Introduction Idiopathic intracranial hypertension (IIH) is a disorder of increased intracranial pressure which is theorized to originate from obesity, hormonal changes, medications, and/or venous sinus stenosis. First-line treatments include weight loss and acetazolamide to lower intracranial pressure. Despite these measures, patients may continue to have symptoms of headache and vision changes or persistent optic disc swelling (papilledema) on exam. Second-line treatments may then be considered including surgical weight loss, venous sinus stenting, or ventriculoperitoneal shunting. There is no formal consensus regarding the best second-line approach in patients with IIH. The purpose of this study is to characterize patients who undergo venous stenting and compare them to patients who are successfully treated with medical therapy only. The hypothesis is that patients with more severe papilledema at presentation, inability to lose weight, persistent symptoms despite medications, and inability to wean from medication will be more likely to undergo venous sinus stenting.

Methods The cohort includes all patients with a diagnosis of IIH and papilledema who were seen at Stanford between 1/2022 and 10/2023. A total of 130 patients were identified with a screening tool that searches for relevant diagnosis codes (G93.2, H47.1, H47.11). Of the 130 patients identified, 90 have been screened for inclusion. Patients who lacked papilledema or had alternative diagnoses for intracranial hypertension such as mass lesions were excluded. Chart review has been completed on 39 patients. Of these, 31 patients received only medical therapy and 8 received medical therapy + stenting. The unpaired t-test was used to calculate between-group differences for continuous variables and the Fisher exact test was used to calculate associations between categorical variables with alpha set to 0.05 for both tests.

Results Stented patients had higher average BMI at presentation (36 vs 33, p=0.17) and higher average opening pressures with lumbar puncture (43 vs 36, p=0.03). Substantial weight loss was uncommon in both groups, and less likely in the stented patients (25% vs 29%, p=1.0). Severe papilledema at presentation was similar between groups (37% vs 35%; p=1.0). Patients who went on to undergo venous stenting were less likely to have had improvement in headache (25% vs 73%, p=0.11) or resolution of papilledema (50% vs 86%, p=0.17) with medical therapy alone and were more likely to have failed weaning from medical therapy (40% vs 28%, p=0.62).

Conclusions In conclusion, patients with IIH who ultimately require venous sinus stenting more often have higher BMI, fail to achieve symptom control with medication, and continue to have papilledema with medication. Stented patients have significantly higher opening pressure at initial lumbar puncture. There is no trend towards stenting in patients with severe papilledema at initial presentation.

Disclosures D. Slawski: None. R. Baron: None. N. Telischak: None.