Comparative Analysis of Dural Venous Sinus Pressures, Gradients, and Dimensions in Idiopathic Intracranial...

Venous sinus stenting (VSS) for idiopathic intracranial hypertension (IIH) improves venous flow in patients with high trans-stenosis pressure gradients. Variability in sinus pressure profiles prompts the need for exploration of venous sinus physiology for better understanding of these findings. Stented patients exhibit characteristic pressure patterns aiding assessments of intervention success. We investigated heterogeneity in venous anatomy and pressures to establish venous profiles that may indicate the benefit of VSS for IIH.

Records of patients who underwent diagnostic venograms, with or without VSS, for suspected or confirmed IIH were retrospectively screened. Venous manometer readings were gathered bilaterally along the sinuses and superior and inferior vena cava. The following pressure gradients were calculated: overall, total cranial, and transverse-sigmoid or trans-stenosis. In addition, venous diameters were measured using 2D venograms. VSS was performed in patients with confirmed IIH diagnoses, adhering to an 8 mm Hg gradient threshold.

We included 224 patients (mean age 38.6 ± 12.6 years; 95.1% women; body mass index averaging 36.4 ± 9.2 kg/m 2 ; 55.4% obese). Middle sagittal sinus diameters were comparable in stented (n = 96) and unstented (n = 128) cohorts, whereas transverse-sigmoid junctions were narrower bilaterally (both P < .001) in the stented cohort, with a higher stenosis percentage (50 ± 12% vs 29.2 ± 21.4%; P < .001). The stented cohort had higher pretreatment opening pressures (35 ± 11.2 vs 27.3 ± 8.1 cmH 2 O; P < .001). Stented patients exhibited significantly higher pressures from the anterior sagittal sinus to the torcula, bilaterally along the transverse sinuses and within the dominant transverse-sigmoid junction (all P < .001). All gradients were notably higher in stented patients (all P < .001). More stented than unstented patients experienced headache improvement (80.0% vs 42.2%; P < .001).

With strict adherence to an 8 mm Hg pressure gradient threshold for stenting, 57% of 224 IIH patients did not receive stents. Stented patients had significant pressure gradients across the transverse-sigmoid junction. Stenting significantly improved headache symptoms, validating this approach to patient selection for VSS.