Treatment of Idiopathic Intracranial Hypertension With Bilateral Trans-stenotic Pressure Gradients: Unilateral Versus Bilateral Venous Sinus Stenting

BACKGROUND AND OBJECTIVES: Venous sinus stenting (VSS) is an established treatment for medically refractory idiopathic intracranial hypertension (IIH), yet the clinical significance of bilateral trans-stenotic venous pressure gradients and the optimal stenting strategy in this setting remains poorly defined. METHODS: We retrospectively reviewed prospectively collected data on consecutive IIH patients undergoing VSS at a single institution (2021-2024). Only patients with a trans-stenotic gradient ≥8 mm Hg confirmed by venous manometry were included. Primary outcomes included symptom improvement, overall treatment response, and need for repeat VSS. RESULTS: Ninety-two patients were included, of whom 44 (48%) demonstrated bilateral venous pressure gradients. Bilateral gradients were more prevalent among Black patients (P = .041) but were not associated with differences in lumbar puncture opening pressure, presenting symptoms, or emergent presentation (P ≥ .05). Among patients with bilateral gradients, unilateral stenting was associated with lower rates of satisfactory clinical response (23% vs 74%; P = .002) and higher rates of repeat intervention (62% vs 3.2%; P < .001) compared with bilateral stenting. Tinnitus resolution was significantly more frequent following bilateral stenting (11% vs 68%; P = .005). Clinical outcomes after staged bilateral stenting after failed unilateral treatment were comparable with those achieved with index bilateral stenting. CONCLUSION: Bilateral venous pressure gradients are common in IIH and identify a subgroup in whom unilateral stenting alone may be insufficient. In these cases, up-front bilateral stenting is often necessary, safe, and associated with superior clinical outcomes.