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Articles
December 26, 2012
Letter to the Editor

Clinical course of idiopathic intracranial hypertension with transverse sinus stenosis

January 15, 2013 issue
80 (3) 289-295

Abstract

Objective:

Transverse sinus stenosis (TSS) is common in idiopathic intracranial hypertension (IIH), but its effect on the course and outcome of IIH is unknown. We evaluated differences in TSS characteristics between patients with IIH with “good” vs “poor” clinical courses.

Methods:

All patients with IIH seen in our institution after September 2009 who underwent a high-quality standardized brain magnetic resonance venogram (MRV) were included. Patients were categorized as having a good or poor clinical course based on medical record review. The location and percent of each TSS were determined for each patient, and were correlated to the clinical outcome.

Results:

We included 51 patients. Forty-six patients had bilateral TSS. The median average percent stenosis was 56%. Seventy-one percent of patients had stenoses >50%. Thirty-five of the 51 patients (69%) had no final visual field loss. Eight patients (16%) had a clinical course classified as poor. There was no difference in the average percent stenosis between those with good clinical courses vs those with poor courses (62% vs 56%, p = 0.44). There was no difference in the percent stenosis based on the visual field grade (p = 0.38). CSF opening pressure was not associated with either location or degree of TSS.

Conclusion:

TSS is common, if not universal, among patients with IIH, and is almost always bilateral. There is no correlation between the degree of TSS and the clinical course, including visual field loss, among patients with IIH, suggesting that clinical features, not the degree of TSS, should be used to determine management in IIH.

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STUDY FUNDING

Supported in part by an unrestricted departmental grant (Department of Ophthalmology) from Research to Prevent Blindness, Inc., New York, NY, and by NIH/NEI core grant P30-EY06360 (Department of Ophthalmology).

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Letters to the Editor
7 February 2013
Bilateral transverse sinus stenosis is only one of the contributing factors involved in IIH
Francesco Bono, MD
Francesco Bono, Catanzaro, Italy; Aldo Quattrone, Catanzaro, Italy

Riggeal et al. [1] found no correlation between the degree of transverse sinus stenosis (TSS) and the clinical course in idiopathic intracranial hypertension (IIH). Our major criticism is that there is no direct evidence of normalization of the CSF pressure in this series. We want to emphasize that the demonstration of normalization of the CSF pressure is needed to support their observation. The authors did not cite our studies [2,3] that may confirm their findings. We studied 14 consecutive patients with IIH for over a 6-year period. At presentation and during the follow-up, patients underwent CSF pressure measurements and MR venography. TSS persisted after normalization of the CSF pressure in 9 patients who had a good clinical course, suggesting the lack of a direct relationship between the caliber of TS and CSF pressure in IIH. Moreover, unilateral TSS was observed in 30% of 111 subjects with normal CSF pressure whereas bilateral TSS occurred only in 1.8% of individuals. [3] Our observations provide evidence that bilateral TSS is only one of the contributing factors involved in IIH. Our findings support Riggeal et al.'s observation and suggest that both clinical course and CSF pressure should determine the management of patients with IIH in clinical practice.

1. Riggeal BD, Bruce BB, Saindane AM, et al. Clinical course of idiopathic intracranial hypertension with transverse sinus stenosis. Neurology 2013;80;289.

2. Bono F, Giliberto C, Mastrandrea C, et al. Transverse sinus stenoses persist after normalization of the CSF pressure in IIH. Neurology 2005; 65:1090-1093.

3. Bono F, Lupo MR, Lavano A, et al. Cerebral MR venography of transverse sinuses in subjects with normal CSF pressure. Neurology 2003;61:1267-1270.

For disclosures, please contact the editorial office at [email protected].

7 February 2013
Re: Clinical course of idiopathic intracranial hypertension with transverse sinus stenosis - Author Reply
Beau B. Bruce, Assistant Professor
Beau B. Bruce, Atlanta, GA; Nancy J. Newman, Atlanta, GA; Valerie Biousse, Atlanta, GA

We appreciate Drs. Bono and Quattrone's contributions to this area of research and thank them for highlighting their work in support of our conclusions. We have also found that bilateral transverse sinus stenosis (TSS) can occur rarely in patients with normal CSF opening pressure. [1] Concerning idiopathic intracranial hypertension (IIH), clinical management in our practice is guided by visual function and symptom severity; we usually obtain lumbar puncture only at the time of diagnosis unless there is diagnostic uncertainty or evidence of worsening. Therefore, it is likely that our results will be useful to others who practice in a similar fashion, even though we did not demonstrate normalization of the CSF opening pressure. In addition, as we reported, [2] there was a trend toward higher initial CSF opening pressure predicting both a poor clinical course and greater visual field loss, even though there was no association between TSS and CSF opening pressure and no association between TSS and clinical course. The association between CSF opening pressure and clinical course in our data reinforces the suggestion by Drs. Bono and Quattrone that CSF opening pressure should be considered in the management of patients with IIH.

1. Kelly LP, Saindane AM, Bruce BB, et al. Does bilateral transverse cerebral venous sinus stenosis exist in patients without increased intracranial pressure? Clin Neurol Neurosurg. 2012 Dec 5. Epub ahead of print.

2. Riggeal BD, Bruce BB, Saindane AM, et al. Clinical course of idiopathic intracranial hypertension with transverse sinus stenosis. Neurology 2013;80;289.

For disclosures, please contact the editorial office at [email protected].

Information & Authors

Information

Published In

Neurology®
Volume 80Number 3January 15, 2013
Pages: 289-295
PubMed: 23269597

Publication History

Received: May 24, 2012
Accepted: September 7, 2012
Published online: December 26, 2012
Published in print: January 15, 2013

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Disclosure

B. Riggeal reports no disclosures. B. Bruce received research support from Teva Pharmaceuticals via an Emory University–approved research agreement; received the American Academy of Neurology Practice Research Fellowship; and receives research support from the NIH (K23-EY019341) and from Pfizer via an Emory University–approved research agreement. A. Saindane, M. Ridha, and L. Kelly report no disclosures. N. Newman received the Research to Prevent Blindness and a Lew R. Wasserman Merit Award. V. Biousse received research support from the NIH (PHS Grant UL1-RR025008). Go to Neurology.org for full disclosures.

Authors

Affiliations & Disclosures

Bryan D. Riggeal, MD
From the Departments of Ophthalmology (B.D.R., B.B.B., M.A.R., L.P.K., N.J.N., V.B.), Neurology (B.B.B., N.J.N., V.B.), Neurological Surgery (N.J.N.), and Radiology and Imaging Sciences (A.M.S.), Emory University School of Medicine; and Rollins School of Public Health and Laney Graduate School (B.B.B.), Emory University, Atlanta, GA.
Disclosure
Scientific Advisory Boards:
1.
NONE
Gifts:
1.
NONE
Funding for Travel or Speaker Honoraria:
1.
NONE
Editorial Boards:
1.
NONE
Patents:
1.
NONE
Publishing Royalties:
1.
NONE
Employment, Commercial Entity:
1.
NONE
Consultancies:
1.
NONE
Speakers' Bureaus:
1.
NONE
Other Activities:
1.
NONE
Clinical Procedures or Imaging Studies:
1.
NONE
Research Support, Commercial Entities:
1.
NONE
Research Support, Government Entities:
1.
NONE
Research Support, Academic Entities:
1.
NONE
Research Support, Foundations and Societies:
1.
Research to Prevent Blindness Grant
Stock/stock Options/board of Directors Compensation:
1.
NONE
License Fee Payments, Technology or Inventions:
1.
NONE
Royalty Payments, Technology or Inventions:
1.
NONE
Stock/stock Options, Research Sponsor:
1.
NONE
Stock/stock Options, Medical Equipment & Materials:
1.
NONE
Legal Proceedings:
1.
NONE
Beau B. Bruce, MD, MS
From the Departments of Ophthalmology (B.D.R., B.B.B., M.A.R., L.P.K., N.J.N., V.B.), Neurology (B.B.B., N.J.N., V.B.), Neurological Surgery (N.J.N.), and Radiology and Imaging Sciences (A.M.S.), Emory University School of Medicine; and Rollins School of Public Health and Laney Graduate School (B.B.B.), Emory University, Atlanta, GA.
Disclosure
Scientific Advisory Boards:
1.
NONE
Gifts:
1.
NONE
Funding for Travel or Speaker Honoraria:
1.
NONE
Editorial Boards:
1.
NONE
Patents:
1.
NONE
Publishing Royalties:
1.
NONE
Employment, Commercial Entity:
1.
NONE
Consultancies:
1.
Kaiser Permanente of Georgia for the CDC Vaccine Safety Datalink
Speakers' Bureaus:
1.
NONE
Other Activities:
1.
NONE
Clinical Procedures or Imaging Studies:
1.
NONE
Research Support, Commercial Entities:
1.
Teva pharmaceuticals, Pfizer
Research Support, Government Entities:
1.
NIH/PHS Grants UL1-RR025008 & KL2-RR025009 2008-2009, NIH/PHS Grant K23-EY019341 2009-present
Research Support, Academic Entities:
1.
NONE
Research Support, Foundations and Societies:
1.
Recipient of AAN/AANF Practice Research Fellowship
Stock/stock Options/board of Directors Compensation:
1.
NONE
License Fee Payments, Technology or Inventions:
1.
NONE
Royalty Payments, Technology or Inventions:
1.
NONE
Stock/stock Options, Research Sponsor:
1.
NONE
Stock/stock Options, Medical Equipment & Materials:
1.
NONE
Legal Proceedings:
1.
NONE
Amit M. Saindane, MD
From the Departments of Ophthalmology (B.D.R., B.B.B., M.A.R., L.P.K., N.J.N., V.B.), Neurology (B.B.B., N.J.N., V.B.), Neurological Surgery (N.J.N.), and Radiology and Imaging Sciences (A.M.S.), Emory University School of Medicine; and Rollins School of Public Health and Laney Graduate School (B.B.B.), Emory University, Atlanta, GA.
Disclosure
Scientific Advisory Boards:
1.
NONE
Gifts:
1.
NONE
Funding for Travel or Speaker Honoraria:
1.
NONE
Editorial Boards:
1.
NONE
Patents:
1.
NONE
Publishing Royalties:
1.
NONE
Employment, Commercial Entity:
1.
NONE
Consultancies:
1.
NONE
Speakers' Bureaus:
1.
NONE
Other Activities:
1.
NONE
Clinical Procedures or Imaging Studies:
1.
NONE
Research Support, Commercial Entities:
1.
NONE
Research Support, Government Entities:
1.
NONE
Research Support, Academic Entities:
1.
NONE
Research Support, Foundations and Societies:
1.
NONE
Stock/stock Options/board of Directors Compensation:
1.
NONE
License Fee Payments, Technology or Inventions:
1.
NONE
Royalty Payments, Technology or Inventions:
1.
NONE
Stock/stock Options, Research Sponsor:
1.
NONE
Stock/stock Options, Medical Equipment & Materials:
1.
NONE
Legal Proceedings:
1.
NONE
Maysa A. Ridha, MD
From the Departments of Ophthalmology (B.D.R., B.B.B., M.A.R., L.P.K., N.J.N., V.B.), Neurology (B.B.B., N.J.N., V.B.), Neurological Surgery (N.J.N.), and Radiology and Imaging Sciences (A.M.S.), Emory University School of Medicine; and Rollins School of Public Health and Laney Graduate School (B.B.B.), Emory University, Atlanta, GA.
Disclosure
Scientific Advisory Boards:
1.
NONE
Gifts:
1.
NONE
Funding for Travel or Speaker Honoraria:
1.
NONE
Editorial Boards:
1.
NONE
Patents:
1.
NONE
Publishing Royalties:
1.
NONE
Employment, Commercial Entity:
1.
NONE
Consultancies:
1.
NONE
Speakers' Bureaus:
1.
NONE
Other Activities:
1.
NONE
Clinical Procedures or Imaging Studies:
1.
NONE
Research Support, Commercial Entities:
1.
NONE
Research Support, Government Entities:
1.
NONE
Research Support, Academic Entities:
1.
NONE
Research Support, Foundations and Societies:
1.
This study was supported in part by a departmental grant (Department of Ophthalmology) from Research to Prevent Blindness, Inc., New York
Stock/stock Options/board of Directors Compensation:
1.
NONE
License Fee Payments, Technology or Inventions:
1.
NONE
Royalty Payments, Technology or Inventions:
1.
NONE
Stock/stock Options, Research Sponsor:
1.
NONE
Stock/stock Options, Medical Equipment & Materials:
1.
NONE
Legal Proceedings:
1.
NONE
Linda P. Kelly, MD
From the Departments of Ophthalmology (B.D.R., B.B.B., M.A.R., L.P.K., N.J.N., V.B.), Neurology (B.B.B., N.J.N., V.B.), Neurological Surgery (N.J.N.), and Radiology and Imaging Sciences (A.M.S.), Emory University School of Medicine; and Rollins School of Public Health and Laney Graduate School (B.B.B.), Emory University, Atlanta, GA.
Disclosure
Scientific Advisory Boards:
1.
NONE
Gifts:
1.
NONE
Funding for Travel or Speaker Honoraria:
1.
NONE
Editorial Boards:
1.
NONE
Patents:
1.
NONE
Publishing Royalties:
1.
NONE
Employment, Commercial Entity:
1.
NONE
Consultancies:
1.
NONE
Speakers' Bureaus:
1.
NONE
Other Activities:
1.
NONE
Clinical Procedures or Imaging Studies:
1.
NONE
Research Support, Commercial Entities:
1.
NONE
Research Support, Government Entities:
1.
NONE
Research Support, Academic Entities:
1.
NONE
Research Support, Foundations and Societies:
1.
NONE
Stock/stock Options/board of Directors Compensation:
1.
NONE
License Fee Payments, Technology or Inventions:
1.
NONE
Royalty Payments, Technology or Inventions:
1.
NONE
Stock/stock Options, Research Sponsor:
1.
NONE
Stock/stock Options, Medical Equipment & Materials:
1.
NONE
Legal Proceedings:
1.
NONE
Nancy J. Newman, MD
From the Departments of Ophthalmology (B.D.R., B.B.B., M.A.R., L.P.K., N.J.N., V.B.), Neurology (B.B.B., N.J.N., V.B.), Neurological Surgery (N.J.N.), and Radiology and Imaging Sciences (A.M.S.), Emory University School of Medicine; and Rollins School of Public Health and Laney Graduate School (B.B.B.), Emory University, Atlanta, GA.
Disclosure
Scientific Advisory Boards:
1.
NONE
Gifts:
1.
NONE
Funding for Travel or Speaker Honoraria:
1.
NONE
Editorial Boards:
1.
(1) Journal of Neuro-Ophthalmology, editorial advisory board, 2 years, associate editor, 2 months, (2) Journal of the Neurological Sciences, editorial board, > 2 years, (3) American Journal of Ophthalmology, executive editor, > 2 years
Patents:
1.
NONE
Publishing Royalties:
1.
(1) Neuro-Ophthalmology Illustrated, Thieme, 2009, (2) Walsh & Hoyt's Clinical Neuro-Ophthalmology The Essentials, 1st and 2nd editions, Lippincott Williams and Wilkins, 1999, 2008, (3) Walsh & Hoyt's Clinical Neuro-Ophthalmology, Lippincott Williams and Wilkins, 5th and 6th editions, 1998, 2005, (4) Blue Books of Neurology: Neuro-Ophthalmology, Butterworth Heinemann Elsevier, 2008
Employment, Commercial Entity:
1.
NONE
Consultancies:
1.
Santhera Pharma -- consultant, Trius Pharma -- consultant
Speakers' Bureaus:
1.
NONE
Other Activities:
1.
NONE
Clinical Procedures or Imaging Studies:
1.
NONE
Research Support, Commercial Entities:
1.
NONE
Research Support, Government Entities:
1.
NONE
Research Support, Academic Entities:
1.
NONE
Research Support, Foundations and Societies:
1.
Research to Prevent Blindness, New York, N.Y., unrestricted departmental grant, Lew R. Wasserman Merit Award, > 2 years
Stock/stock Options/board of Directors Compensation:
1.
NONE
License Fee Payments, Technology or Inventions:
1.
NONE
Royalty Payments, Technology or Inventions:
1.
NONE
Stock/stock Options, Research Sponsor:
1.
NONE
Stock/stock Options, Medical Equipment & Materials:
1.
NONE
Legal Proceedings:
1.
NONE
Valérie Biousse, MD
From the Departments of Ophthalmology (B.D.R., B.B.B., M.A.R., L.P.K., N.J.N., V.B.), Neurology (B.B.B., N.J.N., V.B.), Neurological Surgery (N.J.N.), and Radiology and Imaging Sciences (A.M.S.), Emory University School of Medicine; and Rollins School of Public Health and Laney Graduate School (B.B.B.), Emory University, Atlanta, GA.
Disclosure
Scientific Advisory Boards:
1.
NONE
Gifts:
1.
NONE
Funding for Travel or Speaker Honoraria:
1.
NONE
Editorial Boards:
1.
Editorial boards of: American Journal of Ophthalmology, Journal of Neuro-ophthalmology
Patents:
1.
NONE
Publishing Royalties:
1.
Walsh and Hoyt's Clinical Neuro-Ophthalmology. Williams and Wilkins, Neuro-Ophthalmology Illustrated. Thieme NY
Employment, Commercial Entity:
1.
NONE
Consultancies:
1.
NONE
Speakers' Bureaus:
1.
NONE
Other Activities:
1.
NONE
Clinical Procedures or Imaging Studies:
1.
NONE
Research Support, Commercial Entities:
1.
NONE
Research Support, Government Entities:
1.
NONE
Research Support, Academic Entities:
1.
NONE
Research Support, Foundations and Societies:
1.
Research to Prevent Blindness
Stock/stock Options/board of Directors Compensation:
1.
NONE
License Fee Payments, Technology or Inventions:
1.
NONE
Royalty Payments, Technology or Inventions:
1.
NONE
Stock/stock Options, Research Sponsor:
1.
NONE
Stock/stock Options, Medical Equipment & Materials:
1.
NONE
Legal Proceedings:
1.
NONE

Notes

Correspondence to Dr. Biousse: [email protected]
Go to Neurology.org for full disclosures. Funding information and disclosures deemed relevant by the authors, if any, are provided at the end of the article.

Author Contributions

Bryan Riggeal, MD: study design, acquisition/analysis/interpretation of data, drafting/revising manuscript for content. Beau Bruce, MD, MS: study design, analysis/interpretation of data, revising manuscript for content. Amit Saindane, MD: study design, interpretation of data, revising manuscript for content. Maysa Ridha, MD: interpretation of data. Linda Kelly, MD: interpretation of data. Nancy J. Newman, MD: study design, interpretation of data, revising manuscript for content. Valérie Biousse, MD: study design, interpretation of data, revising manuscript for content.

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