From the Guidelines
Transvenous stenting is not established as a long-term effective treatment for Idiopathic Intracranial Hypertension (IIH) compared to Ventriculoperitoneal (VP) shunting.
Key Points
- The role of neurovascular stenting in IIH is not yet established, and its effectiveness in the long term is unknown 1.
- VP shunting is the preferred CSF diversion procedure for visual deterioration in IIH, with a lower reported revision rate per patient 1.
- CSF diversion procedures, including VP shunting, have limited evidence for treating headache alone in IIH, with 68% of patients continuing to experience headaches at 6 months and 79% at 2 years 1.
- Neurovascular stenting has been reported to improve symptoms of intracranial hypertension, but it requires long-term antithrombotic therapy and carries risks such as stent-adjacent stenosis, vessel perforation, and thrombosis 1.
Considerations
- The decision to use CSF diversion procedures, including VP shunting, should be made in a multidisciplinary setting and following a period of intracranial pressure monitoring 1.
- Patients with IIH often experience migrainous headaches, which may not be effectively managed with CSF diversion procedures alone 1.
- The use of adjustable valves with antigravity or antisiphon devices may help reduce the risk of low-pressure headaches in patients undergoing VP shunting 1.
From the Research
Long-term Effectiveness of Transvenous Stenting in IIH
- The long-term effectiveness of transvenous stenting in Idiopathic Intracranial Hypertension (IIH) has been compared to Ventriculoperitoneal (VP) shunting in several studies 2, 3, 4, 5, 6.
- A retrospective case-control study found that headache recurrence was less common in the transvenous stenting group (31% vs 60%, p=0.015) at the last follow-up, averaging over 1 year 2.
- Another study found that the most common clinical outcome post-transvenous stenting in IIH patients is initial symptomatic improvement followed by symptom recurrence in about 60% at a mean of 274 days, despite a consistent intracranial pressure reduction 3.
- A meta-analysis of 36 studies involving 1066 patients who underwent transvenous stenting found that patients showed significantly lower cerebrospinal fluid (CSF) opening pressure and improvement in symptoms such as tinnitus, papilledema, visual disturbances, and headache 4.
- Long-term patency of venous sinus stents has been evaluated, with one study finding that all stents remained patent with mild (<25%) in-stent stenosis observed in four patients 5.
- Quality of life and need for retreatment after transvenous stenting have also been assessed, with one study finding a non-significant increase in quality of life scores and a significant decrease in Headache Impact Test-6 (HIT-6) scores 6.
Comparison to Ventriculoperitoneal Shunting
- Transvenous stenting has been compared to Ventriculoperitoneal (VP) shunting in terms of long-term outcomes, with one study finding that transvenous stenting was independently associated with reduced odds of headache recurrence (OR 0.24, p=0.015) 2.
- Another study found that transvenous stenting may lead to better outcomes for continued headache relief, but headache recurrence may increase with longer follow-up regardless of treatment modality 2.
- The treatment failure rate and complications rate after transvenous stenting have been reported, with one study finding a treatment failure rate of 8.35% and a complications rate of 5.35% 4.
Symptom Recurrence and Re-equilibration Phenomenon
- Symptom recurrence after transvenous stenting has been observed, with one study finding that recurrence of symptoms occurred at a median of 7 months, even though opening pressure remained lower at follow-up lumbar puncture, suggestive of a re-equilibration phenomenon 6.
- The re-equilibration phenomenon has been suggested as a possible explanation for the recurrence of symptoms after transvenous stenting, despite a consistent intracranial pressure reduction 3, 6.