Shunting, optic nerve sheath fenestration and dural venous stenting for medically refractory idiopathic intracranial hypertension: systematic review and meta-analysis

Daniel B. Scherman, Adam A. Dmytriw, Gia Thanh Nguyen, Nhan Thi Nguyen, Nana Tchantchaleishvili, Julian Maingard, Hamed Asadi, Mark Brooks, Christoph Griessenauer, Christopher Ogilvy, Ajith J. Thomas, Justin M. Moore, Kevin Phan


Background: Cerebrospinal fluid (CSF)-diversion procedures have traditionally been the standard of treatment for patients with medically refractive idiopathic intracranial hypertension (IIH). However, dural venous sinus stent (VSS) placement has been described as a safe and effective procedure for the management of medically refractive IIH. We performed a meta-analysis comparing outcomes and complications of CSF-diversion procedures, VSS and optic nerve sheath fenestration (ONSF) for the treatment of medically refractive IIH.
Methods: Electronic searches were performed using six databases from 1988 to January 2017. Data was extracted and meta-analysed from the identified studies.
Results: From 55 pooled studies, there were 538 CSF-diversion cases, 224 dural venous stent placements, and 872 ONSF procedures. Similar improvements were found in terms of postoperative headaches (CSF vs. VSS vs. ONSF: 84% vs. 78% vs. 62%, P=0.223), papilledema (CSF vs. VSS vs. ONSF: 71% vs. 86% vs. 77%, P=0.192), whilst visual acuity changes favored venous stenting (CSF vs. VSS vs. ONSF: 55% vs. 69% vs. 44%, P=0.037). There was a significantly lower rate of subsequent procedures with venous stent placement (CSF vs. VSS vs. ONSF: 37% vs. 13% vs. 18%, P<0.001), but other complication rates were similar (CSF vs. VSS vs. ONSF: 13% vs. 8% vs. 14%, P=0.28). Subgroup analysis of lumbar-peritoneal vs. ventriculoperitoneal shunts found no differences in symptom improvements, complications and subsequent procedure rates.
Conclusions: Our findings suggest that dural venous sinus stenting may be a viable alternative to traditional surgical interventions in patients who are refractory to medical treatment.