Reductions in bilateral transverse sinus pressure gradients with unilateral transverse venous sinus stenting for idiopathic intracranial hypertension.

BACKGROUND: Venous sinus stenting is an effective treatment for papilledema associated with idiopathic intracranial hypertension (IIH). It is unclear whether unilateral transverse-sigmoid sinus (TSS) stenting adequately decompresses the contralateral TSS system in cases of bilateral transverse sinus stenosis. The objective of this study was to compare changes in bilateral TSS pressure gradients following unilateral TSS stenting in a series of patients with IIH. METHODS: Consecutive patients from a single institution who underwent venous sinus stenting for IIH with measurement of bilateral pressure gradients before and after stenting for IIH were enrolled. Pressure gradients in both TSS pre- and post-stenting were measured during the procedure. The TSS with the highest gradient was stented. Changes in TSS pressure gradients following stent placement were calculated for both TSS. Mean changes in pressure gradients of ipsilateral and contralateral TSS were calculated. RESULTS: Sixteen patients with IIH who underwent TSS stenting were included. All were female. Mean age was 36.4 years. The right-sided TSS was the stented side in 12 (75.0%) patients. The mean pre-stent pressure gradient of the ipsilateral TSS was 19.3 mmHg (SD=10.8), which was reduced to a mean of 3.8 mmHg (3.4) following stent placement (P =<0.0001). On the contralateral (non-stented) side, the mean pre-stent gradient of 15.1 mmHg (7.5) was reduced to a mean of 7.8 mmHg (6.6) following stenting (P=0.006). CONCLUSIONS: The use of a single stent provides some venous decompression of the contralateral non-stented stenosis in most cases of IIH treated with endovascular therapy.

Utility of CT venography in monitoring stent patency in idiopathic intracranial hypertension: retrospective single-center study.

BACKGROUND: Cerebral venous sinus stenting is an established treatment for patients with idiopathic intracranial hypertension (IIH), refractory to medical management and with stenotic venous sinus on conventional cerebral venography. Currently, there are no clear guidelines on optimal noninvasive imaging modality for routine post-stenting follow-up. We investigated diagnostic yield of CT venography (CTV) for evaluation of stent patency. METHODS: We reviewed our clinical database of patients with a diagnosis of IIH, who underwent stenting of stenotic transverse or transverse/sigmoid sinus junction. Patients who had follow-up CTVs after more than 30 days were included in the final study group. All CTVs were reviewed by two readers for in-stent thrombosis, extrinsic stent compression, juxta-stent stenosis, and new contralateral venous sinus stenosis. Inter-observer agreement and association of stent patency with clinical outcomes (headache and papilledema) were assessed. RESULTS: In all 36 included patients with 38 cerebral venograms for stenting, follow-up CTVs demonstrated adequate opacifications of the venous sinuses and stents for confident evaluation for in-stent thrombosis, extrinsic stent compression, juxta-stent stenosis, and new contralateral venous sinus stenosis, with inter-observer agreement coefficient of 0.7, 1.0, 0.8, and 1.0 respectively. Association between abnormal CTV and higher rates of persistent headache and lower rates of headache improvement/resolution was statistically significant (P-value of 0.01). CONCLUSION: CTV is a reliable noninvasive imaging modality for evaluation of cerebral venous sinuses and stent patency following treatment of idiopathic intracranial hypertension with venous sinus stenting and could be used as a routine follow-up study.

Remote ischemic preconditioning for elective endovascular intracranial aneurysm repair: a feasibility study.

OBJECTIVES: Remote ischemic preconditioning has been proposed as a possible potential treatment for ischemic stroke. However, neuroprotective benefits of the pre-procedural administration of remote ischemic preconditioning have not been investigated in patients undergoing an elective endovascular intracranial aneurysm repair procedure. This study investigated the safety and feasibility of remote ischemic preconditioning in patients with an unruptured intracranial aneurysm who undergo elective endovascular treatment. METHODS: In this single-center prospective study, patients with an unruptured intracranial aneurysm undergoing elective endovascular treatment with flow diverters or coiling were recruited. Patients received three intermittent cycles of 5 minutes arm ischemia followed by reperfusion using manual blood cuff inflation/deflation less than 5 hours prior to endovascular treatment. Patients were monitored and followed up for remote ischemic preconditioning-related adverse events and ischemic brain lesions by diffusion -weighted magnetic resonance imaging within 48 hours following endovascular treatment. RESULTS: A total of seven patients aged 60 ± 5 years with an unruptured intracranial aneurysm successfully completed a total of 21 sessions of remote ischemic preconditioning and the required procedures. Except for two patients who developed skin petechiae over their arms, no other serious procedure-related adverse events were observed as a result of the remote ischemic preconditioning procedure. On follow-up diffusion -weighted magnetic resonance imaging, a total of 19 ischemic brain lesions with a median (interquartile range) volume of 245 (61-466) mm3 were found in four out of seven patients. CONCLUSIONS: The application of remote ischemic preconditioning prior to endovascular intracranial aneurysm repair was well tolerated, safe and clinically feasible. Larger sham-controlled clinical trials are required to determine the safety and efficacy of this therapeutic strategy in mitigating ischemic damage following endovascular treatment of intracranial aneurysms.