idiopathic intracranial hypertension

Transverse Sinus Stenosis Is the Most Sensitive MR Imaging Correlate of Idiopathic Intracranial Hypertension

Fellows’ Journal Club

MR imaging and MRV images from 63 patients with idiopathic intracranial hypertension and 96 controls were reviewed by using 3 independent procedures. MRV images were graded for the presence and degree of stenosis of the transverse sinus. Postgadolinium coronal T1-weighted sequences were evaluated independent of MRV. The dimensions of the proximal and distal transverse sinus were measured. Transverse sinus stenosis was identified bilaterally on MRV in 94% of patients with IIH and in 3% of controls. On coronal T1 postgadolinium MR images, transverse sinus stenosis was identified in 83% of patients with IIH and 7% of controls. The authors conclude that transverse sinus stenosis is the most useful and sensitive imaging indicator of this disease state.

Stents for Idiopathic Intracranial Hypertension: Meta-Analyzed, Hypo-Analyzed, and In Need of a Trial

P. Noonan
Department of Radiology
Scott and White Memorial Hospital
Temple, Texas

How did the recent article by Satti et al1 pass muster? A review of the status of venous sinus stent placement in 20132 included more patients with stents than the so-called meta-analysis review in your October 2015 issue. Seven of the studies cited in the 2013 analysis had only 1 patient each and were not included in the 2015 analysis; stripped of those 7 single patient studies, the 2015 meta-analysis looks much like the 2013 review. Nevertheless, why choose to include in the meta-analysis a study with only 4 patients—or the studies with only 10, 12, 15, or 18 patients? The power in both the 2013 review and the current meta-analysis lies in the 52-patient study by Ahmed et al,3 in which CSF opening pressure, an essential criterion for the diagnosis of idiopathic intracranial hypertension (IIH), was not documented in either 11 or 9 patients depending on which meta-analysis one chooses to read. Likewise, the 2 studies with 15 patients each (Fields et al4 and Albuquerque et al5) did not record the CSF opening pressure for any of their included patients; and both the 4-patient study (Owler et al6) and the 18-patient study (Kumpe et al7) did not record CSF opening pressure in 1 and 4 patients, respectively. A study of 10 patients noted to be without recorded CSF opening pressures in the 2013 analysis (Bussière et al8) is noted in Table 4 of the 2015 meta-analysis as having an opening pressure range of 25–50 cm H20. What was the source of that post hoc information?

Given that an elevated CSF pressure is an essential diagnostic criterion of IIH, for which all of these …

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

Editor’s Choice

Editor’s Comments

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