idiopathic intracranial hypertension: assesssment of endovasal techniques for treatment

Idiopathic Intracranial Hypertension: Assesssment of

Endovasal Techniques for TreatmentAngel Mironov

Creighton University Medical CenterOmaha, Nebraska

Background

The idiopathic intracranial hypertension remains a diagnosis of exclusion

( Friedman D., Jacobson D.: Neurology 59, 2002)

The restoring of patency of stenotic dural sinuses in patients with refractory IIH is not sufficient elucidate

The neurointerventional community is still debating and strives to justify neurovascular strategies for treatment

Goals of this study

To document the clinical response to an endovascular improvement of lateral sinus circulation by angioplasty

To clarify the relation of IIH to associate narrowing of lateral dural sinuses

To justify apparently indications for appropriate endovasal treatment

Materials and MethodsDemography

12 patients with refractory IIH

Sex: female – nr:11; male – nr:1 Age range: 16 – 34 years-old BMI kg/m2 range: 20 – 85 CSF opening pressure range: 30 – 95 H2O Progressive headache (nr: 12), visual

disturbance (nr: 11), personality change (nr: 3)

Materials and MethodsDiagnostic

Imaging: MRI, MRV (7) Catheter angiography with retrograde venography Pull-back manometry with blood pressure transducer in the

sagittal sinus, torcular Herophili, proximal and distal transverse sinus, proximal and distal sigmoid sinus, jugular bulb, proximal and distal jugular vein on each side, and in superior vena cava

Focus of interest of venous manometry: a) gradients across the irregularities of lateral sinus b) gradients at confluence of sinuses/jugular bulb

ResultsSinus manometry

Pressure gradients across the sinus irregularities: 1. Group: up to 15 mmHg – 6 cases (4, 6, 7, 8, 9, 12 mm) 2. Group: up to 30 mmHg – 4 cases (21, 25, 26, 30 mm) 3. Group: above 30 mmHg – 2 cases (50/48, 35 mm)

Sinus angioplasty offered for groups 2 and 3: compliant balloons 4 and 4.5 mm

Case report 1

25 year-old obese woman (body mass index 33.1 kg/m2)

Intermittent headache for 3 we Visual disturbance with transient

obscurations, papilledema Raised cerebrospinal fluid pressure - 62

H2O

MR Imaging

Bilateral optic nerve sheath dilatation and papilla protrusion

MR time-of-flow venography

Left internal carotid

Left vertebral

Left lateral sinus

Right lateral sinus

Endovasal manometry

Chart of endovasal manometry of dural sinusesPressure gradients right lateral sinus: 20

mmHgPressure gradients left lateral sinus: 5 mmHg

mmHg 17/15mmHg 16/14

mmHg 16/15 mmHg 17/16

mmHg 22/21mmHg 36/3520 5

Compliant balloon angioplasty

Outcome

Remarkable clinical improvement after angioplasty of right lateral dural sinus in following week with resolution of symptoms

Last follow up: 6 months

Case report 2

26 year-old obese woman (body mass index 35 kg/m2)

6 we history of headache Progressive visual disturbance for 1 we Bilateral papilledema Cerebrospinal fluid raised at 80 H2O Personality change on admission

Optic papilla protrusion

Left lateral sinus

Endovasal manometry:pressure gradients of 48 mmHg

Compliant balloon angioplasty of left lateral sinus

Endovasal manometry: pressure gradients of 50 mmHg

Right lateral sinus

Compliant balloon angioplasty of right lateral sinus

Initial Gd MRI Follow up 6 we Gd MRI

OutcomeLast follow up: 12 months

Remarkable clinical improvement after angioplasty of both lateral venous sinuses in following week with durable resolution of symptoms

Overal ResultsOutcome angioplasty of

sinus

Dramatic and durable improvement for more than 6 months in 4 cases:

jugular vein pressure of 8, 10, 12, and 16 mm Hg

Transitory not sustainable improvement in 2 cases:

jugular vein pressure of 22 and 24 mm Hg

Discussion & Conclusion

Some cases of IIH are exacerbated by a coexistent effect of preexistent anatomic narrowing of the lateral sinuses with elevated across gradients; an improvement of sinus perfusion may break the iterative cycle (?)

Even in case with exposed across gradients the perfusion improvement of sinuses will be not obtainable, as long as the central venous pressure is exceedingly elevated (?)

The lack of clinical response after angioplasty/stenting reflects probably the both – the lack of exposed across gradients (less than 15 mmHg), and the elevation of jugular vein pressure due to central venous pressure elevation (more than 20 mmHg)

END

ResultsSinus manometry

MR venography and conventional venous phase demonstrated patent flow of dural sinuses with hypoplastic/stenotic divisions or irregularities of lateral sinuses in all patients

Pressure gradients across the sinus irregularities: 1. Group: up to 15 mmHg – 6 cases (4, 6, 7, 8, 9, 12

mm) 2. Group: up to 30 mmHg – 4 cases (21, 25, 26, 30

mm) 3. Group: above 30 mmHg – 2 cases (50/48, 35 mm)