Idiopathic Intracranial Hypertension: Assesssment of Endovasal Techniques for Treatment Angel Mironov Creighton University Medical Center Omaha, Nebraska
Feb 24, 2016
Idiopathic Intracranial Hypertension: Assesssment of
Endovasal Techniques for TreatmentAngel Mironov
Creighton University Medical CenterOmaha, Nebraska
Background
The idiopathic intracranial hypertension remains a diagnosis of exclusion
( Friedman D., Jacobson D.: Neurology 59, 2002)
The restoring of patency of stenotic dural sinuses in patients with refractory IIH is not sufficient elucidate
The neurointerventional community is still debating and strives to justify neurovascular strategies for treatment
Goals of this study
To document the clinical response to an endovascular improvement of lateral sinus circulation by angioplasty
To clarify the relation of IIH to associate narrowing of lateral dural sinuses
To justify apparently indications for appropriate endovasal treatment
Materials and MethodsDemography
12 patients with refractory IIH
Sex: female – nr:11; male – nr:1 Age range: 16 – 34 years-old BMI kg/m2 range: 20 – 85 CSF opening pressure range: 30 – 95 H2O Progressive headache (nr: 12), visual
disturbance (nr: 11), personality change (nr: 3)
Materials and MethodsDiagnostic
Imaging: MRI, MRV (7) Catheter angiography with retrograde venography Pull-back manometry with blood pressure transducer in the
sagittal sinus, torcular Herophili, proximal and distal transverse sinus, proximal and distal sigmoid sinus, jugular bulb, proximal and distal jugular vein on each side, and in superior vena cava
Focus of interest of venous manometry: a) gradients across the irregularities of lateral sinus b) gradients at confluence of sinuses/jugular bulb
ResultsSinus manometry
Pressure gradients across the sinus irregularities: 1. Group: up to 15 mmHg – 6 cases (4, 6, 7, 8, 9, 12 mm) 2. Group: up to 30 mmHg – 4 cases (21, 25, 26, 30 mm) 3. Group: above 30 mmHg – 2 cases (50/48, 35 mm)
Sinus angioplasty offered for groups 2 and 3: compliant balloons 4 and 4.5 mm
Case report 1
25 year-old obese woman (body mass index 33.1 kg/m2)
Intermittent headache for 3 we Visual disturbance with transient
obscurations, papilledema Raised cerebrospinal fluid pressure - 62
H2O
MR Imaging
Bilateral optic nerve sheath dilatation and papilla protrusion
MR time-of-flow venography
Left internal carotid
Left vertebral
Left lateral sinus
Right lateral sinus
Endovasal manometry
Chart of endovasal manometry of dural sinusesPressure gradients right lateral sinus: 20
mmHgPressure gradients left lateral sinus: 5 mmHg
mmHg 17/15mmHg 16/14
mmHg 16/15 mmHg 17/16
mmHg 22/21mmHg 36/3520 5
Compliant balloon angioplasty
Outcome
Remarkable clinical improvement after angioplasty of right lateral dural sinus in following week with resolution of symptoms
Last follow up: 6 months
Case report 2
26 year-old obese woman (body mass index 35 kg/m2)
6 we history of headache Progressive visual disturbance for 1 we Bilateral papilledema Cerebrospinal fluid raised at 80 H2O Personality change on admission
Optic papilla protrusion
Left lateral sinus
Endovasal manometry:pressure gradients of 48 mmHg
Compliant balloon angioplasty of left lateral sinus
Endovasal manometry: pressure gradients of 50 mmHg
Right lateral sinus
Compliant balloon angioplasty of right lateral sinus
Initial Gd MRI Follow up 6 we Gd MRI
OutcomeLast follow up: 12 months
Remarkable clinical improvement after angioplasty of both lateral venous sinuses in following week with durable resolution of symptoms
Overal ResultsOutcome angioplasty of
sinus
Dramatic and durable improvement for more than 6 months in 4 cases:
jugular vein pressure of 8, 10, 12, and 16 mm Hg
Transitory not sustainable improvement in 2 cases:
jugular vein pressure of 22 and 24 mm Hg
Discussion & Conclusion
Some cases of IIH are exacerbated by a coexistent effect of preexistent anatomic narrowing of the lateral sinuses with elevated across gradients; an improvement of sinus perfusion may break the iterative cycle (?)
Even in case with exposed across gradients the perfusion improvement of sinuses will be not obtainable, as long as the central venous pressure is exceedingly elevated (?)
The lack of clinical response after angioplasty/stenting reflects probably the both – the lack of exposed across gradients (less than 15 mmHg), and the elevation of jugular vein pressure due to central venous pressure elevation (more than 20 mmHg)
END
ResultsSinus manometry
MR venography and conventional venous phase demonstrated patent flow of dural sinuses with hypoplastic/stenotic divisions or irregularities of lateral sinuses in all patients
Pressure gradients across the sinus irregularities: 1. Group: up to 15 mmHg – 6 cases (4, 6, 7, 8, 9, 12
mm) 2. Group: up to 30 mmHg – 4 cases (21, 25, 26, 30
mm) 3. Group: above 30 mmHg – 2 cases (50/48, 35 mm)