2016 Sep;47(9):2180-2. In the study, 11 women and one man were offered transverse sinus stenting as an alternative to surgical shunting, but only after weight loss, dieting, and drug therapy with acetazolamide, or Diamox, a medication that lowers pressure in the brain, had failed to alleviate their symptoms. The same color arrows apply, including flow jets (green, purple). Patients with a trans-stenosis gradient of 8 mmHg were included, and subsequently underwent venous sinus stenting under GA. A database of patients who underwent VSS during this time period was recorded, while . The most under-recognized cause of pulsatile tinnitus is venous sinus stenosis. The .gov means its official. and patients with stenosis are currently being . The PubMed wordmark and PubMed logo are registered trademarks of the U.S. Department of Health and Human Services (HHS). . The transverse sinuses drain the superior sagittal, occipital, and straight sinus and empties into the sigmoid sinus. Thin section temporal bone CT shows some pretty impressive thinning of the mastoid petrous bone lateral to the sinus. An official website of the United States government. Stenosis of the transverse sinus (TS) and sigmoid sinus (SS), with a trans-stenosis pressure gradient, has been implicated in the pathophysiology of idiopathic intracranial hypertension (IIH). Objective Evaluate the role of venous sinus stenting in the treatment of pulsatile tinnitus among patients with Idiopathic Intracranial Hypertension (IIH) and significant venous sinus stenosis. MRI imaging shows it best. Normal range has not been established but less than 5 cm is expected. Thirty-seven consecutive patients with IIH . The direction of blood flow, impacting temporal bone and sculping out the diverticulum, is shown by open arrow, Cross eye stereo pair images of the same patient. Venous Sinus Stenosis is a type of cerebral venous system disease that obstructs venous blood outflow. Mirror image stenosis on the left is standard. During the following 12~126 months (the median was 62) after stenting of the follow-up, 91.9% (57/62) of the patients obtained good outcomes. Epub 2017 Jan 10. Conclusion: Idiopathic intracranial hypertension (IIH), also known as pseudotumor cerebri, is a condition that affects approximately 100,000 Americans, mostly young women. But if there is significant narrowing, blood flow becomes irregular and turbulent. Safety and efficacy comparison between OACs plus single antiplatelet and dual antiplatelet therapy in patients with cerebral venous sinus stenosis poststenting. Transient visual obscurations occurred in 69% of the patients. Anatomic Asymmetry of Transverse Sinus May Be Irrelevant to the Prognosis of Intracerebral Hemorrhage. You can get a referral for a neurosurgeon to evaluate it. The University of Illinois Hospital and Clinics is a patient-centered organization. MeSH This results in a pulsating, heartbeat-like sound being produced in the vein and picked up by the ear. This is the American ICD-10-CM version of G08 - other international versions of ICD-10 G08 may differ. These treatments often work very well in the beginning, but in the long run there is a risk of failure or requirement of re-treatment, said Dr. Athos Patsalides, an associate professor of radiology in neurological surgery at Weill Cornell Medicine. Accessibility Usually, contrast is better. 3 Cerebral Venous Sinus Thrombosis Incidence Is Higher Than Previously Thought: A Retrospective Population-Based Study. A modern, volumetric post-contrast T1 makes MRV pretty much obsolete. Pseudotumor cerebri is a disorder related to high pressure in the brain. The combined conduit score (CCS) is a grading scheme for the assessment of the degree of transverse-sigmoid sinus stenosis in the setting of idiopathic intracranial hypertension.The score was initially developed for ATECO MR venography 1.. Parameters. Below is a range of imaging findings in venous stenosis. Careful evaluation of the venous sinuses using angiographic methods may reveal inconspicuous stenosis, and endovascular treatment with stenting may be considered in selected cases. Im optimistic about this treatment and am hopeful its a long-term, better solution, Dr. Patsalides said.These specific findings were later published Oct. 21 in PLoS ONE. Li K, Ren M, Meng R, Ding Y, Rajah GB, Wang F, Ji X. J Neurointerv Surg. Endovascular Treatment of Pulsatile Tinnitus Caused by Dural Sinus Stenosis. The above case clearly shows that venous sinus stenosis can persist after shunt correction of intracranial pressure. Their function is to help absorb cerebrospinal fluid which surrounds the brain and spinal cord. This person had intracranial hypertension for over 10 years. the dural venous sinuses, most of which involve the transverse sinus.3,4 Venous sinus stenting of the area of stenosis lowers ICP and treats IIH.5 Since its intro-duction in 2002, venous sinus stenting continues to emerge as a minimally invasive surgical approach that is increasing in popularity with nearly 500 cases In this case, the dominant sinus and PT are both on the left. Some pressure gradient is normal due to head positioning. Raper DMS, Ding D, Chen CJ, Buell TJ, Crowley RW, Liu KC. Stphanie Lenck, MD Marc-Antoine Labeyrie, MD Fabrice Vallee Jean-Pierre Saint-Maurice, MD Antoine Guillonnet, MD Anne-Laure Bernat, MD Pierre Vironneau, MD Emmanuel Houdart, MD. Optic nerve appearance, visual map and spinal fluid pressure before and after venous stenting. The left distal vertebral artery backfills briefly with opacification of the left posterior inferior cerebellar artery. For those with isolated sinus stenosis, the long-term prognosis appears favorable. Venous Sinus Stenosis is a known cause for two conditions: Pulsatile Tinnitus and Idiopathic Intracranial Hypertension. Headaches improved in most patients as well. I've researched pulsatile tinnitus since none of my doctors could find a cause or seemed to know much about it, and have read that venous sinus stenosis is often a cause of pulsatile tinnitus. They are normally scattered throughout the sinuses and other dural structures. The venous stenosis resolved after placement of a stent (red). She went from doctor to doctor, but no one could pinpoint the cause of her condition. Transverse sinus stenosis (TSS) is one of the most common anomalies in venous PT, and it is also a clear etiology of this condition. If that was the only gain of the treatment, I would have been happy.. The 2023 edition of ICD-10-CM G08 became effective on October 1, 2022. Otology & Neurotology: February 2014 Volume 35 Issue 2 p 366370, John M. Mathis, Douglas Mattox, Patrick Malloy, Gregg Zoarski. Recently, a study of angiographic venous sinus diameters demonstrated significantly smaller TS and SSS calibers in patients with IIH compared with patients without IIH. 2017 Jun;9(6):587-590. doi: 10.1136/neurintsurg-2016-012903. When this happens, the pressure upstream of narrowing can become quite high. Our team utilized non-invasive methods measuring the flow within the venous sinus and use magnetic angiography to screen patients that might be candidates for such treatment. Idiopathic intracranial hypertension (IIH), also known as pseudotumor cerebri, is a condition that affects approximately 100,000 Americans, mostly young women. Patency of the vein of Labb after venous stenting of the transverse and sigmoid sinuses. PMC Shields LBE, Shields CB, Yao TL, Plato BM, Zhang YP, Dashti SR. World Neurosurg. . Case report and literature review. This result in improve in the pressure inside the brain and improve the headache and visual symptoms. 2017 Feb;35(1):59-81. doi: 10.1016/j.ncl.2016.08.006. I Dont Think They Exist. Here, there was a 4 mm abrupt pressure change across stenosis. All but the worst quality contrast MRs will show it. Venous stasis ulcers don't heal easily, and they can become infected. Arteriovenous Shunt, Surgical Embolization, Therapeutic Renal Dialysis Treatment Outcome Surgical Flaps The mean age of the 62 patients (range, 13 to 62) was 40 years old, and the mean body mass index was 26 (range 23 to 40). This condition is related to which of the following ? Sinus stenosis (without idiopathic intracranial hypertension) is a benign condition with no apparent increased risk of cerebrovascular accident. Pseudotumor cerebri is a disorder related to high pressure in the brain. Despite the fact that transverse sinus stenosis in IIH may be due to increased intracranial pressure, some authors believe that the rise in intracranial pressure and its effect are worsened by the secondary appearance of the venous sinus stenosis. official website and that any information you provide is encrypted However, There were still 8.0 % (5/62) of the patients with poor outcomes, including optic disc atrophy in 3 patients and stent-interior thrombosis in 2 patients, which occurred 6.3 months after stenting. Can the sound be abolished by ipsilateral jugular compression? My headaches progressed to the point where they were constant, Verostek said. Keywords: Venous sinus stenosis is initially diagnosed by magnetic resonance venography (MRV). At UI Health, our foundation in academic excellence leads to new possibilities in healthcare. Im optimistic about this treatment and am hopeful its a long-term, better solution, Dr. Patsalides said. The most commonly affected sites include the axillary, brachial, cephalic, or brachiocephalic veins, or the SVC. This condition is caused by accumulation of cerebrospinal fluid (CSF) in the brain and typically manifests with headaches and vision loss or other visual symptoms. 1,2 This treatment is effective in improving objective measures, such as papilledema and cerebrospinal fluid opening pressure, as well as improving symptoms of headache and tinnitus. Acting as one-way valves, the arachnoid villi, or arachnoid granulations, help to ensure that the pressure and volume of CSF surrounding the brain does not reach dangerous levels. What continues to be debated is which is the cause and which is the effect. Methods: Analytical, Diagnostic and Therapeutic Techniques and Equipment 5. Results: Verostek, who no longer gets IIH-related headaches and has regained vision in her left eye, said she couldnt imagine life without the surgery. WikiZero zgr Ansiklopedi - Wikipedia Okumann En Kolay Yolu . The vessels are of normal course, caliber and taper regularly. Other causes of venous PT also respond to jugular compression for example, jugular plate dehiscence or sigmoid diverticulum. Tachycardia, also called tachyarrhythmia, is a heart rate that exceeds the normal resting rate. A previous study reported that 84.6% of venous PT patients have varying degrees of bilateral TSS ( Hewes et al., 2020 ). Unlike veins, these sinuses possess no muscular coat. This condition is known as cellulitis, which is dangerous if not treated right away. Under normal circumstances blood flow is smooth. They hope to show stenting will have at least the same outcomes as shunting: improving vision as well as quality of life. These can protrude into the venous sinuses resulting in narrow pathways. Here is an unusual cause of pulsatile tinnitus on a non-dominant sinus side a sigmoid fenestration (arrow). Notice also mirror image flow jet on the left (purple). Weill Cornell Medicine researchers are now designing a head-to-head randomized trial between venous sinus stenting and shunting. However, for a substantial minority the sound is loud, constant, disruptive and profoundly disturbing. These are normal structures that we all have, and they live inside the sinuses, like outcroppings or peninsulas. Usually resolving spontaneously over months or years, it occasionally leads to chronic disability and visual loss. doi: 10.1016/j.wneu.2018.09.070. Acta Neurochirurgica. 2013 Sep 1;5(5):483-6. doi: 10.1136/neurintsurg-2012-010468. Weill Cornell MedicineOffice of External Affairs Thieme Medical Publishers, Inc., 381 Park Avenue South, New York, NY 10016, Pulsatile Tinnitus Venous Sinus Stenosis and Stenting, Arterial Dissection Carotid, Vertebral, Basilar Arteries, Diagnosis and Treatment of Pulsatile Tinnitus, Internal Carotid Artery and Its Aneurysms, Dural Venous Vasculature Intrinsic Dural and Skull Veins, Spinal Vascular Malformations (umbrella page), Cavernous Sinus Dural Fistula Occluded Inferior Petrosal Sinus Access, Compression Fracture Reduction Kyphoplasty Height Restoration Cord Compression Improvement, Gamma Knife DYNA CT Cone Beam CT Targeting, A Case of Even More Critical Basilar Occlusion, Angiography Thalamic Hemorrhage Spot Sign, Archives CT Perfusion of Artery of Percheron Occlusion and Thrombectomy, Archives Falcotentorial Dural Fistula Angiogram, Archives Stroke Intervention Something For Everyone, Archives Traumatic Middle Meningeal Artery Fistula, Archives ACOM aneurysm treatment with bilateral Pipeline devices, Archives Aneurysm Post-Clip Rerupture and Treatment, Archives Blister Aneurysm Pipeline Embolization, Archives Coiled Aneurysm Re-Rupture and Retreatment, Archives Dural Fistula at Anterior Spinal Artery Pedicle Embolization, Archives Dural Fistula Embolization Protecting the Anterior Spinal Artery, Archives Dural Fistula Sagittal Sinus with Parenchymal Hemorrhage, Archives Epidural Hematoma and Middle Meningeal Artery Fistula, Archives Foramen Magnum Preoperative Embolization Particles and nBCA, Archives Left Radial Artery Access Intracranial Vertebral Artery Stent, Archives Petroclival Meningioma Embolization Major ILT Supply, Archives Radial Access Carotid Cavernous Fistula Embolization, Archives Radial Small Right Paraophthalmic Aneurysm, Archives Sigmoid Sinus Fenestration in Pulsatile Tinnitus, Archives Sigmoid Sinus Fistula Focal Trapped Segment, Archives Stroke Balloon-Assisted Tracking Technique, Archives Stroke Distal MCA M4 Mechanical Thrombectomy, Archives Superselective Dural Fistula Embolization 4, Archives Terson Syndrome Subarachnoid Hemorrhage, Archives-Stroke-M3-Sofia5F-aspiration-thrombectomy-and-cool-venous-variants-to-boot, Archives-Ultrasound-Guided-Femoral-Pseudoaneurysm-Compression, Archives_Ethmoid_Fistula_Tranvenous_Embolization, Archives_Lateral_Spinal_Artery_Thrombectomy, Archives_Sphenoparietal_Sinus_aka_Greater_Wing_of_Sphenoid_Dural_Fistula, Archives_Stroke_Bihemispheric_PICA_Lateral_Spinal_Artery, Archives_Stroke_Persistent_Stapedial_Artery_Collateral, Archives_Ulnar_Artery_Access_ACOM_Coiling_Balloon_Protection, BANANA BITES Preoperative Embolization Sphenoid Wing Meningioma Both Arteries and Veins are Important, Basilar Terminus Fenestration vs. SCA aneurysm Good Angiographic Technique, Basilar Thrombectomy via Posterior Communicating Artery, Basilar-ectasia-dissection-pure-arterial-malformation-what-is-it, Bilateral ACA and left MCA emboli use of Perfusion and knowledge of anatomy guide intervention, Brain AVM Symptomatic Venous Varix Embolization, C1 Dural Fistula Endovascular and Surgical Treatment, Carotid Revascularization and Perfusion Pearls, Carotid Web Recurrent Emboli The Imperfect Storm, Case Archives Bow Hunters Syndrome (positional vertebrobasilar insufficiency), Case Archives Carotid Web a Rare Cause of Embolic Stroke, Case Archives Cavernous Sinus Dural Fistula MHT embolization, Case Archives Differential Diagnosis of Skull Base Lesion, Case Archives Dissection with False Lumen, Case Archives Dorsal Spinal Epidural Hematoma, Case Archives Kyphoplasty Paying Attention to Fracture Lines, Case Archives Post-traumatic occipital dural fistula, Case Archives The Nonhappening Epidural Hematoma Post-traumatic Dural Fistula, Case Archives Trigeminal Neuralgia from Lateral Pontine Vein Compression, Case Archives Ventriculostomy (EVD) Hematoma Another Curious Case for the Angiogram, Case Archives Anterior Spinal Artery Duplication, Case Archives Bilateral Carotid Dissections with Lower Cranial Nerve Dysfunction, Case Archives Direct Occipital Dural Fistula Embolization, Case Archives Foramen Magnum Meningioma Embolization, Case Archives Petroclival Meningioma Embolization with MHT Access, Case Archives Postoperative Venous Infarction, Case Archives Sigmoid Sinus Dural Fistula with Extensive Venous Infarction, Case Archives Spinal Cord Hemangioblastoma Preoperative Embolization, Case Archives Sturge Weber Syndrome (Encephalotrigeminal Angiomatosis), Case_Archives_Anterior_Spinal_Artery_PICA_Reconstitution, Cavernous Dural Fistula Achilles Heel Superselective Embolization, Cavernous Sinus Dural Fistula Direct Transorbital Access, Cavernous Sinus Fistula Access via Occluded SUPERIOR Petrosal Sinus, Cerebral Angiography Recognizing Intraprocedural Emboli, Charcot-Bouchard Aneurysms Of Unusual Size? In general, a resting heart rate over 100 beats per minute is accepted as tachycardia in adults. G08 is a billable/specific ICD-10-CM code that can be used to indicate a diagnosis for reimbursement purposes. Recent research showed that many patients with IIH have narrowed veins of the brain, which leads to accumulation of fluid in the brain and an increase in intracranial pressure. All patients were treated at Weill Cornell Medicine. If a significant pressure gradient is detected, a stent is placed. Bethesda, MD 20894, Web Policies Venous Sinus Stenting for Idiopathic Intracranial Hypertension: Where Are We Now? In fact, if you pay attention you will notice that lots of diverticula have an associated stenosis just upstream. The natural history of venous sinus stenosis is overwhelmingly benign. Disclaimer. Stenosis at the proximal transverse/sigmoid sinus junction is the most common location, and can be caused by chronic sinus thrombosis or arachnoid granulations. Its a Siemens volumetric MP-RAGE. Thanks to more education, now they are often correctly picked up and reported. However, there is a lack of evidence of the long-term good outcomes in patients with CVSS who underwent stenting. Venous Sinuses are the large veins located in the brain. 42% of the patients suffered from visual loss, 11.3% pulsatile tinnitus, and 96.8% Papilledema before stenting. 2019 Mar;11(3):307-312. doi: 10.1136/neurintsurg-2018-014328. It causes signs and symptoms of a brain tumor. Does elevated pressure result in collapse of the sinus? I had ten blood clots to the brain and had sever swelling. The visual fields (center) show the vision out of each eye from the patients perspective (white spots are intact, dark spots are missing). In such cases, venous sinus stenting can be extremely effective as a durable cure. From there, the drainage goes to the jugular bulb. University of Illinois Hospital1740 West Taylor StreetChicago, IL 60612, 2023 University of Illinois Hospital & Health Sciences System, Neurology and Neurosurgery Patient Stories. Synonyms: cerebral vein thrombosis, intracranial sinus thrombosis. Symptoms and Causes Chronic venous insufficiency causes many symptoms in your legs and feet. There is as good a flow jet artifact as you can get (green). The question as to whether intracranial hypertension causes venous sinus stenosis or the other way around remains unanswered. Its size and position make it an unlikely cause of PT However, in a few causes they see to be the culprit. A visit to the hospital can be overwhelming. Frontal right ICA views. The symptoms and signs of IH prior to stenting and post-stenting and the incidence of restenosis after stenting were analyzed. TOF MRV of the same patient. Careers. The transverse and sigmoid venous sinuses are located in proximity to the ear (from the brain side). It is a common and usually asymptomatic / incidental finding. Phone: (646) 962-9476, Weill Cornell Medicine researchers are now designing a head-to-head randomized trial between venous sinus stenting and shunting. This condition is caused by accumulation of cerebrospinal fluid (CSF) in the brain and typically manifests with headaches and vision loss or other visual symptoms. Venous sinus stenosis impairs the flow of blood from the brain to the neck, and this backlog causes an excessive amount of CSF to accumulate in the brain, resulting in increased pressure and intracranial hypertension. BACKGROUND AND PURPOSE: Patients with idiopathic intracranial hypertension have transverse sinus stenosis on gadolinium-bolused MRV, but other MR imaging signs are less consistently seen. The sound is typically on the side of the bigger sinus. Notice how much worse the quality is. It is not very much (above 5 is better) but given overall clinical and imaging picture is certainly good enough, Pre-stent measurements. One to two weeks before the procedure, the patient will be instructed to take blood thinners. However, the utility of characterizing stenosis as intrinsic or extrinsic remains indeterminate. Venous sinus stenosis, particularly of the sigmoid sinus, is common and, in vast majority of cases, asymptomatic. Mirror image hypoplastic sinus stenosis (purple) on left, Pressure gradient across the stenosis, as measured by Volcano 014 pressure wire. The transverse and sigmoid venous sinuses that were previously mentioned, run very close to the ear. Below is an example of a really large diverticulum, remodeling the temporal bone, on a DYNA CT modern angiographic version of temporal bone CT, The angiogram shows the diverticulum (arrows). The investigators found that every patient who underwent stenting for venous sinus stenosis had significant improvement in intracranial pressure and all visual parameters. Endovascular Treatment for Venous Sinus Stenosis in Idiopathic Intracranial Hypertension: An Observational Study of Clinical Indications, Surgical Technique, and Long-Term Outcomes. Most patients with pulsatile tinnitus due to venous stenosis are able to tolerate the sound, especially once they learn that the cause is usually not dangerous. A flattened appearance of the sinus is typical, Another patient with IH same flattened appearance of the sinus. As the name implies, it involves placement of a metallic mesh in the shape of a tube/stent in narrowed vein to expand the vein and resolve the narrowing. In such cases, venous sinus stenting can be extremely effective as a durable cure. A CT of the same patient is shown on the left, next to the MRI. At UI Health, we strive to make the patient and visitor experience as stress-free and comfortable as possible. Angio. Hello, I was diagnosed with CVST last year of March. A contrast MRI will do just fine. Venous sinus stenting for idiopathic intracranial hypertension: a review of the literature. It is also called intracranial hypertension. We all know that water shapes stone. FOIA Traditionally, treatment for IIH involves the medication acetazolamide, which reduces the rate of production of CSF fluid, or a surgical procedure called shunting, which involves inserting a tube in the brain that drains excess CSF fluids. However, that is not always the case. However, there are clear instances of sinus stenosis resolution following stenting or immeidately after lumbar puncture. This site needs JavaScript to work properly. To date, very few complications have been reported in IIH patients with venous sinus stent placement. The mean trans-stenotic pressure gradients were 6~43 mmHg prior to stenting and returned to 0~4 mmHg after stent placement. a) Vertebral artery stenosis on left side b) Vertebral artery stenosis on right side c) Subclavian . It is difficult to prove however that they are, unless the diverticulum can be selectively occluded. Patients Sinus venosus defect Subvalvar aortic stenosis (excluding HCM; HCM not addressed in these guide-with previously repaired aortic dissection should avoid high-intensity lines) resistance ET.14 Supravalvar aortic stenosis Straddling atrioventricular valve Ebstein's anomaly Repaired tetralogy of Fallot VSD with . It is likely caused by a collection of arachnoid granulations which are seen as lucent areas a the level of stenosis, Vertebral artery injection best shows stenoses because it fills both sides more evenly most of the time, Pressure measurements, 26-28 cm Hg at superior sagittal sinus and 18 cm Hg at jugular vein. Patients with CVSS may get long-term benefit from stenting, especially when they are accompanied with severe IH. Wires in heart chambers. The transverse (blue) and sigmoid (white) sinuses are normal. Years of jet flow have remodelled the temporal bone to produce a diverticulum (blue). Venous Sinus Stenosis can lead to pulsatile tinnitus. Devasagayam S, Wyatt B, Leyden J, Kleinig T. Stroke. Epub 2012 Aug 4. Like. Idiopathic Intracranial Hypertension is a condition that is characterized by the presence of high pressure in the head. Clipboard, Search History, and several other advanced features are temporarily unavailable. 1300 York AvenueBox 314 of life. Venous Sinus Stenosis is a type of cerebral venous system disease that obstructs venous blood outflow. After my diagnosis, all I saw was a bleak future, until I was presented with a new option.. Bai C, Chen Z, Wu X, Ilagan R, Ding Y, Ji X, Meng R. BMC Neurol. Two weeks after my diagnosis, I lost vision in my left eye, my hearing was going and I was basically bedridden., Bilateral transverse sinus stenosis (veins in blue). This simple and reproducible maneuver stops or markedly reduces flow in the entire transverse/sigmoid/jugular pathway. The above stenosis persisted after shunt placement and further confirmation of shunt function by resolution of most intracranial hypertension symptoms and with valve knowledge of shunt pressure. Sound is usually on the side of bigger sinus with more flow. Venous manometry results from 32 intracranial venous sinus stenosis patients who had undergone diagnostic angiography were obtained. Global views, early and late venous phases. Venous sinus stenosis can cause similar symptoms, but the source of the pressure is what differs. Here is a typical postcontrast axial MRI. This website uses cookies and third party services. 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And sigmoid sinuses a brain tumor the SVC drainage goes to the MRI common usually. Now designing a head-to-head randomized trial between venous sinus stenosis is a type of venous. In a pulsating, heartbeat-like sound being produced in the brain and sever. Patient who underwent stenting for is venous sinus stenosis dangerous intracranial hypertension collapse of the same patient is shown on side! Of a stent ( red ) is as good a flow jet as. Correction of intracranial pressure causes many symptoms in your legs and feet called. Apparent increased risk of cerebrovascular accident mmHg prior to stenting and returned to 0~4 mmHg after stent.., I was diagnosed with CVST last year of March ( green, purple ) compression... Underwent stenting for Idiopathic intracranial hypertension for over 10 years section temporal bone CT shows some pretty impressive thinning the.