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BACKGROUND AND PURPOSE: Dural venous sinus stenosis has been associated with idiopathic intracranial hypertension and isolated venous pulsatile tinnitus. However, the utility of characterizing stenosis as intrinsic or extrinsic remains indeterminate. The aim of this retrospective study was to review preprocedural imaging of patients with symptomatic idiopathic intracranial hypertension and pulsatile tinnitus, classify the stenosis, and assess a trend between stenosis type and clinical presentation while reviewing the frequencies of other frequently seen imaging findings in these conditions. MATERIALS AND METHODS: MRVs of 115 patients with idiopathic intracranial hypertension and 43 patients with pulsatile tinnitus before venous sinus stent placement were reviewed. Parameters recorded included the following: intrinsic or extrinsic stenosis, prominent emissary veins, optic nerve tortuosity, cephalocele, sella appearance, poststenotic fusiform enlargement versus saccular venous aneurysm, and internal jugular bulb diverticula. χ2 cross-tabulation statistics were calculated and recorded for all data. RESULTS: Most patients with idiopathic intracranial hypertension (75 of 115 sinuses, 65%) had extrinsic stenosis, and most patients with pulsatile tinnitus (37 of 45 sinuses, 82%) had intrinsic stenosis. Marked optic nerve tortuosity was more common in idiopathic intracranial hypertension. Cephaloceles were rare in both cohorts, with an increased trend toward the presence in idiopathic intracranial hypertension. Empty sellas were more common in idiopathic intracranial hypertension. Cerebellar tonsils were similarly located at the foramen magnum level in both cohorts. Saccular venous aneurysms were more common in pulsatile tinnitus. Internal jugular bulb diverticula were similarly common in both cohorts. CONCLUSIONS: In this cohort, most patients with idiopathic intracranial hypertension had extrinsic stenosis, and most patients with pulsatile tinnitus had intrinsic stenosis. Awareness and reporting of these subtypes may reduce the underrecognition of potential contributory stenoses in a given patient’s idiopathic intracranial hypertension or pulsatile tinnitus.

Background This report addresses the feasibility of virtual injection software based on contrast-enhanced cone-beam CTs (CBCTs) in the context of cerebrovascular lesion embolization. Intracranial arteriovenous malformation (AVM), dural arteriovenous fistula (AVF) and mycotic aneurysm embolization cases with CBCTs performed between 2013 and 2020 were retrospectively reviewed. Cerebrovascular lesions were reviewed by 2 neurointerventionalists using a dedicated virtual injection software (EmboASSIST, GE Healthcare; Chicago, IL). Points of Interest (POIs) surrounding the vascular lesions were first identified. The software then automatically displayed POI-associated vascular traces from vessel roots to selected POIs. Vascular segments and reason for POI identification were recorded. Using 2D multiplanar reconstructions from CBCTs, the accuracy of vascular traces was assessed. Clinical utility metrics were recorded on a 3-point Likert scale from 1 (no benefit) to 3 (very beneficial). Results Nine cases (7 AVM, 1 AVF, 1 mycotic aneurysm) were reviewed, with 26 POIs selected. Three POIs were in 2nd order segments, 8 POIs in 3rd order segments and 15 POIs in 4th order segments of their respective arteries. The reviewers rated all 26 POI traces – involving a total of 90 vascular segments – as accurate. The average utility score across the 8 questions were 2.7 and 2.8 respectively from each reviewer, acknowledging the software’s potential benefit in cerebrovascular embolization procedural planning. Conclusion The operators considered CBCT-based virtual injection software clinically useful and accurate in guiding and planning cerebrovascular lesion embolization in this retrospective review. Future prospective studies in larger cohorts are warranted for validation of this modality.

Purpose The purpose of this study was to report the technique for intraprocedural guidance of endovascular Venous Sinus Stenting procedures using 3-Dimensional (3D) Magnetic Resonance Venography (MRV) as an overlay on live biplanar fluoroscopy. Materials and methods Venous sinus stenting procedures performed between April and December, 2017 with 3D MRV fusion for live guidance were reviewed in this study. A thin-slice, contrast-enhanced MR Venogram was used to create 2 3D models – vessels and skull – for procedural guidance via augmented fluoroscopy (Vessel ASSIST, GE Healthcare, Chicago, IL). The skull model was used in the registration of the 3D overlay on both the frontal and lateral planes, which required 1–2 min of procedural time. The vessel model was used to mark landmarks such as the cortical vein ostia and stenosis on the 3D overlay fused with biplanar fluoroscopy. The retrospective imaging review was conducted by 3 neurointerventionalists and relied on a consensus confidence ranking on a 3-point Likert scale from 1- low confidence to 3- high confidence. The neurointerventionalists first reviewed the conventional 2-dimensional pre-stent deployment fluoroscopy images and then reviewed the corresponding images with the 3D MRV overlay. They ranked their confidence in their understanding of cortical venous anatomy for each group. Statistical analysis was performed using a Paired T Test at a 99% confidence interval. Results Ten cases were included in the retrospective image review. Operator confidence regarding the location of cortical veins was significantly increased using 3D MRV fusion during venous sinus stenting procedures (1.9 vs 2.9, p = .001). Conclusion 3-Dimensional MRV fusion is feasible and helpful in understanding the venous sinus anatomy and location of important cortical veins during venous sinus stenting procedures.