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Background and Objectives Venous sinus stenting (VSS) is an established treatment for medically refractory idiopathic intracranial hypertension (IIH), yet the clinical significance of bilateral trans-stenotic venous pressure gradients and the optimal stenting strategy in this setting remain poorly defined.Methods We retrospectively reviewed prospectively collected data on consecutive IIH patients undergoing VSS at a single institution (2021-2024). Only patients with a trans-stenotic gradient ≥8 mmHg confirmed by venous manometry were included. Primary outcomes included symptom improvement, overall treatment response, and need for repeat VSS.Results Ninety-two patients were included, of whom 44 (48%) demonstrated bilateral venous pressure gradients. Bilateral gradients were more prevalent among Black patients (p = 0.041) but were not associated with differences in lumbar puncture opening pressure, presenting symptoms, or emergent presentation (p ≥ 0.05). Among patients with bilateral gradients, unilateral stenting was associated with lower rates of satisfactory clinical response (23% vs 74%; p=0.002) and higher rates of repeat intervention (62% vs 3.2%; p<0.001) compared with bilateral stenting. Tinnitus resolution was significantly more frequent following bilateral stenting (11% vs 68%; p = 0.005). Clinical outcomes following staged bilateral stenting after failed unilateral treatment were comparable to those achieved with index bilateral stenting.Conclusions Bilateral venous pressure gradients are common in IIH and identify a subgroup in whom unilateral stenting alone may be insufficient. In these cases, upfront bilateral stenting is often needed and associated with superior clinical outcomes.Disclosures V. El-Hajj: None.