Real Time Intravascular Ultrasound Evaluation and Stent Selection for Cerebral Venous Sinus Stenosis Associated with Idiopathic Intracranial Hypertension

Real Time Intravascular Ultrasound Evaluation and Stent Selection for Cerebral Venous Sinus Stenosis Associated with Idiopathic Intracranial Hypertension | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Article Real Time Intravascular Ultrasound Evaluation and Stent Selection for Cerebral Venous Sinus Stenosis Associated with Idiopathic Intracranial Hypertension Gang Luo, - Raynald, Xu Tong, Yinuo Huang, Zifei Han, Dapeng Sun, and 7 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-5216428/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 11 May, 2025 Read the published version in Scientific Reports → Version 1 posted 6 You are reading this latest preprint version Abstract BACKGROUND The value of intravascular ultrasound (IVUS) in the diagnosis and treatment of the venous system is not well established. OBJECTIVE Introducing a novel approach to utilizing IVUS to evaluate cerebral venous sinus (CVS) stenosis and select stent. METHODS Idiopathic intracranial hypertension (IIH) patients with CVS stenosis who underwent IVUS-guided stenting were included in the data analysis from January 2014 to February 2022. The degree of maximum stenosis was determined based on the cross-sectional area (CSA) measured by IVUS, and a stent selection method was applied in the study. Follow-up evaluations were conducted at 6 months to 1 year after endovascular treatment to assess symptom improvement. Additionally, repeated digital subtraction angiography (DSA) or Magnetic resonance venography (MRV) / (CT venography) CTV was performed to evaluate the stent patency at 6 months to 1 year post-procedure. RESULTS The study included 61 patients. IVUS indicated a lower degree of stenosis compared to conventional DSA measurements when evaluating the degree of stenotic segments preprocedure (74.84 ± 10.12% vs. 78.48 ± 8.72%, p = 0.035). Post-procedural CSA of the most severe stenotic segments showed significant improvement (36.44 ± 8.07 mm 2 vs. 7.42 ± 3.28 mm 2 , p < 0.001). The stent achieved complete expansion (mean stent expansion index, 0.93 ± 0.20) with no significant change in the structure of the reference segment. The trans-stenotic mean pressure gradients (MPGs) across 61 patients significantly decreased from 11.00 ± 6.23 mmHg to 2.09 ± 2.34 mmHg. 47 out of 61 patients received imaging follow-up; among them, 44 (93.6%) demonstrated stent patency in the follow-up imaging. CONCLUSION IVUS has great potential to evaluate the degree and extent of CVS stenosis, assist stent selection, and optimize stent position during the interventional procedure in conjunction with DSA. Health sciences/Diseases/Neurological disorders Health sciences/Neurology/Neurological disorders Cerebral Venous Sinus intravascular ultrasound digital subtraction angiography Figures Figure 1 Figure 2 Figure 3 Figure 4 Introduction It was well recognized that cerebral venous sinus (CVS) stenosis is common among patients with Idiopathic Intracranial Hypertension (IIH), 1 and CVS stenting has increasingly become an effective treatment for these cases, particularly in refractory IIH cases. 2 , 3 The cross-section view of the CVS more closely corresponds to a triangular shape 4 – 6 , which poses a difficulty in lesion assessment and appropriate stent selection using DSA. In addition to angiography, intravascular ultrasound (IVUS) can provide cross-sectional images of vessels and nearby structures, optimizing stent implantation. Recently, IVUS has been recommended for assessment of indeterminate coronary artery disease, carotid artery stenosis, or intracranial artery stenosis . 7 , 8 , 9 However, the value of IVUS in the diagnosis and treatment of the venous system is not well established. 6 The study aimed to assess the severity of CVS stenosis using real-time IVUS, and to propose a method for assisting stent selection based on IVUS. Methods Patients selection Patients presenting with IIH symptoms and undergoing endovascular treatment (EVT) for CVS stenosis between January 1, 2014, and February 1, 2022, in our center were prospectively enrolled. IIH diagnosis was based on: 1) papilledema; 2) normal neurological examination, except for cranial nerve abnormalities; 3) neuroimaging revealing normal brain parenchyma without hydrocephalus, mass, or any structural lesion; 4) normal CSF (cerebrospinal fluid) composition; 5) elevated CSF opening pressure (greater than 250 mmH2O); and 6) additional neuroimaging features supporting an IIH diagnosis. In addition, a diagnosis of IIH can be made even in the absence of papilledema if criteria 2 and 3 are satisfied for unilateral or bilateral abducens nerve palsy 10 . Candidates for VSS were selected based on intractable headaches, progressive papilledema, refractory to standard conservative treatment, and a diagnosis of CVS stenosis ≥ 50% with trans-stenotic MPGs of at least 8 mmHg 6 . MRV, CTV, or DSA was used for screening and following up on CVS stenosis. Exclusion criteria included concurrent venous sinus thrombosis and poor-quality of images. A total of 272 patients were intial enrolled in the study. Of these cases, 85 cases underwent IVUS assessment, and 61 of them underwent IVUS-guided stent implantation (Fig. 1 ). The study was approved by the institutional review boards of our hospitals, and informed consent was obtained pre-procedure. DSA and IVUS assessment DSA examination was necessary to confirm the diagnosis and assess the CVS stenosis before and after stent placement. IVUS was conducted with a 3.5F, 20 MHz Eagle Eye IVUS probe transducer. The probe range was set to 20mm for comprehensive visualization of the venous wall. DSA and IVUS images were assessed by two experienced readers who were blinded to the patient’s clinical information. Any discrepancies were resolved by a third experienced reader. In IVUS (Volcano Corporation, Rancho Cordova, CA, USA) assessment, the luminal lesion border was traced using a slow manual pullback technique at rates of approximately 1.0 mm/s, to calculate the luminal CSA. The reference segments in this study were defined as a segment 5 mm proximal and distal to the stenosis border and were confirmed as healthy segments without stenosis by IVUS. The method for calculating the degree of maximum stenosis of the lesion on IVUS is depicted in Fig. 2 . Three measurements were recorded: the luminal CSA of the site with the most severe stenosis (CSA 1), the luminal CSA of the distal reference segment (CSA 2), and the luminal CSA of proximal reference segment (CSA 3). The formula for the degree of stenosis is (1-[CSA 1/(CSA 2 + CSA 3)/2])🞩100%. The length of CVS stenosis was defined as the distance between the distal and the proximal ends of the stenosis border. Stenosis severity on DSA was determined using the method outlined by James et al 11 , the narrowest luminal diameter affected CVS, as well as the normal diameter of the CVS in the worst view on angiographic projection. Percent stenosis was calculated using the formula: (1 - [smallest diameter/normal diameter]) × 100%. The length of stenosis on DSA is calculated as the sum of the narrowest segment 1 (length between the distal stenosis border and maximum stenosis) and narrowest segment 2 (length between the proximal stenosis border and maximum stenosis). The formula of the length of stenosis on DSA is narrowest segment 1 + narrowest segment 2. Stent selection Consedering that the CVS corresonds more closely to a triangular shape in cross-section view, the study introduced a novel stent selection method. The stent size and length were calculated using formulas derived from IVUS measurements of the proximal and distal reference segments of the lesion. As illustrated in Fig. 3, R 2 represents the radius of circle A 2 , calculated using the formula: \(\:\sqrt{{A}_{2}/2{\pi\:}}\) . Here, A 2 refers to the average triangular area of the proximal (CSA 1 ) and distal (CSA 2 ) reference segments of the lesion. R 3 denotes the radius of circle A 3 , derived from the formula: \(\:\sqrt{{A}_{2}/{\text{C}}_{3}}\) . A3 represents the inscribed circles of the lesion within the triangular structure of the CVS, as inferred from the proximal and distal reference segments. Additionally, C 3 is defined as the average perimeter of the triangular perimeter C1 and C2, representing the proximal and distal reference segments, respectively. The stent diameter (2R 1 ) was determined to be within the range defined by 2R 2 and 2R 3 , expressed mathematically as 2 \(\:\sqrt{{A}_{2}/2{\pi\:}}\) ≤ 2D 1 ≤ \(\:2\sqrt{{A}_{2}/{\text{C}}_{3}}\) and 2(CSA 1 +CSA 2 )/(C 1 + C 2 ) ≤2D 1 ≤2 \(\:\sqrt{\left(CS{A}_{1}+CS{A}_{2}\right)/2\pi\:}\) . The stent length was determined by adding 10 mm to both sides of the distal and proximal stenosis borders, in addition to the length of the stenosis segment. Self-expanding stents (Precise Carotid stent, Cordis, U.S.A; Wallstent, Boston Scientific, USA) with diameters ranging from 7.0mm to 9.0mm and lengths between 30mm and 50mm were utilized for stent implantation. Stenting procedure Before stenting, all patients received a daily dose of 75 mg clopidogrel and 100 mg aspirin for 3–5 days. Procedures were conducted under general anesthesia with intraoperative anticoagulation therapy (dosage 4000–6000 units) and intravenous heparin to maintain an activated clotting time above 250s 12 . Prior to stenting, DSA was performed through arterial femoral access to assess stenosis features and select the worst view. IVUS evaluation and stenting followed a femoral transvenous approach using a short 8-Fr sheath. An 8-Fr guiding catheter was placed at the end of the internal jugular vein (IJV). A 6F intermediate catheter was advanced into the distal transverse sinus (TS) through the 8-Fr guiding catheter. The microcatheter (Rebar-27, Medtronic, Minneapolis, MN) was used to access the superior sagittal sinus (SSS) under microwire guidance. Contrast agent was injected through the microcatheter into the SSS, TS, and sigmoid sinus (SigS). The transtenotic MPGs were measured by a microcatheter-attached pressure transducer, using a venographic roadmap with the worst projection angle of the stenosis and the mid-axillary line as the zero reference point. If the transtenotic MPGs of the CVS stenosis exceeded 8 mmHg, IVUS evaluation and stenting would be carried out. An IVUS probe transducer was advanced across the stenotic sinus segment over a microwire. The radiopaque IVUS transducer probe was slowly retracted from the distal reference segment point to the proximal reference segment point of the lesion using a slow manual pullback technique at rates of approximately 1 mm/sec 6 . All IVUS images were displayed and recorded on a workstation. Following IVUS assessment the stenosis, balloon angioplasty predilatation was performed as the initial treatment. Predilatation was conducted at maximum of 6 atm for 60 seconds using a 5.0–6.0 mm balloon catheter (Sterling balloon catheter, Boston Scientific, U.S.A). Subsequently, stenting procedures were performed. The IVUS assessment was then repeated from the distal to proximal stenting site, yielding another recording. Post-stenting balloon diatation was performed if the residual stenosis of the CSA exceeded 50% at the target lesion site, or if the transtenotic MPGs exceeded 8 mmHg post-stenting. The size of the post-stenting balloon was determined based on 0.8 times the target CVS reference diameter, ensuring adequate the stent stenosis coverage. Subsequently, IVUS and transtenotic MPGs were re-evaluated. The procedure ended when the residual stenosis of the CSA was less than 30% at the target lesion or when the transtenotic MPGs was less than 8 mmHg post dilatation. Anticoagulation and antiplatelet The patients were administered with low-molecular-weight heparin for 3 days post-procedure. They continued to take 100 mg of aspirin and 75 mg of clopidogrel daily for 3 months, followed by life-long use of aspirin or clopidogrel. Follow-up protocol Clinical assessments and radiographic examinations were performed 6 months to 1 year after stent placement. Restenosis was defined as stenosis exceeding 50% within the stent or at the edge of the stent, as verified by angiography. Statistical Analysis Statistical analyses used SPSS Statistics version 21.0 (IBM SPSS, Armonk, NY, USA). Baseline and outcome data were presented as means (standard deviations) or medians (25th and 75th percentiles) for continuous variables and as frequencies or proportions for categorical variables. The paired-sample T test or nonparametric test (Wilcoxon test) was employed to compare mean differences. The categorical and binary data were compared between the groups using the χ2 test or Fisher exact test, respectively. A p-value < 0.05 was considered statistically significant. All methods were in accordance with the Declaration of Helsinki and approved by the Ethical Committee of Beijing Tiantan Hospital. All participants were fully informed of the nature of the study protocol and all gave their written consents regarding participation. Results Clinical characteristics of the patients before the procedure Patients’ baseline characteristics are reported in Table 1 , with 52 out of the 61 patients (85.2%) being female. The mean body mass index (BMI) of the group was 27.8 ± 4.4 kg/m 2 . The most common symptom was visual dysfunction, affecting 50 patients (82.0%). All patients exhibited increased CSF opening pressure, averaging 300.9 ± 46.1 cm H 2 O. The findings also indicated that the primary lesion sites were frequently situated at the junction of the TS and SigS, impacting 45 patients (73.8%). Stenosis was most commonly found on the right side of the venous sinus, affecting 41 patients (67.2%). Table 1 Baseline Characteristics Feature value Gender, female 52 (85.2) Age (mean ± SD), y 36.8 ± 10.2 BMI (mean ± SD), kg/m 2 27.8 ± 4.4 Hypertension 19 (31.1) Dyslipidemia 2 (3.3) Clinical duration Onset to EVT, median (IQR), months Aggravation to EVT, median (IQR), days 4 (1, 12) 30 (30, 60) Clinical presentation Headache 36 (59.0) Tinnitus 12 (19.7) Visual dysfunction 50 (82.0) Binoculus 41 (67.2) Ocellus 9 (14.8) Vision acuity decline 42 (68.9) Visual field defect 5 (8.2) Dysmorphopsia 3 (4.9) Amaurosis 7 (11.5) Diplopia 5 (8.2) Ophthalmic examination Papilledema 52(85.2) Vision acuity (mean ± SD) Left 0.81 ± 0.35 Right 0.81 ± 0.37 Lumbar pressure, (mean ± SD), mm H 2 O 300.9 ± 46.1 Location of stenosis, No. (%) Ts 12 (19.7) Ts-SigS 45 (73.8) Ts and SigS 2 (3.3) Ts and Ts-SigS 1 (1.6) SSS and Ts 1 (1.6) Laterality of stenosis Lt, Rt nomal 1 (1.6) Rt, Lt nomal 9 (14.8) Bilateral 14 (23.0) Lt, Rt hp or occlusion 5 (8.2) Rt, Lt hp or occlusion 32 (52.2) Abbreviations: BMI = body mass index. IQR = interquartile range; IVUS = intravascular ultrasound; EVT = endovascular treatment; TS = transverse sinus; SigS = sigmoid sinus; SSS = superior sagittal sinus; Ts-SigS = junction of transverse sinus and sigmoid sinus; hp = hypoplastic; Lt = left; Rt = right. Data are expressed as No. (%) unless otherwise indicated. IVUS and DSA for CVS stenosis assessment Table 2 displays that the degree of maximum stenosis evaluated by DSA was more severe than that evaluated by IVUS before the procedure (p = 0.035), and milder than the IVUS assessment after the procedure (p < 0.001). Table 2 Angiographic and Procedural Characteristics for Target Lesions compared by IVUS and Angiography Evaluated by IVUS Evaluated by DSA P Value Base imaging data, (mean ± SD) Rate of stenosis, (%) 74.84 ± 10.12 78.48 ± 8.72 0.035 Length of stenosis, mm 21.46 ± 12.90 23.06 ± 13.29 0.610 Degree of stenosis postprocedure, (mean ± SD) 11.40 ± 9.79 5.66 ± 9.65 < 0.001 Abbreviations: TS = transverse sinus; SigS = sigmoid sinus; hp = hypoplastic; Lt = left; Rt = right; IVUS = intravascular ultrasound; DSA = digital subtraction angiography. IVUS-guided stent implantation A total of 74 stents were used in the 61 patients, with a single stent implanted in 50 cases and 24 stents in 11 cases due to long or tandem lesions. The stent sizes employed in this study were detailed in Table 3 . The mean diameter of the stent was 7.94 ± 0.56 mm, with a mean length of 48.36 ± 11.76 mm across the 61 patients. IVUS-guided stent implantation was successful in all cases. A representative case of IVUS-guided CVS stenting is shown in Fig. 4 . Table 3 Summary of the stent sizes utilized in the study Stent Diameter * , mm length ✝ , mm Number, n Precise 8 30 25 8 40 25 Wallstent 7 50 14 9 50 10 Mean, (mean ± SD) 7.94 ± 0.56 48.36 ± 11.76 * The diameter of the 74 stents. ✝ The lengths of the 74 stents from 61 patients were recorded. Accroding to the IVUS measurement results presented in Table 4 , an appropriately sizeed and lengthened stent was selected for EVT. Two patients underwent post-stenting balloon dilatation due to the residual stenosis with a CSA exceeding 50% at the target lesion site. After stenting or post-stenting balloon dilatation, there was a significant improvement in the diameter and CSA of the most severely stenosed segments. The stents fully covered the stenotic segment (p < 0.001), and the CSA of the stenosis significantly improved post-procedure (p < 0.001), while the reference segment of the target lesion did not show significant change post-stenting (p = 0.287). The trans-stenotic MPGs across the 61 patients significantly decreased from 16.27 ± 8.71 mmHg pre-procedure to 1.30 ± 1.60 mmHg post-procedure. Table 4 Target lesion Characteristics pre-postprocedure guided by IVUS Preprocedure Postprocedure P value Variability Mean Mean Distal Proximal Distal Proximal CSA of reference segment, mm 2 , (mean ± SD) 38.24 ± 6.97 39.55 ± 6.56 0.287 36.40 ± 8.33 40.07 ± 8.47 37.79 ± 8.02 41.31 ± 8.47 Perimeter of reference segment, mm, (mean ± SD) 25.42 ± 2.46 24.92 ± 2.57 0.273 24.67 ± 3.01 26.18 ± 2.73 24.45 ± 3.08 25.39 ± 2.57 D derived from A1 and A2, mm, (mean ± SD) D1 D2 7.94 ± 0.60 * 7.95 ± 0.65 5.99 ± 0.81 NA CSA of stenosis, mm 2 (mean ± SD) 7.42 ± 3.28 36.44 ± 8.07 < 0.001 Length of stenosis or stent, mm, (mean ± SD) 21.46 ± 12.90 48.36 ± 11.76 < 0.001 Stent expansion index NA 0.93 ± 0.20 NA MPG, mmHg 16.27 ± 8.71 1.30 ± 1.60 < 0.001 MDP MPP 23.96 ± 4.71 9.70 ± 3.28 12.25 ± 5.25 10.93 ± 4.61 Abbreviations: CSA = cross-sectional area; MPG = mean pressure gradient; MDP = mean distal pressure; MPP = mean proximal pressure; A 1 = a circle area equal to the average value area of reference segment; A 2 = a inscribed circle area of reference segment; D = diameter; D 1 = diameter derived from A 1 ; D 2 = diameter derived from A 1 ; * = mean diameter derived from minimum diameter and maximum diameter passing through the center of the most severe stenosis. Follow-up outcomes Clinical information follow-ups were completed for all patients (Table 5 ). Repeat radiological studies were performed in 47 out of 61 (77.0%) patients. Among the patients who had headaches as a symptom, 91.7% showed improvement or disappearance of their symptoms. The visual function did not significantly change for 5 patients, besides 2 patients experienced worsened symptoms. All 5 patients had a prolonged history of symptoms, and ophthalmoscopic examination revealed severe optic atrophy before the procedure. Table 5 Outcome After IVUS-Guided Dural Venous Sinus Stenting Follow up items 6 months to 1 year after treatment Radiologtic follow-up, n(%) 47 (77.0) DSA 42 (68.9) CTV/MRV 5 (8.2) In-stent restenosis 2 (4.3) Dural arteriovenous fistula 1 (2.1) Clinical follow-up Headache (n = 36) Unchanged or worsened 3 (8.3) Improved 4 (11.1) Disappeared 29 (80.6) Tinnitus (n = 12) Unchanged or worsened 2 (16.7) Improved 1 (8.3) Disappeared 9 (75.0) Papilledema (n = 52) Unchanged or worsened 3 (5.8) Improved 11 (21.2) Normal 38 (73.0) Vision dysfunction (n = 50) Unchanged or worsened 7 (14.0) Improved 11 (22.0) Normal 32 (64.0) Abbreviations: IVUS = intravascular ultrasound; DSA = digital subtraction angiography; CTV = CT venography; MRV = magnetic resonance venography; Data are expressed as No. (%). Discussion The cross-section view of the CVS more closely corresponds to a triangular shape 4 – 6 , which poses difficulty in lesion assessment and appropriate stent selection. Boddu et al. measured the diameter of CVS stenosis by using IVUS and DSA. The results suggested that the degree of stenosis observed on DSA was significantly higher than that on IVUS 13 . Boddu SR et al. used MRV and IVUS to evaluate the baseline CVS. Compared with IVUS measurements, three-dimensional contrast enhancement MRV overestimated the measurements of dimensions, including maximum diameter, area, and perimeter 5 . Although IVUS was used to assess the lesion and guide stent implantation, none of the studies addressed how to select an appropriate stent. Therefore, in our patient cohort, we introduced a method for stenosis evaluation and stent selection using IVUS. In our study, we found that calculating the degree of stenosis for the triangular structure of CVS using CSA and perimeter measurements obtained by IVUS may be more reasonable. As shown in Table 2 , the degree of the maximal stenosis measured by DSA was higher preprocedure and lower postprocedure than that measured by IVUS, indicating potential overestimate or underestimate by DSA compared with IVUS measurements. While there were no significant differences in stenosis length between DSA and IVUS measurements, DSA may overestimate the lesion length compared with IVUS measurements. These findings support previous studies 13 . For stent implantation in patients with CVS stenosis, using an oversized stent may not only significantly alter the original triangular contour of the CVS, but also impede the outflow of cortical veins as they enter the CVS, resulting in life-threatening complications such as hemorrhage, venous infarction, and seizures 14 , 15 . Conversely, an undersized stent may increase the risk of restenosis. Therefore, selecting the appropriate stent size and length can prevent in-stent stenosis and reduce the duration of medical treatment 16 , 17 . In our study, we employed a new method to select the stent using IVUS. With this method, the mean stent size was 7.94 ± 0.56 mm, which fell between the diameter of the circle with an area equal to the average area of the reference segments (7.95 ± 0.65 mm) and the average diameter of an inscribed circle within the CVS, plus the average triangle perimeter of the reference segments (5.99 ± 0.81 mm). The mean stent expansion index was 0.93 ± 0.20. Our data demonstrated that the stent achieved complete expansion (expansion index > 0.8) per IVUS assessment criteria for coronary artery stent implantation 18 . Additionally, the transtenotic MPGs of all patients significantly decreased after the procedure, showing promising results. Despite most of the patients reporting significant improvement in their symptoms during the follow-up, three patients complained of aggravated headaches, two of whom had poor visual function and exacerbated tinnitus. A follow-up DSA revealed that one patient developed a dural arteriovenous fistula (DAVF), the symptom was largely improved after DAVF embolization. The other two patients experienced stent restenosis. One patient presented tandem lesions, and a stent was implanted for each lesion, resulting in a total of two stents. Repeat imaging suggested that the restenosis was located at the edge of the stent between the two. For another patient with in-stent stenosis, the lesion was too extensive to be adequately covered by one stent, so two stents were implanted. Radiological follow-up detected that the stent had separated from its former overlapped site, and restenosis occurred at this site. However, the symptoms of two patients were resolved after a third stent was implanted at the stenotic site. The in-stent restenosis at the stent edge of was probably caused by negative remodeling or intimal hyperplasia 19 . Conversely, using a tandem stent may lead to subacute thrombosis development 20 . Regarding the patients whose visual function did not significantly change after the stenting, all of them had a long history of symptoms, and ophthalmoscopic examination revealed severe optic atrophy before the procedure, which was difficult to reverse 21 . Limitations The small sample size and our single center of IIH patients with CVS restricted our study. Further large-scale studies are needed to validate our evaluation method for CVS stenosis and stent selection using IVUS. Additionally, the stents utilized in the procedure are not tailored for CVS stenosis. The future development of dedicated devices for CVS stenosis will hopefully overcome this limitation. Conclusions IVUS possesses potential to assess the severity and extent of CVS stenosis, aid in stent selection, and optimize stent position during the interventional procedures when used alongside DSA. Declarations Competing interests: All authors identified on this submission have verified that they have no conflicts of interest to disclose. Author Contribution Gang Luo: drafted the manuscript; Raynald -, Xu Tong, Dapeng Sun: critical revision of manuscript for intellectual content; Yinuo Huang, Zifei Han, Bo Wang, Baixue Jia, Zhenbo Shi,: performed the data collection and data analysis; Feng Gao, Ning Ma: study supervision; Zhongrong Miao and Dapeng Mo: study concept and design, analysis and interpretation of data, critical revision of manuscript for intellectual content. Acknowledgments The Study Funded by Beijing Municipal Science & Technology Commission (Z221100007422053) and the Beijing Municipal Administration of Hospitals Incubating Program (PX2017009) to Dapeng Mo and Youth Training Program of Beijing Hospitals Authority (No. QML20190505) to Gang Luo. Data Availability The data used in this study can be available upon reasonable request from the corresponding Author. 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Risk factors associated with progression from papilloedema to optic atrophy: Results from a cohort of 113 patients. BMJ open. Ophthalmol. ; 8 (2023). Additional Declarations No competing interests reported. Cite Share Download PDF Status: Published Journal Publication published 11 May, 2025 Read the published version in Scientific Reports → Version 1 posted Editorial decision: Accepted 28 Apr, 2025 Reviews received at journal 11 Apr, 2025 Reviewers agreed at journal 01 Apr, 2025 Reviewers invited by journal 01 Apr, 2025 Submission checks completed at journal 25 Mar, 2025 First submitted to journal 16 Mar, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-5216428","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Article","associatedPublications":[],"authors":[{"id":437095080,"identity":"f48630cf-df0b-4fcc-ae99-813a8ec07fd3","order_by":0,"name":"Gang Luo","email":"","orcid":"","institution":"Beijing Tiantan Hospital, Capital Medical University","correspondingAuthor":false,"prefix":"","firstName":"Gang","middleName":"","lastName":"Luo","suffix":""},{"id":437095082,"identity":"a392da6e-c5d6-4827-9e29-db46eaf64c6e","order_by":1,"name":"- Raynald","email":"","orcid":"","institution":"Beijing Tiantan Hospital, Capital Medical University","correspondingAuthor":false,"prefix":"","firstName":"-","middleName":"","lastName":"Raynald","suffix":""},{"id":437095083,"identity":"578e57fb-42c1-4900-8d3b-b159ca6d2229","order_by":2,"name":"Xu Tong","email":"","orcid":"","institution":"Beijing Tiantan Hospital, Capital Medical University","correspondingAuthor":false,"prefix":"","firstName":"Xu","middleName":"","lastName":"Tong","suffix":""},{"id":437095084,"identity":"43101a7f-fb5d-4d35-ac75-293bfa34f5f3","order_by":3,"name":"Yinuo Huang","email":"","orcid":"","institution":"Beijing Fengtaiyouanmen Hospital","correspondingAuthor":false,"prefix":"","firstName":"Yinuo","middleName":"","lastName":"Huang","suffix":""},{"id":437095085,"identity":"9df12674-fe9b-476a-9aaa-ba21fadd5a0a","order_by":4,"name":"Zifei Han","email":"","orcid":"","institution":"University of International Business and Economics","correspondingAuthor":false,"prefix":"","firstName":"Zifei","middleName":"","lastName":"Han","suffix":""},{"id":437095086,"identity":"c1ee56ba-a4ec-4b99-a74b-1aef6649c289","order_by":5,"name":"Dapeng Sun","email":"","orcid":"","institution":"Beijing Tiantan Hospital, Capital Medical University","correspondingAuthor":false,"prefix":"","firstName":"Dapeng","middleName":"","lastName":"Sun","suffix":""},{"id":437095087,"identity":"135c6f87-f4f9-4f13-a811-700aae2be59c","order_by":6,"name":"Bo Wang","email":"","orcid":"","institution":"Beijing Tiantan Hospital, Capital Medical University","correspondingAuthor":false,"prefix":"","firstName":"Bo","middleName":"","lastName":"Wang","suffix":""},{"id":437095088,"identity":"699866f8-2af0-4d2a-a303-7b37cf79daa4","order_by":7,"name":"Baixue Jia","email":"","orcid":"","institution":"Beijing Tiantan Hospital, Capital Medical University","correspondingAuthor":false,"prefix":"","firstName":"Baixue","middleName":"","lastName":"Jia","suffix":""},{"id":437095089,"identity":"763c095d-565b-48ce-b8eb-e271734bd1cd","order_by":8,"name":"Zhenbo Shi","email":"","orcid":"","institution":"Beijing Tiantan Hospital, Capital Medical University","correspondingAuthor":false,"prefix":"","firstName":"Zhenbo","middleName":"","lastName":"Shi","suffix":""},{"id":437095090,"identity":"7f27ae73-0718-4c9c-939e-803d75de0c45","order_by":9,"name":"Feng Gao","email":"","orcid":"","institution":"Beijing Tiantan Hospital, Capital Medical University","correspondingAuthor":false,"prefix":"","firstName":"Feng","middleName":"","lastName":"Gao","suffix":""},{"id":437095091,"identity":"83a18426-dc9e-468e-aba4-b952f0aa6c2e","order_by":10,"name":"Ning Ma","email":"","orcid":"","institution":"Beijing Tiantan Hospital, Capital Medical University","correspondingAuthor":false,"prefix":"","firstName":"Ning","middleName":"","lastName":"Ma","suffix":""},{"id":437095092,"identity":"68a78d87-3880-4a83-9036-c7cacf089775","order_by":11,"name":"Zhongrong Miao","email":"","orcid":"","institution":"Beijing Tiantan Hospital, Capital Medical University","correspondingAuthor":false,"prefix":"","firstName":"Zhongrong","middleName":"","lastName":"Miao","suffix":""},{"id":437095093,"identity":"9c13da98-bd56-4a55-aa5b-9d9c9fe47d32","order_by":12,"name":"Dapeng Mo","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAAtUlEQVRIiWNgGAWjYBACA4YDIIqZgZ+Z+fADIrUcZmwAaZFsZ0szIFILM0SLwXkeBQmitJgznj/+6EaFdZ7xYR6g/hqbaIJaLBsOMzbnnEkvNjvMe+ABw7G03AaCDjsA1JLbdjhx22G+BAPGhsMkaNnczGMgQZqWDczEagH6xXA2yC8Sh4GBnECMX8wlDj74nAMMMf7+w4cffKixIayFQeIAmEpAIgkB/gYSFI+CUTAKRsHIBACniEQX/uYejwAAAABJRU5ErkJggg==","orcid":"","institution":"Beijing Tiantan Hospital, Capital Medical University","correspondingAuthor":true,"prefix":"","firstName":"Dapeng","middleName":"","lastName":"Mo","suffix":""}],"badges":[],"createdAt":"2024-10-07 08:23:26","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-5216428/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-5216428/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1038/s41598-025-00505-5","type":"published","date":"2025-05-11T15:57:42+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":79812474,"identity":"6eee7238-e542-447a-ac84-21ab2c711513","added_by":"auto","created_at":"2025-04-03 06:59:58","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":211200,"visible":true,"origin":"","legend":"\u003cp\u003eParticipants enrolled in the Intravascular Ultrasound guidance study on venous sinus stenting.\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-5216428/v1/d6c5426e04b19861c96e154e.png"},{"id":79812476,"identity":"7c766e45-0a1b-49c3-870a-c9b26c90feae","added_by":"auto","created_at":"2025-04-03 06:59:58","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":372773,"visible":true,"origin":"","legend":"\u003cp\u003eA diagram presented CVS stenosis induced by arachnoid granulations, accompanied by IVUS images of the resulting stenosis. (A) The diagram desplayed cross-sectional and longitudinal views of CVS stenosis sites caused by arachnoid granulations, along with reference sections from the proximal and distal segments. The blue section represented the CVS, while the black circles in the cross-sections marked the tips of the IVUS transducer. Sections b and d showed the cross-sectional and longitudinal views of the proximal and distal segments, respectively. Section c displayed the cross-sectional and longitudinal views of the stenosis sites caused by arachnoid granulations. Sections a and a1 exhibited significant arachnoid granulations within the CVS, leading to CVS stenosis. (B) IVUS images displayed cross-sectional and longitudinal views of CVS stenosis sites caused by arachnoid granulations. CSA \u003csub\u003e1\u003c/sub\u003e indicated the luminal CSA at the site of the most severe stenosis caused by arachnoid granulation, while CSA\u003csub\u003e2\u003c/sub\u003e and CSA\u003csub\u003e3\u003c/sub\u003e indicated the luminal CSA at the distal and proximal reference segments, respectively ( a’ depicted significant arachnoid granulation within the CVS, resulting in CVS stenosis) . Note\u0026nbsp;The figure 2A was generated by Adobe Illustrator CC 2022 (http://www.adobe.com/cn/creativecloud/roc /business.html) .\u003c/p\u003e","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-5216428/v1/6dc0857e481ed264914de175.png"},{"id":79813008,"identity":"204cfc64-ff5b-4428-8b2f-3e74fcc8d42f","added_by":"auto","created_at":"2025-04-03 07:07:58","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":513153,"visible":true,"origin":"","legend":"\u003cp\u003eSchematic illustration of the stent diameter selection based on IVUS measurement. (A) Cross-sectional illustration of venous sinuses and adjacent anatomical structures, the blue section indicated the CVS. (B) Cross-sectional illustration of proximal reference segment of the lesion.\u0026nbsp; C\u003csub\u003e1\u003c/sub\u003e denoted the perimeter of triangle \u003cstrong\u003eCVS\u003c/strong\u003e\u0026nbsp; in this segment, while CSA\u003csub\u003e1\u003c/sub\u003e represented its area. The yellow region indicated the area of the inscribed circles within the \u003cstrong\u003eCVS\u003c/strong\u003e triangle of the proximal reference segment. (C) Cross-sectional illustration of the distal reference segment of the lesion.\u0026nbsp; C\u003csub\u003e1\u003c/sub\u003e denoted the perimeter of the \u003cstrong\u003eCVS\u003c/strong\u003e triangle in this segment and CSA\u003csub\u003e2\u003c/sub\u003e represented its area. The yellow region indicated the area of the inscribed circles within the \u003cstrong\u003eCVS\u003c/strong\u003e triangle of the diatal reference segement. (D) Schematic illustration of the hypothesized lesion structure based on IVUS measurements of the proximal and distal reference segments. C\u003csub\u003e3\u003c/sub\u003e denoted the perimeter of the lesion’s \u003cstrong\u003eCVS\u003c/strong\u003e triangle, derived from the IVUS measurements of C\u003csub\u003e1\u003c/sub\u003eand C\u003csub\u003e2\u003c/sub\u003e. A\u003csub\u003e2\u003c/sub\u003e represented the area of the lesion’s \u003cstrong\u003eCVS\u003c/strong\u003e triangle, derived from CSA\u003csub\u003e1\u003c/sub\u003e and CSA\u003csub\u003e2\u003c/sub\u003e, while A\u003csub\u003e3\u003c/sub\u003e indicated the inscribed circles within this triangular structure, inferred from both reference segments. (E) Illustration of stent size selection for lesion, based on cross-sectional area and inscribed circles within the CVS triangular structure, derived from proximal and distal reference segments. The blue area represented the cross-sectional area of the CVS. The yellow area represented the area of inscribed circles within the CVS. The small black squares depicted the cross-sectional area of the stent. R\u003csub\u003e2\u003c/sub\u003e represented the radius calcaluted from the average cross-sectional area of proximal and distal reference segments of the CVS. R\u003csub\u003e3\u003c/sub\u003e was derived from the average area of inscribed circles within proximal and distal reference segments of the CVS. R\u003csub\u003e1\u003c/sub\u003e was the stent radius, which was between R\u003csub\u003e2\u003c/sub\u003e and R\u003csub\u003e3\u003c/sub\u003e. (C) Cross-sectional illustration of stent deployment in the CVS. Note\u0026nbsp;The figure was generated by Adobe Illustrator CC 2022 (http://www.adobe.com/cn/creativecloud/roc /business.html) .\u003c/p\u003e","description":"","filename":"3.png","url":"https://assets-eu.researchsquare.com/files/rs-5216428/v1/f8f00bcef044fead891a94b4.png"},{"id":79812479,"identity":"59ccb9df-3c78-4ae7-8938-6e68ad2241f2","added_by":"auto","created_at":"2025-04-03 06:59:58","extension":"png","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":399883,"visible":true,"origin":"","legend":"\u003cp\u003eThe patient presented with a headache and persistent deterioration of visual function, despite medical treatment for 8 months. \u003cstrong\u003eA and B :\u003c/strong\u003e The angiogram with venous phase images shows severe stenosis of the right transverse sinus before stenting from both the anterior-posterior and oblique views, the transtenotic mean pressure gradient was 14mmHg. Note that there is stenosis of both transverse sinuses. \u003cstrong\u003eA\u003c/strong\u003e\u003csub\u003e\u003cstrong\u003e1\u003c/strong\u003e\u003c/sub\u003e\u003cstrong\u003e and B\u003c/strong\u003e\u003csub\u003e\u003cstrong\u003e1\u003c/strong\u003e\u003c/sub\u003e\u003cstrong\u003e: \u003c/strong\u003eAngiogram with venous phase images demonstrating right transverse sinus post stenting from anterior-posterior view and oblique view. Note obvious change in flow dynamics with\u0026nbsp; 2mmHg of transtenotic mean pressure gradient. \u003cstrong\u003eD: \u003c/strong\u003eIntravascular ultrasound (IVUS) demonstrating echogenic material with a significantly decreased diameter of the right transverse sinus. \u003cstrong\u003ea. \u003c/strong\u003edistal reference segment of tight stenosis on IVUS. \u003cstrong\u003eb.\u003c/strong\u003e tight stenosis on IVUS. \u003cstrong\u003ec.\u003c/strong\u003e proximal reference segment of tight stenosis on IVUS. \u003cstrong\u003eE.\u003c/strong\u003e \u003cstrong\u003ea\u003c/strong\u003e\u003csub\u003e\u003cstrong\u003e1\u003c/strong\u003e\u003c/sub\u003e\u003cstrong\u003e. \u003c/strong\u003edistal reference segment on IVUS post-stenting. b\u003csub\u003e1\u003c/sub\u003e\u003cstrong\u003e. \u003c/strong\u003eIVUS post-stent deployment demonstrated increased cross-sectional area (CSA) at the narrowest site of the right transverse sinus prior to stenting. \u003cstrong\u003ec\u003c/strong\u003e\u003csub\u003e\u003cstrong\u003e1\u003c/strong\u003e\u003c/sub\u003e\u003cstrong\u003e.\u003c/strong\u003e proximal reference segment on IVUS post-stenting.\u003c/p\u003e","description":"","filename":"4.png","url":"https://assets-eu.researchsquare.com/files/rs-5216428/v1/9a7f669a78b120f49b5ef74c.png"},{"id":82537556,"identity":"a4a07341-3bcd-4378-84ea-b25cbfeee0c0","added_by":"auto","created_at":"2025-05-12 16:08:33","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":2561009,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-5216428/v1/c1660987-4264-4cb3-b6b6-16ae24a20f9b.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Real Time Intravascular Ultrasound Evaluation and Stent Selection for Cerebral Venous Sinus Stenosis Associated with Idiopathic Intracranial Hypertension","fulltext":[{"header":"Introduction","content":"\u003cp\u003eIt was well recognized that cerebral venous sinus (CVS) stenosis is common among patients with Idiopathic Intracranial Hypertension (IIH),\u003csup\u003e\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u003c/sup\u003e and CVS stenting has increasingly become an effective treatment for these cases, particularly in refractory IIH cases.\u003csup\u003e\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eThe cross-section view of the CVS more closely corresponds to a triangular shape \u003csup\u003e\u003cspan additionalcitationids=\"CR5\" citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e\u003c/sup\u003e, which poses a difficulty in lesion assessment and appropriate stent selection using DSA. In addition to angiography, intravascular ultrasound (IVUS) can provide cross-sectional images of vessels and nearby structures, optimizing stent implantation. Recently, IVUS has been recommended for assessment of indeterminate coronary artery disease, carotid artery stenosis, or intracranial artery stenosis .\u003csup\u003e\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e\u003c/sup\u003e However, the value of IVUS in the diagnosis and treatment of the venous system is not well established. \u003csup\u003e\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eThe study aimed to assess the severity of CVS stenosis using real-time IVUS, and to propose a method for assisting stent selection based on IVUS.\u003c/p\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003ePatients selection\u003c/h2\u003e \u003cp\u003ePatients presenting with IIH symptoms and undergoing endovascular treatment (EVT) for CVS stenosis between January 1, 2014, and February 1, 2022, in our center were prospectively enrolled. IIH diagnosis was based on: 1) papilledema; 2) normal neurological examination, except for cranial nerve abnormalities; 3) neuroimaging revealing normal brain parenchyma without hydrocephalus, mass, or any structural lesion; 4) normal CSF (cerebrospinal fluid) composition; 5) elevated CSF opening pressure (greater than 250 mmH2O); and 6) additional neuroimaging features supporting an IIH diagnosis. In addition, a diagnosis of IIH can be made even in the absence of papilledema if criteria 2 and 3 are satisfied for unilateral or bilateral abducens nerve palsy\u003csup\u003e\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e\u003c/sup\u003e. Candidates for VSS were selected based on intractable headaches, progressive papilledema, refractory to standard conservative treatment, and a diagnosis of CVS stenosis\u0026thinsp;\u0026ge;\u0026thinsp;50% with trans-stenotic MPGs of at least 8 mmHg\u003csup\u003e\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e\u003c/sup\u003e. MRV, CTV, or DSA was used for screening and following up on CVS stenosis. Exclusion criteria included concurrent venous sinus thrombosis and poor-quality of images. A total of 272 patients were intial enrolled in the study. Of these cases, 85 cases underwent IVUS assessment, and 61 of them underwent IVUS-guided stent implantation (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e The study was approved by the institutional review boards of our hospitals, and informed consent was obtained pre-procedure.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eDSA and IVUS assessment\u003c/h3\u003e\n\u003cp\u003eDSA examination was necessary to confirm the diagnosis and assess the CVS stenosis before and after stent placement. IVUS was conducted with a 3.5F, 20 MHz Eagle Eye IVUS probe transducer. The probe range was set to 20mm for comprehensive visualization of the venous wall. DSA and IVUS images were assessed by two experienced readers who were blinded to the patient\u0026rsquo;s clinical information. Any discrepancies were resolved by a third experienced reader.\u003c/p\u003e \u003cp\u003eIn IVUS (Volcano Corporation, Rancho Cordova, CA, USA) assessment, the luminal lesion border was traced using a slow manual pullback technique at rates of approximately 1.0 mm/s, to calculate the luminal CSA. The reference segments in this study were defined as a segment 5 mm proximal and distal to the stenosis border and were confirmed as healthy segments without stenosis by IVUS. The method for calculating the degree of maximum stenosis of the lesion on IVUS is depicted in Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eThree measurements were recorded: the luminal CSA of the site with the most severe stenosis (CSA 1), the luminal CSA of the distal reference segment (CSA 2), and the luminal CSA of proximal reference segment (CSA 3). The formula for the degree of stenosis is (1-[CSA 1/(CSA 2\u0026thinsp;+\u0026thinsp;CSA 3)/2])\u0026#128937;100%. The length of CVS stenosis was defined as the distance between the distal and the proximal ends of the stenosis border.\u003c/p\u003e \u003cp\u003eStenosis severity on DSA was determined using the method outlined by James et al\u003csup\u003e\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e\u003c/sup\u003e, the narrowest luminal diameter affected CVS, as well as the normal diameter of the CVS in the worst view on angiographic projection. Percent stenosis was calculated using the formula: (1 - [smallest diameter/normal diameter]) \u0026times; 100%. The length of stenosis on DSA is calculated as the sum of the narrowest segment 1 (length between the distal stenosis border and maximum stenosis) and narrowest segment 2 (length between the proximal stenosis border and maximum stenosis). The formula of the length of stenosis on DSA is narrowest segment 1\u0026thinsp;+\u0026thinsp;narrowest segment 2.\u003c/p\u003e\n\u003ch3\u003eStent selection\u003c/h3\u003e\n\u003cp\u003eConsedering that the CVS corresonds more closely to a triangular shape in cross-section view, the study introduced a novel stent selection method. The stent size and length were calculated using formulas derived from IVUS measurements of the proximal and distal reference segments of the lesion.\u003c/p\u003e \u003cp\u003eAs illustrated in Fig.\u0026nbsp;3, R\u003csub\u003e2\u003c/sub\u003e represents the radius of circle A\u003csub\u003e2\u003c/sub\u003e, calculated using the formula: \u003cspan class=\"InlineEquation\"\u003e\u003cspan class=\"mathinline\"\u003e\\(\\:\\sqrt{{A}_{2}/2{\\pi\\:}}\\)\u003c/span\u003e\u003c/span\u003e. Here, A\u003csub\u003e2\u003c/sub\u003e refers to the average triangular area of the proximal (CSA\u003csub\u003e1\u003c/sub\u003e) and distal (CSA\u003csub\u003e2\u003c/sub\u003e) reference segments of the lesion.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eR\u003csub\u003e3\u003c/sub\u003e denotes the radius of circle A\u003csub\u003e3\u003c/sub\u003e, derived from the formula: \u003cspan class=\"InlineEquation\"\u003e\u003cspan class=\"mathinline\"\u003e\\(\\:\\sqrt{{A}_{2}/{\\text{C}}_{3}}\\)\u003c/span\u003e\u003c/span\u003e. A3 represents the inscribed circles of the lesion within the triangular structure of the CVS, as inferred from the proximal and distal reference segments. Additionally, C\u003csub\u003e3\u003c/sub\u003e is defined as the average perimeter of the triangular perimeter C1 and C2, representing the proximal and distal reference segments, respectively.\u003c/p\u003e \u003cp\u003eThe stent diameter (2R\u003csub\u003e1\u003c/sub\u003e) was determined to be within the range defined by 2R\u003csub\u003e2\u003c/sub\u003e and 2R\u003csub\u003e3\u003c/sub\u003e, expressed mathematically as 2\u003cspan class=\"InlineEquation\"\u003e\u003cspan class=\"mathinline\"\u003e\\(\\:\\sqrt{{A}_{2}/2{\\pi\\:}}\\)\u003c/span\u003e\u003c/span\u003e\u0026le; 2D\u003csub\u003e1\u003c/sub\u003e \u0026le;\u003cspan class=\"InlineEquation\"\u003e\u003cspan class=\"mathinline\"\u003e\\(\\:2\\sqrt{{A}_{2}/{\\text{C}}_{3}}\\)\u003c/span\u003e\u003c/span\u003e and 2(CSA\u003csub\u003e1\u003c/sub\u003e+CSA\u003csub\u003e2\u003c/sub\u003e)/(C\u003csub\u003e1\u003c/sub\u003e\u0026thinsp;+\u0026thinsp;C\u003csub\u003e2\u003c/sub\u003e) \u0026le;2D\u003csub\u003e1\u003c/sub\u003e \u0026le;2\u003cspan class=\"InlineEquation\"\u003e\u003cspan class=\"mathinline\"\u003e\\(\\:\\sqrt{\\left(CS{A}_{1}+CS{A}_{2}\\right)/2\\pi\\:}\\)\u003c/span\u003e\u003c/span\u003e. The stent length was determined by adding 10 mm to both sides of the distal and proximal stenosis borders, in addition to the length of the stenosis segment.\u003c/p\u003e \u003cp\u003eSelf-expanding stents (Precise Carotid stent, Cordis, U.S.A; Wallstent, Boston Scientific, USA) with diameters ranging from 7.0mm to 9.0mm and lengths between 30mm and 50mm were utilized for stent implantation.\u003c/p\u003e\n\u003ch3\u003eStenting procedure\u003c/h3\u003e\n\u003cp\u003eBefore stenting, all patients received a daily dose of 75 mg clopidogrel and 100 mg aspirin for 3\u0026ndash;5 days. Procedures were conducted under general anesthesia with intraoperative anticoagulation therapy (dosage 4000\u0026ndash;6000 units) and intravenous heparin to maintain an activated clotting time above 250s\u003csup\u003e\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e\u003c/sup\u003e. Prior to stenting, DSA was performed through arterial femoral access to assess stenosis features and select the worst view. IVUS evaluation and stenting followed a femoral transvenous approach using a short 8-Fr sheath. An 8-Fr guiding catheter was placed at the end of the internal jugular vein (IJV). A 6F intermediate catheter was advanced into the distal transverse sinus (TS) through the 8-Fr guiding catheter. The microcatheter (Rebar-27, Medtronic, Minneapolis, MN) was used to access the superior sagittal sinus (SSS) under microwire guidance. Contrast agent was injected through the microcatheter into the SSS, TS, and sigmoid sinus (SigS). The transtenotic MPGs were measured by a microcatheter-attached pressure transducer, using a venographic roadmap with the worst projection angle of the stenosis and the mid-axillary line as the zero reference point. If the transtenotic MPGs of the CVS stenosis exceeded 8 mmHg, IVUS evaluation and stenting would be carried out. An IVUS probe transducer was advanced across the stenotic sinus segment over a microwire. The radiopaque IVUS transducer probe was slowly retracted from the distal reference segment point to the proximal reference segment point of the lesion using a slow manual pullback technique at rates of approximately 1 mm/sec\u003csup\u003e6\u003c/sup\u003e. All IVUS images were displayed and recorded on a workstation. Following IVUS assessment the stenosis, balloon angioplasty predilatation was performed as the initial treatment. Predilatation was conducted at maximum of 6 atm for 60 seconds using a 5.0\u0026ndash;6.0 mm balloon catheter (Sterling balloon catheter, Boston Scientific, U.S.A). Subsequently, stenting procedures were performed. The IVUS assessment was then repeated from the distal to proximal stenting site, yielding another recording. Post-stenting balloon diatation was performed if the residual stenosis of the CSA exceeded 50% at the target lesion site, or if the transtenotic MPGs exceeded 8 mmHg post-stenting. The size of the post-stenting balloon was determined based on 0.8 times the target CVS reference diameter, ensuring adequate the stent stenosis coverage. Subsequently, IVUS and transtenotic MPGs were re-evaluated. The procedure ended when the residual stenosis of the CSA was less than 30% at the target lesion or when the transtenotic MPGs was less than 8 mmHg post dilatation.\u003c/p\u003e\n\u003ch3\u003eAnticoagulation and antiplatelet\u003c/h3\u003e\n\u003cp\u003eThe patients were administered with low-molecular-weight heparin for 3 days post-procedure. They continued to take 100 mg of aspirin and 75 mg of clopidogrel daily for 3 months, followed by life-long use of aspirin or clopidogrel.\u003c/p\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eFollow-up protocol\u003c/h2\u003e \u003cp\u003eClinical assessments and radiographic examinations were performed 6 months to 1 year after stent placement. Restenosis was defined as stenosis exceeding 50% within the stent or at the edge of the stent, as verified by angiography.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec9\" class=\"Section2\"\u003e \u003ch2\u003eStatistical Analysis\u003c/h2\u003e \u003cp\u003eStatistical analyses used SPSS Statistics version 21.0 (IBM SPSS, Armonk, NY, USA). Baseline and outcome data were presented as means (standard deviations) or medians (25th and 75th percentiles) for continuous variables and as frequencies or proportions for categorical variables. The paired-sample T test or nonparametric test (Wilcoxon test) was employed to compare mean differences. The categorical and binary data were compared between the groups using the χ2 test or Fisher exact test, respectively. A p-value\u0026thinsp;\u0026lt;\u0026thinsp;0.05 was considered statistically significant.\u003c/p\u003e \u003cp\u003e All methods were in accordance with the Declaration of Helsinki and approved by the Ethical Committee of Beijing Tiantan Hospital. All participants were fully informed of the nature of the study protocol and all gave their written consents regarding participation.\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003eClinical characteristics of the patients before the procedure\u003c/p\u003e \u003cp\u003ePatients\u0026rsquo; baseline characteristics are reported in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e, with 52 out of the 61 patients (85.2%) being female. The mean body mass index (BMI) of the group was 27.8\u0026thinsp;\u0026plusmn;\u0026thinsp;4.4 kg/m\u003csup\u003e2\u003c/sup\u003e. The most common symptom was visual dysfunction, affecting 50 patients (82.0%). All patients exhibited increased CSF opening pressure, averaging 300.9\u0026thinsp;\u0026plusmn;\u0026thinsp;46.1 cm H\u003csub\u003e2\u003c/sub\u003eO. The findings also indicated that the primary lesion sites were frequently situated at the junction of the TS and SigS, impacting 45 patients (73.8%). Stenosis was most commonly found on the right side of the venous sinus, affecting 41 patients (67.2%).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eBaseline Characteristics\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFeature\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003evalue\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGender, female\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e52 (85.2)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge (mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD), y\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e36.8\u0026thinsp;\u0026plusmn;\u0026thinsp;10.2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBMI (mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD), kg/m\u003csup\u003e2\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e27.8\u0026thinsp;\u0026plusmn;\u0026thinsp;4.4\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHypertension\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e19 (31.1)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDyslipidemia\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e2 (3.3)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eClinical duration\u003c/p\u003e \u003cp\u003eOnset to EVT, median (IQR), months\u003c/p\u003e \u003cp\u003eAggravation to EVT, median (IQR), days\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4 (1, 12)\u003c/p\u003e \u003cp\u003e30 (30, 60)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eClinical presentation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHeadache\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e36 (59.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTinnitus\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e12 (19.7)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVisual dysfunction\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e50 (82.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBinoculus\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e41 (67.2)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOcellus\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e9 (14.8)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVision acuity decline\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e42 (68.9)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVisual field defect\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e5 (8.2)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDysmorphopsia\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e3 (4.9)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAmaurosis\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e7 (11.5)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDiplopia\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e5 (8.2)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOphthalmic examination\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePapilledema\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e52(85.2)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVision acuity (mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLeft\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.81\u0026thinsp;\u0026plusmn;\u0026thinsp;0.35\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRight\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.81\u0026thinsp;\u0026plusmn;\u0026thinsp;0.37\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLumbar pressure, (mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD), mm H\u003csub\u003e2\u003c/sub\u003eO\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e300.9\u0026thinsp;\u0026plusmn;\u0026thinsp;46.1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLocation of stenosis, No. (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTs\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e12 (19.7)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTs-SigS\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e45 (73.8)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTs and SigS\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e2 (3.3)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTs and Ts-SigS\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1 (1.6)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSSS and Ts\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1 (1.6)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLaterality of stenosis\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLt, Rt nomal\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1 (1.6)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRt, Lt nomal\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e9 (14.8)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBilateral\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e14 (23.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLt, Rt hp or occlusion\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e5 (8.2)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRt, Lt hp or occlusion\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e32 (52.2)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"3\"\u003eAbbreviations: BMI\u0026thinsp;=\u0026thinsp;body mass index. IQR\u0026thinsp;=\u0026thinsp;interquartile range; IVUS\u0026thinsp;=\u0026thinsp;intravascular ultrasound; EVT\u0026thinsp;=\u0026thinsp;endovascular treatment; TS\u0026thinsp;=\u0026thinsp;transverse sinus; SigS\u0026thinsp;=\u0026thinsp;sigmoid sinus; SSS\u0026thinsp;=\u0026thinsp;superior sagittal sinus; Ts-SigS\u0026thinsp;=\u0026thinsp;junction of transverse sinus and sigmoid sinus; hp\u0026thinsp;=\u0026thinsp;hypoplastic; Lt\u0026thinsp;=\u0026thinsp;left; Rt\u0026thinsp;=\u0026thinsp;right. Data are expressed as No. (%) unless otherwise indicated.\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eIVUS and DSA for CVS stenosis assessment\u003c/p\u003e \u003cp\u003eTable\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e displays that the degree of maximum stenosis evaluated by DSA was more severe than that evaluated by IVUS before the procedure (p\u0026thinsp;=\u0026thinsp;0.035), and milder than the IVUS assessment after the procedure (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eAngiographic and Procedural Characteristics for Target Lesions compared by IVUS and Angiography\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\"\u0026plusmn;\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\"\u0026plusmn;\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eEvaluated by IVUS\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eEvaluated by DSA\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eP Value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBase imaging data, (mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRate of stenosis, (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e \u003cp\u003e74.84\u0026thinsp;\u0026plusmn;\u0026thinsp;10.12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e78.48\u0026thinsp;\u0026plusmn;\u0026thinsp;8.72\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.035\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLength of stenosis, mm\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e \u003cp\u003e21.46\u0026thinsp;\u0026plusmn;\u0026thinsp;12.90\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e23.06\u0026thinsp;\u0026plusmn;\u0026thinsp;13.29\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.610\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDegree of stenosis postprocedure,\u003c/p\u003e \u003cp\u003e(mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e11.40\u0026thinsp;\u0026plusmn;\u0026thinsp;9.79\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5.66\u0026thinsp;\u0026plusmn;\u0026thinsp;9.65\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"4\"\u003eAbbreviations: TS\u0026thinsp;=\u0026thinsp;transverse sinus; SigS\u0026thinsp;=\u0026thinsp;sigmoid sinus; hp\u0026thinsp;=\u0026thinsp;hypoplastic; Lt\u0026thinsp;=\u0026thinsp;left; Rt\u0026thinsp;=\u0026thinsp;right; IVUS\u0026thinsp;=\u0026thinsp;intravascular ultrasound; DSA\u0026thinsp;=\u0026thinsp;digital subtraction angiography.\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eIVUS-guided stent implantation\u003c/p\u003e \u003cp\u003eA total of 74 stents were used in the 61 patients, with a single stent implanted in 50 cases and 24 stents in 11 cases due to long or tandem lesions. The stent sizes employed in this study were detailed in Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e. The mean diameter of the stent was 7.94\u0026thinsp;\u0026plusmn;\u0026thinsp;0.56 mm, with a mean length of 48.36\u0026thinsp;\u0026plusmn;\u0026thinsp;11.76 mm across the 61 patients. IVUS-guided stent implantation was successful in all cases. A representative case of IVUS-guided CVS stenting is shown in Fig.\u0026nbsp;\u003cspan refid=\"Fig4\" class=\"InternalRef\"\u003e4\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eSummary of the stent sizes utilized in the study\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eStent\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eDiameter\u003csup\u003e*\u003c/sup\u003e, mm\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003elength\u003csup\u003e✝\u003c/sup\u003e, mm\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eNumber, n\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePrecise\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e30\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e25\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e40\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e25\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWallstent\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e50\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e14\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e50\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e10\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMean, (mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e7.94\u0026thinsp;\u0026plusmn;\u0026thinsp;0.56\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e48.36\u0026thinsp;\u0026plusmn;\u0026thinsp;11.76\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"4\"\u003e* The diameter of the 74 stents.\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"4\"\u003e✝ The lengths of the 74 stents from 61 patients were recorded.\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eAccroding to the IVUS measurement results presented in Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e, an appropriately sizeed and lengthened stent was selected for EVT. Two patients underwent post-stenting balloon dilatation due to the residual stenosis with a CSA exceeding 50% at the target lesion site. After stenting or post-stenting balloon dilatation, there was a significant improvement in the diameter and CSA of the most severely stenosed segments. The stents fully covered the stenotic segment (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001), and the CSA of the stenosis significantly improved post-procedure (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001), while the reference segment of the target lesion did not show significant change post-stenting (p\u0026thinsp;=\u0026thinsp;0.287). The trans-stenotic MPGs across the 61 patients significantly decreased from 16.27\u0026thinsp;\u0026plusmn;\u0026thinsp;8.71 mmHg pre-procedure to 1.30\u0026thinsp;\u0026plusmn;\u0026thinsp;1.60 mmHg post-procedure.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab4\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eTarget lesion Characteristics pre-postprocedure guided by IVUS\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"9\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c9\" colnum=\"9\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003ePreprocedure\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\" morerows=\"2\" rowspan=\"3\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c7\" namest=\"c6\"\u003e \u003cp\u003ePostprocedure\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c8\" morerows=\"2\" rowspan=\"3\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c9\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003eP value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVariability\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003eMean\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c7\" namest=\"c6\"\u003e \u003cp\u003eMean\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eDistal\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eProximal\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eDistal\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003eProximal\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eCSA of reference segment,\u003c/p\u003e \u003cp\u003emm\u003csup\u003e\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u003c/sup\u003e, (mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003e38.24\u0026thinsp;\u0026plusmn;\u0026thinsp;6.97\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c7\" namest=\"c6\"\u003e \u003cp\u003e39.55\u0026thinsp;\u0026plusmn;\u0026thinsp;6.56\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c9\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e0.287\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003e36.40\u0026thinsp;\u0026plusmn;\u0026thinsp;8.33\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003e40.07\u0026thinsp;\u0026plusmn;\u0026thinsp;8.47\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003e37.79\u0026thinsp;\u0026plusmn;\u0026thinsp;8.02\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003e41.31\u0026thinsp;\u0026plusmn;\u0026thinsp;8.47\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003ePerimeter of reference segment, mm, (mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003e25.42\u0026thinsp;\u0026plusmn;\u0026thinsp;2.46\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c7\" namest=\"c6\"\u003e \u003cp\u003e24.92\u0026thinsp;\u0026plusmn;\u0026thinsp;2.57\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c9\"\u003e \u003cp\u003e0.273\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003e24.67\u0026thinsp;\u0026plusmn;\u0026thinsp;3.01\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003e26.18\u0026thinsp;\u0026plusmn;\u0026thinsp;2.73\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003e24.45\u0026thinsp;\u0026plusmn;\u0026thinsp;3.08\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003e25.39\u0026thinsp;\u0026plusmn;\u0026thinsp;2.57\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eD derived from A1 and A2, mm, (mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD)\u003c/p\u003e \u003cp\u003eD1 D2\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" morerows=\"1\" nameend=\"c7\" namest=\"c6\" rowspan=\"2\"\u003e \u003cp\u003e7.94\u0026thinsp;\u0026plusmn;\u0026thinsp;0.60\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003e7.95\u0026thinsp;\u0026plusmn;\u0026thinsp;0.65\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003e5.99\u0026thinsp;\u0026plusmn;\u0026thinsp;0.81\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c9\"\u003e \u003cp\u003eNA\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCSA of stenosis, mm\u003csup\u003e\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003cp\u003e(mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003e7.42\u0026thinsp;\u0026plusmn;\u0026thinsp;3.28\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c7\" namest=\"c6\"\u003e \u003cp\u003e36.44\u0026thinsp;\u0026plusmn;\u0026thinsp;8.07\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLength of stenosis or stent, mm, (mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003e21.46\u0026thinsp;\u0026plusmn;\u0026thinsp;12.90\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c7\" namest=\"c6\"\u003e \u003cp\u003e48.36\u0026thinsp;\u0026plusmn;\u0026thinsp;11.76\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eStent expansion index\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003eNA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c7\" namest=\"c6\"\u003e \u003cp\u003e0.93\u0026thinsp;\u0026plusmn;\u0026thinsp;0.20\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eNA\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMPG, mmHg\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003e16.27\u0026thinsp;\u0026plusmn;\u0026thinsp;8.71\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c7\" namest=\"c6\"\u003e \u003cp\u003e1.30\u0026thinsp;\u0026plusmn;\u0026thinsp;1.60\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMDP MPP\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003e23.96\u0026thinsp;\u0026plusmn;\u0026thinsp;4.71 9.70\u0026thinsp;\u0026plusmn;\u0026thinsp;3.28\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c7\" namest=\"c6\"\u003e \u003cp\u003e12.25\u0026thinsp;\u0026plusmn;\u0026thinsp;5.25 10.93\u0026thinsp;\u0026plusmn;\u0026thinsp;4.61\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"9\"\u003eAbbreviations: CSA\u0026thinsp;=\u0026thinsp;cross-sectional area; MPG\u0026thinsp;=\u0026thinsp;mean pressure gradient; MDP\u0026thinsp;=\u0026thinsp;mean distal pressure; MPP\u0026thinsp;=\u0026thinsp;mean proximal pressure; A\u003csub\u003e1\u003c/sub\u003e\u0026thinsp;=\u0026thinsp;a circle area equal to the average value area of reference segment; A\u003csub\u003e2\u003c/sub\u003e\u0026thinsp;=\u0026thinsp;a inscribed circle area of reference segment; D\u0026thinsp;=\u0026thinsp;diameter; D\u003csub\u003e1\u003c/sub\u003e\u0026thinsp;=\u0026thinsp;diameter derived from A\u003csub\u003e1\u003c/sub\u003e; D\u003csub\u003e2\u003c/sub\u003e\u0026thinsp;=\u0026thinsp;diameter derived from A\u003csub\u003e1\u003c/sub\u003e; \u003csup\u003e*\u003c/sup\u003e = mean diameter derived from minimum diameter and maximum diameter passing through the center of the most severe stenosis.\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eFollow-up outcomes\u003c/p\u003e \u003cp\u003eClinical information follow-ups were completed for all patients (Table\u0026nbsp;\u003cspan refid=\"Tab5\" class=\"InternalRef\"\u003e5\u003c/span\u003e). Repeat radiological studies were performed in 47 out of 61 (77.0%) patients. Among the patients who had headaches as a symptom, 91.7% showed improvement or disappearance of their symptoms. The visual function did not significantly change for 5 patients, besides 2 patients experienced worsened symptoms. All 5 patients had a prolonged history of symptoms, and ophthalmoscopic examination revealed severe optic atrophy before the procedure.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab5\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 5\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eOutcome After IVUS-Guided Dural Venous Sinus Stenting\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"2\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFollow up items\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003e6 months to 1 year after treatment\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRadiologtic follow-up, n(%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e47 (77.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDSA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e42 (68.9)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCTV/MRV\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5 (8.2)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIn-stent restenosis\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2 (4.3)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDural arteriovenous fistula\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1 (2.1)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eClinical follow-up\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHeadache (n\u0026thinsp;=\u0026thinsp;36)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eUnchanged or worsened\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3 (8.3)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eImproved\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4 (11.1)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDisappeared\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e29 (80.6)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTinnitus (n\u0026thinsp;=\u0026thinsp;12)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eUnchanged or worsened\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2 (16.7)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eImproved\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1 (8.3)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDisappeared\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e9 (75.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePapilledema (n\u0026thinsp;=\u0026thinsp;52)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eUnchanged or worsened\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3 (5.8)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eImproved\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e11 (21.2)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNormal\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e38 (73.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVision dysfunction (n\u0026thinsp;=\u0026thinsp;50)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eUnchanged or worsened\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e7 (14.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eImproved\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e11 (22.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNormal\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e32 (64.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"2\"\u003eAbbreviations: IVUS\u0026thinsp;=\u0026thinsp;intravascular ultrasound; DSA\u0026thinsp;=\u0026thinsp;digital subtraction angiography; CTV\u0026thinsp;=\u0026thinsp;CT venography; MRV\u0026thinsp;=\u0026thinsp;magnetic resonance venography; Data are expressed as No. (%).\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThe cross-section view of the CVS more closely corresponds to a triangular shape\u003csup\u003e\u003cspan additionalcitationids=\"CR5\" citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e\u003c/sup\u003e, which poses difficulty in lesion assessment and appropriate stent selection. Boddu et al. measured the diameter of CVS stenosis by using IVUS and DSA. The results suggested that the degree of stenosis observed on DSA was significantly higher than that on IVUS\u003csup\u003e\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e\u003c/sup\u003e. Boddu SR et al. used MRV and IVUS to evaluate the baseline CVS. Compared with IVUS measurements, three-dimensional contrast enhancement MRV overestimated the measurements of dimensions, including maximum diameter, area, and perimeter\u003csup\u003e\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e\u003c/sup\u003e. Although IVUS was used to assess the lesion and guide stent implantation, none of the studies addressed how to select an appropriate stent. Therefore, in our patient cohort, we introduced a method for stenosis evaluation and stent selection using IVUS. In our study, we found that calculating the degree of stenosis for the triangular structure of CVS using CSA and perimeter measurements obtained by IVUS may be more reasonable. As shown in Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e, the degree of the maximal stenosis measured by DSA was higher preprocedure and lower postprocedure than that measured by IVUS, indicating potential overestimate or underestimate by DSA compared with IVUS measurements. While there were no significant differences in stenosis length between DSA and IVUS measurements, DSA may overestimate the lesion length compared with IVUS measurements. These findings support previous studies\u003csup\u003e\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eFor stent implantation in patients with CVS stenosis, using an oversized stent may not only significantly alter the original triangular contour of the CVS, but also impede the outflow of cortical veins as they enter the CVS, resulting in life-threatening complications such as hemorrhage, venous infarction, and seizures\u003csup\u003e\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e\u003c/sup\u003e. Conversely, an undersized stent may increase the risk of restenosis. Therefore, selecting the appropriate stent size and length can prevent in-stent stenosis and reduce the duration of medical treatment\u003csup\u003e\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e\u003c/sup\u003e. In our study, we employed a new method to select the stent using IVUS. With this method, the mean stent size was 7.94\u0026thinsp;\u0026plusmn;\u0026thinsp;0.56 mm, which fell between the diameter of the circle with an area equal to the average area of the reference segments (7.95\u0026thinsp;\u0026plusmn;\u0026thinsp;0.65 mm) and the average diameter of an inscribed circle within the CVS, plus the average triangle perimeter of the reference segments (5.99\u0026thinsp;\u0026plusmn;\u0026thinsp;0.81 mm). The mean stent expansion index was 0.93\u0026thinsp;\u0026plusmn;\u0026thinsp;0.20. Our data demonstrated that the stent achieved complete expansion (expansion index\u0026thinsp;\u0026gt;\u0026thinsp;0.8) per IVUS assessment criteria for coronary artery stent implantation\u003csup\u003e\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e\u003c/sup\u003e. Additionally, the transtenotic MPGs of all patients significantly decreased after the procedure, showing promising results.\u003c/p\u003e \u003cp\u003eDespite most of the patients reporting significant improvement in their symptoms during the follow-up, three patients complained of aggravated headaches, two of whom had poor visual function and exacerbated tinnitus. A follow-up DSA revealed that one patient developed a dural arteriovenous fistula (DAVF), the symptom was largely improved after DAVF embolization. The other two patients experienced stent restenosis. One patient presented tandem lesions, and a stent was implanted for each lesion, resulting in a total of two stents. Repeat imaging suggested that the restenosis was located at the edge of the stent between the two. For another patient with in-stent stenosis, the lesion was too extensive to be adequately covered by one stent, so two stents were implanted. Radiological follow-up detected that the stent had separated from its former overlapped site, and restenosis occurred at this site. However, the symptoms of two patients were resolved after a third stent was implanted at the stenotic site. The in-stent restenosis at the stent edge of was probably caused by negative remodeling or intimal hyperplasia\u003csup\u003e\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e\u003c/sup\u003e. Conversely, using a tandem stent may lead to subacute thrombosis development \u003csup\u003e\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e\u003c/sup\u003e. Regarding the patients whose visual function did not significantly change after the stenting, all of them had a long history of symptoms, and ophthalmoscopic examination revealed severe optic atrophy before the procedure, which was difficult to reverse\u003csup\u003e\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e \u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003eLimitations\u003c/h2\u003e \u003cp\u003eThe small sample size and our single center of IIH patients with CVS restricted our study. Further large-scale studies are needed to validate our evaluation method for CVS stenosis and stent selection using IVUS. Additionally, the stents utilized in the procedure are not tailored for CVS stenosis. The future development of dedicated devices for CVS stenosis will hopefully overcome this limitation.\u003c/p\u003e \u003c/div\u003e"},{"header":"Conclusions","content":"\u003cp\u003eIVUS possesses potential to assess the severity and extent of CVS stenosis, aid in stent selection, and optimize stent position during the interventional procedures when used alongside DSA.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e \u003ch2\u003eCompeting interests:\u003c/h2\u003e \u003cp\u003eAll authors identified on this submission have verified that they have no conflicts of interest to disclose.\u003c/p\u003e \u003c/p\u003e\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eGang Luo: drafted the manuscript; Raynald -, Xu Tong, Dapeng Sun: critical revision of manuscript for intellectual content; Yinuo Huang, Zifei Han, Bo Wang, Baixue Jia, Zhenbo Shi,: performed the data collection and data analysis; Feng Gao, Ning Ma: study supervision; Zhongrong Miao and Dapeng Mo: study concept and design, analysis and interpretation of data, critical revision of manuscript for intellectual content.\u003c/p\u003e\u003ch2\u003eAcknowledgments\u003c/h2\u003e \u003cp\u003eThe Study Funded by Beijing Municipal Science \u0026amp; Technology Commission (Z221100007422053) and the Beijing Municipal Administration of Hospitals Incubating Program (PX2017009) to Dapeng Mo and Youth Training Program of Beijing Hospitals Authority (No. QML20190505) to Gang Luo.\u003c/p\u003e\u003ch2\u003eData Availability\u003c/h2\u003e\u003cp\u003eThe data used in this study can be available upon reasonable request from the corresponding Author.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eSatti, S. R., Leishangthem, L. \u0026amp; Chaudry, M. I. Meta-analysis of csf diversion procedures and dural venous sinus stenting in the setting of medically refractory idiopathic intracranial hypertension. \u003cem\u003eAJNR Am. J. Neuroradiol.\u003c/em\u003e \u003cb\u003e36\u003c/b\u003e, 1899\u0026ndash;1904 (2015).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKanagalingam, S. \u0026amp; Subramanian, P. S. Cerebral venous sinus stenting for pseudotumor cerebri: A review. \u003cem\u003eSaudi J. ophthalmology: official J. Saudi Ophthalmological Soc.\u003c/em\u003e \u003cb\u003e29\u003c/b\u003e, 3\u0026ndash;8 (2015).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eFargen, K. M. et al. Recommendations for the selection and treatment of patients with idiopathic intracranial hypertension for venous sinus stenting. \u003cem\u003eJ. Neurointerv Surg.\u003c/em\u003e \u003cb\u003e10\u003c/b\u003e, 1203\u0026ndash;1208 (2018).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLublinsky, S. et al. Automated cross-sectional measurement method of intracranial dural venous sinuses. \u003cem\u003eAJNR Am. J. Neuroradiol.\u003c/em\u003e \u003cb\u003e37\u003c/b\u003e, 468\u0026ndash;474 (2016).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBoddu, S. R., Gobin, P., Oliveira, C., Dinkin, M. \u0026amp; Patsalides, A. Anatomic measurements of cerebral venous sinuses in idiopathic intracranial hypertension patients. \u003cem\u003ePloS one\u003c/em\u003e. \u003cb\u003e13\u003c/b\u003e, e0196275 (2018).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRaynald, Chen, N. et al. Intravascular ultrasound characteristics of different types of stenosis in idiopathic intracranial hypertension with venous sinus stenosis. \u003cem\u003eJ. neurointerventional Surg.\u003c/em\u003e \u003cb\u003e16\u003c/b\u003e, 506\u0026ndash;511 (2024).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLevine, G. N. et al. 2011 accf/aha/scai guideline for percutaneous coronary intervention. A report of the american college of cardiology foundation/american heart association task force on practice guidelines and the society for cardiovascular angiography and interventions. \u003cem\u003eJ. Am. Coll. Cardiol.\u003c/em\u003e \u003cb\u003e58\u003c/b\u003e, e44\u0026ndash;122 (2011).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eClark, D. J., Lessio, S., O'Donoghue, M., Schainfeld, R. \u0026amp; Rosenfield, K. Safety and utility of intravascular ultrasound-guided carotid artery stenting. \u003cem\u003eCatheterization Cardiovasc. interventions: official J. Soc. Cardiac Angiography Interventions\u003c/em\u003e. \u003cb\u003e63\u003c/b\u003e, 355\u0026ndash;362 (2004).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eJoan, M. M. et al. Utility of intravascular ultrasound examination during carotid stenting. \u003cem\u003eAnn. Vasc. Surg.\u003c/em\u003e \u003cb\u003e23\u003c/b\u003e, 606\u0026ndash;611 (2009).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRaynald, Huo, X. et al. Characteristics and outcomes of the idiopathic intracranial hypertension treatment in intrinsic and extrinsic stenosis: A single-center experience in china. \u003cem\u003eNeurol. therapy\u003c/em\u003e. \u003cb\u003e10\u003c/b\u003e, 1029\u0026ndash;1044 (2021).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWest, J. L. et al. Correlation between angiographic stenosis and physiologic venous sinus outflow obstruction in idiopathic intracranial hypertension. \u003cem\u003eJ. Neurointerv Surg.\u003c/em\u003e \u003cb\u003e11\u003c/b\u003e, 90\u0026ndash;94 (2019).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAsif, H. et al. Idiopathic intracranial hypertension: 120-day clinical, radiological, and manometric outcomes after stent insertion into the dural venous sinus. \u003cem\u003eJ. Neurosurg.\u003c/em\u003e \u003cb\u003e129\u003c/b\u003e, 723\u0026ndash;731 (2018).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBoddu, S. D. M. \u0026amp; Patsalides, A. Role of intravascular ultrasound in the intracranial cerebral venous sinus angioplasty and stenting. \u003cem\u003eJ. Neurointerv Surg.\u003c/em\u003e \u003cb\u003e7(Suppl\u003c/b\u003e (1), A92\u0026ndash;A93 (2015).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRaper, D. M. S. et al. Patency of the vein of labbe after venous stenting of the transverse and sigmoid sinuses. \u003cem\u003eJ. Neurointerv Surg.\u003c/em\u003e \u003cb\u003e9\u003c/b\u003e, 587\u0026ndash;590 (2017).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDinkin, M. J. \u0026amp; Patsalides, A. Venous sinus stenting for idiopathic intracranial hypertension: Where are we now? \u003cem\u003eNeurol. Clin.\u003c/em\u003e \u003cb\u003e35\u003c/b\u003e, 59\u0026ndash;81 (2017).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLenck, S. et al. Stenting of the lateral sinus in idiopathic intracranial hypertension according to the type of stenosis. \u003cem\u003eNeurosurgery\u003c/em\u003e \u003cb\u003e80\u003c/b\u003e, 393\u0026ndash;400 (2017).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eShazly, T. A. et al. Venous sinus stenting shortens the duration of medical therapy for increased intracranial pressure secondary to venous sinus stenosis. \u003cem\u003eJ. Neurointerv Surg.\u003c/em\u003e \u003cb\u003e10\u003c/b\u003e, 310\u0026ndash;314 (2018).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSonoda, S. et al. Current clinical use of intravascular ultrasound imaging to guide percutaneous coronary interventions. \u003cem\u003eCardiovasc. intervention Ther.\u003c/em\u003e \u003cb\u003e35\u003c/b\u003e, 30\u0026ndash;36 (2020).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eIchimoto, E. et al. Mechanism of edge restenosis after sirolimus-eluting stent implantation. \u003cem\u003eJ. Invasive Cardiol.\u003c/em\u003e \u003cb\u003e24\u003c/b\u003e, 55\u0026ndash;57 (2012).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSun, X. et al. Risk factors of subacute thrombosis after intracranial stenting for symptomatic intracranial arterial stenosis. \u003cem\u003eStroke\u003c/em\u003e \u003cb\u003e48\u003c/b\u003e, 784\u0026ndash;786 (2017).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAttia, R. et al. Risk factors associated with progression from papilloedema to optic atrophy: Results from a cohort of 113 patients. \u003cem\u003eBMJ open. Ophthalmol.\u003c/em\u003e ;\u003cb\u003e8\u003c/b\u003e (2023).\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"scientific-reports","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"scirep","sideBox":"Learn more about [Scientific Reports](http://www.nature.com/srep/)","snPcode":"","submissionUrl":"","title":"Scientific Reports","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Scientific Reports","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Cerebral Venous Sinus, intravascular ultrasound, digital subtraction angiography","lastPublishedDoi":"10.21203/rs.3.rs-5216428/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-5216428/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBACKGROUND\u003c/h2\u003e \u003cp\u003eThe value of intravascular ultrasound (IVUS) in the diagnosis and treatment of the venous system is not well established.\u003c/p\u003e\u003ch2\u003eOBJECTIVE\u003c/h2\u003e \u003cp\u003eIntroducing a novel approach to utilizing IVUS to evaluate cerebral venous sinus (CVS) stenosis and select stent.\u003c/p\u003e\u003ch2\u003eMETHODS\u003c/h2\u003e \u003cp\u003eIdiopathic intracranial hypertension (IIH) patients with CVS stenosis who underwent IVUS-guided stenting were included in the data analysis from January 2014 to February 2022. The degree of maximum stenosis was determined based on the cross-sectional area (CSA) measured by IVUS, and a stent selection method was applied in the study. Follow-up evaluations were conducted at 6 months to 1 year after endovascular treatment to assess symptom improvement. Additionally, repeated digital subtraction angiography (DSA) or Magnetic resonance venography (MRV) / (CT venography) CTV was performed to evaluate the stent patency at 6 months to 1 year post-procedure.\u003c/p\u003e\u003ch2\u003eRESULTS\u003c/h2\u003e \u003cp\u003eThe study included 61 patients. IVUS indicated a lower degree of stenosis compared to conventional DSA measurements when evaluating the degree of stenotic segments preprocedure (74.84\u0026thinsp;\u0026plusmn;\u0026thinsp;10.12% vs. 78.48\u0026thinsp;\u0026plusmn;\u0026thinsp;8.72%, p\u0026thinsp;=\u0026thinsp;0.035). Post-procedural CSA of the most severe stenotic segments showed significant improvement (36.44\u0026thinsp;\u0026plusmn;\u0026thinsp;8.07 mm\u003csup\u003e\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u003c/sup\u003e vs. 7.42\u0026thinsp;\u0026plusmn;\u0026thinsp;3.28 mm\u003csup\u003e\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u003c/sup\u003e, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001). The stent achieved complete expansion (mean stent expansion index, 0.93\u0026thinsp;\u0026plusmn;\u0026thinsp;0.20) with no significant change in the structure of the reference segment. The trans-stenotic mean pressure gradients (MPGs) across 61 patients significantly decreased from 11.00\u0026thinsp;\u0026plusmn;\u0026thinsp;6.23 mmHg to 2.09\u0026thinsp;\u0026plusmn;\u0026thinsp;2.34 mmHg. 47 out of 61 patients received imaging follow-up; among them, 44 (93.6%) demonstrated stent patency in the follow-up imaging.\u003c/p\u003e\u003ch2\u003eCONCLUSION\u003c/h2\u003e \u003cp\u003eIVUS has great potential to evaluate the degree and extent of CVS stenosis, assist stent selection, and optimize stent position during the interventional procedure in conjunction with DSA.\u003c/p\u003e","manuscriptTitle":"Real Time Intravascular Ultrasound Evaluation and Stent Selection for Cerebral Venous Sinus Stenosis Associated with Idiopathic Intracranial Hypertension","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-04-03 06:59:53","doi":"10.21203/rs.3.rs-5216428/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Accepted","date":"2025-04-29T01:49:08+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-04-11T10:29:44+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"33032563697628841526610892907884601609","date":"2025-04-01T22:47:02+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-04-01T12:01:22+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-03-25T07:45:17+00:00","index":"","fulltext":""},{"type":"submitted","content":"Scientific Reports","date":"2025-03-16T09:09:01+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"scientific-reports","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"scirep","sideBox":"Learn more about [Scientific Reports](http://www.nature.com/srep/)","snPcode":"","submissionUrl":"","title":"Scientific Reports","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Scientific Reports","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"6bf4c2e0-e021-4b0d-acbb-80c02acdf9c7","owner":[],"postedDate":"April 3rd, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[{"id":46542827,"name":"Health sciences/Diseases/Neurological disorders"},{"id":46542828,"name":"Health sciences/Neurology/Neurological disorders"}],"tags":[],"updatedAt":"2025-05-12T16:03:17+00:00","versionOfRecord":{"articleIdentity":"rs-5216428","link":"https://doi.org/10.1038/s41598-025-00505-5","journal":{"identity":"scientific-reports","isVorOnly":false,"title":"Scientific Reports"},"publishedOn":"2025-05-11 15:57:42","publishedOnDateReadable":"May 11th, 2025"},"versionCreatedAt":"2025-04-03 06:59:53","video":"","vorDoi":"10.1038/s41598-025-00505-5","vorDoiUrl":"https://doi.org/10.1038/s41598-025-00505-5","workflowStages":[]},"version":"v1","identity":"rs-5216428","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-5216428","identity":"rs-5216428","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}