In this episode, host Dr. Michael Barraza interviews neurointerventional radiologist Dr. Aaron Bress about transverse sinus stenting for benign intracranial hypertension.
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SHOW NOTES
Aaron starts off the discussion by describing his typical patient population that requires stenting. Patients usually present to the clinic experiencing headaches, vision issues, and pulsatile tinnitus. Typically, these patients are female and overweight, and have been referred from headache clinics, neurosurgeons, and ENT specialists. Around 50% of his patients arrive with prior diagnoses and a complete workup already done, and they only require the procedure to be done. For the remaining patients, Aaron starts from scratch, emphasizing meticulous preparation imaging, which includes MRV with contrast.
Aaron has a sequential approach for outpatients. He typically conducts diagnostic and treatment processes separately, to ensure that no complicating fistulas are present during interventions. Three months after the procedure, patients are referred for follow-ups with ophthalmologists to verify progress.
During the procedure, Aaron starts with a diagnostic angiogram from the groin. During this time, he also obtains pressure measurements using a 27 mm diagnostic microcatheter. He typically measures from superior central sinus and then works his way back. He then obtains an MR venogram, which typically shows bilateral transverse sinus stenosis, and he measures pressure on both sides of the sinus. For him, a significant enough gradient to stent is typically 10 mmHg, however clinical presentation remains a key factor in deciding to stent patients with a lesser gradient.
For the treatment procedure, patients are prescribed 75 mg Plavix and baby aspirin for five days before the intervention. On the day of the procedure, general anesthesia is administered, due to its neck-based approach. This approach not only provides better maneuverability, but also avoids complications associated with the heart, given the complexities of navigating the transverse sinus junction. Stent sizing remains highly personalized and tailored to the size of the patient's sinus, with no rigid guidelines in place. Patients typically stay overnight, with clear communication regarding the likelihood of experiencing a headache post-treatment. Following the procedure, they adhere to a six-month regimen of the dual antiplatelet therapy, which improves their recovery and treatment outcomes.
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