1. Angel Mironov Creighton University Medical Center Omaha, Nebraska

2.  The idiopathic intracranial hypertension remains a diagnosis of exclusion  ( Friedman D., Jacobson D.: Neurology 59, 2002)  The restoring of patency of stenotic dural sinuses in patients with refractory IIH is not sufficient elucidate  The neurointerventional community is still debating and strives to justify neurovascular strategies for treatment

3.  To document the clinical response to an endovascular improvement of lateral sinus circulation by angioplasty  To clarify the relation of IIH to associate narrowing of lateral dural sinuses  To justify apparently indications for appropriate endovasal treatment

4. Demography 12 patients with refractory IIH  Sex: female – nr:11; male – nr:1  Age range: 16 – 34 years-old  BMI kg/m2 range: 20 – 85  CSF opening pressure range: 30 – 95 H 2 O  Progressive headache (nr: 12), visual disturbance (nr: 11), personality change (nr: 3)

5. Diagnostic  Imaging: MRI, MRV (7)  Catheter angiography with retrograde venography  Pull-back manometry with blood pressure transducer in the sagittal sinus, torcular Herophili, proximal and distal transverse sinus, proximal and distal sigmoid sinus, jugular bulb, proximal and distal jugular vein on each side, and in superior vena cava  Focus of interest of venous manometry: a) gradients across the irregularities of lateral sinus b) gradients at confluence of sinuses/jugular bulb

6. Sinus manometry  Pressure gradients across the sinus irregularities: 1. Group: up to 15 mmHg – 6 cases (4, 6, 7, 8, 9, 12 mm) 2. Group: up to 30 mmHg – 4 cases (21, 25, 26, 30 mm) 3. Group: above 30 mmHg – 2 cases (50/48, 35 mm)  Sinus angioplasty offered for groups 2 and 3: compliant balloons 4 and 4.5 mm

7.  25 year-old obese woman (body mass index 33.1 kg/m2)  Intermittent headache for 3 we  Visual disturbance with transient obscurations, papilledema  Raised cerebrospinal fluid pressure - 62 H 2 O

8. MR Imaging Bilateral optic nerve sheath dilatation and papilla protrusion

9. MR time-of-flow venography

10. Left internal carotid Left vertebral

11. Left lateral sinus

12. Right lateral sinus

13. Endovasal manometry

14. Pressure gradients right lateral sinus: 20 mmHg Pressure gradients left lateral sinus: 5 mmHg mmHg 17/15 mmHg 16/14 mmHg 16/15mmHg 17/16 mmHg 22/21mmHg 36/35 20 5 5

15. Compliant balloon angioplasty

16.  Remarkable clinical improvement after angioplasty of right lateral dural sinus in following week with resolution of symptoms Last follow up: 6 months

17.  26 year-old obese woman (body mass index 35 kg/m2)  6 we history of headache  Progressive visual disturbance for 1 we  Bilateral papilledema  Cerebrospinal fluid raised at 80 H 2 O  Personality change on admission

18. Optic papilla protrusion

19. Left lateral sinus Endovasal manometry: pressure gradients of 48 mmHg

20. Compliant balloon angioplasty of left lateral sinus

21. Endovasal manometry: pressure gradients of 50 mmHg Right lateral sinus

22. Compliant balloon angioplasty of right lateral sinus

23. Initial Gd MRI Follow up 6 we Gd MRI

24. Last follow up: 12 months  Remarkable clinical improvement after angioplasty of both lateral venous sinuses in following week with durable resolution of symptoms

25. Outcome angioplasty of sinus  Dramatic and durable improvement for more than 6 months in 4 cases: jugular vein pressure of 8, 10, 12, and 16 mm Hg  Transitory not sustainable improvement in 2 cases: jugular vein pressure of 22 and 24 mm Hg

26.  Some cases of IIH are exacerbated by a coexistent effect of preexistent anatomic narrowing of the lateral sinuses with elevated across gradients; an improvement of sinus perfusion may break the iterative cycle (?)  Even in case with exposed across gradients the perfusion improvement of sinuses will be not obtainable, as long as the central venous pressure is exceedingly elevated (?)  The lack of clinical response after angioplasty/stenting reflects probably the both – the lack of exposed across gradients (less than 15 mmHg), and the elevation of jugular vein pressure due to central venous pressure elevation (more than 20 mmHg)

28. Sinus manometry  MR venography and conventional venous phase demonstrated patent flow of dural sinuses with hypoplastic/stenotic divisions or irregularities of lateral sinuses in all patients  Pressure gradients across the sinus irregularities: 1. Group: up to 15 mmHg – 6 cases (4, 6, 7, 8, 9, 12 mm) 2. Group: up to 30 mmHg – 4 cases (21, 25, 26, 30 mm) 3. Group: above 30 mmHg – 2 cases (50/48, 35 mm)