Comparative Effectiveness of Venous Sinus Stenting and Ventricular Shunting for Idiopathic Intracranial Hypertension: A Phenotype-Stratified, Propensity-Matched Cohort Study

BACKGROUND AND OBJECTIVES: Venous sinus stenting (VSS) has emerged as an alternative treatment for selected idiopathic intracranial hypertension (IIH) cases, but its comparative effectiveness and safety vs ventricular shunting (VS) remain uncertain. Given the heterogeneity of IIH, we hypothesized that outcomes differ by patient phenotype defined by obesity and visual disturbance at diagnosis. METHODS: Adults with IIH who underwent VSS or VS shunting were identified using TriNetX. Patients were stratified into 4 prespecified phenotypes: nonobese-visual-disturbance (NO-V), nonobese-no-visual-disturbance (NO-NV), obese-visual-disturbance (OV), and obese-no-visual-disturbance (ONV). Within each phenotype, 1:1 propensity score matching balanced baseline demographics, comorbidities, and laboratory parameters. Primary outcomes were persistent headache, papilledema, and visual disturbance within 24 months. Secondary outcomes included retreatment, head computed tomography use, and emergency department visits. RESULTS: After matching (NO-V = 69, NO-NV = 186, OV = 305, ONV = 440 per arm), cohorts were well balanced. In NO-NV, VS was associated with higher rates of headache (risk difference RD: 0.11, P = .049), visual disturbances (RD: 0.11, P = .010), and emergency department visits (RD: 0.15, P = .006). NO-V showed no primary outcome differences, although vestibular disorders were more common with shunts (RD: 0.15, P = .008). In OV, VS shunting was linked to higher rates of visual deficits (RD: 0.11, P = .045). Conversely, in ONV, shunting was associated with lower rates of papilledema (RD: −0.6, P = .024) and pulsatile tinnitus (RD: −0.5, P = .004) but increased headaches (RD: 0.12, P < .001). Across phenotypes, shunted patients had greater head computed tomography use and retreatment rates, while VSS patients more often required ongoing medical therapy. CONCLUSION: The comparative effectiveness of VSS and VS in IIH varies by phenotype. VSS appears preferable in nonobese patients without visual symptoms, whereas VS may better control papilledema in obese patients without visual disturbance. Both treatments show similar efficacy in patients with baseline visual impairment. These findings underscore the need for phenotype-guided, prospective trials.