Transverse venous sinus stenting versus cerebrospinal fluid shunting in idiopathic intracranial hypertension: a multi-institutional and multinational database study

Clinical Snapshot

Key Findings

• P Value: P<0.001

• Effect Size: OR 0.169 for repeat interventions with TVS stenting

• Primary Outcome: Treatment failure requiring repeat interventions: 9.6% (TVS stenting) vs 38.6% (CSF shunting)

• Nnt Or Sensitivity: NNT = 3.4 (to prevent one treatment failure with TVS stenting vs CSF shunting)

• Confidence Interval: 95% CI 0.136 to 0.212

Clinical Application

Both procedures available in major Australian neurosurgical centres, though TVS stenting requires specialized neurointerventional expertise Relevant to Australian practice where both procedures are PBS-funded. Results support current RACGP guidelines recommending multidisciplinary approach to IIH management Adult IIH patients requiring surgical intervention, particularly those with venous sinus stenosis

Abstract

BACKGROUND: Cerebrospinal fluid (CSF) shunting and transverse venous sinus (TVS) stenting are promising treatment choices for idiopathic intracranial hypertension (IIH), addressing different aspects of IIH pathophysiology. However, large-scale comparative data remain limited. METHODS: We performed a multinational, multi-institutional, retrospective propensity score-matched analysis using the TriNetX platform. Adult patients diagnosed with IIH who underwent either TVS stenting or CSF shunting were included. The primary outcome was treatment failure, defined as the need for subsequent procedures (repeat TVS stenting, CSF shunt, or optic nerve fenestration). Secondary outcomes included residual symptoms (headache, visual disturbances, dizziness, and pulsatile tinnitus), ongoing use of IIH-related medications (furosemide, acetazolamide, and topiramate), and healthcare utilization, assessed through unplanned hospital readmissions and emergency department (ED) visits at 1 year follow-up. RESULTS: Of 134 530 IIH patients identified, 1362 underwent TVS stenting and 5278 underwent CSF shunting. After propensity score matching, patients who received TVS stenting had significantly lower odds of repeat interventions (9.6% vs 38.6%; OR 0.169, 95% CI 0.136 to 0.212, P<0.001). They also had significantly lower odds of residual headache, visual disturbances, and papilledema. However, stenting was associated with higher odds of persistent pulsatile tinnitus (6.7% vs 2.2%; OR 3.183, P<0.001). TVS stenting was associated with lower odds of unplanned inpatient readmissions (24.1% vs 40.5%; OR 0.466, P<0.001) and ED visits (22.0% vs 34.0%; OR 0.548, P<0.001). CONCLUSION: Both TVS stenting and CSF shunting resulted in symptomatic improvement and reduced medication use in patients with IIH. However, stenting was associated with significantly lower treatment failure rates, fewer residual papilledema, headaches and visual symptoms, and reduced healthcare utilization. Persistent pulsatile tinnitus was more common following stenting.

References

1. 1.Intrapiromkul, J., Rai, A. T., & Lakhani, D. A. (2024). Transverse venous sinus stenting versus cerebrospinal fluid shunting in idiopathic intracranial hypertension: a multi-institutional and multinational database study. Journal of Neurointerventional Surgery. https://doi.org/10.1136/jnis-2024-022174