Venous stenting for idiopathic intracranial hypertension: lessons learned from a high-volume practice

INTRODUCTION In recent years, venous sinus stenting (VSS) has emerged as an effective surgical treatment for idiopathic intracranial hypertension (IIH) with concomitant venous sinus stenosis. Metaanalyses of small series of VSS have demonstrated an excellent safety profile with improvement in headaches, pulsatile tinnitus, papilledema, and visual symptoms in the majority of patients. This has led to a rapid growth of VSS being performed with few practitioners having substantial experience. This fact is concerning for several reasons. First, little is known about the pathophysiology of the stenosis or why it might recur following stenting, other than untested theories. 3 Second, more realistic series suggest that as many as 60% of patients with IIH have symptoms that persist or recur after VSS. Third, major complications, including death, occur in about 2% of treated patients. These complications are largely avoidable and can potentially be minimized by thoughtful patient selection and safe procedural techniques. Yet recommendations for the selection of patients and performance of VSS are quite limited, with little published advice or educational resources available for surgeons interested in performing these procedures. The purpose of this manuscript is to present lessons learned from a highvolume VSS practice to aid neurointerventionalists in caring for patients with IIH. My personal experience includes over 150 VSS stent procedures and over 400 cerebral venogram procedures over a 5year period (roughly 30 and 80 procedures annually, respectively). Admittedly, there is little scientific evidence supporting most of the principles presented, but for those learning points where some data exist, references are included. In many instances, alternative strategies not discussed in this paper may be equally (or more) effective; there are many ways to take good care of patients. As such, the views expressed in this commentary are strictly my own and should not be considered ‘evidencebased,’ but instead represent ‘pearls’ from an experienced practitioner to aid physicians with limited experience with this procedure.