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Counterpoint: stenting for idiopathic intracranial hypertension should be trialed
  1. Colin P Derdeyn1,
  2. Michael Wall2
  1. 1Radiology, University of Iowa Hospitals and Clinics, Iowa City, Iowa, USA
  2. 2Ophthalmology, University of Iowa Hospitals and Clinics, Iowa City, Iowa, USA
  1. Correspondence to Dr Colin P Derdeyn, Radiology, University of Iowa Hospitals and Clinics, Iowa City, IA 52242, USA; colin-derdeyn{at}uiowa.edu

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We have an obligation to our patients to prove that what we do works—that the benefits of our procedures outweigh their risks. That evidence base is notably lacking for dural sinus stenting for patients with idiopathic intracranial hypertension (IIH).

We do not dispute that many patients with IIH have a pressure gradient in their dural sinuses, typically due to what is almost certainly extrinsic compression of their transverse sinuses.1 Stenting of these patients reduces central venous and intracranial pressure, conclusively and dramatically.2 This is generally accompanied by improvement in many of the symptoms reported by these patients.3 We also do not dispute that it is reasonable to offer stenting to some patients, but with the caveat that the evidence regarding many aspects of this procedure is weak.

There is a long list of unanswered questions regarding venous sinus stenting for patients with IIH. The sum of our knowledge regarding the risks and benefits of this procedure are from case series: no randomized trial has been reported to date. While the risk of complications from this procedure is low in terms of frequency (2–3%), some can be catastrophic.4 Many studies to date have lacked objective or quantifiable measurements of outcome, such as stabilization or improvement in visual fields, for example. There is uncertainty regarding indications for treatment. Is headache alone an indication? Should we be using an objective threshold value for visual loss? If …

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Footnotes

  • Twitter @CPDerdeyn

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests Consulting (Data and Safety Monitoring Committee): Silkroad (NITE trial); Penumbra (Thunder Trial); NoNO (Escape NEXT, Frontier trials). Equity (Pulse Therapeutics - Stock Options).

  • Provenance and peer review Not commissioned; internally peer reviewed.

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