Under Pressure: Unraveling the Central Venous Influence in Idiopathic Intracranial Hypertension

Background: While the role of dural venous stenosis in idiopathic intracranial hypertension (IIH) is well-established, the complex interplay between intracranial and extracranial factors contributing to pathological intracranial venous congestion remains poorly understood. Objective: This study explores venous sinus pressure profiles in cohorts with elevated CVP (eCVP) and normal CVP (nCVP). Methods: We retrospectively included adult patients (≥18 years) who underwent invasive diagnostic venography, with or without therapeutic intent, for a suspected or confirmed diagnosis of IIH. Patient venous dimensions and pressures were extracted and dichotomized into eCVP and nCVP for comparison, with additional subgroup analysis in patient elevated transverse-sigmoid/trans-stenosis pressure gradient (eTSPG) and normal TSPG (nTSPG). Results: We included 98 patients with CVP measurements. Patients with eCVP exhibited higher opening pressures (OP, 32.3 ± 11.1 versus 29.9 ± 9.9, p = 0.04; Table 1 ). Unlike patients with stenosis, who demonstrated elevated venous pressures only upstream of the stenotic segment ( Table 2 ), patients with eCVP displayed elevated venous pressures throughout the entire venous sinuses (Table 3). The eCVP cohort not only exhibited a narrower stenotic segment but also significantly narrower sagittal, transverse, and sigmoid sinuses ( p < 0.05; Table 1 ), suggesting a more global impact of elevated OP rather than just the transverse-sigmoid junction. Furthermore, patients with eCVP demonstrated a delayed onset of gradient formation and a higher-pressure gradient before plateauing compared with nCVP for the same OP (Figure 2), indicating increased compliance of the dural venous walls. Conclusion: This series highlights the variability in venous sinus dimensions, pressures, and gradient profiles with increasing OP, stratified by eCVP and nCVP. While eCVP initially protects against gradient development, it ultimately results in higher venous pressures, which hinder CSF resorption significantly more than for nCVP, thereby increasing OP to a much greater extent. Patients with eCVP demonstrated more compliant dural venous sinus walls, which could influence the long-term effectiveness of venous sinus stenting. Publication History Article published online: 27 February 2026 © 2026. Thieme. All rights reserved. Georg Thieme Verlag KG Oswald-Hesse-Straße 50, 70469 Stuttgart, Germany