Venous Manometry Insights: Diagnostic Criteria Utility and Clinical Correlation in Patients with Refractory Idiopathic Intracranial Hypertension
Areeba Nisar1, Enchao Qiu1, Isha Sharan2, Jenny Chan2, Nivethitha Arunkumar2, Dagmar Beier5, Rigmor Jensen6, Scott Faro3, Prabath Mondel3, Neelu Jain3, Kiran Talekar3, Nicole Spare1, Simy Parikh1, Syed Omar Shah4, Michael Marmura1, Mark Moster7, James Evans4, Reid Gooch4, Hsiangkuo Yuan1
1Department of Neurology, 2Sidney Kimmel Medical College, 3Departmet of Radiology, 4Department of Neurosurgery, Thomas Jefferson Univeristy Hospital, 5Odense University Hospital, 6Rigshospitalet, 7Neuro-Ophthalmology -Wills Eye Hospital
Objective:
To investigate the clinical parameters of refractory idiopathic intracranial hypertension (rIIH) and sensitivity/specificity of IIH diagnostic criteria based on venous manometry (VM) confirmed transverse sinus stenosis (TSS).
Background:
TSS can be evaluated objectively by VM. However, how VM measurements correlate with IIH parameters and sensitivity/specificity of the 2013 (Friedman) and 2023 (modified Korsbaek; based on 2/3 signs: papilledema, OP ≥25 cmH2O, ≥3 imaging signs) IIH criteria remains unknown.
Design/Methods:
Patients with rIIH, no pertinent brain or spine surgery or secondary IIH, undergoing VM at Thomas Jefferson University Hospital between 01/2022 and 10/2023 were retrospectively evaluated for IIH parameters (e.g., lumbar puncture opening pressure [OP], body-mass index [BMI]), VM measurements (e.g., intravenous pressure [IVP] at torcula, internal jugular [IJ], and trans-stenotic pressure gradient [TSPG]), and 2013/2023 IIH diagnostic criteria. Patients who received venous sinus stenting (VSS) were also evaluated on the treatment responses.
Results:
48 rIIH patients (age 38.9±9.9 years, BMI 36.8±9.1 kg/m2, all female) were identified and reviewed. VM confirmed 35 (72.9%) TSS patients (TSPG ≥8mmHg). The 2013 and 2023 criteria achieved sensitivity/specificity of 62.9%/30.8% and 85.7%/30.8%, respectively. Between TSS vs. non-TSS patients, there was no difference between OP (34±10.6 vs. 34.5±9.5, p=0.451) and BMI (38.0±8.4 vs. 36.3±8.5, p=0.601). No significant correlation (Pearson’s) was seen between BMI/OP vs. torcula (p=0.683/0.857), right TSPG (p=0.224/0.569), left TSPG (p=0.438/0.200), right IJ (p=0.051/0.792), and left IJ (p=0.265/0.564). BMI and OP were not correlated (p=0.297). Three months after VSS in TSS patients, improvement was seen in 25 (80.6%) with headaches, 19 (61.3%) with vision symptoms, and 18 (58.1%) with pulsatile tinnitus.
Conclusions:
Compared to the 2013 criteria, the 2023 criteria appear more sensitive in identifying TSS in rIIH patients and are equally specific. IIH parameters, such as BMI and OP, may not directly reflect the underlying IVP or TSS. VSS may improve IIH symptoms, but long-term follow-up is needed.