Background Idiopathic intracranial hypertension (IIH) is a chronic disorder with debilitating symptoms, including headaches, visual disturbances, and pulsatile tinnitus. A high prevalence of venous sinus stenosis (VSS) is observed in IIH patients. The anatomical proximity of the stenosis to the inner ear often contributes to pulsatile tinnitus. An elevated lumbar puncture (LP) opening pressure (OP) >25 cmH₂O is a key diagnostic criterion for IIH; however, a subset of patients presented with VSS and classic IIH symptoms but with normal LP OP. While venous sinus stenting is a viable treatment option for typical IIH patients, its effectiveness in atypical IIH patients (classic symptoms, VSS but with normal LP OP) remains unexplored. Methods We conducted a retrospective study of 191 IIH patients with pulsatile tinnitus and VSS who underwent venous sinus stenting at two tertiary care centers between 2012 and 2024. Patients were stratified into two groups: those with elevated LP OP (≥25 cmH₂O, typical IIH) and those with normal LP OP (<25 cmH₂O, atypical IIH). Baseline clinical characteristics, pre‐ and post‐stenting venous pressure monitors, and clinical outcomes (headache and tinnitus improvement) were analyzed and compared for up to 12 months post‐procedure. Results Of the 191 patients, 152 had elevated OP and 39 had normal OP. The cohort with normal OP was significantly older than the typical IIH group (39 ± 11 vs. 35 ± 11 years, p=0.03). Baseline characteristics were comparable between groups, except for a higher incidence of baseline hearing loss in the normal OP group, and more typical IIH patients used acetazolamide. Pre‐stenting venous pressure gradients were not significantly different. Venous sinus stenting significantly reduced the venous pressure gradient and improved headaches in both cohorts. Notably, a higher proportion of patients in the normal OP group had improvement of their tinnitus compared to the elevated OP group by 12 months post treatment (84% vs. 69%, p=0.05). Conclusion Our preliminary findings indicate that venous sinus stenting is a highly effective intervention for reducing the venous pressure gradients and relieving symptoms of either typical or atypical IIH patients. Patients with normal OP tended to be older and had a higher rate of tinnitus improvement post‐stenting. To our knowledge, this is the first large cohort study to directly compare these patient groups, suggesting that treatment decisions should be guided by symptoms and venous pressure monitor findings rather than LP OP alone. These results will be validated upon the completion of our ongoing study. image
Sujani Bandela (Sat,) studied this question.