Time is vision: a systematic review of urgent venous sinus stenting for fulminant idiopathic intracranial hypertension

We systematically evaluated the evidence for urgent venous sinus stenting (VSS) as a sight-saving strategy in fulminant idiopathic intracranial hypertension (IIH), a rapidly progressive phenotype with imminent risk of irreversible visual loss. A comprehensive search of PubMed, Embase, Web of Science, and Scopus identified reports of patients meeting fulminant IIH criteria who underwent VSS as an urgent intervention; eligible studies required detailed clinical characterization and post-stenting visual or papilledema outcomes. Seven studies published between 2015 and 2023, comprising 23 patients, met inclusion criteria. Across cohorts, patients were young, predominantly female, and uniformly presented with severe papilledema and rapidly declining visual function, frequently after failure or intolerance of maximal medical therapy and/or cerebrospinal fluid diversion. All patients had dural venous sinus stenosis with a documented trans-stenotic pressure gradient prior to treatment and underwent technically successful stent placement. Urgent VSS was associated with high rates of papilledema resolution or marked improvement. There was stabilization or improvement of visual acuity and visual fields in nearly all reported cases, and substantial relief of headache and pulsatile tinnitus where documented. Need for subsequent shunting or optic nerve sheath fenestration was uncommon, and reported complications were infrequent and non-catastrophic, with no procedure-related mortality. Although limited by small sample size, retrospective design, and heterogeneity in fulminant definitions and outcome reporting, the available data support urgent VSS as a rational, venous outflow–targeted, and potentially vision-preserving option in carefully selected fulminant IIH with venous sinus stenosis, warranting prospective, comparative evaluation.