Published: March 18, 2013

Reviewed by Zalman S. Agus, MD; Emeritus Professor, Perelman School of Medicine at the University of Pennsylvania and Dorothy Caputo, MA, BSN, RN, Nurse Planner

An endovascular stent placed in the transverse sinus significantly reduced the pressure gradient of pseudotumor cerebri, improving tinnitus as well as visual function, a small, single-center study showed.

Of the 12 patients in the study, 11 reported tinnitus improvement, 10 saw improvement in visual function, and seven had significant improvement in headaches, Martin Radvany, MD, of Uniformed Services University of the Health Sciences in Bethesda, Md., and colleagues found.

Most demonstrated these improvements between 6 and 12 weeks after treatment, the group reported in the Journal of Neuro-Ophthalmology.

Pseudotumor cerebri presents as raised intracranial pressure with normal cerebrospinal fluid (CSF) analysis, and without clinical or imaging evidence of a space-occupying pathology. Approximately 10% to 20% of patients will experience vision loss caused by prolonged papilledema with secondary optic nerve atrophy. Pseudotumor cerebri is most common in obese premenopausal women ages 18 to 40.

"Debilitating headache is the usual presenting symptom," the authors noted.

Conventional treatment consists of oral acetazolamide, which is limited in long-term use by its side effects. Surgical options such as optic nerve sheath fenestration and CSF diversion procedures also are available.

In the past, most cases of pseudotumor cerebri appeared to have no identifiable etiology, and, thus, they were classified as "idiopathic intracranial hypertension," the authors noted in their introduction.

But some pseudotumor cerebri patients demonstrate imaging evidence of stenosis in one or both transverse sinuses. In some cases, this is resolved by lowering intracranial pressure; in others, stenosis remains until it is opened by stenting.

The patient population consisted of 11 women and one man (mean age 39) with a mean body mass index of 32.6 kg/m2. They all had headaches and papilledema. Eleven patients reported subjective pulsatile tinnitus.

All patients failed medical treatment for pseudotumor cerebri prior to stent placement. Lumbar puncture in all patients demonstrated elevated CSF pressures ranging from 29 to 55 cm of water. Endovenous pressure in the transverse sinus ranged from 5 mm Hg to 28 mm Hg in the cohort.

"In the case of bilateral stenoses, the side with the larger gradient was targeted," the authors noted.

Post stenting, endovenous pressure ranged from 0 to 4 mm Hg.

"Visual acuity was stable or improved in 22 of 24 eyes, and color vision was stable or improved in 21 of 24 eyes," the researchers reported. In addition, visual fields improved or remained stable in 19 of 24 eyes, and 11 of 12 patients achieved papilledema resolution.

Two patients required additional stenting to resolve symptoms. One of these patients also underwent ventriculoperitoneal shunt surgery after 6-month follow-up, which stabilized her visual function and eliminated her headaches.

Using the Headache Impact Test-6 (HIT-6) for assessment (range 36 to 78), patients reported headaches from 40 to 78 prior to stenting. Post procedure, HIT-6 scores ranged from 36 to 78.

"Following stenting, headaches resolved completely in two patients and improved in five, but persisted in the remaining five patients," the authors reported. "Of five patients in this series who continued to have headaches despite normalization of CSF pressure after stenting, four responded to migraine prophylactic medications."

Tinnitus was present in 11 of 12 patients prior to treatment. After stent placement, it improved on the stented side in all 11 patients. Improvement on both sides was noted by four of seven patients with bilateral tinnitus.

Limitations included the fact that only a carefully screened subset of patients who failed medical therapy made up the cohort, the fact that treatment was not standardized or randomized, and the small sample size of the study, the authors noted.


Action Points
Many cases of pseudotumor cerebri have no obvious cause and have been referred to as idiopathic intracranial hypertension. Some patients, however, have been found to have stenosis of one or both transverse sinuses.
In this small study, patients with pseudotumor cerebri associated with transverse sinus stenosis were treated with stenting of the stenosis, and the procedure was generally effective in treating visual dysfunction and tinnitus.


Primary source: Journal of Neuro-Ophthalmology
Source reference:
Radvany MG, et al "Visual and neurological outcomes following endovascular stenting for pseudotumor cerebri associated with transverse sinus stenosis" J Neuro-Ophthalmol 2013; 0: 1-6.