Venous Sinus Stenting in Idiopathic Intracranial Hypertension 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

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

• 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

• 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