A pilot study and novel angiographic classification for superior sagittal sinus stenting in patients with non-thrombotic intracranial venous occlusive disease

Raper DM, Buell TJ, Ding D, Pomeraniec IJ, Crowley RW, Liu KC.

Key points:

  • Assess the outcomes after Superior Sagittal Sinus (SSS) stenting in patients with VOD.

  • Describe a novel angiographic classification system for the SSS.

The majority of stenosis of an intracranial dural sinus, cause of intracranial hypertension (IIH) or chronic headache without IIH, involve the transverse (TS) and sigmoid (SS) sinuses. However, a subset of patients with intracranial venous occlusive disease (VOD) has SSS stenosis with trans-stenosis pressure gradient. This SSS stenosis may be primary or secondary, developed after initial TS stenting. Currently, the safety and efficacy of VSS for SSS stenosis is unknown. In their paper, published online January 12, 2017 in the Journal of NeuroInterventional Surgery, the study authors offer a pilot study about stenting of the SSS and a novel angiographic classification of the SSS.

Raper D.M.S., Buell T.J., Ding D., et al. performed an institutional review of a prospective database of patients who underwent diagnostic angiography and venous manometry at the University of Virginia from February 2014 to August 2016. All patients who underwent stenting of the SSS for VOD were included in the study. They collected baseline variables, morphology and location of venous sinus stenosis, maximum mean venous pressure (MVP), and trans-stenosis pressure gradient; they assessed outcomes data (post-stenting MVP and pressure gradient, as well change in preoperative neurological and ophthalmologic symptoms, when available). Details about venous sinus stenting have been described in this previous article:

 Venous sinus stenting for reduction of intracranial pressure in IIH: a prospective pilot study., 1–8. http://doi.org/10.3171/2016.8.JNS16879 

Patients characteristics

Main characteristics
 N (%)
Cohort size 19
Sex All female
Primary stenosis 11
Secondary stenosis 8
Clinical presentations and outcomes
Clinical characteristics
 Clinical presentation  Clinical improvement
Headache 19 10 (67.7%)
Pulsatile tinnitus 14 7 (63.6%)
Transient visual obscuration 13 6 (50%)

Authors collected the anatomic characteristics of the SSS (the position of the vein of Trolard, atresia of the SSS in the anterior frontal lobe, and variations of torcular anatomy, proposing a novel segmentation: four equal segments numbered from S1 (proximally at the torcula) to S4 (distally at the frontal pole). In this cohort of patients the majority of SSS stenting is performed in IIH patients in which SSS stenosis was associated with TS and SS stenosis (only one patient had an isolated SSS stenosis) and the proximal S1 segment of the SSS was involved in the vast majority of cases (95%). There were no cases of S3 or S4 stenosis. 15 patients with trans-stenotic pressure gradient >4 mmHg reported post-stent improvement in symptoms.

Angiographic classification of SSS

In conclusion, authors demonstrated feasibility and efficacy of SSS stenting in patients with SSS stenosis and a trans-sten0sis pressure gradient >4 mmHg, but is a pilot study.  Further studies and additional follow-up are necessary to determine the durability of  SSS stenting as well as its appropriate indications and long-term clinical outcomes.

 

Reference

– Raper DM, Buell TJ, Ding D, Pomeraniec IJ, Crowley RW, Liu KC. A pilot study and novel angiographic classification for superior sagittal sinus stenting in patients with non-thrombotic intracranial venous occlusive disease. J Neurointerv Surg. 2017 Jan 12. doi: 10.1136/neurintsurg-2016-012906. [Epub ahead of print]

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