Fifty shades of gradients: does the pressure gradient in venous sinus stenting for idiopathic intracranial hypertension matter? A systematic review.
OBJECTIVE
The role of venous sinus stenting (VSS) for idiopathic intracranial hypertension (IIH) is not well understood. The aim of this systematic review is to attempt to identify subsets of patients with IIH who will benefit from VSS based on the pressure gradients of their venous sinus stenosis.


METHODS
MEDLINE/PubMed was searched for studies reporting venous pressure gradients across the stenotic segment of the venous sinus, pre- and post-stent pressure gradients, and clinical outcomes after VSS. Findings are reported according to the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines.


RESULTS
From 32 eligible studies, a total of 186 patients were included in the analysis. Patients who had favorable outcomes had higher mean pressure gradients (22.8 ± 11.5 mm Hg vs 17.4 ± 8.0 mm Hg, p = 0.033) and higher changes in pressure gradients after stent placement (19.4 ± 10.0 mm Hg vs 12.0 ± 6.0 mm Hg, p = 0.006) compared with those with unfavorable outcomes. The post-stent pressure gradients between the 2 groups were not significantly different (2.8 ± 4.0 mm Hg vs 2.7 ± 2.0 mm Hg, p = 0.934). In a multivariate stepwise logistic regression controlling for age, sex, body mass index, CSF opening pressure, pre-stent pressure gradient, and post-stent pressure gradient, the change in pressure gradient with stent placement was found to be an independent predictor of favorable outcome (p = 0.028). Using a pressure gradient of 21 as a cutoff, 81/86 (94.2%) of patients with a gradient > 21 achieved favorable outcomes, compared with 82/100 (82.0%) of patients with a gradient ≤ 21 (p = 0.022).


CONCLUSIONS
There appears to be a relationship between the pressure gradient of venous sinus stenosis and the success of VSS in IIH. A randomized controlled trial would help elucidate this relationship and potentially guide patient selection.
['McDougall|Cameron M|CM|', 'Ban|Vin Shen|VS|', 'Beecher|Jeffrey|J|', 'Pride|Lee|L|', 'Welch|Babu G|BG|']
D001794:Blood Pressure D003392:Cranial Sinuses D006801:Humans D019635:Neurosurgical Procedures D011559:Pseudotumor Cerebri D015607:Stents D016896:Treatment Outcome
pressure gradient venous sinus stenting idiopathic intracranial hypertension BMI = body mass index ICP = intracranial pressure IIH = idiopathic intracranial hypertension PRISMA = Preferred Reporting Items for Systematic Reviews and Meta-Analyses VSS = venous sinus stenting interventional neurosurgery pseudotumor cerebri venous stenosis