Utilizing intravascular ultrasound for optimizing patient selection in venous sinus stenting: A pilot study

Abstract

Background

Venous sinus stenting (VSS) is an established treatment for idiopathic intracranial hypertension (IIH), and pulsatile tinnitus (PT), but optimal patient selection remains a challenge. Current protocols rely on catheter angiography and manometry-based pressure gradients, which can be operator-dependent and subject to measurement variability. Intravascular ultrasound (IVUS) offers real-time, cross-sectional visualization of venous anatomy, potentially providing more consistent and objective assessments of stenosis severity.

Methods

We conducted a retrospective study of 31 patients undergoing venography with IVUS over an eight-month period for suspected venous sinus stenosis. The point of maximal stenosis severity was measured using both angiography and IVUS, and findings were compared to intravascular pressure gradients. A pressure difference or gradient of ≥8 mmHg in IIH and ≥4 mmHg in PT across the stenosis was considered clinically significant based on prior prospective trial criteria.

Results

Patients included those with IIH (41.9%) or PT (58.1%). Mean maximal stenosis was 51.2% by angiography and 65.2% by IVUS. The agreement between different reviewers measuring angiographic stenosis was low (r²=.19), and IVUS-based stenosis correlated more strongly with pressure gradients than angiographic estimates (r = .78 vs. .46, p = .044). An IVUS-measured stenosis ≥53.2% predicted a clinically significant pressure gradient (≥8 mmHg) with 100% sensitivity and 66.7% specificity. No IVUS-related complications occurred.

Conclusion

IVUS is a safe and promising adjunct to conventional venography for assessing venous sinus stenosis, with stronger correlation to physiologic pressure gradients than angiographic estimates. These findings suggest that IVUS may enhance patient selection for venous sinus stenting by more accurately identifying candidates likely to benefit from intervention, potentially increasing treatment eligibility and intervention rates. By refining diagnostic accuracy, IVUS may also contribute to improved long-term symptom relief. Nonetheless, given the retrospective, single-center design and limited sample size, larger prospective studies are warranted to validate these findings and assess their impact on clinical outcomes.