Neurosurgery. 2026;99(3):710-720
Endovascular treatment of idiopathic intracranial hypertension raises a question beyond correcting the narrowest venous segment: how much of the transverse sinus should be supported by the stent? Jaikumar and colleagues explore the relationship between venous coverage, pressure profiles and subsequent symptoms in an adult cohort. Their analysis suggests that the extent of transverse sinus reinforcement deserves attention during planning, while also highlighting the influence of the wider venous circulation. However, its observational design and inclusion of recurrent symptoms within the improvement category prevent a conclusion that longer coverage guarantees lasting benefit.
Objective
To assess whether the length and proportion of transverse sinus covered by a stent, together with venous anatomy and hemodynamics, were associated with symptom improvement after venous sinus stenting.
Methods
The authors retrospectively studied 114 adults treated between January 2017 and December 2024. Median age was 36 years, and 109 patients were women. Exclusions included relevant meningiomas, established jugular compression etiologies, previous venous sinus thrombosis, missing procedural venography and lumbar puncture within seven days before the qualifying manometry.
The transverse sinus segment was measured on venography from the lateral margin of the superior sagittal sinus to the end of the stenotic segment. Subtracting the unstented distance between that medial landmark and the stent yielded the length of transverse sinus reinforcement. This anatomical measurement is not simply the nominal length of the implanted device.
Separate regression models examined headache, visual symptoms, tinnitus and papilledema. The first three outcomes were patient-reported; papilledema was assessed by a neuro-ophthalmologist. Crucially, complete or partial improvement and recurrence after initial improvement were grouped together, against no change or worsening. The models therefore did not isolate sustained symptom control.
Main results
Improvement was recorded in 93/110 patients with headache, 74/93 with visual symptoms, 30/35 with tinnitus and 77/89 with papilledema; these totals included subsequent recurrences.
Longer transverse sinus coverage was associated with lower adjusted odds of no improvement or worsening for headache (OR 0.782; 95% CI 0.617-0.990), visual symptoms (0.581; 0.387-0.873) and tinnitus (0.881; 0.781-0.993), but not significantly for papilledema (p = 0.052). Elevated jugular-pressure physiology was associated with worse visual outcomes, with considerable uncertainty. Percentage coverage and torcular distance did not consistently reproduce the association with absolute covered length.
Interpretation
Planning should consider the residual unstented segment, venographic anatomy and pressure profile rather than focal stenosis alone. This does not establish a rule for extending stents toward the torcula. Increased wall compliance and adjacent collapse remain hypotheses: neither was directly measured, and wall-thickness mapping was separate exploratory work.
Persistent symptoms should not automatically be attributed to insufficient coverage, because downstream venous pressure may also influence response. However, the jugular-pressure surrogate cannot reliably distinguish systemic venous hypertension from local outflow effects and is not a stand-alone diagnostic test.
Limitations
The retrospective, single-center design is vulnerable to treatment-selection and ascertainment bias. Two-dimensional measurements imperfectly represent a three-dimensional sinus. Follow-up was variable and incomplete, and symptom assessment was largely subjective. Most importantly, grouping recurrence with improvement prevents the reported associations from establishing durability.
Several models contained many predictors relative to the small number of adverse outcomes. The very wide confidence intervals and extreme coefficients in some tables raise concerns about instability and overfitting. Related measurements of total sinus length, covered length, uncovered distance and percentage coverage also warrant caution when interpreting individual coefficients. These are methodological concerns arising from the reported models, not proof that the observed association is absent.
The study does not establish an optimal coverage length, a universal landing zone or the comparative safety of routinely implanting longer or additional stents.
Clinical takeaway
Assess transverse sinus coverage in the context of the entire venous anatomy and pressure profile. This study supports further evaluation of coverage length as a planning variable, but does not justify routine maximal reinforcement or a promise of recurrence prevention. Distinguish initial response from sustained benefit when counseling patients and judging outcomes.