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Published on: February 8, 2022
Incidence and Predictors of Rebound Intracranial Hypertension after Transvenous Embolization of CSF-Venous Fistulas
Derrek Schartz1, Peter G Kranz2, Timothy J Amrhein2
1From the Department of Radiology, Duke University Medical Center, Durham, North Carolina derrek.schartz@duke.edu.
Insights
Rebound intracranial hypertension (RIH) is common after transvenous embolization (TVE) for cerebrospinal fluid-venous fistulas (CVF), affecting 80% of patients. Moderate-to-severe RIH occurred in 54%, highlighting the need for vigilant post-procedure monitoring.
Area of Science:
- Neurosurgery
- Interventional Radiology
- Neurology
Background:
- Cerebrospinal fluid-venous fistulas (CVF) are a primary cause of spontaneous intracranial hypotension (SIH).
- Transvenous embolization (TVE) is a standard treatment for CVFs.
- Rebound intracranial hypertension (RIH) is a potential complication following TVE and CSF leak closure.
Purpose of the Study:
- To determine the incidence and severity of post-procedure RIH in patients with CVFs treated with TVE.
- To identify predictors of moderate-to-severe RIH and the need for therapeutic lumbar puncture (LP).
Main Methods:
- Retrospective cohort study of consecutive patients undergoing TVE for SIH due to CVF.
- Early clinical follow-up (1-3 days post-TVE) assessed RIH presence and severity (absent, mild, moderate, severe).
- Logistic regression analyzed predictors of moderate-to-severe RIH and need for therapeutic LP.
Main Results:
- RIH occurred in 80% of 100 patients (105 TVE procedures for 132 CVFs).
- Moderate-to-severe RIH was observed in 54% of cases; 7.6% required therapeutic LP.
- TVE of a single CVF and higher pre-TVE opening pressure were associated with increased risk of moderate-to-severe RIH and need for LP, respectively.
Conclusions:
- Early RIH is a frequent complication after TVE for CVFs, with a high incidence of moderate-to-severe symptoms.
- Routine early clinical follow-up is crucial for managing RIH post-TVE.
- Proceduralists must be prepared to manage RIH effectively.
Background And Purpose:
CSF-venous fistula (CVF) is a common cause of spontaneous intracranial hypotension (SIH) and can be treated with transvenous embolization (TVE). Rebound intracranial hypertension (RIH) is an important periprocedural consideration after TVE and CSF leak closure. The purpose of this study was to determine the incidence and severity of postprocedural RIH among patients with CVFs treated with TVE.
Materials And Methods:
This investigation was a single-center, retrospective cohort of consecutive patients treated with TVE for SIH due to a CVF. Patients were included who had early (1-3 days post-TVE procedure) clinical follow-up documenting the presence/severity of RIH. RIH was classified as absent, mild (ie, rated 1-4/10 in severity), moderate (ie, rated 5-7/10), or severe (ie, rated 8-10/10). The rate of RIH was then determined. Logistic regression analysis was used to evaluate clinical predictors of moderate-to-severe RIH and the need for eventual therapeutic lumbar puncture.
Results:
In total, 100 consecutive patients (mean age, 59.4 years; 63% female) who underwent 105 TVE procedures for 132 CVFs were included. RIH of any severity (mild-to-severe) occurred in 80% of cases after TVE and was moderate-to-severe in 54% of cases. A therapeutic lumbar puncture was needed for RIH in 8 cases (7.6%). On multivariate regression, TVE of a single CVF (versus >1 CVF) was independently associated with the occurrence of moderate-to-severe RIH (OR, 2.8 [95% CI, 1.04-7.85], P = .04). Furthermore, higher pre-TVE opening pressure (third tertile, 17-28 cmH2O) was associated with eventual need for therapeutic lumbar puncture (OR, 5.0 [95% CI, 1.14-25.9], P = .03).
Conclusions:
Early RIH is common after TVE, with symptoms occurring in 80% of all cases. Approximately one-half of patients will experience moderate-to-severe RIH early after TVE. These findings underscore the value of routine early follow-up after TVE and emphasize the need for proceduralists to be familiar with management strategies for RIH.
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