Extrinsic versus intrinsic stenosis as a means of clinical triage for patients with symptomatic dural venous sinus stenosis.

PURPOSE: Patients with intracranial venous sinus stenosis may not only pose a diagnostic dilemma, but often a therapeutic dilemma when it comes to their clinical triage. While the management of such patients is clearer in the setting of papilledema, those without papilledema but other overlapping symptoms in this spectrum of disease are left to be triaged between a variety of physician specialties. The purpose of our study is to describe our single-center experience using a phenotype- and symptom-driven triage framework for patients with symptomatic dural venous sinus stenosis, and to report clinical outcomes following application of this standardized conservative-first treatment protocol.

METHODS

We conducted a retrospective review of patients seen in consultation for symptomatic dural venous sinus stenosis and categorized patients according to the presence of primary extrinsic stenosis (69% of patients) or primary intrinsic stenosis (31% of patients). Patients with symptomatic primary extrinsic stenosis were pooled into longer-term conservative management strategies including weight loss and medication, while those with primary intrinsic stenosis were pooled into a more active preparation for intervention.

RESULTS

Of 120 patients (83 extrinsic, 37 intrinsic), 78% of extrinsic stenosis patients responded to conservative therapy (65/83; 95% CI 68-86%), compared with 43% of intrinsic stenosis patients (16/37; 95% CI 27-61%; p = 0.027). Intrinsic stenosis was independently associated with escalation to stenting (OR 2.75, 95% CI 1.22-6.20, p = 0.014). Higher baseline THI score predicted intervention, with each 10-point increase associated with an 85% increase in odds of stenting (OR 1.85, 95% CI 1.45-2.35, p < 0.001). Clinically meaningful THI reductions (>20 points) were observed across all treated groups, with the greatest absolute reduction in intrinsic stented patients (mean decrease 55.7 points).

CONCLUSION

Selective implementation of venous stent intervention versus conservative therapy based on stenosis subtype and tinnitus burden allow for tailored regimens that lead to improved patient outcomes while reducing unnecessary invasive intervention.