Meta-Analysis of CSF Diversion Procedures and Dural Venous Sinus Stenting in the Setting of Medically Refractory Idiopathic Intracranial Hypertension

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The authors performed a PubMed search of all peer-reviewed articles from 1988–2014 for patients who underwent a procedure for medically refractory idiopathic intracranial hypertension. The CSF diversion procedure analysis included 435 patients. Postprocedure in this group, there was improvement of vision in 54%, headache in 80%, and papilledema in 70%. The dural venous sinus stenting analysis included 136 patients. In this group, after intervention, there was improvement of vision in 78%, headache in 83%, and papilledema in 97% of patients. The current clinical paradigm of CSF diversion first should be re-examined given the good technical success and low complication rates of stenting.

Abstract

BACKGROUND AND PURPOSE

In medically refractory idiopathic intracranial hypertension, optic nerve sheath fenestration or CSF shunting is considered the next line of management. Venous sinus stenosis has been increasingly recognized as a treatable cause of elevated intracranial pressure in a subset of patients. In this article, we present the results of the largest meta-analysis of optic nerve sheath fenestration, CSF shunting, and dural venous sinus stenting. This is the only article that compares these procedures, to our knowledge.

MATERIALS AND METHODS

We performed a PubMed search of all peer-reviewed articles from 1988 to 2014 for patients who underwent a procedure for medically refractory idiopathic intracranial hypertension.

RESULTS

Optic nerve sheath fenestration analysis included 712 patients. Postprocedure, there was improvement of vision in 59%, headache in 44%, and papilledema in 80%; 14.8% of patients required a repeat procedure with major and minor complication rates of 1.5% and 16.4%, respectively. The CSF diversion procedure analysis included 435 patients. Postprocedure, there was improvement of vision in 54%, headache in 80%, and papilledema in 70%; 43% of patients required at least 1 additional surgery. The major and minor complication rates were 7.6% and 32.9%, respectively. The dural venous sinus stenting analysis included 136 patients. After intervention, there was improvement of vision in 78%, headache in 83%, and papilledema in 97% of patients. The major and minor complication rates were 2.9% and 4.4%, respectively. Fourteen additional procedures were performed with a repeat procedure rate of 10.3%. Three patients had contralateral stent placement, while 8 had ipsilateral stent placement within or adjacent to the original stent. Only 3 patients required conversion to CSF diversion or 2.2% of patients with stents.

CONCLUSIONS

Patients with medically refractory idiopathic intracranial hypertension have traditionally undergone a CSF diversion procedure as the first intervention. This paradigm may need to be re-examined, given the high technical and clinical success and low complication rates with dural venous sinus stenting.

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Meta-Analysis of CSF Diversion Procedures and Dural Venous Sinus Stenting in the Setting of Medically Refractory Idiopathic Intracranial Hypertension
jross
Jeffrey Ross • Mayo Clinic, Phoenix

Dr. Jeffrey S. Ross is a Professor of Radiology at the Mayo Clinic College of Medicine, and practices neuroradiology at the Mayo Clinic in Phoenix, Arizona. His publications include over 100 peer-reviewed articles, nearly 60 non-refereed articles, 33 book chapters, and 10 books. He was an AJNR Senior Editor from 2006-2015, is a member of the editorial board for 3 other journals, and a manuscript reviewer for 10 journals. He became Editor-in-Chief of the AJNR in July 2015. He received the Gold Medal Award from the ASSR in 2013.

One thought on “Meta-Analysis of CSF Diversion Procedures and Dural Venous Sinus Stenting in the Setting of Medically Refractory Idiopathic Intracranial Hypertension

  • October 24, 2015 at 2:55 pm
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    I’m a believer! Makes me wonder whether we need to change the name of this disorder to better reflect the presumed pathophysiology.

    Does everyone perform CTV in patients with clinical presentation of pseudotumor?

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