Venous Sinus Stenting In Patients Research Articles

Combined surgical repair and venous sinus stenting for patients with skull base encephaloceles secondary to dural venous sinus stenosis.

Chronically elevated intracranial pressure (ICP) seen in idiopathic intracranial hypertension (IIH) can cause the development of skull base encephaloceles and cerebrospinal fluid (CSF) leaks. Surgical repair and ventriculoperitoneal shunt (VPS) placement are mainstays of treatment. Venous sinus stenting (VSS) is a newly accepted treatment modality. The goal of this study was thus to determine if VSS can be used to treat symptoms and prevent recurrence after surgical encephalocele repair. Retrospective chart review of patients that had surgical repair of encephaloceles followed by VSS for symptomatic stenosis with elevated pressure gradient. A total of 13 patients underwent a combined encephalocele repair and VSS. Seventy-two percent were female; 46% had headaches, 69% pulsatile tinnitus, and 92% CSF rhinorrhea or otorrhea. One had seizures. Mean lumbar opening pressure was 23.3 ± 2.6cm H2O; the average sagittal-to-jugular pressure gradient was 12.7 ± 1.8 cmH2O and was elevated in all patients. Four patients had middle fossa craniotomy for repair of tegmen defect (one bilateral); one had a retrosigmoid craniotomy for repair of a sigmoid plate defect. Eight had an endoscopic endonasal repair for sphenoid or cribriform plate encephalocele. There were no VSS procedural complications or complications associated with dual antiplatelet therapy. One patient had meningitis after endoscopic repair that was treated with antibiotics. One patient had recurrence of both CSF leak and venous stenosis adjacent to the stent requiring repeat repair and VSS. There was no further recurrence. In patients with dural sinus stenosis and encephaloceles requiring repair, VSS can be performed safely within weeks of surgery for relief of symptoms, resolution of underlying pathology, and prevention of CSF leak recurrence.

Intracranial venous stenting for idiopathic intracranial hypertension.

There is increasing evidence in the literature to support venous sinus stenting in patients with idiopathic intracranial hypertension who fail first-line therapy. Venous sinus stenting is a safe and successful technique compared with cerebrospinal fluid diversion procedures. This study examines the clinical outcomes of patients post intracranial venous stenting for intracranial hypertension across three tertiary hospitals in Western Australia. A retrospective analysis was performed on 83 consecutive patients treated with intracranial venous stenting for IIH at three tertiary hospitals from October 2013 to March 2020. Data were collected from outpatient clinic letters, electronic discharge letters, electronic radiological imaging and procedural reports. 89.2% patients were able to cease Acetazolomide post stenting. 78.3% patients reported resolution of headaches. 84.3% patients demonstrated resolution of their papilloedema. 91.6% patients demonstrated improvement of their visual acuity. Compared with a recent meta-analysis by Satti and Chaudry in 2015, our results demonstrated a higher technical success rate and lower complication rates. Our study findings support the paradigm shift from CSF diversion procedures to venous sinus stenting in patients with IIH who fail first-line therapy. Venous sinus stenting has a high technical success rate and significantly lower complication rates than other invasive treatments.

Dural Venous Sinus Stenting in Idiopathic Intracranial Hypertension: A National Database Study of 541 Patients.

Dural venous sinus stenting (VSS) is an effective intervention for patients with idiopathic intracranial hypertension (IIH) refractory to medical treatment. Our goal was to evaluate the efficacy by utilizing a large multi-institutional sample. Five hundred forty-one patients >18years old who underwent VSS within 3years of IIH diagnosis were queried using Current Procedural Terminology and International Classification of Diseases, Tenth Revision codes from the TriNetX Analytics Network. Patient demographics, baseline symptoms, procedures, and clinical outcomes were evaluated within 1 year postoperatively. Outcomes examined were headache, tinnitus, blindness/low vision, optic nerve sheath fenestration (ONSF), cerebrospinal fluid (CSF) shunt, and use of medications (acetazolamide, methazolamide, furosemide, topiramate, tricyclic antidepressants, and valproate) for IIH. Prestent and poststent data were compared using Fisher exact test, and the odds ratios were computed using the Baptista-Pike method. The mean age at VSS was 36.7±10.6; 92% were female, 65% of patients were Caucasian, 25% were Black/African American, 1% were Asian, and 9% were of other/unknown race. Within the 1-year follow-up, acetazolamide and topiramate use were significantly reduced post-VSS (P < 0.0001∗; odds ratio, 0.45; confidence interval, 0.35-0.57 and P= 0.03∗; odds ratio, 0.71; confidence interval, 0.52-0.95, respectively). Also, headaches, visual disturbance, dizziness/giddiness, and tinnitus significantly improved post-VSS (P < 0.005∗). Finally, the number of CSF shunt procedures and ONSF procedures demonstrated no significant change post-VSS (P > 0.05). VSS is an effective and safe procedure resulting in significant improvement of headaches, visual impairment, dizziness, and tinnitus, acetazolamide and topiramate usage were lower after VSS in patients with IIH. The paucity of pre-VSS and post-VSS CSF shunt and ONSF procedure data does not provide enough evidence to establish significance.

Comparison of microcatheter and pressure wire for venous sinus manometric evaluation of patients with idiopathic intracranial hypertension.

Venous sinus manometry performed by microcatheter to assess candidacy for venous sinus stenting in patients with idiopathic cranial pressure (IIH) can be tiring, time-consuming and unreliable. Pressure wire is widely used to measure coronary pressure and evaluate coronary stenosis severity, but venous sinus manometry using the pressure guide wire has only been reported in one case, and few studies have examined the accuracy of this approach. To compare venous manometry performed by microcatheter with by pressure wire under awake setting in patients with IIH. The manometry results of 30 patients with IIH were recorded by Rebar-27 microcatheter and a pressure wire under awake setting. The mean venous pressures (MVPs) and trans-stenosis pressure gradients were obtained and compared between microcatheter and pressure wire. Paired t-test) were used to evaluate the data between the two groups. MVPs in superior sagittal sinus (SSS) and torcula were slightly higher with microcatheter, though without statistically significant differences (p > 0.05). MVPs in transverse sinus (TS) and sigmoid sinus (SS) were significantly higher with microcatheter (p < 0.05). Trans-stenotic pressure gradient with microcatheter was significantly higher than with pressure wire (p＜0.001). Intracranial venous pressure measured with the microcatheter and pressure wire showed a moderate difference. Compared with the traditional microcatheter method，the pressure wire is safe, fast and effective method to identify the patient needing intervention.

Venous sinus stenting for the treatment of isolated pulsatile tinnitus: Results of a prospective trial.

This prospective study evaluates the effectiveness and safety of venous sinus stenting for patients with isolated pulsatile tinnitus and lateral sinus stenosis. Patients with isolated pulsatile tinnitus and lateral sinus stenosis with a minimum trans stenotic gradient of 4 mm Hg were treated with stenting. Pulsatile tinnitus before and after treatment was assessed with the Tinnitus Handicap Inventory (THI). Periprocedural adverse events, neurological complications, clinical and radiographic follow-up were also recorded. A total of 42 patients (41 females and 1 male) were included in the study (median age of 37.5 years). Thirty patients had post-stenotic fusiform and 12 had post-stenotic saccular venous sinus aneurysm. In addition to stenting, coils were used to treat the patients with saccular venous aneurysms. The median follow-up was 5 months (range 1 to 34 months). Most patients had complete (39/42) or near-complete (2/42) resolution of their pulsatile tinnitus post-procedure. There were no serious adverse events. Stenting of the lateral venous sinus is a safe and effective treatment for patients with isolated pulsatile tinnitus due to venous sinus stenosis.

Femoral-Long Sheath-Reshape-Anchoring-Stenting (FLRAS) Technique in Venous Sinus Stenting for Idiopathic Intracranial Hypertension

To evaluate the efficacy and safety of the novel Femoral-Long Sheath-Reshape-Anchoring-Stenting (FLRAS) technique (developed by Dr. Hongbo Zheng) for venous sinus stenting in patients with idiopathic intracranial hypertension. Retrospective, single center study. We comparatively analyzed clinical and imaging data from consecutive patients with idiopathic intracranial hypertension who underwent venous sinus stenting using either traditional technique from June 2013 to May 2015 or FLRAS technique (described in this mansucript) from May 2015 to May 2018. A total of 20 patients (mean age, 36.7 [range, 17-50] years; 15 women) were enrolled in the study. In FLRAS group (n=12) vs. traditional stenting group (n=8): mean procedure duration was significantly shorter (48.3 min vs. 92.5 min, P <0.001), and procedure success rate was numerically higher (100% vs. 87.5%, P>0.05), with no vs. 2 complications, respectively. Use of FLRAS technique for venous sinus stenting in patients with idiopathic intracranial hypertension appeared to yield favorable outcomes relative to use of the traditional stenting technique. A large, multicenter, randomized study is warranted to confirm these findings.

Resolution of Pulsatile Tinnitus after Venous Sinus Stenting in Patients with Idiopathic Intracranial Hypertension

ObjectiveEvaluate the role of venous sinus stenting in the treatment of pulsatile tinnitus among patients with Idiopathic Intracranial Hypertension (IIH) and significant venous sinus stenosis.Subjects and MethodsA written informed consent approved by the Weill Cornell institutional review board was signed and obtained from the study participants. Thirty-seven consecutive patients with IIH and venous sinus stenosis who were treated with venous sinus stenting between Jan.2012-Jan.2016 were prospectively evaluated. Patients without pulsatile tinnitus were excluded. Tinnitus severity was categorized based on “Tinnitus Handicap Inventory” (THI) at pre-stent, day-0, 1-month, 3-month, 6-month, 12-month, 18-month and 2-year follow-up. Demographics, body-mass index (BMI), pre and post VSS trans-stenotic pressure gradient were documented. Statistical analysis performed using Pearson’s correlation, Chi-square analysis and Fischer’s exact test.Results29 patients with a mean age of 29.5±8.5 years M:F = 1:28. Median (mean) THI pre and post stenting were: 4 (3.7) and 1 (1) respectively. Median time of tinnitus resolution post VSS was 0-days. There was significant improvement of THI (Δ Mean: 2.7 THI [95% CI: 2.3–3.1 THI], p<0.001) and transverse-distal sigmoid sinus gradient (Δ Mean: -15.3 mm Hg [95% CI: 12.7–18 mm Hg], p<0.001) post-stenting. Mean follow-up duration of 26.4±9.8 months (3–44 months). VSS was feasible in 100% patients with no procedural complications. Three-patients (10%) had recurrent sinus stenosis and tinnitus at mean follow-up of 12 months (6–30 months).ConclusionVenous sinus stenting is an effective treatment for pulsatile tinnitus in patients with IIH and venous sinus stenosis.

Venous sinus stenting in patients without idiopathic intracranial hypertension

BackgroundVenous sinus stenting is an effective treatment for patients with idiopathic intracranial hypertension (IIH) and venous sinus stenosis.ObjectiveTo determine the usefulness of venous sinus stenting in the treatment of patients...

E-068 transverse sinus configurations in pseudotumor cerebri patients without elevated pressure gradients

Background and purpose Venous Sinus Stenosis is found in up to 90% of patients who present with pseudotumor cerebri. Presently, most operators who perform venous sinus stenting in patients with pseudotumor cerebri use a gradient threshold of 8 mmHg to determine whether stenting is indicated, hypothesizing that such a gradient indicates a physiologically significant stenosis. This study assesses the anatomy of screened patients that have gradient negative pseudotumor cerebri; monitoring for degree of stenosis, co-dominance, and laterality. Methods Patients in the prospectively maintained pseudotumor cerebri database were assessed to ascertain which patients with clinically diagnosed medically refractory pseudotumor cerebri had undergone venous pressure monitoring. The anatomy was assessed looking at degree of co-dominance as well as minimal and maximal luminal diameter as assessed on post contrast SPGR MRI. Results 71 patients were screened yielding 13 patients who had undergone venous pressuring monitoring with gradients of 8 mmHg or less. 2 were patients that had undergone re-measurements post stent and excluded from this study. Of the 11 remaining patients, 9 were judged to be co-dominant, using the definition of a ratio of > 2:1 in diameter of the dominant vessel:non dominant. Average maximal luminal diameter of the aggregate transverse sinuses was 7.8 mm, and the mean degree of stenosis was 40%. Conclusions The degree of co-dominance in medically refractory, gradient negative pseudotumor cerebri, is higher than what is seen in historical gradient positive pseudotumor cerebri. Further research is needed to see whether endovascular therapy or diagnosis is worthwhile in such patients. Disclosures C. Chung: None. M. Luciano: None. S. John: None. G. Kosmorsky: None. L. Lystad: None. F. Hui: None.

E-074 venous sinus stenting for idiopathic intracranial hypertension is not associated with cortical venous occlusion

<h3>Background</h3> The effect of dural venous sinus stenting has been investigated for the treatment of idiopathic intracranial hypertension (IIH), but the effect of stenting on the long-term patency of the cortical draining veins, especially the vein of Labbé (VOL), remains unknown. <h3>Methods</h3> We reviewed our database of 38 IIH patients with 41 stented dural venous sinuses between October 2006 and December 2014. Demographic, clinical, and radiological data were reviewed. Follow-up catheter angiographic data were included when available. <h3>Results</h3> Stent placement spanned the ostium of the VOL in 35 patients (92.1%), with no immediate effect on the drainage of the VOL. Follow-up angiography (mean, 35.1 months; range, 1.7–80.7 months) was available in 24 patients, 21 of whom had stents spanning the VOL ostium. The VOL remained patent without occlusion or drainage alteration in all 21 patients. There were no immediate or long-term intracranial complications. <h3>Conclusions</h3> Dural venous sinus stenting for patients with IIH does not affect the immediate or long-term patency of the VOL, and is not associated with intracranial complications. <h3>Disclosures</h3> M. Levitt: None. F. Albuquerque: None. A. Ducruet: None. M. Kalani: None. C. Mulholland: None. C. McDougall: None.

E-113 role of intravascular ultrasound in the intracranial cerebral venous sinus angioplasty and stenting

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.

Venous sinus stenting for idiopathic intracranial hypertension is not associated with cortical venous occlusion

BackgroundThe effect of dural venous sinus stenting has been investigated for the treatment of idiopathic intracranial hypertension (IIH) but the effect of stenting on the long-term patency of the cortical...

Efficacy of endovascular stenting in dural venous sinus stenosis for the treatment of idiopathic intracranial hypertension

Multiple pathophysiological mechanisms have been proposed for the increased intracranial pressure observed in idiopathic intracranial hypertension (IIH). The condition is well characterized, with intractable headaches, visual obscurations, and papilledema as dominant features, mainly affecting obese women. With the advent of MR venography and increased use of cerebral angiography, there has been recent emphasis on the significant number of patients with IIH found to have associated nonthrombotic dural venous sinus stenosis. This has led to a renewed interest in endovascular stenting as a treatment for IIH. However, the assumption that venous stenosis leads to a high pressure gradient that decreases CSF resorption through arachnoid villi requires further evidence. In this paper, the authors analyze the published results to date of dural venous sinus stenting in patients with IIH. They also present a case from their institution for illustration. The pathophysiological mechanism in IIH requires further elucidation, but venous sinus stenosis with subsequent intracranial hypertension appears to be an important mechanism in at least a subgroup of patients with IIH. Among these patients, 78% had complete relief or improvement of their main presenting symptoms after endovascular stenting. Resolution or improvement in papilledema was seen in 85.1% of patients. Endovascular stenting should be considered whenever venous sinus stenosis is diagnosed in patients with IIH.