Hemodynamic unmasking of serial cerebral venous sinus stenoses following treatment of the rate-limiting lesion

An 18-year-old female presented with headaches, transient visual obscurations, and papilledema secondary to a primary superior sagittal sinus (SSS) stenosis caused by compression from a presumed parasagittal meningioma, with an associated secondary dominant transverse-sigmoid junction (TSJ) stenosis.1 2 3 Initial venous manometry demonstrated a hemodynamically significant pressure gradient across the TSJ stenosis but only a 4 mm Hg gradient across the SSS stenosis. Following TSJ stenting, repeat venous manometry unmasked the hemodynamic significance of the SSS stenosis, prompting subsequent SSS stenting.4 5 Final venous manometry demonstrated elimination of all hemodynamically significant pressure gradients, with improvement in headaches and papilledema at follow-up.6 7 This technical video (video 1) demonstrates how serial cerebral venous sinus stenoses can confound interpretation of venous manometry; it highlights the importance of repeat venous manometry following treatment of the rate-limiting lesion, as the hemodynamic significance of adjacent stenoses may only become apparent once the dominant pressure gradient has been eliminated. Video 1 . Technical video demonstrating the impact of serial cerebral venous sinus stenoses on venous manometry and the role of repeat pressure measurements in guiding endovascular treatment.