Lessons Learned from Stenting Neurovascular Lesions

Educational Objectives

The goal of this program is to improve the management of idiopathic intracranial hypertension (IIH). After hearing and assimilating this program, the clinician will be better able to:

1. Diagnose IIH.
2. Evaluate recent evidence on the use of venous stents in the management of IIH.

Summary

Pseudotumor cerebri (idiopathic intracranial hypertension [IIH]): the initial diagnostic criteria, published in 1937, included elevated intracranial pressure (ICP), visual symptoms resulting from papilledema, and the absence of tumor on cranial imaging (ie, ventriculography); as imaging improved, nuances were added to the criteria and to the nomenclature for different syndromes; epidemiology — Higgins et al (2017) described the prevalence of IIH to be ≈1 in 100,000 individuals in the 1990s; the frequency is increasing as a greater proportion of the population becomes overweight; IIH is more common in women

Treatment of IIH: the initial neurosurgical treatment was lumboperitoneal shunting and decompressive craniectomy; Azad et al (2020) suggested that lumboperitoneal and ventriculoperitoneal shunting improved headache by ≈60% and papilledema by 80% to 90%; in many patients, papilledema is treatable, but headaches persist; treatments for lowering IIH revolve around the brain, blood, and cerebrospinal fluid (CSF); CSF can be lowered through lumbar puncture, acetazolamide (Diamox), or shunting; craniectomy provides decompression of the brain; venous stenting was initially described in the 1990s; Higgins et al (2002) discussed stenting of the transverse sigmoid sinus in a patient with venous stenosis creating a gradient

Pathophysiology: the sinuses are made of dura; increased ICP pushes on the sinus, causing venous compression and venous hypertension, which increases the pressure on the sinus; the inciting event for this phenomenon is not clearly understood, but the loop leads to increased ICP; Morris et al (2017) found that, anatomically, the transverse sigmoid sinus is the most susceptible location where the dura can be narrowed by elevated ICP; patients who undergo stenting may develop stenosis outside of the stent, although the torcula is relatively protected; stenting became popular in the 2000s

Recent evidence: a meta-analysis by Nicholson et al (2019) involving 474 patients undergoing venous stenting for IIH with a mean follow-up of 18 mo demonstrated 94% improvement in papilledema, 80% improvement in headaches, and 90% improvement in pulsatile tinnitus, with ≈10% recurrence; in-stent restenosis is rare with venous stenting; the treatment for juxtapositional stenosis involves placing another stent or a shunt; the major complication rate is 2%

Workflow for IIH: for patients with papilledema and elevated opening pressure on lumbar puncture, magnetic resonance imaging and magnetic resonance venography are performed; shunts are recommended for patients without sinus stenosis; patients with sinus stenosis typically undergo diagnostic cerebral angiography and venous manometry; venous stenting is recommended for patients with significant gradients (≥8 mm Hg); there are unresolved questions around patients with headache and pulsatile tinnitus but without papilledema, those who do not have evidence of venous stenosis on MRI (angiogram and venogram may still show stenosis), and those who have lower gradients (may benefit from stenting); experience at Raphael Center for Neurorestoration (Thomas Jefferson University) — ≈33% of referrals for possible venous stenting come from ophthalmologists and ≈33% from neurosurgeons; some are referred from neurology or otolaryngology; patients with a CSF leak may have undiagnosed elevated ICP without any other symptoms; patients differ in how much symptoms (eg, pulsatile tinnitus, headaches) bother them; most patients undergo stenting of the transverse sinus, and some undergo stenting at the sagittal sinus; papilledema and headaches improved in ≈90% of patients, tinnitus in ≈80%, and vision changes (eg, floaters, blackouts, tunnel vision) in 75%; loss of vision (ie, blackouts) is considered an absolute emergency; patients must see an ophthalmologist

Procedure: a catheter is inserted into the femoral vein to place the stent and measure pressures in the sinuses; patients must take dual antiplatelet therapy (ie, aspirin with clopidogrel [Plavix] or ticagrelor [Brilinta]); the anticoagulant is usually taken for 3 to 6 mo, and aspirin for a total of 1 yr; stenting is performed under general anesthesia and requires an overnight stay; even patients with an inciting event for increased ICP (eg, meningioma) can have areas of venous congestion that are amenable to stenting; complications — include groin hematoma and contrast extravasation; the overall safety profile of stenting is favorable; patient selection and long-term follow-up are important

Future directions: the randomized OPEN-UP trial comparing shunts (gold standard) vs stents for patients with headache, loss of vision, elevated opening pressure, and gradients ≥8 mm Hg is underway; another innovation is the use of stent electrodes in the superior sagittal sinus to communicate with the motor cortex; this could be used for patients with, eg, amyotrophic lateral sclerosis or paraplegia

Questions and answers: timing of venous stenting in the context of a CSF leak is made after consultation with the neurosurgeon; stenting is usually performed after a few weeks; therapy starts with acetazolamide, unless recent lumbar puncture was performed; repeat imaging is not recommended for patients who remain asymptomatic after treatment

Readings

Barkatullah AF, Leishangthem L, Moss HE. MRI findings as markers of idiopathic intracranial hypertension. Curr Opin Neurol. 2021 Feb 1;34(1):75-83. doi: 10.1097/WCO.0000000000000885. PMID: 33230036; PMCID: PMC7856277; Guo XB, Wei S, Guan S. Intracranial venous pressures manometry for patients with idiopathic intracranial hypertension: Under awake setting or general anesthesia. Front Neurol. 2019;10:751. Published 2019 Jul 12. doi:10.3389/fneur.2019.00751; Higgins JN, Owler BK, Cousins C, et al. Venous sinus stenting for refractory benign intracranial hypertension. Lancet. 2002;359(9302):228-230. doi:10.1016/S0140-6736(02)07440-8; Higgins JNP, Pickard JD, Lever AML. Chronic fatigue syndrome and idiopathic intracranial hypertension: Different manifestations of the same disorder of intracranial pressure?. Med Hypotheses. 2017;105:6-9. doi:10.1016/j.mehy.2017.06.014; Morris PP, Black DF, Port J, et al. Transverse sinus stenosis is the most sensitive mr imaging correlate of idiopathic intracranial hypertension. AJNR Am J Neuroradiol. 2017;38(3):471-477. doi:10.3174/ajnr.A5055; Nicholson P, Brinjikji W, Radovanovic I, et al. Venous sinus stenting for idiopathic intracranial hypertension: a systematic review and meta-analysis. J Neurointerv Surg. 2019;11(4):380-385. doi:10.1136/neurintsurg-2018-014172.

Disclosures

For this program, the following relevant financial relationships were disclosed and mitigated to ensure that no commercial bias has been inserted into this content: Dr. Gooch is a consultant for Stryker Corporation. Members of the planning committee reported nothing relevant to disclose. Dr. Gooch’s lecture includes information related to the off-label or investigational use of a therapy, product, or device.

Acknowledgements

Dr. Gooch was recorded at the 6th Annual New Jersey Neurovascular & Neurosciences Symposium, held on November 9, 2023, in Mount Laurel, NJ, and presented by Thomas Jefferson University. For information on upcoming CME activities from this presenter, please visit jefferson.edu. Audio Digest thanks the speakers and presenters for their cooperation in the production of this program.

CME/CE INFO

Accreditation:

The Audio- Digest Foundation is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.

The Audio- Digest Foundation designates this enduring material for a maximum of 0.75 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Audio Digest Foundation is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center's (ANCC's) Commission on Accreditation. Audio Digest Foundation designates this activity for 0.75 CE contact hours.

Lecture ID:

NE150602

Expiration:

This CME course qualifies for AMA PRA Category 1 Credits™ for 3 years from the date of publication.

Instructions:

To earn CME/CE credit for this course, you must complete all the following components in the order recommended: (1) Review introductory course content, including Educational Objectives and Faculty/Planner Disclosures; (2) Listen to the audio program and review accompanying learning materials; (3) Complete posttest (only after completing Step 2) and earn a passing score of at least 80%. Taking the course Pretest and completing the Evaluation Survey are strongly recommended (but not mandatory) components of completing this CME/CE course.

Estimated time to complete this CME/CE course:

Approximately 2x the length of the recorded lecture to account for time spent studying accompanying learning materials and completing tests.

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