Venous Sinus Stenting Versus Ventriculoperitoneal Shunting for Idiopathic Intracranial Hypertension: A Propensity Score-Weighted Comparative Analysis of Safety and Clinical Outcomes

BACKGROUND AND OBJECTIVES: Venous sinus stenting (VSS) and ventriculoperitoneal shunting (VPS) are established interventions for idiopathic intracranial hypertension (IIH), yet comparative evidence remains limited. Treatment selection is often influenced by institutional preference, and retrospective studies are frequently affected by baseline differences between patient groups. This study aimed to compare outcomes between VSS and VPS using propensity score overlap weighting to reduce confounding by indication and achieve balanced comparison. METHODS: A retrospective cohort study was conducted including all patients treated with VSS or VPS for IIH at a single institution between 2021 and 2024. Baseline demographics, clinical characteristics, procedural details, and postoperative outcomes were collected. Propensity scores were estimated using logistic regression, and overlap weights were applied to generate a balanced pseudopopulation. Weighted logistic regression was used to compare postoperative complications, clinical outcomes, unsatisfactory treatment response, and need for salvage procedures. RESULTS: A total of 139 patients were included (VSS: n = 99; VPS: n = 40). Overlap weighting achieved near-perfect covariate balance (all standardized mean difference <0.1). After weighting, VSS was associated with significantly lower odds of postoperative complications compared with VPS [odds ratio (OR) 0.06, 95% CI 0.02-0.23; P < .001]. Persistently elevated postoperative opening pressure was more frequent after VSS (OR 10.64, 95% CI 1.88-60.15; P = .008). Rates of unsatisfactory treatment response (OR 0.51, P = .153), need for salvage procedures (OR 1.80, P = .326), and resolution of headache, papilledema, tinnitus, and visual symptoms were not significantly different between treatments (all P ≥.05). CONCLUSION: In this propensity score-weighted comparison, VSS and VPS produced similar symptom-based outcomes and rates of unsatisfactory treatment response. However, VSS demonstrated a substantially more favorable procedural safety profile, with significantly fewer and less severe complications. These findings suggest that VSS may offer a safer alternative to VPS for appropriately selected patients while providing comparable clinical effectiveness.