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Venous Sinus Stenting for Pseudotumor Cerebri

In some people with pseudotumor cerebri (PTC), the normal absorption of cerebrospinal fluid into the veins of the brain is impaired due to a narrowing of the venous sinuses, passageways that convey blood and CSF from the brain to the jugular veins and eventually to the heart. This narrowing of these passageways over time can increase pressure inside the skull and cause pseudotumor cerebri.

If weight loss and medication have not controlled your PTC, your doctor may recommend a contrast enhanced MR venogram or contrast enhanced CT venogram to see if there is a narrowing in your venous sinuses. If so, the next step is referral to a interventional neuro-radiologist to see if you might benefit from having a stent placed in the vein to open up the narrowing.

Advantages of Venous Sinus Stenting

Medications such as acetazolamide (Diamox®) are difficult to take for a long time because of side effects. Likewise, procedures to relieve the pressure, such as optic nerve sheath fenestration or shunt placement, do not always offer a long-term solution.

Each of these procedures has a risk of complications: Shunts can become clogged or disconnected, and approximately half of patients with a shunt experience bleeding or infection. About 60 percent of shunts fail after a year. Complications of optic nerve sheath fenestration include a risk of visual loss and vascular problems.

Venous sinus stenting is a relatively new procedure and researchers are still gathering data regarding how long the procedure manages PTC and what complications may occur over time.Stenting seems to address the underlying cause of the high pressure that characterizes PTC, but the exact mechanism remains controversial. So far, at Johns Hopkins Cerebral Fluid Disorders Center, stents our team has placed have lasted over 8 years.

As you work with your team to consider a stent or any other procedure to help manage your PTC, is important to remember that none of these surgical interventions (ONSF, shunt, stent) has been studied in a randomized trial.

Placing the Venous Stent

An interventional neuro-radiologist places the stent while you are under anesthesia or deep sedation.

First, your doctor will conduct a conventional cerebral angiogram to look for any misshapen blood vessels that can be contributing to your PTC. The angiograms involves using a small catheter to examine cerebral blood flow and the specific location of the blood vessels inside your head.

The next step is to measure the pressure gradient across the narrowing in the veins. A stent is only appropriate if the narrowing in your blood vessel causes a certain level of pressure.

After your surgery, you will rest and be observed in the intensive care unit overnight. You will be taking blood thinners starting a few days before the procedure and continue your medication for several months afterward to prevent clots from forming on the stent.

Stenting: Potential Complications

The potential complications include those related to general anesthesia as well as complications related to cerebral angiography and stenting, which include both the possibility of bleeding into the brain or clotting around the stent. It is possible that the stent could move or that you could develop another narrowing area near the stent after it is in place.