Delayed Complication of Venous Sinus Stenting for Idiopathic Intracranial Hypertension
Objective:
To report a case of delayed in-stent venous thrombosis 9 years after placement.
Background:
Venous sinus stenting is becoming more widely accepted as a treatment for medically refractory Idiopathic Intracranial Hypertension (IIH). One of the leading hypotheses for disease mechanism is venous sinus stenosis (VSS). Weight gain and hormonal changes are considered inciting factors that result in slight elevations of intracranial pressure (ICP), resulting in collapse of the venous sinus, blocking venous outflow, leading to further venous hypertension, ultimately resulting in reduced CSF absorption, and further increase in ICP. Venous stenting may halt this process. However, it remains controversial with limited data regarding long term efficacy and sequela. The overall complication rate is reported to be less than <6%, but precise rates of in-stent thrombosis vary. As this is considered an early complication, patients typically are on anti-thrombotics for less than 1 year.
Design/Methods:
Case Report and Literature Review.
Results:
A 33-year-old female with obesity and IIH status post venous stent 9 years prior presented with worsening headaches over several weeks. Headaches were worse when lying flat and associated with visual floaters. Neurologic exam was non-focal and ophthalmologic exam revealed trace optic disc edema. CTV was notable for a left transverse sinus stent with nonocclusive thrombus in the medial aspect causing 2 cm of severe stenosis. She had been on dual antiplatelet therapy (DAPT) for 1 year after her stent placement only, but currently was not on any medications. She was treated in the same manner as a cerebral venous thrombosis (CVT) with systemic anticoagulation.
Conclusions:
No standard guidelines exist regarding anti-thrombotic therapy or monitoring. With placements of stents elsewhere (venous or arterial), it is common practice patients end up on lifelong anti-thrombotic therapy after de-escalation from DAPT. This should be adopted as standard practice to prevent complications and secondary exacerbations of disease state.
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