Introduction and purpose Interventional treatment for transverse sinus stenosis with venous sinus stenting is emerging as a viable, and minimally invasive treatment for medically refractory idiopathic intracranial hypertension (IIH). However, this therapeutic intervention remains under-recognized and often accompanied by limited diagnostic evaluation and neurointerventional referral. We present the commonly employed neuroimaging paradigm in the South Eastern Virginia population with IIH, and seek to highlight areas of improvement to better stratify patients based on disease mechanism, incorporating neuroanatomic and pathophysiologic considerations.

Materials and methods We conducted a retrospective chart review within our health system from January 2018 to September 2018, extracting clinical data from 70 cases. From this data, 59 were categorized as confirmed IIH, with 11 presently undergoing workup. The following variables were analyzed in those with confirmed IIH: patient demographics, presenting symptoms, papilledema, and neuroimaging.

Results Fifty-seven female and two male patients with confirmed IIH (n = 59) with a mean age of 38 and BMI of 39.2 exhibited headache (98%), vision changes (80%), pulse-synchronous tinnitus (48%), and papilledema (64%) at disease onset. Median cerebrospinal fluid (CSF) opening pressure was 36 cm H2O. Extent of diagnostic evaluation was assessed and retrospective review of MR venography (MRV) conducted. Twenty-eight (47.4%) patients in this cohort underwent MRV imaging, amongst whom 20 (71.4%) exhibited asymmetric venous sinuses or evidence of venous sinus stenosis. Two of the 20 patients (10%) were referred for neurointerventional evaluation based on suspected transverse sinus stenosis as the mechanism for refractory IIH. Both patients underwent successful transvenous sinus stenting with resolution of transvenous sinus pressure gradient, and clinical symptoms.

Conclusion In this retrospective cohort of IIH, fewer than half of these patients underwent MRV to evaluate for transverse sinus stenosis as a possible mechanism. However, when evaluated with an MRV, over 2/3 of these patients demonstrated asymmetric venous sinus or frank stenosis. The referral of such patients to neurointervention was rare. Our study highlights the overall under-recognition of transverse venous sinus asymmetry/stenosis as a treatable entity and stresses the importance of obtaining an MRV and referring patients for neurointerventional evaluation.

Disclosures P. Ramakrishnan: 3; C; Cerenovus. C. Berry: None. S. Leinfelder: None. W. Leesch: 3; C; Penumbra Inc. 4; C; Cerebrotech Inc. 6; C; Stryker, Medtronic, Terumo. J. Sanderson: None.