Symptom Phenotypes and Treatment Failure of Dural Venous Sinus Stenting in Idiopathic Intracranial Hypertension: A Nationwide Analysis

BACKGROUND AND OBJECTIVES: Dural venous sinus stenting (VSS) is an emerging intervention for idiopathic intracranial hypertension (IIH), particularly in patients with venous sinus stenosis. However, real-world estimates of treatment failure are limited, and predictors of poor outcomes remain poorly understood. METHODS: We conducted a retrospective cohort study using the 2016 to 2022 Nationwide Readmissions Database to identify adult patients with IIH who underwent elective VSS. Patients with hydrocephalus or concurrent cerebrospinal fluid diversion or optic nerve sheath fenestration were excluded. The primary outcome was IIH-related inpatient readmission within 300 days; repeat intervention was a secondary outcome. Cox proportional hazards models were used to assess associations between baseline characteristics and treatment failure. RESULTS: Among 1497 patients, the 300-day rate of IIH-related inpatient readmission was 9.6%, and the repeat intervention rate was 6.5%. Presenting symptoms included visual-only (18.9%), headache-only (16.0%), visual with other symptoms (10.7%), and mixed or other symptoms without visual loss (54.4%). Compared with visual-only presentations (2.6%), headache-only symptoms were associated with a significantly higher risk of IIH-related inpatient readmission (18.5%; hazard ratio [HR] 8.35, P = .002). Visual-plus-other and nonvisual mixed phenotypes were also associated with increased risk (HR 4.25, P = .043; and HR 4.50, P = .012). Similar trends were observed for repeat intervention, but did not reach statistical significance. CONCLUSION: In this large, nationally representative cohort, headache-only and mixed-symptom phenotypes were significantly associated with worse outcomes compared with visual-only presentations. These findings underscore the importance of individualized risk stratification and symptom-specific counseling when selecting patients for VSS.