Incidence and Predictors of Rebound Intracranial Hypertension after Transvenous Embolization of CSF-Venous Fistulas.

BACKGROUND AND PURPOSE: CSF-venous fistula (CVF) is a common cause of spontaneous intracranial hypotension (SIH) and can be treated with transvenous embolization (TVE). Rebound intracranial hypertension (RIH) is an important periprocedural consideration after TVE and CSF leak closure. The purpose of this study was to determine the incidence and severity of postprocedural RIH among patients with CVFs treated with TVE. MATERIALS AND METHODS: This investigation was a single-center, retrospective cohort of consecutive patients treated with TVE for SIH due to a CVF. Patients were included who had early (1-3 days post-TVE procedure) clinical follow-up documenting the presence/severity of RIH. RIH was classified as absent, mild (ie, rated 1-4/10 in severity), moderate (ie, rated 5-7/10), or severe (ie, rated 8-10/10). The rate of RIH was then determined. Logistic regression analysis was used to evaluate clinical predictors of moderate-to-severe RIH and the need for eventual therapeutic lumbar puncture. RESULTS: In total, 100 consecutive patients (mean age, 59.4 years; 63% female) who underwent 105 TVE procedures for 132 CVFs were included. RIH of any severity (mild-to-severe) occurred in 80% of cases after TVE and was moderate-to-severe in 54% of cases. A therapeutic lumbar puncture was needed for RIH in 8 cases (7.6%). On multivariate regression, TVE of a single CVF (versus >1 CVF) was independently associated with the occurrence of moderate-to-severe RIH (OR, 2.8 [95% CI, 1.04-7.85], P = .04). Furthermore, higher pre-TVE opening pressure (third tertile, 17-28 cmH2O) was associated with eventual need for therapeutic lumbar puncture (OR, 5.0 [95% CI, 1.14-25.9], P = .03). CONCLUSIONS: Early RIH is common after TVE, with symptoms occurring in 80% of all cases. Approximately one-half of patients will experience moderate-to-severe RIH early after TVE. These findings underscore the value of routine early follow-up after TVE and emphasize the need for proceduralists to be familiar with management strategies for RIH.

Duke Scholars

Author Timothy James Amrhein Radiology, Neuroradiology