Introduction

Idiopathic intracranial hypertension (IIH), or perhaps more accurately chronic intracranial venous hypertension syndrome (CIVHS),1 is a disabling condition often resulting in severe pressure headaches, visual symptoms, and tinnitus. In the last decade, venous sinus stenting (VSS) has emerged as a safe and effective treatment for patients with IIH with associated venous sinus stenosis and a documented trans-stenosis pressure gradient (TSPG). While meta-analyses of small retrospective series have demonstrated low rates of retreatment with high rates of headache and visual improvement,2–4 some recent studies have revealed that many patients (as high as 60%) develop symptom recurrence after VSS.5 There are very few published articles that provide neurointerventionists with recommendations regarding the selection and treatment of IIH patients6 and essentially no evidence-based recommendations are available regarding the specifics of stent construct lengths or sizes. Further, questions remain about the pathophysiologic mechanism at play and why recurrent stenosis develops. Experience gained from a high-volume VSS practice has provided important insights into these phenomena. Herein I propose a unifying theory that explains the pathophysiology of de novo and recurrent venous sinus stenosis in IIH patients, with attention given to how this may impact stent construct size and length.