DSS_prez.qmd

---
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title: "Dural Sinus Stenting"
author: "Mirindi Kabangu"
institute: "Indiana University School of Medicine"
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---

# Case

"Chronic headaches"

::: aside
Case was modified for teaching purposes
:::

## History {.scrollable}

15-year-old girl with no PMHx

Presents with chronic "throbbing headachs"

-   **Headache Characteristics**:
    -   Severe, throbbing headaches
    -   Occurs daily, lasting several hours
    -   Worsens with coughing or straining (Valsalva maneuver)
-   **Visual Disturbances**:
    -   Double vision (diplopia)
    -   Transient vision loss (lasting a few seconds to minutes)
-   **Auditory Symptoms**:
    -   Whooshing sound in the ears (pulsatile tinnitus), particularly noticeable at night

## Physical Examination {auto-animate="true"}

::: columns
::: {.column width="40%"}
130/85 mmHg

75 bpm

16 breaths per minute

98.6?F (37?C)

85 kg (187 lbs)

160 cm (5'3")

BMI: 33.2 kg/m?
:::

::: {.column width="60%"}
:::
:::

## Physical Examination {auto-animate="true"}

::: columns
::: {.column width="40%"}
::: {.fragment .higlight-red}
130/85 mmHg
:::

75 bpm

16 breaths per minute

98.6?F (37?C)

85 kg (187 lbs)

160 cm (5'3")

BMI: 33.2 kg/m?
:::

::: {.column width="60%"}
::: {.fragment .fade-up}
Alert and oriented, in no acute distress
:::

::: {.fragment .fade-up}
Papilledema observed on fundoscopic exam
:::

::: {.fragment .fade-up}
Mild sixth nerve palsy (limited lateral eye movement)
:::

::: {.fragment .fade-up}
Normal strength and tone in all extremities
:::

::: {.fragment .fade-up}
Intact sensation to light touch and pinprick
:::
:::
:::

:::

## Initial Presentation

**Meet Sarah, a 15-year-old girl who presents to the clinic with a three-month history of progressive headaches. Her headaches are described as severe, throbbing, and often accompanied by visual disturbances such as seeing double and experiencing transient vision loss. Additionally, Sarah reports hearing a whooshing sound in her ears that synchronizes with her heartbeat, particularly noticeable at night. Concerned about these symptoms, Sarah and her parents seek medical attention.**

------------------------------------------------------------------------

::: question
Given Sarah's presentation of severe headaches, visual disturbances, and pulsatile tinnitus, what is the most likely diagnosis?

::: choices
::: choice
Migraine
:::

::: choice
Cluster headache
:::

::: {.choice .correct-choice}
Idiopathic intracranial hypertension
:::

::: choice
Tension headache
:::
:::
:::

<details>

<summary><strong>Answer and Explanation</strong></summary>

**Answer: C. Idiopathic intracranial hypertension**

**Explanation:** Sarah's symptoms of severe headaches, visual disturbances, and pulsatile tinnitus are characteristic of IIH, especially when accompanied by papilledema, which should be confirmed on further examination.

</details>

------------------------------------------------------------------------

## Visit to the Primary Care Physician

**Sarah's primary care physician performs a comprehensive history and physical examination. Given her symptoms, Sarah is referred to an ophthalmologist for further evaluation of her visual complaints.**

------------------------------------------------------------------------

::: question
During the ophthalmology appointment, the ophthalmologist performs a fundoscopy and discovers papilledema. What does the presence of papilledema suggest in the context of Sarah's symptoms?

::: choices
::: choice
It is a benign finding with no significance
:::

::: {.choice .correct-choice}
It suggests increased intracranial pressure
:::

::: choice
It indicates a possible retinal detachment
:::

::: choice
It confirms a diagnosis of glaucoma
:::
:::
:::

<details>

<summary><strong>Answer and Explanation</strong></summary>

**Answer: B. It suggests increased intracranial pressure**

**Explanation:** Papilledema is swelling of the optic disc due to increased intracranial pressure, which aligns with Sarah's symptoms of headaches and vision changes. It requires prompt further investigation.

</details>

------------------------------------------------------------------------

## Seeking Further Medical Attention

**Following the discovery of papilledema, Sarah's ophthalmologist refers her back to the primary care physician with a recommendation for neuroimaging and further evaluation by a neurologist.**

------------------------------------------------------------------------

::: question
What is the next best step in the evaluation of Sarah's condition, considering her symptoms and the finding of papilledema?

::: choices
::: choice
Prescribe migraine medication
:::

::: {.choice .correct-choice}
Order a brain MRI and MRV
:::

::: choice
Start corticosteroids
:::

::: choice
Refer to a neurologist
:::
:::
:::

<details>

<summary><strong>Answer and Explanation</strong></summary>

**Answer: B. Order a brain MRI and MRV**

**Explanation:** The next step is to confirm the diagnosis of IIH and rule out other causes of increased intracranial pressure. An MRI can help exclude mass lesions, while an MRV can identify venous sinus stenosis.

</details>

------------------------------------------------------------------------

## Diagnostic Imaging

**Sarah undergoes a brain MRI, which comes back normal, ruling out any masses or structural abnormalities. However, the MRV reveals stenosis of the transverse sinuses.**

------------------------------------------------------------------------

::: question
According to the latest guidelines, what additional test is crucial to confirm the diagnosis of IIH and assess intracranial pressure?

::: choices
::: {.choice .correct-choice}
Lumbar puncture
:::

::: choice
CT scan of the head
:::

::: choice
Electroencephalogram (EEG)
:::

::: choice
Carotid ultrasound
:::
:::
:::

<details>

<summary><strong>Answer and Explanation</strong></summary>

**Answer: A. Lumbar puncture**

**Explanation:** A lumbar puncture is essential to measure the opening pressure, which is typically elevated in IIH, and to exclude other causes of increased intracranial pressure. This is recommended by current guidelines.

</details>

------------------------------------------------------------------------

## Management Plan

**Sarah's lumbar puncture reveals an elevated opening pressure of 30 cm H2O, confirming the diagnosis of IIH. Initial management with acetazolamide 500 mg twice daily and lifestyle modifications is started.**

------------------------------------------------------------------------

::: question
What is the primary mechanism of action of acetazolamide in the management of IIH?

::: choices
::: choice
Increases cerebrospinal fluid (CSF) absorption
:::

::: {.choice .correct-choice}
Decreases CSF production
:::

::: choice
Reduces cerebral blood flow
:::

::: choice
Acts as a diuretic to reduce intracranial pressure
:::
:::
:::

<details>

<summary><strong>Answer and Explanation</strong></summary>

**Answer: B. Decreases CSF production**

**Explanation:** Acetazolamide is a carbonic anhydrase inhibitor that reduces cerebrospinal fluid production, thereby lowering intracranial pressure. This is supported by clinical guidelines for IIH management.

</details>

------------------------------------------------------------------------

## Persistent Symptoms

**Despite initial treatment with acetazolamide and lifestyle modifications, Sarah's symptoms persist, and her vision continues to deteriorate.**

------------------------------------------------------------------------

::: question
According to the latest guidelines, what is the recommended next step in Sarah's management, considering her refractory symptoms and worsening vision?

::: choices
::: {.choice .correct-choice}
Increase the dose of acetazolamide to 1000 mg twice daily
:::

::: choice
Add topiramate to her treatment
:::

::: choice
Refer to interventional radiology for dural sinus stenting
:::

::: choice
Start corticosteroids
:::
:::
:::

<details>

<summary><strong>Answer and Explanation</strong></summary>

**Answer: A. Increase the dose of acetazolamide to 1000 mg twice daily**

**Explanation:** Before proceeding to more invasive options, increasing the dose of acetazolamide is a reasonable next step to attempt to better manage intracranial pressure as per guidelines.

</details>

------------------------------------------------------------------------

## Counseling on Treatment Options

**Sarah's symptoms remain refractory to maximum medical therapy. She is counseled on further treatment options, including ventriculoperitoneal (VP) shunt and dural sinus stenting.**

------------------------------------------------------------------------

::: question
What are key factors to consider when counseling a patient on choosing between a VP shunt and dural sinus stenting for IIH?

::: choices
::: choice
Invasiveness of the procedure
:::

::: choice
Risk of complications and need for revisions
:::

::: choice
Patient preference and lifestyle
:::

::: {.choice .correct-choice}
All of the above
:::
:::
:::

<details>

<summary><strong>Answer and Explanation</strong></summary>

**Answer: D. All of the above**

**Explanation:** Key factors include the invasiveness of the procedure, the risk of complications and need for revisions, and the patient's preference and lifestyle. Dural sinus stenting is less invasive and typically has fewer complications compared to VP shunting.

</details>

------------------------------------------------------------------------

## Decision and Procedure

**Sarah opts for dural sinus stenting after discussing her options with her healthcare team. She is referred to an interventional radiologist and undergoes venous angiogram to evaluate for stenosis.**

------------------------------------------------------------------------

::: question
During the dural sinus stenting procedure, what is the minimum pressure gradient on venography recommended for stenting according to guidelines?

::: choices
::: choice
2 mmHg
:::

::: {.choice .correct-choice}
4 mmHg
:::

::: choice
6 mmHg
:::

::: choice
8 mmHg
:::
:::
:::

<details>

<summary><strong>Answer and Explanation</strong></summary>

**Answer: B. 4 mmHg**

**Explanation:** According to guidelines, a minimum pressure gradient of 4 mmHg is recommended on venography to justify st

------------------------------------------------------------------------

## Follow-Up and Outcome

**After the stenting procedure, Sarah's symptoms significantly improve. Her headaches diminish, her vision is restored, and the pulsatile tinnitus resolves.**

------------------------------------------------------------------------

::: question
What follow-up care is recommended for Sarah post-stenting to ensure continued improvement and monitor for potential complications?

::: choices
::: choice
Regular neurological assessments
:::

::: choice
Periodic imaging to monitor stent patency
:::

::: choice
Continued acetazolamide therapy
:::

::: {.choice .correct-choice}
All of the above
:::
:::
:::

<details>

<summary><strong>Answer and Explanation</strong></summary>

**Answer: D. All of the above**

**Explanation:** Post-stenting care includes regular neurological assessments, periodic imaging to ensure the stent remains patent, and continued acetazolamide therapy to manage intracranial pressure. These recommendations align with follow-up guidelines for IIH.

</details>

------------------------------------------------------------------------

## Challenge Questions

------------------------------------------------------------------------

#### Predictive Factors for DVSS Success

::: question
Which of the following factors is most predictive of a successful outcome following dural venous sinus stenting (DVSS) for IIH?

::: choices
::: choice
Patient's age
:::

::: {.choice .correct-choice}
Reduction in trans-stenotic pressure gradient
:::

::: choice
Initial severity of papilledema
:::

::: choice
Duration of symptoms before treatment
:::
:::
:::

<details>

<summary><strong>Answer and Explanation</strong></summary>

**Answer: Reduction in trans-stenotic pressure gradient**

**Explanation:** The review identifies that a significant reduction in the trans-stenotic pressure gradient is a key predictive factor for successful outcomes following DVSS in IIH patients.

</details>

------------------------------------------------------------------------

#### Differential Diagnosis of IIH

::: question
Which condition must be ruled out to definitively diagnose idiopathic intracranial hypertension (IIH)?

::: choices
::: choice
Normal pressure hydrocephalus
:::

::: choice
Chiari malformation
:::

::: choice
Subarachnoid hemorrhage
:::

::: {.choice .correct-choice}
Venous sinus thrombosis
:::
:::
:::

<details>

<summary><strong>Answer and Explanation</strong></summary>

**Answer: Venous sinus thrombosis**

**Explanation:** To definitively diagnose IIH, venous sinus thrombosis must be ruled out, as it can present with similar symptoms but requires different management.

</details>

------------------------------------------------------------------------

#### Improvement in Visual Disturbances

::: question
What percentage of patients experienced improvement in visual disturbances after undergoing venous sinus stenting, according to the meta-analysis?

::: choices
::: choice
75%
:::

::: choice
80%
:::

::: {.choice .correct-choice}
88%
:::

::: choice
95%
:::
:::
:::

<details>

<summary><strong>Answer and Explanation</strong></summary>

**Answer: 88%**

**Explanation:** 88% of patients experienced improvement in visual disturbances after undergoing venous sinus stenting.

</details>

------------------------------------------------------------------------

#### Reduction in Acetazolamide Dosage

::: question
What is the average reduction in acetazolamide dosage following DVSS at the 3-month postoperative assessment?

::: choices
::: question
From 1000mg to 500mg daily
:::

::: choice
From 750mg to 250mg daily
:::

::: {.choice .correct-choice}
From 950mg to 300mg daily
:::

::: choice
From 500mg to 100mg daily
:::
:::
:::

<details>

<summary><strong>Answer and Explanation</strong></summary>

**Answer: From 950mg to 300mg daily**

**Explanation:** The average daily dose of acetazolamide decreased from 950mg to 300mg at the 3-month postoperative assessment following DVSS.

</details>

------------------------------------------------------------------------

#### Impact of Comorbid Conditions

::: question
How do comorbid conditions such as polycystic ovary syndrome (PCOS) impact the management of IIH?

::: choices
::: choice
They do not impact the management of IIH
:::

::: choice
They complicate the diagnosis but not the treatment
:::

::: {.choice .correct-choice}
They may necessitate a multidisciplinary approach to treatment
:::

::: choice
They only affect the choice of surgical intervention
:::
:::
:::

<details>

<summary><strong>Answer and Explanation</strong></summary>

**Answer: They may necessitate a multidisciplinary approach to treatment**

**Explanation:** Comorbid conditions such as PCOS can affect the management of IIH, requiring a multidisciplinary approach to address both IIH and the underlying conditions.

</details>

------------------------------------------------------------------------

## Summary

-   IIH is characterized by increased intracranial pressure without a detectable cause.
-   Diagnosis involves imaging and lumbar puncture to measure opening pressure, following the latest guidelines.
-   Initial management includes medication and lifestyle changes, with dural sinus stenting as an option for refractory cases, supported by current clinical guidelines.

## About This Presentation

This educational resource was created to help surgical and neurological surgery residents prepare for their boards by learning about the diagnosis and management of idiopathic intracranial hypertension (IIH) through the journey of a patient case study.

**Author:** Mirindi T. Kabangu

**Contact:** [mkabangu\@iu.edu](mailto:mkabangu@iu.edu)