gms | German Medical Science

Objective: Benign intracranial hypertension (BIH), traditionally termed pseudotumor cerebri, is a challenging disease complex with diverse etiologies. Because of improved MR venography sequences and interventional angiography techniques, the focus has shifted within the last decade to an appreciation of possible venous causes, namely non-thrombotic sinus stenosis. Although not wide-spread yet, successful treatment of this pathology by interventional venous stenting has been repeatedly described. Here we report our experience of the last three years in diagnosis and treatment of BIH-patients with venous stenosis.

Methods: We analyzed our prospectively collected patient database of patients with BIH and suspected venous stenosis. The clinical files and imaging data were studied and analyzed for: Pre- and (possible) postinterventional symptoms, ophthalmology examinations, BMI of patients, grade of the stenosis in MRI and angiography, intravenous pressure proximal and distal of the stenosis, follow up and imaging results after venous stenting.

Results: We have investigated 10 patients with BIH and suspected venous stenosis in MR venography. 9/10 patients were affected by the complete clinical triad of headaches, visual disturbances and papilledema. A significant stenosis could be confirmed in conventional angiography in 8/10 patients. By retrograde venography, the pressure gradient proximal and distal to the stenosis was measured (mean values; range in mmHg): proximal (21.75; 15-28), distal (6.6; 3-9), pressure-gradient (15.2; 5-25). The stenosis was located at the sagittal sinus in 3 patients, and the transverse sinus in 5 patients. If located in the transverse sinus, the contralateral sinus was hypoplastic in four and stenotic in one patient. Venous stenting was indicated in all patients, however due to a F-V-Leiden mutation in one patient, stenting was performed in 7/8 patients only. Clinically, stenting was successful (significant improvement of the symptom-triad) in 6/7 patients (85%), one patient had continuous symptoms, which however disappeared after a significant weight loss. Radiographically, stenting was successful in all patients with a persisting significant reduction of the stenosis. In one patient a redilatation of the stent was needed twice until the result was finally satisfactory. No complications occurred during treatment or follow up (26 months (mean)). These numbers correlate with findings in the literature, where successful treatment is reported in 85-95%, the need for re-stenting in 10% and relevant complications in 5%.

Conclusion: Standardized diagnostic protocols in patients with BIH should include MR venography. In cases with suspected stenosis, angiographic confirmation and pressure gradient determination by retrograde venography is necessary, before venous stenting can be discussed as a safe and long-lasting treatment option.