Transcript Idiopathic Intracranial Hypertension: Assesssment of

Angel Mironov
Creighton University Medical Center
Omaha, Nebraska
 The
idiopathic intracranial hypertension
remains a diagnosis of exclusion

( Friedman D., Jacobson D.: Neurology 59, 2002)
 The
restoring of patency of stenotic dural
sinuses in patients with refractory IIH is not
sufficient elucidate
 The neurointerventional community is still
debating and strives to justify neurovascular
strategies for treatment
 To
document the clinical response to an
endovascular improvement of lateral sinus
circulation by angioplasty
 To
clarify the relation of IIH to associate narrowing
of lateral dural sinuses
 To
justify apparently indications for appropriate
endovasal treatment
Demography
12 patients with refractory IIH
 Sex:
female – nr:11; male – nr:1
 Age
range: 16 – 34 years-old
 BMI
kg/m2 range: 20 – 85
 CSF
opening pressure range: 30 – 95 H2O
 Progressive
headache (nr: 12), visual disturbance
(nr: 11), personality change (nr: 3)
Diagnostic

Imaging: MRI, MRV (7)

Catheter angiography with retrograde venography


Pull-back manometry with blood pressure transducer in the sagittal
sinus, torcular Herophili, proximal and distal transverse sinus,
proximal and distal sigmoid sinus, jugular bulb, proximal and distal
jugular vein on each side, and in superior vena cava
Focus of interest of venous manometry:
a) gradients across the irregularities of lateral sinus
b) gradients at confluence of sinuses/jugular bulb
Sinus manometry
 Pressure
gradients across the sinus irregularities:
1. Group: up to 15 mmHg – 6 cases (4, 6, 7, 8, 9, 12 mm)
2. Group: up to 30 mmHg – 4 cases (21, 25, 26, 30 mm)
3. Group: above 30 mmHg – 2 cases (50/48, 35 mm)
 Sinus
angioplasty offered for groups 2 and 3:
compliant balloons 4 and 4.5 mm
 25
year-old obese woman (body mass index
33.1 kg/m2)
 Intermittent
headache for 3 we
 Visual
disturbance with transient
obscurations, papilledema
 Raised
cerebrospinal fluid pressure - 62 H2O
MR Imaging
Bilateral optic nerve sheath dilatation
and papilla protrusion
MR time-of-flow venography
Left vertebral
Left internal carotid
Left lateral sinus
Right lateral
sinus
Endovasal manometry
Pressure gradients right lateral sinus: 20 mmHg
Pressure gradients left lateral sinus: 5 mmHg
mmHg 36/35
mmHg 22/21
5
20
mmHg 16/15
mmHg 16/14
mmHg 17/16
mmHg 17/15
Compliant balloon angioplasty
Last follow up: 6 months
 Remarkable
clinical improvement after
angioplasty of right lateral dural sinus in
following week with resolution of
symptoms
 26
year-old obese woman (body mass index 35
kg/m2)
6
we history of headache
 Progressive
 Bilateral
visual disturbance for 1 we
papilledema
 Cerebrospinal
 Personality
fluid raised at 80 H2O
change on admission
Optic papilla protrusion
Left lateral sinus
Endovasal manometry:
pressure gradients of 48
mmHg
Compliant balloon
angioplasty of left
lateral sinus
Right lateral sinus
Endovasal manometry:
pressure gradients of 50 mmHg
Compliant balloon
angioplasty of right
lateral sinus
Initial Gd MRI
Follow up 6 we Gd MRI
Last follow up: 12 months
 Remarkable
clinical improvement after
angioplasty of both lateral venous sinuses
in following week with durable resolution of
symptoms
Outcome angioplasty of sinus
 Dramatic
and durable improvement for more than
6 months in 4 cases:
jugular vein pressure of 8, 10, 12, and 16 mm Hg
 Transitory
cases:
not sustainable improvement in 2
jugular vein pressure of 22 and 24 mm Hg



Some cases of IIH are exacerbated by a coexistent effect
of preexistent anatomic narrowing of the lateral sinuses
with elevated across gradients; an improvement of sinus
perfusion may break the iterative cycle (?)
Even in case with exposed across gradients the perfusion
improvement of sinuses will be not obtainable, as long as
the central venous pressure is exceedingly elevated (?)
The lack of clinical response after angioplasty/stenting
reflects probably the both – the lack of exposed across
gradients (less than 15 mmHg), and the elevation of jugular
vein pressure due to central venous pressure elevation
(more than 20 mmHg)
Sinus manometry


MR venography and conventional venous phase
demonstrated patent flow of dural sinuses with
hypoplastic/stenotic divisions or irregularities of lateral
sinuses in all patients
Pressure gradients across the sinus irregularities:
1. Group: up to 15 mmHg – 6 cases (4, 6, 7, 8, 9, 12 mm)
2. Group: up to 30 mmHg – 4 cases (21, 25, 26, 30 mm)
3. Group: above 30 mmHg – 2 cases (50/48, 35 mm)