{
  "abstract": "Introduction Trigeminal neuralgia (TN) is classically attributed to arterial neurovascular compression; however, atypical mechanisms such as regional intracranial venous hypertension may produce a pressure-dependent form of TN that remains underrecognized. This potentially reversible etiology has important diagnostic and therapeutic implications. Venous sinus stenting (VSS) is an established treatment for intracranial venous outflow obstruction, though its role in TN is rarely reported. We present a case of pressure-dependent TN successfully treated with transverse sinus stenting, emphasizing the importance of venous hemodynamics in TN evaluation.Materials and Methods A 33-year-old female presented with recurrent, left-sided, electric shock-like facial pain in the V2/V3 distribution, refractory to medical therapy, including carbamazepine and oxcarbazepine. Brain magnetic resonance imaging demonstrated a prominent vein contacting the proximal cisternal segment of the trigeminal nerve without evidence of neurovascular compression ( figure 1-A). Lumbar puncture revealed elevated opening pressure (29 cm H2O), with transient pain relief lasting several days, suggesting a pressure-dependent mechanism. MR venography identified bilateral transverse sinus narrowing (figure 1-B), and diagnostic cerebral venography confirmed severe right transverse sinus stenosis with a trans-stenotic gradient of approximately 10 mmHg and hypoplastic left transverse sinus. Contrast injection in the proximal right transverse sinus demonstrated engorged veins along the skull base. (figure 1-C). Based on imaging and hemodynamic data, the patient underwent endovascular angioplasty and stenting of the right transverse sinus under general anesthesia, with post-stenting venography confirming resolution of the stenosis and of the trans-stenotic gradient (figure 1-D).Results Immediately following stenting, the patient reported complete resolution of TN. Follow-up imaging demonstrated patency of the stent without evidence of complications. The patient discontinued all neuropathic medications and remained pain-free at subsequent follow-up. The correlation of symptom improvement with lumbar puncture and post-stenting hemodynamic changes supports the diagnosis of pressure-dependent TN secondary to regional venous hypertension. No adverse events were observed, and clinical follow-up confirmed durable symptom resolution. At 6-month follow-up, the patient continued to report complete and sustained resolution of TN , supporting the durability of the intervention.Conclusion Regional intracranial venous hypertension can cause pressure-dependent TN without arterial compression. In patients with refractory TN and hemodynamically significant transverse sinus stenosis, endovascular stenting offers a targeted and durable treatment. Recognizing this mechanism is critical for appropriate selection and management. Further studies are needed to refine hemodynamic criteria and evaluate long-term outcomes of VSS.Disclosures E. Rahmanova: None. S. Rahmanov: None. B. Adada: None. H. Borghei-Razavi: None. M. Obrzut: None.Abstract E-207 Figure 1A. Contrast enhanced T1 weighted axial MRI image demonstrates a prominent vein in contact with the left trigeminal nerve root entry zone (long white arrow). B. Contrast enhanced MR venogram demonstrates a severe stenosis in the dominant right transverse sinus (short white arrow), with a hypoplastic left transverse sinus. C. Selective microcatheter injection in the proximal right transverse sinus demonstrates a severe stenosis of the right transverse sinus (short black arrow) and a hypoplastic left transverse sinus. There is significant venous drainage through engorged veins along the skull base. D. Selective microcatheter injection in the proximal right transverse sinus after stent placement across the stenosis demonstrates complete resolution of the stenosis (curved black arrow). There is now preferential venous flow through the right transverse sinus",
  "authors": [
    {
      "affiliations": [
        "Neurology, Cleveland Clinic Florida, Weston, FL"
      ],
      "name": "E Rahmanova"
    },
    {
      "affiliations": [
        "Neurology, Cleveland Clinic Florida, Weston, FL"
      ],
      "name": "S Rahmanov"
    },
    {
      "affiliations": [
        "Neurology, Cleveland Clinic Florida, Weston, FL"
      ],
      "name": "B Adada"
    },
    {
      "affiliations": [
        "Neurology, Cleveland Clinic Florida, Weston, FL"
      ],
      "name": "H Borghei-Razavi"
    },
    {
      "affiliations": [
        "Neurology, Cleveland Clinic Florida, Weston, FL"
      ],
      "name": "M Obrzut"
    }
  ],
  "title": "E-207 Endovascular transverse sinus stenting as a targeted management strategy for pressure-dependent trigeminal neuralgia",
  "uid": "01646c27-4c93-5cd0-9d9a-b3f17127b3c2"
}