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Three Part Question

In [patients with pseudotumor cerebri] does [venous sinus stenting] improve [headache and papilledema]

Clinical Scenario

A patient presents with headache and transient visual loss. He is diagnosed with pseudotumor cerebri. Conservative therapy fails. Could sinus stenting be an alternative treatment?

Search Strategy

Medline 1966-05/2006 using the PubMed interface
(pseudotumor cerebri) OR (benign intracranial hypertension) AND (sinus stenting)

Search Outcome

7 papers found of which 2 were irrelevant to the study question or of insufficient quality for inclusion

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
Higgins JN, Owler BK, Cousins C, Pickard JD. 19 Jan 2002 UK	1 patient with pseudotumor cerebri, headache and papilledema. 3 weeks and 1 year follow up	Case Report	Headache	Improvement	Only 1 patient
			Visual Disturbance	Cure
Owler BK, Allan R, Parker G, Besser M. Feb 2003 Australia	1 patient with pseudotumor cerebri for 10 years who developed CSF rhinorrhoea. Direct retrograde cerebral venography (DRCV) demonstrated venous sinus obstruction due to a filling defect.	Case study	Venous sinus obstruction	Treated	Symptom treatment? 1 patient.
Higgins JN, Cousins C, Owler BK, Sarkies N, Pickard JD. Dec 2003 UK	12 patients with refractory IIH had dilatation of venous sinus. Intrasinus pressures were recorded before and after the procedure. Patients were assessed at 8–12 weeks	Case review	Headache	5 treated, 2 improved, 5 untreated	Only 12 patients
			Papilledema	4/8 improved
Ogungbo B, Roy D, Gholkar A, Mendelow AD. Dec 2003 UK	37-year-old lady with symptoms and signs suggestive of benign intracranial hypertension. Obstruction of the right transverse sinus with high pressure (40 mmHg) proximal to the obstruction and low pressure (15 mmHg) distally. 3- and 6-month follow up	Case report	Headache	Cured	1 patient
			Visual disturbance/papilledema	Cured
Rajpal S, Niemann DB, Turk AS. Apr 2005 USA	15-year-old boy with pseudotumor cerebri. 1-, 2- and 6-months follow up	Case Report	Headache	treated	1 patient
			Papilledema	treated

Comment(s)

There are only 4 case reports and 1 review with 12 patients in the literature. No RTCs. No long term follow ups.

Clinical Bottom Line

Venous sinus stenting may prove to be a beneficial and minimally invasive treatment option for these individuals. However more studies and RCTs are required to prove that, to address the complications and to characterize the patient subgroups that would benefit from venous sinus stenting.

References

1. Higgins JN, Owler BK, Cousins C, Pickard JD. Venous sinus stenting for refractory benign intracranial hypertension. Lancet 2002 Jan 19; 228-30.
2. Owler BK, Allan R, Parker G, Besser M. Pseudotumour cerebri, CSF rhinorrhoea and the role of venous sinus stenting in treatment. British Journal of Neurosurgery 2003 Feb;79-83.
3. Higgins JN, Cousins C, Owler BK, Sarkies N, Pickard JD. Idiopathic intracranial hypertension: 12 cases treated by venous sinus stenting. Journal of Neurology Neurosurgery and Psychiatry 2003 Dec;1662-6
4. Ogungbo B, Roy D, Gholkar A, Mendelow AD. Endovascular stenting of the transverse sinus in a patient presenting with benign intracranial hypertension. British Journal of Neurosurgery 2003 Dec;565-8
5. Rajpal S, Niemann DB, Turk AS. Transverse venous sinus stent placement as treatment for benign intracranial hypertension in a young male: case report and review of the literature. Journal of Neurosurgery 2005 Apr;342-6.