Venous Sinus Stenting in Idiopathic Intracranial Hypertension Indications [Neurosurgery Wiki]

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====== Venous Sinus Stenting in Idiopathic Intracranial Hypertension Indications ======

===== I. Core Indications =====
Venous sinus stenting (VSS) is indicated in selected patients with IIH who meet the following criteria:

  * **Refractory IIH**:
    * Persistent elevated intracranial pressure (ICP) despite:
      * Weight loss
      * Medical therapy (e.g., acetazolamide, topiramate)
      * Serial lumbar punctures or temporary CSF diversion
    * Progressive or threatened **visual loss**
    * Severe or intractable **headache** with features of venous outflow obstruction

  * **Radiological Evidence of Venous Sinus Stenosis**:
    * Focal stenosis of the **transverse** or **sigmoid sinus**
    * Confirmed by:
      * CT Venography (CTV)
      * MR Venography (MRV)
      * Digital Subtraction Angiography (DSA)

  * **Hemodynamic Confirmation**:
    * Trans-stenotic pressure gradient ≥ **8–10 mmHg** on catheter venography

===== II. Supportive Findings =====
These findings are supportive but not mandatory for stenting:

  * Venous sinus waveform abnormalities (e.g., “collapsing” or “thumping” waveforms)
  * Elevated lumbar puncture opening pressure > 25 cm H₂O
  * MRI features:
    * Empty sella
    * Optic nerve sheath distension
    * Flattening of the posterior globe
  * Papilledema
  * Transient improvement after lumbar puncture

===== III. Contraindications / Relative Exclusions =====

  * Absence of a measurable trans-stenotic pressure gradient
  * Intrinsic stenosis due to arachnoid granulations without pressure gradient
  * Uncontrolled hypercoagulable states
  * Poor vascular access or unfavorable stent anatomy
  * Active CNS infection or inflammation
  * Urgent need for rapid CSF decompression

===== IV. Special Considerations =====

  * **Optic nerve sheath fenestration** may be preferred in isolated visual loss
  * **CSF diversion (e.g., ventriculoperitoneal shunt)** may be favored when:
    * There is no significant venous stenosis
    * Multiple contributing factors exist for ICP elevation
    * Rapid clinical deterioration requires urgent decompression