoperitoneal/pleural shunting (VPS) or, more recently, by venous sinus stenting (VSS). Unfortunately, this chronic disease can lead to multiple clinical encounters which increases financial burden. Therefore, identifying ways to effectively treat IIH definitively while limiting healthcare costs are of great interest. METHODS: This is a retrospective study of IIH patients diagnosed via modified Dandy criteria who received VPS (n=27) or VSS (n=27) from May 2008–May 2019. Visual outcomes were reported by a neuro-ophthalmologist at approximately 1-month post-procedure. Costs of emergency department as well as and outpatient/inpatient encounters for neurosurgery and ophthalmology were obtained from the index procedure to 3 years post-procedure. RESULTS: VSS patients had higher pre-intervention ophthalmology evaluation rates (stents: n = 22, 88.9%; shunts: n = 7, 23.1%; p &lt; 0.0001). Papilledema was present in most patients (VSS 82.6% vs VPS 66.7%, p = 0.60) and all patients had stable/improved papilledema at follow-up. Two VSS patients (4.9%) required a second stent. Four VSS patients (9.8%) had a VPS placed. No VPS patients received a VSS. Encounter cost for VSS placement were more expensive than primary VPS placement ($10,749 vs $13,648; p = 0.002). However, at 1.5 years after index procedure, cumulative VPS cost surpassed VSS and persisted at 3 years ($22,674 vs $17,441, p = 0.039). CONCLUSIONS: VPS and VSS have similar visual outcomes with all cases having stable or improved papilledema. The upfront cost of VSS is greater than VPS; however, VPS quickly surpasses VSS in cost by 1.5 years after index procedure and continues to study endpoint at 3 years. These results may help guide multi-disciplinary care for patients with IIH.

BackgroundVenous sinus stenting (VSS) has emerged as a safe and effective treatment option for idiopathic intracranial hypertension. Many physicians routinely admit patients to the intensive care unit (ICU) for close...