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

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.