Preoperative venography, antiplatelet agents, and postoperative manometry are among the few recommendations considered to having a strong evidence base.
A recent literature review may be helpful for clinicians in selecting and treating idiopathic intracranial hypertension (IIH) patients with venous sinus stenting. However, many questions remain about this poorly-understood condition, the authors note in a paper published online July 20, 2018, ahead of print in the Journal of NeuroInterventional Surgery.
“There are few, if any, guidelines or recommendations for the selection and treatment of patients with IIH [using] stenting, with considerable heterogeneity among practitioners and centers,” lead author Kyle M. Fargen, MD (Wake Forest University School of Medicine, Winston-Salem, NC), told Neurovascular Exchange in an email. “Much of the practice variability stems from the nature of the published literature on the topic, which is predominantly encompassed by low quality, small retrospective series. Only a few prospective studies exist, and no randomized clinical trials are yet available. This review was completed to help summarize the available evidence, to inform readers about the existing studies, and to try to provide the best recommendations possible to standardize care.”
The investigators conducted the literature review based on all reports of venous sinus stenting for the treatment of intracranial hypertension, which included 8 systemic reviews or meta-analyses and 29 published patient series. They identified and outlined recommendations with regard to patient selection for diagnostic catheter angiography, angiography procedural considerations, stenting procedural considerations, and retreatment. The authors emphasized that a lack of randomized trials and few published prospective studies in this area limits the applicability of standard grading scales for recommendations and levels of evidence. Instead, they used the available literature to identify each recommendation as “strong”, “moderate”, or “weak.”
Recommendations identified as “strong” based on published evidence and expert
· Venography should be performed to assess candidacy for treatment prior to stenting
· Antiplatelet agents should be administered prior to stenting and in the follow-up period for at least 3-6 months following stenting
· Post-stenting manometry should be performed to confirm resolution of the pressure gradient after stenting to document procedural success
· It is reasonable to repeat angiography and manometry on patients with recurrence of symptoms after resolution with stenting to evaluate for recurrent stenosis
Additional recommendations, evaluated to as “moderate” and “weak”, are listed and discussed in the paper.
Standardization of Care Needed
Fargen said he hopes that this synthesis of the available evidence can help inform physicians and promote sorely-needed standardization of care.
“For instance,” he pointed out, “many practitioners continue to perform diagnostic venography to determine candidacy for stenting with patients under general anesthesia. We know from several studies that general anesthesia greatly affects the measured pressure gradients and has the tendency to falsely minimize the pressure gradient across the stenosis, suggesting that patients will not benefit from stenting when in actuality they are good candidates under normal physiologic (awake) conditions.”
Many clinical questions remain, said Fargen, none of which have been addressed by this review. These include, “Why does this disease process occur predominantly in only a small percentage of young, overweight females but only rarely in others? How are intracranial pressure, venous sinus stenosis and venous congestion interrelated? How do we best select patients for treatment? What is an acceptable pressure gradient to treat?” He concluded that additional research is needed to answer these and other lingering questions.
Fargen KM, Liu K, Garner RM, et al. Recommendations for the selection and treatment of patients with idiopathic intracranial hypertension for venous sinus stenting. J Neurointerv Surg. 2018;Epub ahead of print.
Fargen reports no relevant conflicts of interest.