Via a systematic literature review of limited available data, investigators assessed treatment outcomes for dural venous sinus stenting (DVSS) in patients with idiopathic intracranial hypertension (IIH).
Study design
Surgical intervention for patients with IIH is usually reserved for those with progressive, severe visual symptoms and signs at presentation, or progressive visual loss or severe headaches despite medical therapy. One of these interventions is DVSS. This systematic literature review describes the technical details of DVSS and evaluated the available published evidence and recommendations for the role of DVSS in patients with IIH.
Outcomes
Although multiple studies generally show a favorable outcome for DVSS in improving headaches and vision, there is a lack of solid evidence for its role. No data from randomized controlled trials have been published in the current literature, and what is available is based on retrospective, small-scale, single-center studies. To date, data suggest that the higher the trans-stenotic pressure gradient, the better the outcome; however, there is no clear cutoff for an abnormal gradient. Many of the published studies use an arbitrary cutoff of 8 mm Hg, which is considered to be of moderate evidence. The current recommendation is for venous sinus manometry to be performed for the selection of eligibility for DVSS, keeping in mind that manometry can be affected by several factors, including anesthesia, end-tidal CO2, and relative head position, all of which were not accounted for in many of the studies. The authors of this review did not find evidence-based guidelines on specific indications for DVSS in IIH. The American Academy of Ophthalmology clinical update highlights variability in approach to the indications of DVSS in IIH among different clinicians based on personality, experience, and training.
Limitations
Available data are based on small, retrospective studies with a wide range of diagnostic inclusion criteria, anesthetic and procedural techniques, and follow-ups. While no randomized controlled trials to date have assessed the role of DVSS in IIH in comparison with other surgical modalities, it is challenging to do so, given the wider spectrum of patients undergoing cerebrospinal fluid diversion procedures as compared with those undergoing DVSS.
Clinical significance
Managing patients with IIH should include a stepwise approach based on symptoms and signs at presentation as well as disease progression, potentially beginning with conservative management strategies such as losing weight, avoiding precipitating medications, and controlling underlying risk factors. Medical treatment includes acetazolamide and/or topiramate. If surgical intervention is deemed appropriate, the technique used should be based on the patient’s characteristics, investigation results, and expertise within the treatment center.