Outcomes of venous sinus stenting versus ventriculoperitoneal shunting for fulminant idiopathic intracranial hypertension: a dual-center analysis

OBJECTIVE: Venous sinus stenting (VSS) has emerged as a promising and less invasive treatment alternative to CSF diversion for patients with idiopathic intracranial hypertension (IIH). Fulminant IIH (fIIH) is a rare manifestation of IIH, affecting 2%-3% of IIH patients and characterized by rapid, progressive, and severe visual loss. Outcomes following different treatment modalities for fIIH remain unclear. METHODS: A dual-center retrospective cohort study was done comparing patients who underwent VSS or ventriculoperitoneal shunting (VPS) for fIIH over a 5-year time frame, defined as rapid visual loss secondary to IIH refractory to medical management. Patient demographic characteristics, baseline symptom characteristics focusing on headache and visual decline, operative parameters, postoperative complications, and outcomes were collected. The decision to proceed with VSS or VPS was based on surgeon discretion and institutional preference. Data were analyzed using the bivariate t-test or chi-square test as appropriate, and multivariate logistic regression was used to identify significant predictors. RESULTS: A total of 39 patients who underwent treatment for fIIH were identified, of whom 46% (n = 18) underwent VPS and 54% (n = 21) underwent VSS. The VSS cohort included more females (100% vs 76%, p = 0.03), otherwise no differences were seen in age, BMI, rate of preoperatively diagnosed headache disorder or psychiatric disorder, acetazolamide usage, preoperative papilledema grade, preoperative average visual acuity, or preoperative opening pressure. On univariate regression, VSS was associated with improved headache reduction (58% vs 25%, p < 0.001) as well as decreased headache recurrence (27% vs 65%, p = 0.03). Both cohorts showed a high rate of improvement in papilledema postoperatively (93.3% for VSS vs 92.8% for VPS, p > 0.99), and there was no significant difference in the rates of postoperative visual acuity improvement (83% for VSS vs 50% for VPS, p = 0.17). VPS patients were more likely to have reductions in acetazolamide usage postoperatively (85% vs 22%, p = 0.001). No postoperative hemorrhages, access site complications, or stent thromboses were observed. On multivariate regression, no significant predictors of improvement in headache severity, papilledema, or visual acuity were observed. CONCLUSIONS: Among patients presenting with fIIH, VSS is comparable to VPS with respect to visual outcomes defined as improvement in papilledema. Larger randomized studies are required to determine differences in outcomes between VSS and VPS in this subpopulation of IIH patients.