Cerebral Venous Sinus Stenosis Research Articles

MRI signs of intracranial hypertension in morbidly obese and normal-weight individuals.

Idiopathic intracranial hypertension (IIH) is associated with intracranial abnormalities, although not obligatory, which can be detected with cranial MRI. Obesity is an important risk factor for IIH and a pathogenetic link is suspected but the extent to which these MRI signs are already related to obesity has not yet been examined. We investigated whether IIH-MRI signs are present more often in obese individuals with a BMI > 30 kg/m² than in individuals of normal weight. Brain MRI of 32 obese and 53 normal-weight participants from the Food-Chain-Plus cohort were analyzed for three main signs of IIH: (I) stenosis of the transverse sinus, (II) increased width of the optic nerve sheath, and (III) reduction of pituitary height. In addition, a scoring system for the MRI signs was applied. Furthermore, tortuosity of the optic nerve and flattening of the posterior globe were considered as additional MRI signs. Obese participants had a significantly higher MRI score (p < 0.001) than those in the normal-weight cohort, with significant differences in quantitative measurements of cerebral venous sinus stenosis (p < 0.001), widening of the optic nerve sheath (p < 0.05), and flattening of the pituitary gland (p < 0.05) also always being observed more frequently and in a more pronounced manner in the obese group. Furthermore, our findings correlated significantly with BMI and proportionately with hip and waist circumference. Obese individuals show a significantly higher prevalence of cerebral MRI signs related to IIH. This supports the hypothesis that obesity is a risk factor for possible intracranial hypertension and reinforces the suspicion that obesity is involved in the pathomechanism of IIH. · Obesity is associated with changes such as those seen in IIH.. · BMI, weight, and body measurements correlate with the expression of MRI signs of IIH.. · To prevent IIH symptoms in obesity, the pathomechanism must be further clarified..

Arm-only combined transarterial and transvenous access for neurointerventional procedures: a double-center retrospective study.

This study aims to share our experience with the arm-only combined transarterial and transvenous access approach for neurointerventional procedures and evaluate its efficacy and safety. The arm-only combined transarterial and transvenous access approach was performed using the right/bilateral proximal radial arteries and the right forearm superficial vein system, guided by ultrasonic guidance. Arterial access closure was achieved using a transradial band radial compression device, while manual compression was utilized for venous approach closure. Thirteen procedures were successfully performed using the arm-only combined transarterial and transvenous access approach, yielding favorable outcomes. The procedures included dural arteriovenous fistula embolization (seven cases), cerebral arteriovenous malformation embolization (four cases), venous sinus thrombosis catheter-directed thrombolysis and intravenous thrombectomy (one case), and cerebral venous sinus stenosis manometry (one case). All procedures were uneventful, allowing patients to ambulate on the same day. At discharge, all patients exhibited modified Rankin scores of 0-2, without any access site or perioperative complications. This double-center study preliminarily demonstrates the feasibility and safety of arm-only combined transarterial and transvenous access applied in neurointerventional procedures for complicated cerebrovascular diseases. The proximal radial artery and forearm superficial vein are recommended as the primary access sites. Unobstructed compression is strongly recommended for radial approach closure. This study aimed to add evidence and experience on the arm-only combined transarterial and transvenous access, as a new approach, for neurointerventional treatment that required arteriovenous approaches.

Intensive mannitol slow infusion post-stenting may attenuate stenting-related early adverse effects in patients with cerebral venous sinus stenosis.

To analyze intensive slow mannitol poststenting on attenuating stenting-related early adverse effects in cerebral venous sinus stenosis (CVSS). This real-world study enrolled subacute or chronic CVSS patients from January 2017 through March 2022 and divided them into DSA only and stenting post-DSA groups. The later group was subdivided into control (without extra mannitol use) and intensive slow mannitol subgroup (immediate extra mannitol 250-500 mL, 2 mL/min infusion post-stenting) after signed informed consent. All data were compared. A total of 95 eligible patients entered into final analysis, in which 37 cases underwent DSA only and 58 cases underwent stenting post-DSA. Finally, 28 patients were entered into intensive slow mannitol subgroup and 30 in control. Stenting group vs. DSA group, HIT-6 scores and WBC counts were higher in the former (both p < 0.001). Intensive slow mannitol subgroup vs. control on the third day post-stenting, a statistically significant reductions were noticed in the former on WBC counts (6.19 ± 1.86 × 109 /L vs. 9.59 ± 2.05 × 109 /L); HIT-6 scores (degree of headache) (40.00 (38.00-40.00) vs. 49.00 (41.75-55.25)) and brain edema surrounding the stent on CT maps (17.86% vs.96.67%), all p < 0.001. Stenting-related severe headache, inflammatory biomarkers elevation, and brain edema aggravation can be attenuated by intensive slow mannitol infusion.

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

To compare the long-term safety and efficacy of stenting in correcting cerebral venous sinus stenosis (CVSS) and internal jugular venous stenosis (IJVS). 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. 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. Using stents to correct IH and related neurological issues has shown to be a safe and effective approach for both IJVS and CVSS.

The Negative Prognostic Role of Inflammatory Biomarkers in Patients With Chronic Cerebrospinal Venous Insufficiency.

The pathologic consequences of inflammatory responses in chronic cerebrospinal venous insufficiency (CCSVI) remains poorly understood. Hence, this study was aimed to evaluate the peripheral inflammatory biomarkers in patients with intracranial and extracranial CCSVI pathology. In addition, the relationship between inflammatory cytokine profile and CCSVI prognosis was also evaluated. Patients diagnosed with CCSVI between July 2017 and July 2019 were included and subsequently divided into 3 groups based on the location of stenosis. The inflammatory biomarker assay included neutrophil-to-lymphocyte ratios (NLRs), platelet-to-lymphocyte ratios (PLRs), red blood cell distribution widths (RDW), C-reactive protein (CRP) levels, interleukin-6 (IL-6) levels, and neuron-specific enolase levels. Clinical outcomes were assessed using the modified Rankin Scale and Patient Global Impression of Change score. Univariate and multivariate regression analyses were performed to identify significant prognostic factors for poorer outcomes. Finally, we established a nomogram based on the multivariate regression analysis. We enrolled 248 patients in total, including 102 males and 146 females, with an average age of 57.85±12.28 years. Compared with patients with internal jugular vein stenosis, cerebral venous sinus stenosis (CVSS) patients were mostly younger and had been suffering from headaches and severe papilledema. Higher levels of NLR, RDW, and CRP were also observed in the CVSS group. Multivariate analysis indicated that NLR, PLR, and IL-6 were the independent prognostic factors for poor CCSVI outcomes. The clinical presentations and increases in NLR, PLR, IL-6, and CRP levels could be distinctly marked in patients with CVSS-related CCSVI than that in internal jugular vein stenosis-related CCSVI, indicating poor prognostic outcomes in these patients. A proinflammatory state might be associated with CCSVI pathology.

Cerebral Venous-Associated Brain Damage May Lead to Anxiety and Depression.

Background and purpose: Anxiety and depression are common in patients with Cerebral venous outflow disturbance (CVOD). Here, we aimed to explore possible mechanisms underlying this phenomenon. Methods: We enrolled patients diagnosed with imaging-confirmed CVOD, including internal jugular venous stenosis (IJVS) and cerebral venous sinus stenosis (CVSS) between 2017 and 2020. All of them had MRI/PWI scans. The Hamilton Anxiety Scale (HAMA) and 24-item Hamilton Depression Scale (HAMD) were used to evaluate the degree of anxiety and depression at the baseline and three months post-stenting. In addition, the relationships between the HAMA and HAMD scores, white matter lesions, and cerebral perfusion were analyzed using multiple logistic regressions. Results: A total of 61 CVOD patients (mean age 47.95 ± 15.26 years, 59.0% females) were enrolled in this study. Over 70% of them reported symptoms of anxiety and/or depression. Severe CVOD-related anxiety correlated with older age (p = 0.046) and comorbid hyperlipidemia (p = 0.005). Additionally, head noise, sleep disturbances, and white matter lesions (WMLs) were common risk factors for anxiety and depression (p < 0.05). WMLs were considered an independent risk factor for anxiety based on multiple regression analysis (p = 0.029). Self-contrast displayed that CVOD-related anxiety (p = 0.027) and depression (p = 0.017) scores could be corrected by stenting, as the hypoperfusion scores in the limbic lobes of patients with anxiety and depression were significantly higher than those in patients without. Conclusions: CVOD-induced hypoperfusion-mediated changes in the white matter microstructure may represent an underlying mechanism of anxiety and depression in patients with chronic CVOD.

Editorial

Editorial

Cerebral Venous Outflow Implications in Idiopathic Intracranial Hypertension-From Physiopathology to Treatment.

In this review, we provide an update on the pathogenesis, diagnosis, and management of adults with idiopathic intracranial hypertension (IIH) and implications of the cerebral venous system, highlighting the progress made during the past decade with regard to mechanisms of the venous outflow pathway and its connection with the cerebral glymphatic and lymphatic network in genesis of IIH. Early diagnosis and treatment are crucial for favorable visual outcomes and to avoid vision loss, but there is also a risk of overdiagnosis and misdiagnosis in many patients with IIH. We also present details about treatment of intracranial hypertension, which is possible in most cases with a combination of weight loss and drug treatments, but also in selected cases with surgical interventions such as optic nerve sheath fenestration, cerebral spinal fluid (CSF) diversion, or dural venous sinus stenting for some patients with cerebral venous sinus stenosis, after careful analysis of mechanisms of intracranial hypertension, patient clinical profile, and method risks.

Safety and efficacy comparison between OACs plus single antiplatelet and dual antiplatelet therapy in patients with cerebral venous sinus stenosis poststenting

Background and purposeThe present strategies regarding poststent management for cerebral venous sinus stenosis (CVSS) are inconsistent. Herein, we compared the safety and efficacy of oral anticoagulants (OACs) plus single antiplatelet therapy and dual antiplatelet therapy for CVSS poststenting.MethodsA real-world observational study conducted from January 2009 through October 2019 enrolled patients who were diagnosed with CVSS and received stenting. Patients were divided into two groups according to the management they received poststenting. Group 1: OACs plus a single antiplatelet agent (clopidogrel 75 mg or aspirin 100 mg) and Group 2: dual antiplatelet therapy (clopidogrel 75 mg plus aspirin 100 mg). The safety (such as major or minor bleeding or venous thrombosis) and efficacy (the incidences of cerebral venous sinus restenosis, intrastent thrombosis, or stent displacement) of the two groups were compared.ResultsThere were a total of 110 eligible patients in the final analysis, including 79 females and 31 males with a mean age of 43.42 ± 13.23 years. No major bleeding or venous thrombosis occurred in either of the two groups. Two minor bleeding events occurred in group 2 (one with subcutaneous bleeding points in both lower limbs, another with submucosal bleeding in the mouth), whereas no bleeding events occurred in Group 1. In addition, at the 1-year follow-up, one case of intraluminal restenosis and two cases of in-stent thrombi occurred in Group 2, while none occurred in Group 1. Neither stenosis at stent-adjacent segments nor stent migration was detected in either group during the 1-year following stent placement.ConclusionOACs plus single antiplatelet therapy and dual antiplatelet therapy alone are both safe and efficacious management strategies after CVSS stent placement. The former may have more advantages than the latter for inhibiting intrastent thrombosis. However, further research by larger, multicenter clinical trials is needed.

Anatomic Variation of the Lateral Sinus in Patients With Idiopathic Intracranial Hypertension: Delineation With Black-Blood Contrast-Enhanced MRI.

Objectives: The purpose of this study was to describe the peculiar anatomic variations in the lateral sinus and analyze the patterns of cerebrospinal fluid (CSF) drainage by using high-resolution (HR) black-blood (BB) contrast-enhanced magnetic resonance imaging (MRI) in patients with idiopathic intracranial hypertension (IIH).Methods: Total 33 IIH patients who were found cerebral venous sinus stenosis (CVSS) by MR venography (MRV) were enrolled in this study. HR-BB contrast-enhanced MRI was used to assess the features of anatomical variations in transverse sinus and sigmoid sinus. The development of bilateral sinuses was firstly evaluated, including unilateral hypoplasia with contralateral dominance or bilateral balanced development. Then, four kinds of anatomical variations were eventually recorded, including circumscribed stenosis, arachnoid granulation (AG), fibrous septum (FS), and brain herniation (BH) into dural venous sinus (DVS).Results: Bilateral venous drainage dysfunction was found in 30(90.9%) patients, whereas only 3(9.1%) patients presented unilateral venous drainage dysfunction. There was no difference in clinical symptoms between the two groups. The most common case is hypoplasia in unilateral sinus combined with anatomic variation in the contralateral dominant transverse sinus such as AG and BH into DVS. Total of 52 anatomic variations were finally found in bilateral sinuses in 33 enrolled patients, including 19(36.5%)AGs, 12(23.1%)FS, 7(13.5%) BH into DVS and 14(26.9%) circumscribed stenoses. Moreover, 41(62.1%) lateral sinuses showed enhancement in T1-weight-enhanced MRI.Conclusions: Patients with CVSS almost had CSF outflow disorders, whatever bilateral equalization or unilateral hypoplasia with contralateral dominance. Four types of main anatomic variations, including circumscribed stenosis, AG, FS, and BH into DVS, caused venous reflux obstruction by elevating the intracranial press (ICP).

Atypical visual impairment associated to cerebral sinus stenosis related to COVID-19 thrombosis

Cerebralvenoussinus stenosis (CVSS) may further complicate cerebral venous thrombosis(CVT) which is a rare thromboembolic complications in COVID-19 patients. We report a case of post COVID 19 CVT-related CVSS associated to intracranial hypertension (ICH). We discuss the possible mechanisms of highly asymmetric visual repercussions of ICH.

Investigation of the Prevalence of Cerebral Transverse Venous Sinus Stenosis in Idiopathic Intracranial Hypertension

Purpose: Idiopathic intracranial hypertension (IIH) is an increase in intracranial pressure with a normal cerebrospinal fluid (CSF) composition that is not due to a secondary cause. The existence of cerebral transverse venous sinus stenosis and changes in venous outflow in IIH has recently gotten a lot of attention, and this situation is becoming increasingly important in terms of diagnosis and treatment plan. &#x0D; This study aimed to investigate how frequent cerebral transverse venous sinus stenosis is in patients with IIH. &#x0D; Methods: The demographic profile of 27 patients with IIH who were followed up in the hospital's neurological headache outpatient clinic and the occurrence of cerebral transverse venous stenosis on cranial magnetic resonance venography (MRV) were studied. Considering the pre-diagnosis of cerebral venous thrombosis (SVT), patients who underwent magnetic resonance venography (MRV) and whose SVT was ruled out during their follow-up were included as the control group. This control group consisted of 48 patients diagnosed with migraine, tension-type headache (TTH), and new-onset daily persistent headache.&#x0D; Results: When MRVs were investigated, cerebral transverse venous sinus stenosis was detected in %55.6 (n=15) of IIH patients and 25% (n=12) of the control group (p = 0.017).&#x0D; Conclusions: The frequency of cerebral transverse sinus stenosis in MRV of patients diagnosed with IIH was found to be significantly higher in this study than in the control group. These findings indicated that cerebral transverse venous stenosis can play a role in the progression of IIH.

Chinese expert consensus on the interventional management of venous sinus stenosis

Venous sinus stenosis is a rare cerebrovascular disease. The management of venous sinus stenosis remains controversial. The evidence-based medical evidence was limited. There was not a specific consensus or guideline on the disease. This expert consensus provides an overview of cerebral venous sinus stenosis and comprehensive recommendations for the diagnosis, management, and interventional treatment by reviewing the relevant literature. The intended audience includes physicians and other healthcare providers who are responsible for patients with cerebral venous sinus stenosis. The present consensus aims to standardize and improve the clinical practice of venous sinus stenosis in China.

Endovascular Dural Venous Sinus Stenting for the Treatment of Papilledema in Idiopathic Intracranial Hypertension

Abstract Introduction: Recently a subset of patients with Benign Intracranial hypertension has been identified that have cerebral dural venous stenosis. Recent studies have demonstrated that venous sinus stenting can result in normalization of these pressures and resultant resolution of ophthalmologic findings. Methods: Twenty-six patients were referred to a single institution for optic nerve swelling due to Benign Intracranial hypertension and found to have cerebral dural venous sinus stenosis. These patients subsequently underwent cerebral venous sinus stenting. Ophthalmic manifestations were evaluated pre and post procedure as well as intravascular pressure measurements and pressure gradients before and after the stenting procedure. The pre and postoperative ophthalmologic findings were tabulated as well as the pre and post procedure pressure measurements before and after stenting. Results: The average preprocedural pressure gradient measured 13.8 mmHg and was reduced to 1.3 mmHg after the stenting procedure. 25 of 26 patients had improvement in their papilledema after the stenting procedure. No complications occurred during or after the procedure. Conclusion: Endovascular Dural Venous sinus stenting is a safe and effective treatment modality for the ophthalmic manifestations of Benign Intracranial Hypertension in those patients found to have cerebral venous sinus stenosis.

Pathogenesis and Management in Cerebrovenous Outflow Disorders.

In keeping with its status as one of the major causes of disability and mortality worldwide, brain damage induced by cerebral arterial disease has been the subject of several decades of scientific investigation, which has resulted in a vastly improved understanding of its pathogenesis. Brain injury mediated by venous etiologies, however, such as cerebral, jugular, and vertebral venous outflow disturbance, have been largely ignored by clinicians. Unfortunately, this inattention is not proportional to the severity of cerebral venous diseases, as the impact they exact on the quality of life of affected patients may be no less than that of arterial diseases. This is evident in disease sequelae such as cerebral venous thrombosis (CVT)-mediated visual impairment, epilepsy, and intracranial hypertension; and the long-term unbearable head noise, tinnitus, headache, dizziness, sleeping disorder, and even severe intracranial hypertension induced by non-thrombotic cerebral venous sinus (CVS) stenosis and/or internal jugular venous (IJV) stenosis. In addition, the vertebral venous system (VVS), a large volume, valveless vascular network that stretches from the brain to the pelvis, provides a conduit for diffuse transmission of tumors, infections, or emboli, with potentially devastating clinical consequences. Moreover, the lack of specific features and focal neurologic signs seen with arterial etiologies render cerebral venous disease prone to both to misdiagnoses and missed diagnoses. It is therefore imperative that awareness be raised, and that as comprehensive an understanding as possible of these issues be cultivated. In this review, we attempt to facilitate these goals by systematically summarizing recent advances in the diagnosis and treatment of these entities, including CVT, CVS stenosis, and IJV stenosis, with the aim of providing a valid, practical reference for clinicians.

Predicting the need for retreatment in venous sinus stenting for idiopathic intracranial hypertension

BackgroundIdiopathic intracranial hypertension is a disease of raised intra-cranial pressure of unknown etiology. Lateral cerebral venous sinus stenosis (VSS) has been increasingly reported in these patients, and stenting has emerged...

Perioperative mannitol intensive use may avoid the early complication of cerebral venous sinus stenting.

BackgroundCerebral venous sinus (CVS) stenting has been widely applied for correcting CVS stenosis. However, there are still some potential complications. The purpose of this study is to investigate the impact of perioperative management on avoiding complications of CVS stenting.MethodsPatients confirmed as CVS stenosis were enrolled from January 2014 through November 2019. All CVS stenosis were corrected by stenting when the trans-stenotic mean pressure gradient (MPG) was up to or over 8 mmHg. Patients were divided into perioperative management group and control group. Patients in the former group underwent transiently mannitol 250 mL intravenous infusion immediately prior to stenting besides routine ICP control. While patients in control group underwent the same routine treatment as in the perioperative management group. The clinical symptoms, intracranial pressure (ICP), and MPG of the patients were compared before and after stenting. In addition, the complications between the two groups were compared.ResultsA total of 81 eligible patients were finally enrolled in this study, including 64 females and 17 males, mean aged 45.35±13.83 years. After stenting, the stenotic CVS restored normal blood flow and MPG decreased significantly [10.0 (8.0–15.0) vs. 0.0 (0.0–0.7) mmHg, P<0.001]. Headache, tinnitus, visual impairment, visual loss, Frisén papilledema grade (FPG), and ICP were ameliorated immediately (P<0.001) in the majority of patients in the two groups. However, the incidence of intracranial hemorrhage was higher in control group (11.4% vs. 0.0%, P=0.031).ConclusionsA transiently strict preoperative ICP control by mannitol may inhibit CVS stenting-related hemorrhage, which makes the stenting safer and more effective on correcting the CVS stenosis.

The Role of Arachnoid Granulations and the Glymphatic System in the Pathophysiology of Idiopathic Intracranial Hypertension.

Idiopathic intracranial hypertension (IIH) is a disorder characterized by long-standing elevated intracranial pressure (ICP). As the name applies, no uniform cause has been identified. IIH is typically characterized by headaches, pulsatile tinnitus, and visual deterioration. Anomalies in cerebrospinal fluid (CSF) absorption are implicated in the pathophysiology of IIH. Non-invasive imaging of the brain parenchyma and the cerebral venous sinus has improved, and research has gained a better understanding of the role of cerebral venous sinus stenosis. Both have led to a better delineation of the role of arachnoid granulations (AG) and the glymphatic system in the development of IIH. IIH may occur as a result of restrictions of CSF absorption from the venous system, and or the congestion and overflow of the glymphatic system. Elucidating these mechanisms will lead to greater understanding of its underlying pathophysiologic mechanisms.

Role of Resistivity Index Analysis in the Prediction of Hemodynamically Significant Venous Sinus Stenosis in Patient With Idiopathic Intracranial Hypertension.

The resistivity index (RI) in cerebral venous sinus stenosis (VSS) has not been studied in patients with idiopathic intracranial hypertension (IIH). To evaluate the role of RI measured by quantitative magnetic resonance venogram (QMRV) as a noninvasive tool in the diagnosis of venous hypertension associated with VSS in IIH. Retrospective evaluation of 13 consecutive IIH patients who underwent venous sinus stenting at our institution between 2013 and 2018.Patients' demographics, clinical presentation, cerebral mean venous sinus pressure (MVP), and RI both pre- and poststenting were recorded. The baseline RI was also compared to a control group. Among 13 patients of IIH, 11 had unilateral VSS in dominant sinus, whereas 2 had bilateral VSS. RI was significantly higher in IIH patients compared to the control group in the superior sagittal (SSS) and transverse sinuses (TS) (0.21 vs 0.11, P=.01 and 0.22 vs 0.13, P=.03, respectively). The MVP (in mm Hg) decreased significantly after venous sinus stenting in the SSS (41.9 to 22.5, P<.001) and TS (39.4 to 19.5, P<.001), which was also associated with a significant reduction of the RI (0.22 vs 0.17, P<.01 in SSS and 0.23 vs 0.17, P=.03 in TS) poststenting. RI calculated using QMRV can serve as a noninvasive tool to aid in the diagnosis of hemodynamically significant VSS. The study had a small sample size, and larger multicenter studies would be required to validate the results further.

Abstract 167: Efficacy of Endovascular Treatment for Idiopathic Intracranial Hypertension: Cerebral Venous Sinus Stenosis Treated by Stenting

Objective: To explore the diagnosis of cerebral venous sinus stenosis (CVSS) in idiopathic intracranial hypertension (IIH), and to evaluate the efficacy and risk of venous sinus stenting treatment for CVSS. Methods: 40 patients with refractory IIH complicated with CVSS underwent examination with magnetic resonance venography (MRV), digital subtraction angiography (DSA) and direct retrograde cerebral venography and manometry to confirm morphologic features of IlH and measure venous pressure.The CSF pressure on lumbar puncture ranged from 250 to 500 mmH 2 O with normal composition. All patients had headache, and funduscopic examination demonstrated papilledema for all patients. 28 patients who showed severe stenosis of venous sinuses with the pressure gradient across the stenosis &gt;100 mmH 2 O were treated with venous sinus stenting and were followed-up for more than 12 months.Intrasinus pressures were recorded before and after the procedure and correlated with clinical outcome during the follow-up period. Results: Sinus stenting angioplasty was successful in all 28 patients.In all patients venous sinus stenosis was improved after stenting procedure (the residual stenosis rate&lt;20%) and intrasinus pressure was reduced (the pressure gradient vanished or&lt;20 mmH 2 O ).The clinical symptoms in all the patients were improved or disappeared at discharge and intracranial pressures were normalized within 3 months after the procedure.During the follow-up period of (16.3±11) months (range 12 to 36 months),no patient had recurrence of IIH.In all cases, DSA or MRV was performed at 12-month follow-up and demonstrated the absence of sinus thrombosis or in-stent stenosis. Conclusions: Patients with refractory IIH should be assessed for CVSS. MRV or DSA was recommended for these patients as a routine work-up.Cerebral venography and manometry are helpful to evaluate the relation between venous outflow obstruction and intracranial hypertension.If severe CVSS is presented in patients who experienced medical treatment failure, endovascular stent placement could be an alternative to classic surgical approaches. Additional randomized and controlled clinical research is deserved.