Dural venous sinus stenting technique for idiopathic intracranial hypertension in patients with tortuous venous anatomy.

Venous sinus stenting (VSS) for medically refractory idiopathic intracranial hypertension (IIH) is emerging as a safe and effective alternative to shunting. However, stent navigation past the jugular bulb with commonly used carotid stenting systems via femoral access in cases with tortuous venous anatomy can present a challenge, leading to procedural failure. We present a technical refinement using a cervical access and peripheral vascular stent with a more stable 0.035-in. delivery platform as an alternative to the traditional approach to simplify the procedure and overcome the technical difficulties in cases with tortuous venous anatomy. Our institutional database for patients who had IIH and undergone VSS using the peripheral vascular stent between 2013 and 2023 was retrospectively reviewed. Data on 36 patients (33 women, 3 men, mean age 32 years) was collected. VSS was technically successful in all patients (100%) without major complications or thrombosis. There was one case of minor neck cellulitis treated with oral antibiotics. Three patients underwent repeat stenting, and 2 patients had ventriculoperitoneal shunt placement after stenting due to persistent or recurrent symptoms. All patients (100%) had improvement or resolution of papilledema; however, six patients had evidence of optic atrophy and persistent vision loss. Headache was resolved or improved in 91% of patients. In the presence of tortuous venous anatomy, VSS using cervical access and a peripheral vascular stent with a more stable 0.035-in. delivery platform can be considered as a safe and effective alternative approach with shorter procedure time. This approach is particularly advantageous in situations where the procedure is prolonged or high dose of contrast has been administered due to the technical challenges associated with the traditional use of carotid systems via femoral access for stent delivery.

Pitfalls in the Use of Stereoacuity in the Diagnosis of Nonorganic Visual Loss.

PURPOSE: The Titmus Stereotest (Stereo Optical Co., Inc., Chicago, IL) has been used to estimate visual acuity (VA) in the evaluation of nonorganic visual loss. Previous predictions were derived from optical degradation of VA in normal subjects and may not account for the variability seen in patients with neuro-ophthalmic pathologies included in the differential diagnosis of nonorganic visual loss. The purpose of this study was to evaluate the relationship between Titmus stereoacuity and minimal VA based on a real-world testing environment. DESIGN: Cross-sectional observational study. PARTICIPANTS: All patients treated at the authors' neuro-ophthalmology service between April 25, 2014, and July 31, 2014. METHODS: All subjects underwent routine neuro-ophthalmic examination, including Titmus stereoacuity measurements. A compound Bayesian logit-lognormal model accounting for heteroscedasticity was used to determine 95% and 99% prediction intervals of the worse eye's near VA based on stereoacuity. Logarithm of the minimum angle of resolution VA and log stereoacuity were analyzed. MAIN OUTCOME MEASURES: Titmus stereoacuity and worse eye VA. RESULTS: Of 561 patients, 364 subjects 11 to 91 years of age were included. Titmus stereoacuity was associated positively with VA: 9 circles correct (40 seconds of arc) indicated VA of at least 20/40 with 95% confidence and VA of at least 20/79 with 99% confidence; 6 circles correct (80 seconds of arc) indicated VA of at least 20/62 and 20/180, respectively; and 4 circles correct (140 seconds of arc) indicated VA of at least 20/110 and 20/570, respectively. CONCLUSIONS: When fully accounting for individual variation and the full spectrum of neuro-ophthalmic diseases affecting VA, stereoacuity remains associated with VA, but previous commonly used VA estimates based on stereoacuity overestimated VA. Our results more accurately predict minimum VA from Titmus stereoacuity and should be used preferentially when evaluating patients with suspected nonorganic visual loss. We demonstrated that Titmus stereoacuity cannot definitively establish normal VA, and therefore can suggest, but not fully establish, the diagnosis of nonorganic visual loss.