Abstract

Transverse sinus stenosis is common in patients with Idiopathic Intracranial Hypertension (IIH) and transverse sinus (TS) stenting is an emerging treatment option for certain patients. We present a case of refractory vision loss in a patient with IIH treated by urgent TS stenting.

The patient is a 31 year old African American female with type II diabetes mellitus, asthma, obstructive sleep apnea, and morbid obesity who presented with rapidly deteriorating visual acuity after a more gradual decline over three to four months associated with intermittent and progressively worsening headaches, exacerbated by supine positioning. Initial ophthalmologic examination revealed marked bilateral optic nerve head swelling. Routine CT and MR examinations of the brain were unremarkable. Intracranial MR venography revealed a high grade stenosis of the dominant right transverse sinus. A diagnostic and therapeutic lumbar puncture was performed, revealing a markedly elevated opening pressure of 53 cm H2O, with closing pressure of 28 cm H2O after removal of 32 mL CSF. Laboratory CSF analysis was unremarkable. The patient experienced a transient improvement in symptoms, but the vision loss rapidly recurred over the next day. Subsequently, intracranial catheter venography was performed, redemonstrating the aforementioned high grade stenosis of the dominant right TS with a less severe stenosis of the nondominant left TS. Prestenotic TS pressure measured 70 mmHg; poststenotic sigmoid sinus pressure measured 20 mmHg for a gradient of 50 mmHg across the stenosis. After balloon angioplasty and placement of a self-expanding stent, the gradient was reduced to 1 mmHg with pre- and poststenotic pressures of 21 and 20 mmHg, respectively. After the procedure, the patient reported significant improvement in visual acuity and she was discharged the next day on daily aspirin (indefinitely) and plavix (3 months).

The case demonstrates an example of the viability of urgent TS stenting in select patients with IIH and refractory symptoms. While this case is unique in that our patient suffered rapid vision changes necessitating urgent intervention, her clinical course also reiterates the potential utility of TS stenting in patients with less acute presentations.