Venous sinus stenting: where does it fit in the treatment paradigm for cerebrospinal fluid leaks?

OBJECTIVE: Spontaneous CSF leaks are traditionally managed with surgical repair. However, a growing body of evidence suggests that some of these leaks may result from idiopathic intracranial hypertension (IIH) and/or elevated intracranial pressure (ICP) due to underlying venous sinus stenosis-an association that remains underrecognized. Venous sinus stenting (VSS) may address CSF leaks by restoring normal venous outflow and reducing ICP. However, few series have evaluated VSS as a primary or adjunctive treatment for CSF leaks. Herein, the authors present a case series highlighting the role of VSS in both contexts. METHODS: The authors performed a retrospective review of the medical records of all patients with spontaneous CSF leaks treated using VSS at a single center from December 2020 through June 2024. Patients underwent VSS either as primary treatment or following surgical repair. Clinical data, imaging studies, venous pressures, treatment course, and outcomes were analyzed. RESULTS: Fourteen patients underwent VSS of the transverse-sigmoid sinuses to manage active CSF leaks and/or prevent leak recurrence. All patients had presumed IIH, 5 had papilledema, and 12 had received acetazolamide therapy. Seven patients had undergone prior CSF leak repair surgery. VSS served as the primary treatment in 8 patients, whereas 6 underwent a staged approach, with recent skull base surgeries occurring a median of 71 days prior to stenting (range 41-157 days). The mean superior sagittal sinus pressure was 24 mm Hg (range 18-36 mm Hg), and the mean transstenotic gradient was 10 mm Hg (range 7-16 mm Hg). By the last follow-up (median 1.1 years), 13 patients had attained complete resolution of the CSF leak. Ten of the 12 patients initially taking acetazolamide were weaned off the medication, and all 5 patients with papilledema had leak resolution post-VSS. CONCLUSIONS: VSS may serve as an effective primary or adjunctive treatment for spontaneous CSF leaks in select patients with evidence of intracranial hypertension. Further prospective studies are needed to validate these findings and clarify patient selection.