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J Neurol Surg B Skull Base
DOI: 10.1055/a-2493-1205
Original Article

Venous Sinus Stenting for Cerebrospinal Fluid Leaks in Setting of Idiopathic Intracranial Hypertension—An Institutional Series and Systematic Review of Literature

Jaims Lim
1   Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, New York, United States
2   Department of Neurosurgery, Gates Vascular Institute at Kaleida Health, Buffalo, New York, United States
,
Vinay Jaikumar 
1   Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, New York, United States
2   Department of Neurosurgery, Gates Vascular Institute at Kaleida Health, Buffalo, New York, United States
,
Bernard K. Okai
3   University at Buffalo Jacobs School of Medicine and Biomedical Sciences, Buffalo, New York, United States
,
Megan D. Malueg
3   University at Buffalo Jacobs School of Medicine and Biomedical Sciences, Buffalo, New York, United States
,
Hamid Sharif Khan
1   Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, New York, United States
2   Department of Neurosurgery, Gates Vascular Institute at Kaleida Health, Buffalo, New York, United States
,
Collin Liu
1   Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, New York, United States
2   Department of Neurosurgery, Gates Vascular Institute at Kaleida Health, Buffalo, New York, United States
,
Alexander Fritz
1   Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, New York, United States
2   Department of Neurosurgery, Gates Vascular Institute at Kaleida Health, Buffalo, New York, United States
,
Moleca Ghannam
1   Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, New York, United States
2   Department of Neurosurgery, Gates Vascular Institute at Kaleida Health, Buffalo, New York, United States
,
Elad I. Levy
1   Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, New York, United States
2   Department of Neurosurgery, Gates Vascular Institute at Kaleida Health, Buffalo, New York, United States
4   Canon Stroke and Vascular Research Center, University at Buffalo, Buffalo, New York, United States
5   Jacobs Institute, Buffalo, New York, United States
6   Department of Radiology, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, New York, United States
,
Adnan H. Siddiqui
1   Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, New York, United States
2   Department of Neurosurgery, Gates Vascular Institute at Kaleida Health, Buffalo, New York, United States
4   Canon Stroke and Vascular Research Center, University at Buffalo, Buffalo, New York, United States
5   Jacobs Institute, Buffalo, New York, United States
6   Department of Radiology, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, New York, United States
,
Kunal Vakharia
7   Department of Neurosurgery, University of South Florida, Tampa, Florida, United States
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Abstract

Introduction Chronic cerebrospinal fluid (CSF) pressure in idiopathic intracranial hypertension (IIH) can erode the skull base and cause CSF leaks, necessitating surgical repair or other interventions. Venous sinus stenting (VSS) may restore normal CSF reabsorption and flow, reducing elevated pressures and warranting further investigation as a treatment for IIH-related CSF leaks.

Methods We retrospectively reviewed charts of IIH patients who underwent VSS for CSF leak repair, analyzing clinical presentation, imaging, treatment, and follow-up. A systematic review of PubMed and Embase was conducted, with continuous variables reported as medians and interquartile ranges (IQRs).

Results We included two institutional cases and seven cases from the systematic review. Median age was 51 years (35–53), with eight female and six obese patients. Among six patients with prior confirmed IIH, four of five treated with acetazolamide were refractory. All presented with CSF rhinorrhea, six had a history of leaks, and four were recurrences. Seven had bony dehiscence. All had bilateral venous stenosis with a pressure gradient of 6 mmHg (3–8.25) and underwent unilateral VSS, with one patient also undergoing angioplasty. Over a 12-month follow-up (11–27), leaks resolved in all patients but one within 3 months (0.875–3). Four had recurrences by 7.15 months (4.8–9); one resolved spontaneously, another after angioplasty, and two required ventriculoperitoneal shunting. One patient underwent additional dural grafting for new sphenoid dehiscence, achieving resolution.

Conclusion VSS can be an effective initial treatment for IIH-related CSF leaks; but if VSS does not adequately address underlying intracranial pressures, additional medical and surgical interventions are warranted to prevent recurrent leaks.

Keywords

idiopathic intracranial hypertension - cerebrospinal fluid leak - venous sinus stenosis - venous sinus stenting - transverse sinus - systematic review

Previous Presentation

Accepted for Oral Presentation at North American Skull Base Society 33rd Annual Meeting from February 16 to 18, 2024, Atlanta, GA, United States of America.


Ethical Approval

University at Buffalo Institutional Review Board approval: STUDY00008517. The systematic review was exempt from requiring a formal protocol.


Author Contributions

The conceptualization of the project was carried out by JL, VJ, AHS, and KV. The methodology was developed by JL, VJ, HSK, CL, AF, MG, EIL, AHS, and KV. Validation involved JL, VJ, HSK, CL, AF, MG, BKO, MDM, EIL, AHS, and KV. Formal analysis was not applicable. The investigation was conducted by JL, VJ, HSK, CL, AF, MG, BKO, and MDM. Resources were provided by EIL, AHS, and KV. Data curation was done by JL, VJ, HSK, CL, AF, MG, BKO, and MDM. The original draft of the writing was composed by JL and VJ, while the review and editing were done by all the authors. Visualization was handled by JL, VJ, HSK, CL, AF, MG, BKO, MDM, EIL, AHS, and KV. Supervision was carried out by EIL, AHS, and KV. Project administration was managed by JL and VJ.


Supplementary Material



Publication History

Received: 03 November 2024

Accepted: 27 November 2024

Article published online:
26 December 2024

© 2024. Thieme. All rights reserved.

Georg Thieme Verlag KG
Rüdigerstraße 14, 70469 Stuttgart, Germany

 

  • References

  • 1 Bidot S, Levy JM, Saindane AM. et al. Spontaneous skull base cerebrospinal fluid leaks and their relationship to idiopathic intracranial hypertension. Am J Rhinol Allergy 2021; 35 (01) 36-43
    CrossrefPubMedSearch in Google Scholar
  • 2 Georgalas C, Oostra A, Ahmed S. et al. International consensus statement: spontaneous cerebrospinal fluid rhinorrhea. Int Forum Allergy Rhinol 2021; 11 (04) 794-803
    CrossrefPubMedSearch in Google Scholar
  • 3 Hong CS, Kundishora AJ, Elsamadicy AA, Vining EM, Manes RP, Omay SB. A unique subset: idiopathic intracranial hypertension presenting as spontaneous CSF leak of the anterior skull base. J Neurol Surg B Skull Base 2021; 83 (02) 105-115
    PubMedSearch in Google Scholar
  • 4 Pérez MA, Bialer OY, Bruce BB, Newman NJ, Biousse V. Primary spontaneous cerebrospinal fluid leaks and idiopathic intracranial hypertension. J Neuroophthalmol 2013; 33 (04) 330-337
    CrossrefPubMedSearch in Google Scholar
  • 5 Bedarida V, Labeyrie MA, Eliezer M. et al. Association of spontaneous cerebrospinal fluid rhinorrhea with transverse venous sinus stenosis: a retrospective matched case-control study. Int Forum Allergy Rhinol 2020; 10 (12) 1295-1299
    CrossrefPubMedSearch in Google Scholar
  • 6 Chaaban MR, Illing E, Riley KO, Woodworth BA. Spontaneous cerebrospinal fluid leak repair: a five-year prospective evaluation. Laryngoscope 2014; 124 (01) 70-75
    CrossrefPubMedSearch in Google Scholar
  • 7 Bidot S, Levy JM, Saindane AM, Oyesiku NM, Newman NJ, Biousse V. Do most patients with a spontaneous cerebrospinal fluid leak have idiopathic intracranial hypertension?. J Neuroophthalmol 2019; 39 (04) 487-495
    CrossrefPubMedSearch in Google Scholar
  • 8 Quatre R, Attye A, Righini CA. et al. Spontaneous cerebrospinal fluid rhinorrhea: association with body weight and imaging data. J Neurol Surg B Skull Base 2017; 78 (05) 419-424
    Thieme ConnectPubMedSearch in Google Scholar
  • 9 Buchowicz B, Chen BS, Bidot S. et al; CSF-Leak Study Group. Prediction of postoperative risk of raised intracranial pressure after spontaneous skull base cerebrospinal fluid leak repair. J Neuroophthalmol 2021; 41 (04) e490-e497
    CrossrefPubMedSearch in Google Scholar
  • 10 Lobo BC, Baumanis MM, Nelson RF. Surgical repair of spontaneous cerebrospinal fluid (CSF) leaks: a systematic review. Laryngoscope Investig Otolaryngol 2017; 2 (05) 215-224
    CrossrefPubMedSearch in Google Scholar
  • 11 Lim J, Monteiro A, Kuo CC. et al. Stenting for venous sinus stenosis in patients with idiopathic intracranial hypertension: an updated systematic review and meta-analysis of the literature. Neurosurgery 2024; 94 (04) 648-656
    PubMedSearch in Google Scholar
  • 12 Agha RA, Sohrabi C, Mathew G, Franchi T, Kerwan A, O'Neill N. PROCESS Group. The PROCESS 2020 Guideline: updating consensus Preferred Reporting Of CasESeries in Surgery (PROCESS) Guidelines. Int J Surg 2020; 84: 231-235
    CrossrefPubMedSearch in Google Scholar
  • 13 Higgins JN, Axon PR, Macfarlane R. Spontaneous intracranial hypotension complicated by subdural effusions treated by surgical relief of cranial venous outflow obstruction. J Neurol Surg Rep 2020; 81 (04) e59-e65
    Thieme ConnectPubMedSearch in Google Scholar
  • 14 Lenck S, Nouet A, Shotar E. et al. Transverse sinus stenting without surgical repair in idiopathic CSF rhinorrhea associated with transverse sinus stenoses: a pilot study. J Neurosurg 2021; 136 (06) 1745-1751
    CrossrefPubMedSearch in Google Scholar
  • 15 San Millán D, Hallak B, Wanke I. et al. Dural venous sinus stenting as a stand-alone treatment for spontaneous skull base CSF leak secondary to venous pseudotumor cerebri syndrome. Neuroradiology 2019; 61 (09) 1103-1106
    CrossrefPubMedSearch in Google Scholar
  • 16 Fargen KM, Liu K, Garner RM, Greeneway GP, Wolfe SQ, Crowley RW. Recommendations for the selection and treatment of patients with idiopathic intracranial hypertension for venous sinus stenting. J Neurointerv Surg 2018; 10 (12) 1203-1208
    CrossrefPubMedSearch in Google Scholar
  • 17 Nicholson P, Brinjikji W, Radovanovic I. et al. Venous sinus stenting for idiopathic intracranial hypertension: a systematic review and meta-analysis. J Neurointerv Surg 2019; 11 (04) 380-385
    CrossrefPubMedSearch in Google Scholar
  • 18 Levitt MR, Albuquerque FC, Gross BA. et al. Venous sinus stenting in patients without idiopathic intracranial hypertension. J Neurointerv Surg 2017; 9 (05) 512-515
    CrossrefPubMedSearch in Google Scholar