2025 年 19 巻 1 号 論文ID: oa.2024-0100
Objective: In medically refractory idiopathic intracranial hypertension (IIH), venous sinus stenosis (VSS) stenting has been an effective treatment modality. Among patients who experience recurrent symptoms and develop new stenosis, the optimal treatment strategy is unknown. The aim of this study was to investigate the role of rescue re-stenting in patients with recurrence after prior successful stenting.
Methods: This was a single center, retrospective review from a prospectively maintained IIH registry. Between 2012 and 2023, patients who underwent interventions for confirmed IIH and angiographically demonstrable VSS were included. The cohort was divided into those who underwent a single stenting procedure (single stent group) and those who underwent re-stenting due to recurrence of symptoms and new angiographic stenosis (re-stent group).
Results: Ninety seven patients were included: 87 in the single stent group and 10 in the re-stent group, with a median age of 32 (interquartile range 26–38). 94% were female. Both groups had similar baseline demographic and clinical characteristics. There was similar improvement in papilledema and tinnitus. Headache improvement was greater in the single stent group at 6 weeks (88.4% vs. 60.0%, p = 0.04, single vs. re-stent group), but similar at 6 months post-procedure. For visual disturbances, there was similar improvement at 6 weeks, but greater improvement in the single stent group at 6 months post-procedure (86.8% vs. 75.0%, p = 0.04, single vs. re-stent group). None of the re-stented patients required rescue ventriculoperitoneal shunt placement.
Conclusion: Re-stenting among IIH patients with recurrent symptoms after initial successful VSS stenting is feasible with similar efficacy in improving symptoms.
Over the past several years, the incidence of idiopathic intracranial hypertension (IIH) has been estimated to have increased over 100%, correlating with the rise in obesity.1,2) During this same time period, venous sinus stenting in medically refractory cases of IIH has emerged as an effective minimally invasive treatment modality,3,4) leading to increased utilization when compared to ventriculoperitoneal shunt (VPS) placement and/or optic nerve sheath fenestration (ONSF).5) Aside from immediate procedural-related factors, development of new stenosis at the stent interface (adjacent) or distant to initial stent placement (e.g., contralateral transverse sinus or within the superior sagittal sinus) remains a concern for long-term effectiveness in symptom alleviation among a subset of patients. Reports of re-stenosis in the literature vary, but have been estimated in studies to range from ~11% to 22%.6–10)
The re-emergence of symptoms in the presence of re-stenosis following successful stenting highlights the complex pathophysiology of IIH. Elevated intracranial pressure (ICP) in IIH is theorized to result from either an overproduction of cerebrospinal fluid (CSF), impaired CSF resorption, or a combination of each. Intrinsic stenosis and extrinsic compression of the dural venous sinuses may be a primary or secondary driver of venous hypertension that impedes CSF outflow.11) Identification of re-stenosis after successful stenting represents a putative treatment target for patients who develop recurrent symptoms. Whether invasive CSF diversion or additional endovascular management represents the optimal re-treatment strategy in these cases is unclear. Therefore, we sought to investigate the clinical outcomes of patients following rescue re-stenting, clinical factors associated with re-stenosis after initial successful stenting, and angiographic predictors of recurrence.
A similar protocol for patient population and treatment selection previously described by our group was utilized.12) From a single institutional prospectively maintained registry, patients undergoing angiography for evaluation of IIH were identified between 2012 and 2023. Inclusion criteria consisted of patients with clinical signs and/or symptoms of IIH, previous non-invasive imaging (CT venography or MR venography) demonstrating venous sinus stenosis (VSS) and elevated opening pressure (OP) on lumbar puncture (defined as >20 cm H2O). Patients subsequently underwent catheter angiography and venous sinus pressure measurement. They were treated with a venous sinus stent if the following criteria were met: (1) clinical signs and/or symptoms of elevated ICP (2) demonstrable stenosis of a dominant transverse and/or sigmoid sinus by angiography and (3) a venous pressure gradient >1 mmHg across the stenotic region of interest. The degree of clinical improvement following venous sinus stenting was recorded at 6 weeks and 6 months following the final procedure. Catheter angiography and OP measurement by lumbar puncture were both repeated at 6 months following venous sinus stent placement. For patients with recurrence of symptoms and re-stenosis adjacent and/or distal to previous venous sinus stent on follow-up angiography, an additional venous stent was deployed followed by repeat angiography 6 months later. No interpolation for missing data was performed. The study was approved by Institutional Review Board (HSC-MS-17-0524) and all patients or their guardian consented for the procedures.
Treatment protocols Measurement of venous sinus pressure gradientA 7-French Envoy MPC guide catheter (Cerenovus, Raynham, MA, USA) was advanced into the appropriate jugular bulb. A Phenom 27 microcatheter (Medtronic Neurovascular, Irvine, CA, USA) over an Asahi 14 exchange length microwire (Asahi Intecc USA, Irvine, CA, USA) was then advanced into the superior sagittal sinus. Through the microcatheter, venous sinus manometry measurements were then recorded within the superior sagittal sinus, torcula, transverse sinus, sigmoid sinus and jugular bulb. Following venous sinus stent deployment, these measurements were repeated. The end tidal CO2 was kept stable between 38 and 42 mmHg throughout the procedure to maintain the consistency of venous sinus pressure measurements. Venous sinus manometry was performed under general anesthesia.
Venous sinus stent placementA Precise Pro RX self-expandable 8 × 40 mm stent (Cardinal Health, Dublin, OH, USA) was placed across the region of VSS. Balloon angioplasty to ensure proper stent opening and wall apposition was done at the discretion of the neurointerventionalist utilizing a 7 × 20 mm Aviator angioplasty balloon (Cardinal Health) over an Asahi Black 0.014-inch microwire (Asahi Intecc USA). Angiography was performed immediately following venous sinus stent deployment to confirm placement and restoration of the luminal caliber. Technical success was defined as complete restoration of the luminal caliber of the stented venous sinus. All patients were started on aspirin 325 mg and clopidogrel (37.5 or 75 mg) once daily 7 days prior to the planned procedure. Target aspirin activity as measured by aspirin reactivity unit assay was 350–450 and for clopidogrel 80–180 as measured by plavix reactivity unit assay. For patients unresponsive to plavix based on assay results, ticagrelor or prasugrel were used as a substitute. Patients were maintained on dual antiplatelet therapy for a minimum of 6 months post-stent(s) placement, at which time repeat angiography was performed to assess for venous sinus stent patency.
Outcome measuresPrimary outcome was defined as improvement in clinical symptoms at 6 weeks and 6 months and included headache, presence of papilledema, pulsatile tinnitus, and visual disturbances. Visual disturbances were defined as patient reported blurry vision, wavy vision, double vision, and temporary blindness. Secondary outcomes included improvement in venous sinus pressure gradient immediately after stent placement, change in CSF OP 6 months after venous sinus stent placement, and rate of VPS rescue.
Statistical analysisBaseline demographic data, clinical characteristics and clinical outcomes of both treatment groups were compared utilizing the Student’s t-test for continuous variables and Fisher’s exact test for categorical variables. A p-value of less than 0.05 was selected to indicate statistical significance. All statistical analysis was performed utilizing Stata Statistical: Release 17 (StataCorp, College Station, TX, USA).
In total, there were 97 patients who met inclusion criteria. 87 patients had improvement of their symptoms after a single interventional stenting procedure (single stent group), while 10 patients were noted to have initial improvement and/or complete resolution of their symptoms, but developed recurrent clinical symptoms with new demonstrable VSS by angiography and underwent re-stenting (re-stent group). Baseline demographic and clinical characteristics are summarized in Table 1. The median age was 32 (interquartile range 26–38), mean body mass index (BMI) 35.9 kg/m2, and approximately 94% of the total cohort were females. There was no statistically significant difference among demographic and clinical data between the 2 groups. The VSS within the single stent group was classified as extrinsic in 77 patients and intrinsic in 10 patients secondary to arachnoid granulation. In comparison, within the re-stented group, initial VSS was classified as extrinsic in 9 patients and intrinsic in 1 patient.
| Single stent (n = 87) | Re-stenting (n = 10) | p-Value | |
|---|---|---|---|
| Age, years, mean (SD) | 32.8 (11.0) | 35.1 (11.7) | 0.54 |
| Female sex, n (%) | 82 (94.3) | 9 (90.0) | 0.49 |
| BMI, kg/m2, mean (SD) | 37.3 (8.2) | 34.8 (6.8) | 0.36 |
| Change in BMI, kg/m2 (SD) | –0.27 (2.8) | 0.03 (2.0) | 0.78 |
| Prior Diamox use, n (%) | 40 (46.0) | 5 (50.0) | 1.00 |
| Shunt prior to endovascular intervention, n (%) | 4 (4.6) | 1 (10.0) | 0.43 |
| Opening pressure, cm H2O, mean (SD) | 33.9 (10.2) | 31.0 (6.6) | 0.38 |
| Post-op opening pressure, cm H2O, mean (SD) | 21.6 (7.4) | 25.8 (5.7) | 0.13 |
| Change in opening pressure, cm H2O, mean (SD) | 12.0 (10.7) | 5.1 (9.0) | 0.08 |
| Venous sinus pressure gradient, mmHg, mean (SD) | 8.8 (6.4) | 7.4 (4.9) | 0.49 |
| Post-op pressure gradient, mmHg, mean (SD) | 1.4 (2.8) | 1.5 (1.8) | 0.93 |
| Change in pressure gradient, mmHg, mean (SD) | 7.4 (5.6) | 5.9 (4.9) | 0.41 |
BMI, body mass index; SD, standard deviation
Of note, both groups had similar pre- (33.9 ± 10.2 vs. 31.0 ± 6.6 cm H2O, p = 0.38, single stent vs. re-stent group) and post-procedure (21.6 ± 7.4 vs. 25.8 ± 5.7 cm H2O, p = 0.13, single stent vs. re-stent group) CSF OP, as well as similar pre- (8.8 ± 6.4 vs. 7.4 ± 4.9 mmHg, p = 0.49, single vs. re-stent group) and post-procedure (1.4 ± 2.8 vs. 1.5 ± 1.8 mmHg, p = 0.93, single stent vs. re-stent group) venous pressure gradient across the area of stenosis. Prior to placement of the first venous sinus stent, 45 patients (46.3%) were taking acetazolamide (Diamox) and 5 (5.2%) patients underwent placement of VPS. Nine patients (10.3%) in the single-stent group underwent placement of 2 stents during the initial procedure, 8 of which were at the bilateral transverse-sigmoid venous sinus and 1 who required stenting to the superior sagittal sinus. In comparison, only 1 patient in the re-stenting group (10.0%) underwent stenting of the bilateral transverse-sigmoid venous sinuses. The contralateral sinus was stented during the initial procedure due to incomplete resolution of venous sinus pressure gradient after initial stent placement and presence of contralateral VSS. Technical success was achieved in all cases of venous sinus stenting with or without angioplasty.
Initial presenting symptoms of headache, papilledema, tinnitus, and visual disturbances were similar between the 2 treatment groups (Table 2). Among the re-stented patients, all had resolution of their initial symptoms following initial stenting, with the exception to 1 patient who had persistent headache and tinnitus, but resolution of the papilledema. Recurrence of headaches occurred in 70%, papilledema in 50%, tinnitus in 70%, and visual disturbances in 40% of the re-stented patients following initial improvement (Table 3). Improvement of clinical symptoms among each group was subsequently assessed at 6 weeks and 6 months following their final stenting procedure. There was similar improvement in papilledema and tinnitus at both assessment periods in each group. Headache improvement was higher in the single stent group at 6 weeks (88.4% vs. 60.0%, p = 0.04, single stent vs. re-stent group), but similar at 6 months (94.1% vs. 75.0%, p = 0.17, single stent vs. re-stent group). In contrast, there was similar improvement in visual disturbance at 6 weeks (83.3% vs. 75.0%, p = 0.62, single stent vs. re-stent group), but greater improvement in the single stent group at 6 months post-procedure (86.8% vs. 75.0%, p = 0.04, single stent vs. re-stent group). None of the re-stented patients required rescue VPS placement, compared to 1 patient in the single stent group. This patient had recurrence of severe headaches and papilledema, with repeat lumbar puncture demonstrating an OP of 40 cm H2O, and a patent venous sinus stent with no evidence of new stenosis or venous pressure gradient on repeat angiography.
| Single stent (n = 87) | Re-stenting (n = 10) | p-Value | |
|---|---|---|---|
| Initial presenting symptom | |||
| Headache (%) | 84/87 (96.6) | 10/10 (100) | 1.00 |
| Papilledema (%) | 76/84 (90.5) | 10/10 (100) | 1.00 |
| Tinnitus (%) | 75/87 (86.2) | 10/10 (100) | 0.36 |
| Visual disturbances (%) | 79/86 (91.8) | 8/10 (81.8) | 0.24 |
| Symptom improvement, n (%) | 6 weeks | 6 months | 6 weeks | 6 months | 6 weeks | 6 months |
| Headache (%) | 61/69 (88.4) | 64/68 (94.1) | 6/10 (60.0) | 8/10 (80.0) | 0.04 | 0.17 |
| Papilledema (%) | 47/52 (90.4) | 48/51 (94.1) | 5/5 (100.0) | 8/10 (80.0) | 1.00 | 0.19 |
| Tinnitus (%) | 56/60 (93.3) | 59/63 (93.7) | 7/10 (70.0) | 8/10 (80.0) | 0.06 | 0.19 |
| Visual disturbance (%) | 55/66 (83.3) | 59/68 (86.8) | 6/8 (75.0) | 6/8 (75.0) | 0.62 | 0.04 |
| VPS rescue, n (%) | 1 (1.2) | 0 (0.0) | 1.00 |
VPS, ventriculoperitoneal shunt
| Patient | Recurrent symptoms | Location of new stenosis | Intervention | Time to recurrence (months) | Pre-restenting opening pressure (cm H2O) | Pre-stent venous pressure gradient (mmHg) | Post-stent venous pressure gradient (mmHg) |
|---|---|---|---|---|---|---|---|
| 1 | Headache, tinnitus, visual disturbance | Interface | Re-stent | 23 | 32 | 3 | 0 |
| 2 | Headache, papilledema, tinnitus | Interface and SSS | Re-stent x2 | 9 | N/A | 10 | 2 |
| 3 | Headache, tinnitus, visual disturbance | Interface | Re-stent | 8 | 33 | 4 | 0 |
| 4 | Headache, tinnitus | Contralateral TS | Re-stent | 2 | N/A | 3 | 0 |
| 5 | Headache, papilledema, tinnitus | Interface | Re-stent | 4 | N/A | 3 | 0 |
| 6 | Papilledema, tinnitus | Contralateral TS | Re-stent | 9 | N/A | 5 | 0 |
| 7 | Visual disturbance | Contralateral TS | Re-stent | 7 | 28 | 0 | 0 |
| 8 | Headache, papilledema | SSS | Re-stent | 13 | 26 | 1 | 0 |
| 9 | Headache, papilledema | Interface | Re-stent | 4 | N/A | 0 | 0 |
| 10 | Tinnitus, visual disturbance | Interface | Re-stent | 5 | 30 | 3 | 0 |
N/A, not applicable; SSS, superior sagittal sinus; TS, transverse sinus
Among the 10 patients who were re-stented, a summary of their recurrent symptoms and clinical characteristics are presented in Table 3. New proximal or distal interface stenosis was the most common type occurring in 60% of the patients. All new, angiographic stenosis in the re-stented group was classified as extrinsic. Mean time to recurrence of clinical symptoms was 8.4 months from initial stenting. Among the 5 patients who underwent repeat lumbar puncture prior to re-stenting, the mean OP was 29.8 cm H2O, of which only 1 had evidence of papilledema on repeat neuro-ophthalmological examination. Except for 1 patient, the remaining 5 patients did not undergo repeat lumbar puncture despite recurrent clinical symptoms due to the presence of papilledema on neuro-ophthalmological examination. Mean venous pressure gradient across the new area of stenosis was 3.2 mmHg, with a mean gradient of 0.2 mmHg following placement of an additional stent. In comparison, among the single stent group, 9 patients (10.3%) had asymptomatic new angiographically demonstrable VSS on 6-month follow-up, all consisting of extrinsic interface stenosis (Supplemental Table 1). The new stenosis rate within the total cohort after initial treatment was 19.6% (19/97). Asymptomatic and symptomatic re-stenosis patients had similar baseline and clinical characteristics compared to those without re-stenosis, including changes in BMI, but had a higher OP measured at 6-months following final stent placement (25.7 ± 9.4 vs. 21.1 ± 6.4 cm H2O, re-stenosis vs. no re-stenosis, p = 0.02) (Supplemental Table 2).
Venous sinus stenting has become increasingly more frequent in the treatment of medically refractory IIH. While numerous studies have demonstrated the effectiveness of stenting in the setting of angiographically demonstrable VSS, the management of patients who develop recurrent symptoms with new interface or distal stenosis (contralateral transverse-sigmoid venous sinus or superior sagittal sinus) following initial successful venous sinus stenting is unclear. In our cohort, rescue re-stenting in patients with new angiographically demonstrable VSS showed similar efficacy in alleviating recurrent symptoms of headache, papilledema and tinnitus. Importantly, symptom resolution after re-stenting occurred despite the presence of low venous sinus pressure gradient across the new stenosis at the time of re-stenting. With none of the re-stented patients requiring rescue VPS placement, re-stenting could represent a new standard of care for treating this patient population in the future.
To the best of our knowledge, this is the largest single center patient cohort specifically investigating rates and efficacy of rescue re-stenting among IIH patients. In a systematic review and meta-analysis of 24 studies comprising 473 patients, Saber et al.9) found the rate of stent-adjacent stenosis to be 14% (95% confidence interval of 11%–18%), similar to the 19.6% reported in our cohort. Kumpe et al.13) investigated re-stenting among 10 patients who developed recurrent symptoms and new stenosis adjacent or distal to the previously deployed venous sinus stent. Importantly, these patients all demonstrated a venous sinus pressure gradient across the new stenosis of greater than 10 mmHg. Similarly, Ahmed et al.6) detailed 6 patients who developed recurrent symptoms and new adjacent stent stenosis and had a mean venous sinus pressure gradient of 19 mmHg prior to re-stenting. In comparison, our re-stented patients had a new mean venous sinus pressure gradient of only 3.2 mmHg across the new stenosis, highlighting a high gradient may not be obligatory for treatment response. This finding has not been previously reported among patients with recurrent symptoms and new stenosis. Our group demonstrated a similar effect in a previous analysis among low venous sinus pressure gradient single-stent patients, emphasizing this treatment effect may also extend to patients who require re-stenting.14) It should be noted, however, all venous sinus manometry in our study was performed under general anesthesia. Venous sinus pressures have been previously demonstrated to differ between conscious sedation and general anesthesia, with some studies reporting lower overall pressures under general anesthesia15) and others reporting higher pressures.16) It has been our institution’s practice to perform a single angiographic procedure with venous manometry and stenting, if indicated, in all patients under general anesthesia, thereby making for a uniform variable across the study population. Therefore, while venous sinus pressure gradient is an important determinant, it represents just one component in a multifactorial decision to pursue stenting in symptomatic patients with angiographic stenosis. Nonetheless, the mean time to recurrence of 8.4 months in our study suggests stent failure due to re-stenosis may occur early in the post-operative period, warranting a close follow-up to optimize timely re-treatment.
Our study additionally demonstrated higher mean OP at 6 months post-stenting as a predictor of new angiographic VSS (asymptomatic and symptomatic); however, we did not identify any clinical or angiographic predictors of symptomatic re-stenosis. Others have reported elevated lumbar puncture OP prior to initial stent placement as a predictor of initial stent failure, though this is limited by small sample size (total cohort, n = 18; re-stenting, n = 3).17) To date, definitive predictors of re-stenosis or why certain patients who develop re-stenosis do not develop recurrent symptoms, have yet to be uncovered. Based on analysis of our cohort, 90% (9/10) of the patients in the re-stenting group had initial VSS classified as extrinsic. On follow-up diagnostic work-up, most had persistent elevated OP on lumbar puncture or objective signs of elevated ICP (e.g., papilledema), with repeat angiography demonstrating the re-stenosis was extrinsic in all cases. This would support the theory of persistent or recurrent elevations in ICP leading to extrinsic compression of the venous sinus not protected by initial stenting. In contrast, 100% (9/9) of patients in the single stent group who developed asymptomatic re-stenosis also had new angiographic stenosis classified as extrinsic, with no objective signs of elevated ICP. Therefore, additional theories that might explain the cause of the re-stenosis include a flow-related venopathy resulting in stenosis proximal to the stent, like what may occasionally be seen in arteriovenous fistulas utilized for hemodialysis.7) Alternatively, when re-stenosis occurs at locations other than adjacent to the stent, such as the contralateral transverse sinus, preferential drainage through the newly stented sinus may lead to contralateral atrophy.7) What determines whether a re-stenosis becomes symptomatic remains unclear and future studies will be needed to determine clinical and angiographic characteristics that could differentiate this.
None of the patients in the single stent group with VSS initially classified as intrinsic developed re-stenosis, while only 1 patient in the re-stented group initially had intrinsic stenosis. Intrinsic stenosis secondary to arachnoid granulations is thought to result in impaired CSF outflow, with more severe obstruction resulting from elevated ICP causing increased invagination of arachnoid membrane within the lumen of the dural venous sinuses.18) Thus, this variation of VSS may represent a focal phenomenon with lower recurrence rates once treated with stenting that has sufficient radial force to restore the luminal caliber of the venous sinus. While not demonstrated in our study, patients may have a combination of intrinsic and extrinsic VSS, potentially making them susceptible to develop symptomatic lesions caused by different mechanisms in the future with continued elevated ICP. In addition, the 1 patient that required VPS due to recurrence of severe symptoms, but without evidence of angiographic re-stenosis, highlights the likely complex pathophysiology of IIH. While VSS has been closely associated with IIH, hormonal factors, lymphatic dysfunction, and CSF hypersecretion are also thought to drive the pathogenesis and may have contributed to this patient’s recurrence.18)
While obesity is a known significant risk factor for IIH, our study did not demonstrate any association between weight change and re-stenosis following initial treatment, either asymptomatic or symptomatic. Our cohort had a relatively stable weight throughout the study period without significant difference between the groups, as most of the patients remained overweight due to difficulty losing weight despite strong recommendations and referral to weight loss clinic. Further investigation is warranted within a cohort where fluctuations in weight occur to better characterize any potential contribution to re-stenosis. Additionally, duration of dual antiplatelet therapy (DAPT) following venous sinus stenting has also been postulated to influence development of new angiographic stenosis and recurrence of symptoms, with shorter durations potentially leading to re-stenosis due to discontinuation of DAPT prior to complete endothelialization. In a meta-regression analysis, Sheriff et al.19) noted a trend towards in-stent stenosis among patients on DAPT for only 3 months following venous stent placement, but no significant difference in combined stent adjacent or in-stent stenosis. All patients in our current study had been compliant with DAPT through 6 months following initial stenting, and if warranted, after re-stenting. Whether there is a subset of patients that may benefit from longer duration of DAPT to protect against symptomatic re-stenosis remains an area of active investigation, especially since patients in our cohort developed recurrence as far out as 23 months following initial stenting.
Given the retrospective nature, our study was prone to the limitations inherent to such a study design and we did not compare to a non-endovascular treated cohort (e.g., VPS or ONSF). While there were 97 patients within the total cohort, a larger scale study would be beneficial, especially in the context of elucidating clinical and angiographic predictors of re-stenosis. In addition, while most patients followed up after their initial procedure, there were several patients within the single stent group that were lost to follow-up. In the re-stented group, 5 patients did not have repeat neuro-ophthalmologic examination at 6 weeks post-procedure, but these data were available at the 6-month mark. There was more significant improvement among single stented patients regarding visual disturbances at 6 months, which could have been qualified with objective ophthalmologic data, as opposed to subjective patient reported visual symptoms. Furthermore, although our follow-up period for the study was analyzed at 6 months after their final procedure, the current follow-up data within our prospective registry of re-stented patients ranges from 6 to 34 months. Nonetheless, longer follow-up among the entire cohort would be beneficial in assessing whether treatment effects are sustained.
Lastly, the use of only 8 × 40 mm stents during initial treatment represents a technique limitation. Although this was sufficient to cover the length of initial stenosis, many instances of new symptomatic, angiographically demonstrable stenoses were interface rather than in-stent stenosis, suggesting an extrinsic mechanism of recurrence. As such, whether oversized stents in terms of diameter and more metal coverage along the course of the entire transverse-sigmoid venous sinus would protect against re-stenosis and re-emergence of symptoms remains unknown and subject to on-going investigation.
IIH is becoming increasingly prevalent within the population and can be challenging to treat when first line medical therapies fail. Although venous sinus stenting has emerged as an effective minimally invasive treatment modality in appropriately selected patients, re-stenosis may result in re-emergence of symptoms that have significant morbidity. Our findings suggest re-stenting, even in the presence of low venous sinus pressure gradient, is feasible and effective in alleviating recurrent symptoms, without need for VPS placement. Larger scale studies and long-term follow-up will be essential in confirming our findings.
Summary of patients who underwent single stenting procedure without recurrence of symptoms and developed new angiographically demonstrable venous sinus stenosis on follow-up
Supplemental Table 2Comparison of baseline demographic and clinical characteristics among patients with (symptomatic and asymptomatic) and without angiographic re-stenosis at 6-month follow-up angiography
This study was supported by the Dipaolo Family Research Fund.
The authors declare that they have no conflicts of interest.
