A unifying theory explaining venous sinus stenosis and recurrent stenosis following venous sinus stenting in patients with idiopathic intracranial hypertension

INTRODUCTION Idiopathic intracranial hypertension (IIH), or perhaps more accurately chronic intracranial venous hypertension syndrome (CIVHS), is a disabling condition often resulting in severe pressure headaches, visual symptoms, and tinnitus. In the last decade, venous sinus stenting (VSS) has emerged as a safe and effective treatment for patients with IIH with associated venous sinus stenosis and a documented transstenosis pressure gradient (TSPG). While metaanalyses of small retrospective series have demonstrated low rates of retreatment with high rates of headache and visual improvement, some recent studies have revealed that many patients (as high as 60%) develop symptom recurrence after VSS. There are very few published articles that provide neurointerventionists with recommendations regarding the selection and treatment of IIH patients and essentially no evidencebased recommendations are available regarding the specifics of stent construct lengths or sizes. Further, questions remain about the pathophysiologic mechanism at play and why recurrent stenosis develops. Experience gained from a highvolume VSS practice has provided important insights into these phenomena. Herein I propose a unifying theory that explains the pathophysiology of de novo and recurrent venous sinus stenosis in IIH patients, with attention given to how this may impact stent construct size and length.