Goodwin C Rory, Elder Benjamin D, Ward Ayobami, Orkoulas-Razis Dennis, Kosztowski Thomas A, Hoffberger Jamie, Moghekar Abhay, Radvany Martin, Rigamonti Daniele
The Johns Hopkins Hospital, Department of Neurosurgery, Baltimore, USA.
The Johns Hopkins Hospital, Department of Neurosurgery, Baltimore, USA.
Clin Neurol Neurosurg. 2014 Dec;127:75-8. doi: 10.1016/j.clineuro.2014.09.015. Epub 2014 Oct 6.
Idiopathic intracranial hypertension (IIH) when no underlying etiology is found, is a clinical syndrome characterized by elevated intracranial pressure (ICP) (>25 cm H2O), which may lead to headaches and visual symptoms. In patients with IIH who are found to have transverse sinus stenosis, placement of a venous stent across the stenosis has been shown to lower ICP and to resolve the symptoms in several case series, with generally favorable results. In this study, we examine common risk factors associated with failure of transvenous stenting for IIH. If venous sinus stenting fails, CSF diversion should be considered as the next line of treatment.
We retrospectively reviewed the records of eighteen patients diagnosed with IIH who underwent venous sinus stenting for transverse sinus stenosis with a mean pressure gradient (MPG) of at least 4 mmHg. Fifteen of these patients did not need further treatment. We compared their pre- and post-treatment, neurological and neuro-ophthalmological evaluations to the three patients who went on to have a shunt placement as a second line treatment.
Shunting after stent placement patients (n=3) had a mean age of 30 years and a mean body mass index of 36.6 kg/m(2), whereas the group that underwent stent placement alone (n=15) had a mean age of 40.7 years and a mean body mass index of 33.3 kg/m(2). In the shunting after stent placement group, the mean opening pressure on the most recent lumbar puncture obtained prior to any intervention was 50 cm of H2O, whereas the group that underwent stent placement alone had an opening CSF pressure of 37 cm of H2O which was statistically significant (p<0.05). There were no other significant differences in pre- or post-intervention factors between the two groups.
In patients with IIH and documented evidence of venous sinus stenosis with a pressure gradient, venous sinus stenting should be the primary treatment of choice; however, some patients may be refractory to stenting and still require permanent CSF diversion, which can be complicated in these chronically anticoagulated patients. Patients with persistent papilledema post-stenting and highly elevated opening pressure pre-stenting should be followed closely as they are at greatest risk of requiring a shunt and failing stenting.
特发性颅内高压（IIH）是在未发现潜在病因时，以颅内压（ICP）升高（>25 cm H₂O）为特征的临床综合征，可导致头痛和视觉症状。在被发现有横窦狭窄的IIH患者中，在狭窄处放置静脉支架已在多个病例系列中显示可降低ICP并缓解症状，总体效果良好。在本研究中，我们探讨与IIH经静脉支架置入失败相关的常见危险因素。如果静脉窦支架置入失败，应考虑脑脊液分流作为下一步治疗方案。
我们回顾性分析了18例诊断为IIH且因横窦狭窄接受静脉窦支架置入、平均压力梯度（MPG）至少为4 mmHg的患者的记录。其中15例患者无需进一步治疗。我们将他们治疗前后的神经学和神经眼科评估结果与另外3例作为二线治疗接受分流置管的患者进行了比较。
支架置入后进行分流的患者（n = 3）平均年龄为30岁，平均体重指数为36.6 kg/m²，而仅接受支架置入的组（n = 15）平均年龄为40.7岁，平均体重指数为33.3 kg/m²。在支架置入后进行分流的组中，在任何干预之前最近一次腰椎穿刺测得的平均初压为50 cm H₂O，而仅接受支架置入的组脑脊液初压为37 cm H₂O，差异有统计学意义（p < 0.05）。两组干预前后的其他因素无显著差异。
对于有静脉窦狭窄且有压力梯度记录证据的IIH患者，静脉窦支架置入应是首选的主要治疗方法；然而，一些患者可能对支架置入无效，仍需要永久性脑脊液分流，而这在这些长期抗凝的患者中可能会很复杂。支架置入后持续存在视乳头水肿且支架置入前初压高度升高的患者应密切随访，因为他们最有可能需要分流且支架置入失败。
