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Stenting remains second-line option until it can be directly compared to standard surgical techniques, researchers say.

Venous stenting is as effective as medical therapy for the management of idiopathic intracranial hypertension, according to new data from a small series of patients.

Medical therapy is generally the first-line option for idiopathic intracranial hypertension. When that fails, the current standard surgical treatments include cerebrospinal fluid shunting and optic nerve sheath fenestration. However, these two interventions are not effective in all cases, usually fail to treat all presenting symptoms, and require multiple revisions. Increasing evidence suggests that venous stenting may be a better choice.

“In select patients who fail to respond to medical therapy or are unable to tolerate it, the short-term success rate and the favorable safety profile of [venous] stenting make it a viable option for treatment of elevated [intracranial pressure] associated with venous stenosis,” lead author Tarek A. Shazly, MD (University of Pittsburgh, Pittsburgh, PA), told Neurovascular Exchange in an email.

Shazly and colleagues’ early findings were published online May 9, 2017, ahead of print in the Journal of NeuroInterventional Surgery.

The investigators conducted cerebral venography and manometry in 12 patients with idiopathic intracranial hypertension associated with papilledema, increased intracranial pressure, and radiological evidence of dural sinus stenosis. All patients were offered venous stenting, and six agreed. The remaining six patient were managed with oral acetazolamide alone.

At baseline, there was a trend toward a higher average relative pressure gradient across the venous narrowing in the surgical group (29 ± 16.3 mm Hg vs 17.6 ± 9.3 mm Hg, P = 0.09) However, mean values for lumbar puncture opening pressure, average retinal nerve fiber layer (RNFL) thickness (as measured by spectral domain optical coherence tomography), and best corrected visual acuity were all similar for both groups of patients.

At 6 months, mean average RNFL was significantly reduced in both groups.

RNFL With and Without Venous Stenting

Mean best corrected visual acuity at 6 months was 20/27 among stented patients and 20/24 among patients given medical therapy.

There was a trend toward reduced need for medical therapy in the stented group. The total duration of acetazolamide treatment was 188 ± 209 days in the stented patients, compared with 571 ± 544 days in the medical therapy group (P = 0.07).

One patient with severe vision loss at baseline continued to lose vision despite anatomically successful stenting with a resolution of papilledema and normalization of intracranial pressure, said Shazly. He cited this case as “a reminder of the need for better patient selection criteria. Despite the fact that stenting seems to be successful in the vast majority of cases, it may be considered [only] as a replacement for shunting or optic nerve sheath fenestration in patients with severe, sight-threatening papilledema, as we currently lack any evidence of its efficacy compared to these ‘standard’ treatments.”

Confirms Earlier Findings

“The results of our study are in agreement with the vast majority of the increasing number of published papers that support the beneficial rule of venous sinus stenting in the treatment of intracranial hypertension,” concluded Shazly. He said he and his colleagues “suggest that venous sinus stenting is a valuable option for patients with mild to moderate papilledema with no or mild vision loss who fail medical therapy. Additionally, we feel that it should be considered in patients who have stable papilledema and visual function who remain dependent on high dose of acetazolamide for more than 6 months.”

In terms of future directions, Shazly identified the “million dollar question”—how safe and effective will venous stenting be long-term? This is a concern, he said, because “unlike carotid and cardiac stents that are typically implanted in arteries with fast blood flow in older patients, venous stents are placed in venous sinuses with a much slower blood flow, typically in much younger patients with much many years ahead of them. The duration of antiplatelet therapy, the best stent design, and material [are all] hot topics for debate.”

Amgad El Mekabaty (The Johns Hopkins Hospital, Baltimore, MD), pointed out in an email to NVX that both medical therapy and venous stenting are already known to reduce papilloedema in idiopathic intracranial hypertension and that surgery remains, with few exceptions, only considered when medical therapy fails. In that light, he said, it would have been helpful to know if patients had tried and failed medical therapy prior to be offered the option of stenting.

That said, El Mekabaty noted that the study, though small, provides “good documentation on the thickness of the retinal nerve fiber layer in 12 patients. [It also] documents nicely that patients who underwent [stenting] had a clinically significant reduction in medical treatment period compared with medical treatment alone. This effect was not statistically significant, probably due to the small case number.” Reducing the number of days of medical therapy is associated with the benefits of improved patient satisfaction and compliance, El Mekabaty added.

Source:

Shazly TA, Jadhav AP, Aghaebrahim A, et al. Venous sinus stenting shortens the duration of medical therapy for increased intracranial pressure secondary to venous sinus stenosis. J NeuroInterv Surg. 2017;Epub ahead of print.

Disclosures:

Shazly and El Mekabaty report no relevant conflicts of interest.

Related Stories:

• Interest in Venous Stenting to Treat Idiopathic Intracranial Hypertension Grows
• Extensive Dural Sinus Stenting Shows Promise for Idiopathic Intracranial Hypertension

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