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Potter O, Menon V, Mollan SP. Risk factors and disease associations in people living with idiopathic intracranial hypertension. Expert Rev Neurother 2024; 24:681-689. [PMID: 38803205 DOI: 10.1080/14737175.2024.2359420] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2024] [Accepted: 05/21/2024] [Indexed: 05/29/2024]
Abstract
INTRODUCTION Idiopathic intracranial hypertension is a neurological condition characterized by a raised intracranial pressure and papilledema, leading to chronic headaches and visual disturbances. By recognizing modifiable risk factors and deploying evidence-based interventions, healthcare providers have the potential to mitigate the burden of the disease and improve patient outcomes. AREAS COVERED It is well known that the condition occurs in predominantly pre-menopausal females who live with obesity particularly in the context of recent weight gain. This review discusses what risk factors may contribute to the metabolic underpinnings of cerebrospinal fluid dysregulation. There are a number of disease associations that are important to screen for as they can alter management. EXPERT OPINION There is emerging evidence to suggest that idiopathic intracranial hypertension is a systemic metabolic disease and it is unknown what are all the risk factors are that precipitate the condition. Targeting certain hardwired risk factors is unachievable. However, as recent weight gain has been identified as a predominant risk factor for the development of the disease and relapse, modification of body weight should be the primary aim of management. Insightful research into the involvement of the neuroendocrine axis driving cerebrospinal fluid dysregulation now has the potential for the development of therapeutic targets.
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Affiliation(s)
- Olivia Potter
- Birmingham Neuro-Ophthalmology, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Vaishnavi Menon
- Birmingham Neuro-Ophthalmology, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Susan P Mollan
- Birmingham Neuro-Ophthalmology, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
- Translational Brain Science, Institute of Metabolism and Systems Research, University of Birmingham, Edgbaston, UK
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Prem Senthil M, Anand S, Chakraborty R, Bordon JE, Constable PA, Brown S, Al-Dasooqi D, Simon S. Exploring the utility of retinal optical coherence tomography as a biomarker for idiopathic intracranial hypertension: a systematic review. J Neurol 2024:10.1007/s00415-024-12481-3. [PMID: 38856724 DOI: 10.1007/s00415-024-12481-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2024] [Revised: 05/24/2024] [Accepted: 05/26/2024] [Indexed: 06/11/2024]
Abstract
This study aimed to examine the existing literature that investigated the effectiveness of optical coherence tomography (OCT) and optical coherence tomography angiography (OCT-A) as a biomarker for idiopathic intracranial hypertension (IIH). Our search was conducted on January 17th, 2024, and included the databases, Medline, Scopus, Embase, Cochrane, Latin American and Caribbean Health Sciences Literature (LILACS), International Standard Randomized Controlled Trial Number (ISRCTN) registry, and the International Clinical Trials Registry Platform (ICTRP). Our final review included 84 articles. In 74 studies, OCT was utilized as the primary ocular imaging method, while OCT-A was employed in two studies including eight studies that utilized both modalities. Overall, the results indicated that IIH patients exhibited significant increases in retinal nerve fiber layer (RNFL) thickness, total retinal and macular thickness, optic nerve head volume, and height, optic disc diameter and area, rim area, and thickness compared to controls. A significant correlation was observed between cerebrospinal fluid (CSF) pressure and OCT parameters including RNFL thickness, total retinal thickness, macular thickness, optic nerve head volume, and optic nerve head height. Interventions aimed at lowering CSF pressure were associated with a substantial improvement in these parameters. Nevertheless, studies comparing peripapillary vessel density using OCT-A between IIH patients and controls yielded conflicting results. Our systematic review supports OCT as a powerful tool to accurately monitor retinal axonal and optic nerve head changes in patients with IIH. Future research is required to determine the utility of OCT-A in IIH.
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Affiliation(s)
- Mallika Prem Senthil
- College of Nursing and Health Sciences, Caring Futures Institute, Flinders University, Bedford Park, Adelaide, South Australia, 5042, Australia.
| | - Saumya Anand
- College of Nursing and Health Sciences, Caring Futures Institute, Flinders University, Bedford Park, Adelaide, South Australia, 5042, Australia
| | - Ranjay Chakraborty
- College of Nursing and Health Sciences, Caring Futures Institute, Flinders University, Bedford Park, Adelaide, South Australia, 5042, Australia
| | - Jose Estevez Bordon
- College of Nursing and Health Sciences, Caring Futures Institute, Flinders University, Bedford Park, Adelaide, South Australia, 5042, Australia
| | - Paul A Constable
- College of Nursing and Health Sciences, Caring Futures Institute, Flinders University, Bedford Park, Adelaide, South Australia, 5042, Australia
| | - Shannon Brown
- Central Library, Flinders University, Bedford Park, Adelaide, South Australia, Australia
| | - Dalia Al-Dasooqi
- College of Nursing and Health Sciences, Caring Futures Institute, Flinders University, Bedford Park, Adelaide, South Australia, 5042, Australia
| | - Simu Simon
- University of Adelaide, Adelaide, South Australia, Australia
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Cejvanovic S, Sheikh Z, Hamann S, Subramanian PS. Imaging the brain: diagnosis aided by structural features on neuroimaging studies. Eye (Lond) 2024:10.1038/s41433-024-03142-w. [PMID: 38783084 DOI: 10.1038/s41433-024-03142-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2024] [Revised: 04/29/2024] [Accepted: 05/08/2024] [Indexed: 05/25/2024] Open
Abstract
The use of neuroimaging allows the ophthalmologist to identify structural lesions in the orbit or along the neuroaxis that allow for more accurate diagnosis and treatment of patients with neuro-ophthalmic diseases. The primary imaging tools include computed tomography (CT) and magnetic resonance imaging (MRI), both of which can be used to evaluate the brain, spinal cord and canal, and orbits. Neurovascular structures, both arterial and venous, also can be imaged in high resolution with modern CT and MR angiography and CT and MR venography. In many cases, invasive procedures such as catheter angiography can be avoided with these studies, and angiography is often reserved for confirmation of vascular lesions combined with endovascular treatment. In this article, we illustrate how the evaluation of patients presenting with neuro-ophthalmic diseases involving the afferent and efferent visual pathways can be optimized with the use of appropriate diagnostic imaging studies. The complementary value of ophthalmic imaging is also demonstrated, and the advantages and disadvantages of both CT and MRI as well as their use in longitudinal patient follow up is demonstrated.
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Affiliation(s)
| | - Zahir Sheikh
- Department of Neurology, Sue Anschutz-Rodgers University of Colorado Eye Center and University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Steffen Hamann
- Department of Ophthalmology, Rigshospitalet, Glostrup, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Prem S Subramanian
- Department of Neurology, Sue Anschutz-Rodgers University of Colorado Eye Center and University of Colorado School of Medicine, Aurora, Colorado, USA.
- Department of Ophthalmology, Sue Anschutz-Rodgers University of Colorado Eye Center and University of Colorado School of Medicine, Aurora, Colorado, USA.
- Department of Neurosurgery, Sue Anschutz-Rodgers University of Colorado Eye Center and University of Colorado School of Medicine, Aurora, Colorado, USA.
- Department of Surgery (Division of Ophthalmology), Uniformed Services University of the Health Sciences, Bethesda, MD, USA.
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Friedman DI. The Pseudotumor Cerebri Syndrome. Neurol Clin 2024; 42:433-471. [PMID: 38575259 DOI: 10.1016/j.ncl.2024.02.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/06/2024]
Abstract
Pseudotumor cerebri syndrome is a syndrome of increased cerebrospinal fluid pressure without ventriculomegaly, mass lesion, or meningeal abnormality. It is either primary (idiopathic intracranial hypertension, IIH) or secondary. A secondary cause is unlikely when adhering to the diagnostic criteria. Permanent visual loss occurs if undetected or untreated, and the associated headaches may be debilitating. Fulminant disease may result in blindness despite aggressive treatment. This study addresses the diagnosis and management of IIH including new insights into the pathobiology of IIH, updates in therapeutics and causes of overdiagnosis.
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Bassi ST, Pamu R, Ambika S, Praveen S, Priyadarshini D, Dharini V, Padmalakshmi K. Optical coherence tomography in papilledema: A probe into the intracranial pressure correlation. Indian J Ophthalmol 2024; 72:672-676. [PMID: 38189420 PMCID: PMC11168544 DOI: 10.4103/ijo.ijo_1648_23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2023] [Revised: 10/02/2023] [Accepted: 10/05/2023] [Indexed: 01/09/2024] Open
Abstract
PURPOSE To study the optic nerve head characteristics on optical coherence tomography (OCT) in patients with papilledema and correlate them with intracranial pressure (ICP). METHODS A retrospective hospital-based study of 46 eyes of 23 patients with bilateral optic disc edema secondary to increased ICP. The clinical profile and the OCT features in terms of retinal nerve fiber layer thickness (RNFL), ganglion cell inner plexiform layer (GCIPL) thickness, and enhanced depth imaging (EDI) B scan images of the optic nerve head were studied and correlated with the ICP. RESULTS Papilledema was secondary to idiopathic intracranial hypertension (IIH) ( n = 20), obstructive hydrocephalus ( n = 2), and communicating hydrocephalus ( n = 1). The mean ICP in 20 IIH patients was 347 mmH 2 O. The ICP and RNFL thickness in all four quadrants were found to be weakly positively correlated: superior RNFL r (38) = 0.17, P = 0.30, and nasal RNFL r (38) = 0.30, P = 0.05, inferior RNFL r (38) = 0.29, P = 0.07, and temporal RNFL, r (38) = -0.001, P = 0.99. The GCIPL layer thickness and the ICP were weakly negatively correlated in all sectors: superior (38) = -0.23, P = 0.16, superonasal, r (38) = -0.07, P = 0.67, inferonasal r (38) = -0.08, P = 0.64, inferior r (38) = -0.21, P = 0.19, inferotemporal r (38) = -0.23, P = 0.17, superotemporal, r (38) -0.21, P = 0.20. Descriptive features on the B scan, such as peripapillary hyperreflective ovoid mass-like structures and microcystic spaces, were observed most commonly with an ICP of 251-350 mmH 2 O, and the hyperreflective dots in the RNFL layer and Bruch's membrane inward denting were observed more commonly with an ICP of 351-450 mmH 2 O. CONCLUSION The RNFL thickness in all four quadrants had a weak positive correlation, and the GCIPL layer had a weak negative correlation with the ICP. The EDI descriptive features on OCT may vary with ICP.
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Affiliation(s)
- Shikha Talwar Bassi
- Deputy Director, Department of Neuroophthalmology Services, Sankara Nethralaya, Chennai, Tamil Nadu, India
| | - Ramesh Pamu
- Resident, Department of Comprehensive Ophthalmology, Sankara Nethralaya, Chennai, Tamil Nadu, India
| | - Selvakumar Ambika
- Director, Department of Neuroophthalmology Services, Sankara Nethralaya, Chennai, Tamil Nadu, India
| | - Smita Praveen
- Consultant, Department of Neuroophthalmology Services, Sankara Nethralaya, Chennai, Tamil Nadu, India
| | - Durga Priyadarshini
- Consultant, Department of Neuroophthalmology Services, Sankara Nethralaya, Chennai, Tamil Nadu, India
| | - Vidhya Dharini
- Consultant, Department of Neuroophthalmology Services, Sankara Nethralaya, Chennai, Tamil Nadu, India
| | - K Padmalakshmi
- Consultant, Department of Neuroophthalmology Services, Sankara Nethralaya, Chennai, Tamil Nadu, India
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Abri Aghdam K, Soltan Sanjari M, Chaibakhsh S, Fathi Z, Kazemi P, Aghajani A. Assessment of the relationship between structural and functional tests in patients with idiopathic intracranial hypertension. Int Ophthalmol 2024; 44:121. [PMID: 38427085 DOI: 10.1007/s10792-024-03054-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2023] [Accepted: 02/16/2024] [Indexed: 03/02/2024]
Abstract
PURPOSE To assess the relationship between structural and functional tests in mild and moderate idiopathic intracranial hypertension (IIH). METHODS Patients with mild and moderate IIH and a control group were enrolled. Best-corrected visual acuity (BCVA), macular ganglion cell layer (MGCL) thickness, peripapillary retinal nerve fiber layer (pp RNFL) thickness, perimetric mean deviation (MD), and photopic negative responses (PhNR) of the electroretinogram were recorded. The associations between structural (pp RNFL and MGCL thickness) and functional (PhNR amplitude, MD and BCVA) parameters were assessed. RESULTS 154 eyes from 78 subjects (74 eyes from IIH patients and 80 eyes from healthy subjects) were included in this comparative observational study. The MGCL thickness, VA, pp RNFL, and PhNR base-to-trough (BT) amplitude were significantly worse in moderate IIH. The BCVA and MD were associated with MGCL thickness only in moderate IIH. The relationship between MD and MGCL thickness started when MD fell below -5.7 dB. CONCLUSIONS The association between functional and structural parameters varies between mild and moderate IIH. The MD and MGCL thickness outperformed in assessing disease severity in mild and moderate IIH, respectively. The association between MD and MGCL thickness could be considered in IIH severity categorization.
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Affiliation(s)
- Kaveh Abri Aghdam
- Eye Research Center, Eye Department, The Five Senses Health Institute, School of Medicine, Iran University of Medical Sciences, Tehran, Iran
| | - Mostafa Soltan Sanjari
- Eye Research Center, Eye Department, The Five Senses Health Institute, School of Medicine, Iran University of Medical Sciences, Tehran, Iran
| | - Samira Chaibakhsh
- Rajaie Cardiovascular Medical and Research Institute, Iran University of Medical Sciences, Tehran, Iran
| | - Zahra Fathi
- Eye Research Center, Eye Department, The Five Senses Health Institute, School of Medicine, Iran University of Medical Sciences, Tehran, Iran
| | - Pegah Kazemi
- Eye Research Center, Eye Department, The Five Senses Health Institute, School of Medicine, Iran University of Medical Sciences, Tehran, Iran
| | - Ali Aghajani
- Isfahan Eye Research Center, Department of Ophthalmology, Isfahan University of Medical Sciences, Isfahan, Iran.
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Kaya Tutar N, Kale N. The Relationship between Lumbar Puncture Opening Pressure and Retinal Nerve Fiber Layer Thickness in the Diagnosis of Idiopathic Intracranial Hypertension: Is a Lumbar Puncture Always Necessary? Neurologist 2024; 29:91-95. [PMID: 37839079 DOI: 10.1097/nrl.0000000000000528] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2023]
Abstract
OBJECTIVES Idiopathic intracranial hypertension (IIH), is characterized by elevated intracranial pressure (ICP) without an identified cause. Today, lumbar puncture (LP) is the most common method used for diagnosis by measuring cerebrospinal fluid (CSF) pressure to reflect intracranial pressure. This invasive examination has significant disadvantages, such as complications and negative experiences for patients. Therefore, noninvasive methods for ICP measurement are desired. Optical coherence tomography (OCT) is widely used for the diagnosis and follow-up of IIH patients as it reflects papilledema. The aim of this study is to investigate the relationship between CSF pressure and OCT parameters and the ability of OCT in the diagnostic approach. METHODS In our study, patients who were followed up with a diagnosis of IIH with complete neuro-ophthalmological examinations, including visual acuity (VA), visual field, and OCT imaging within 24 hours before lumbar puncture, were retrospectively evaluated. CSF pressure, visual acuity LogMAR, mean deviation of visual fields, retinal nerve fiber layer (RNFL) thickness measured by OCT, and treatment protocols were obtained from our hospital data system. RESULTS A total of 42 eyes of 21 patients were enrolled in the study. A statistically significant positive and moderate correlation was found between CSF pressure values and average RNFL thickness ( r =0.507; P =0.001). The same relationship was demonstrated in all 4 quadrants: inferior, superior, nasal, and temporal. CONCLUSIONS Increased peripapillary RNFL thickness in optic nerve head OCT may be correlated with increased ICP in IIH patients. A larger number of patients are needed to better understand the correlation between OCT parameters and CSF pressure in patients with IIH.
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Affiliation(s)
- Nurhan Kaya Tutar
- Department of Neurology, Bagcilar Training and Research Hospital, Istanbul, Turkey
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Remolí-Sargues L, Monferrer-Adsuara C, López-Salvador B, García-Villanueva C, Gracia-García A, Castro-Navarro V, Cervera-Taulet E. Optical coherence tomography angiography analysis in patients with intracranial hypertension. Eur J Ophthalmol 2024:11206721241228349. [PMID: 38258450 DOI: 10.1177/11206721241228349] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2024]
Abstract
INTRODUCTION Evidence on peripapillary microvasculature in intracranial hypertension (IH) after the regression of papilledema is still scarce. The aim of this preliminary study was to determine the association between structural changes in the optic nerve and the retina and peripapillary microvasculature in patients with IIH. METHODS We conducted a retrospective study. The study included 39 eyes of 21 patients with IIH. Treatment for IIH and history of obesity were registered from each patient. Moreover, OCT analysis including retinal nerve fiber layer (RNFL) thickness and ganglion cell-inner plexiform layer (GCIPL) thickness, and OCTA analysis including perfusion density (PD) and flux index (FI) of the radial peripapillary capillary plexus were performed. RESULTS Correlation analysis revealed a high correlation between GCIPL thickness and peripapillary PD and FI (p < 0,05, r > 0,7), whereas the degree of correlation between RNFL thickness and peripapillary microvascular parameters was low (p < 0,05, r < 0,7). Patients with regressed papilledema had significantly lower GCIPL thickness and peripapillary PD than control subjects (p < 0,05). CONCLUSION Peripapillary microvascular measurements are highly correlated with GCIPL thickness in patients with IIH. Moreover, GCIPL thickness and peripapillary PD are significantly inferior in patients with regressed papilledema compared to control group. Thus, we suggested that peripapillary microvascular parameters may be an early indicator of optic nerve atrophy in patients with IIH.
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Affiliation(s)
- Lidia Remolí-Sargues
- Department of Ophthalmology, Consorcio Hospital General Universitario of Valencia, Av. Tres Cruces 2, 46014, Valencia, Spain
| | - Clara Monferrer-Adsuara
- Department of Ophthalmology, Consorcio Hospital General Universitario of Valencia, Av. Tres Cruces 2, 46014, Valencia, Spain
| | - Belén López-Salvador
- Department of Ophthalmology, Consorcio Hospital General Universitario of Valencia, Av. Tres Cruces 2, 46014, Valencia, Spain
| | - Carolina García-Villanueva
- Department of Ophthalmology, Consorcio Hospital General Universitario of Valencia, Av. Tres Cruces 2, 46014, Valencia, Spain
| | - Alicia Gracia-García
- Department of Ophthalmology, Consorcio Hospital General Universitario of Valencia, Av. Tres Cruces 2, 46014, Valencia, Spain
| | - Verónica Castro-Navarro
- Department of Ophthalmology, Consorcio Hospital General Universitario of Valencia, Av. Tres Cruces 2, 46014, Valencia, Spain
| | - Enrique Cervera-Taulet
- Department of Ophthalmology, Consorcio Hospital General Universitario of Valencia, Av. Tres Cruces 2, 46014, Valencia, Spain
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Wang H, Cao L, Kwapong WR, Liu G, Wang R, Liu J, Wu B. Optic Nerve Head Changes Measured by Swept Source Optical Coherence Tomography and Angiography in Patients with Intracranial Hypertension. Ophthalmol Ther 2023; 12:3295-3305. [PMID: 37792243 PMCID: PMC10640446 DOI: 10.1007/s40123-023-00822-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2023] [Accepted: 09/18/2023] [Indexed: 10/05/2023] Open
Abstract
INTRODUCTION This study explored the structural and microvascular changes in the optic nerve head (ONH) of patients with intracranial hypertension (IH) by using swept-source optical coherence tomography (SS-OCT)/OCT angiography (OCTA) and evaluated their association with clinical features. METHODS The optic disc morphology, peripapillary retinal nerve fiber layer (pRNFL), ganglion cell-inner plexiform layer (GCIPL), and microvascular densities of the nerve fiber layer plexus (NFLP), superficial vascular plexus (SVP), intermediate capillary plexus (ICP), and deep capillary plexus (DCP) were measured by the SS-OCT/OCTA tool. Frisen score, visual acuity, and intracranial pressure were assessed and recorded in patients with IH. RESULTS Sixty-one patients with IH and 65 controls were included in this study. Patients with IH showed thicker pRNFL and GCIPL thickness with larger ONH rim area when compared to controls (P < 0.001). Microvascular densities were increased in NFLP while densities were reduced in SVP, ICP, and DCP when compared to controls (P < 0.001). Structural thickness and microvascular densities were significantly correlated with Frisen scores (P < 0.05) and intracranial pressure (P < 0.05) in patients with IH. CONCLUSION Structural and microvasculature variations of the ONH were found in patients with IH compared to controls. Importantly, we showed that structural and microvascular changes in the ONH were correlated with their Frisen score and intracranial pressure in patients with IH.
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Affiliation(s)
- Hang Wang
- Department of Neurology, West China Hospital, Sichuan University, No. 37 Guo Xue Xiang, Chengdu, 610041, China
| | - Le Cao
- Department of Neurology, West China Hospital, Sichuan University, No. 37 Guo Xue Xiang, Chengdu, 610041, China
| | - William Robert Kwapong
- Department of Neurology, West China Hospital, Sichuan University, No. 37 Guo Xue Xiang, Chengdu, 610041, China
| | - Guina Liu
- Department of Ophthalmology, West China Hospital, Sichuan University, No. 37 Guo Xue Xiang, Chengdu, 610041, China
| | - Ruilin Wang
- Department of Ophthalmology, West China Hospital, Sichuan University, No. 37 Guo Xue Xiang, Chengdu, 610041, China
| | - Junfeng Liu
- Department of Neurology, West China Hospital, Sichuan University, No. 37 Guo Xue Xiang, Chengdu, 610041, China.
| | - Bo Wu
- Department of Neurology, West China Hospital, Sichuan University, No. 37 Guo Xue Xiang, Chengdu, 610041, China.
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Yiangou A, Mollan SP, Sinclair AJ. Idiopathic intracranial hypertension: a step change in understanding the disease mechanisms. Nat Rev Neurol 2023; 19:769-785. [PMID: 37957260 DOI: 10.1038/s41582-023-00893-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/11/2023] [Indexed: 11/15/2023]
Abstract
The understanding of idiopathic intracranial hypertension (IIH) has evolved over the past few years. Previously, IIH was considered a disease exclusively affecting the neuro-ophthalmic axis, characterized by raised intracranial pressure, headache and papilloedema, and resulting in the risk of severe and permanent visual loss and life-changing disabling headaches. Recent advances have begun to redefine IIH as a probable metabolic disease involving a range of systemic manifestations. More than 95% of individuals affected by the disease are women of reproductive age with obesity. The incidence is rapidly rising and parallels the escalating worldwide obesity rates. Contemporary insights identify associations with insulin resistance, type 2 diabetes and a twofold increased risk of cardiovascular disease in excess of that driven by obesity alone. Adipose distribution in people with IIH, like that in other metabolic diseases, is preferentially centripetal and is associated with changes in intracranial pressure. Evidence now demonstrates adipose tissue dysfunction in people with IIH, involving transcriptional and metabolic priming for lipogenesis and weight gain. Hormonal perturbations are also observed, including a unique phenotype of androgen excess that promotes cerebrospinal fluid secretion. Knowledge of these additional disease features is driving research into novel therapeutic targets and altering the approach to multidisciplinary care.
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Affiliation(s)
- Andreas Yiangou
- Institute of Metabolism and Systems Research, University of Birmingham, Birmingham, UK
- Department of Neurology, Queen Elizabeth Hospital Birmingham, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Susan P Mollan
- Institute of Metabolism and Systems Research, University of Birmingham, Birmingham, UK
- Birmingham Neuro-Ophthalmology, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Alexandra J Sinclair
- Institute of Metabolism and Systems Research, University of Birmingham, Birmingham, UK.
- Department of Neurology, Queen Elizabeth Hospital Birmingham, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK.
- Centre for Endocrinology, Diabetes and Metabolism, Birmingham Health Partners, Birmingham, UK.
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Kwapong WR, Cao L, Pan R, Wang H, Ye C, Tao W, Liu J, Wu B. Retinal microvascular and structural changes in intracranial hypertension patients correlate with intracranial pressure. CNS Neurosci Ther 2023; 29:4093-4101. [PMID: 37287365 PMCID: PMC10651994 DOI: 10.1111/cns.14298] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2023] [Revised: 05/23/2023] [Accepted: 05/26/2023] [Indexed: 06/09/2023] Open
Abstract
AIMS We aimed to evaluate the retinal microvascular and structural changes in intracranial hypertension (IH) patients compared with an age- and sex-matched control group. We also investigated the association between clinical parameters and retinal changes in IH patients. METHODS Intracranial hypertension patients were divided into eyes with papilledema (IH-P) and eyes without papilledema (IH-WP). IH patients underwent lumbar puncture to measure intracranial pressure (ICP); visual acuity was performed using the Snellen chart. Optical coherence tomography (OCT) was used to image and measure the retinal nerve fiber layer (RNFL) and ganglion cell-inner plexiform layer (GCIPL) while OCT angiography was used to image and measure the superficial vascular complex (SVC) and deep vascular complex (DVC). RESULTS Intracranial hypertension patients showed reduced microvascular densities and thinner retinal thicknesses compared with the control group (all p < 0.001). Compared with the control group, IH-P showed reduced microvascular densities and thinner retinal thicknesses (all p < 0.001). IH-P showed reduced SVC density and thinner retinal thicknesses when compared with IH-WP (p = 0.008 for SVC, p = 0.025 for RNFL, and p = 0.018 for GCIPL). ICP correlated with the microvascular densities and GCIPL thickness in IH patients (p = 0.025 for GCIPL, p = 0.004 for SVC, and p = 0.002 for DVC). A significant association of ICP with SVC (p = 0.010) and DVC (p = 0.005) densities were also found in IH-P. CONCLUSIONS Given the observed differences in these noninvasive retinal imaging markers, further research into their clinical utility in IH is needed.
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Affiliation(s)
| | - Le Cao
- Department of Neurology, West China HospitalSichuan UniversityChengduChina
| | - Ruosu Pan
- Department of Neurology, West China HospitalSichuan UniversityChengduChina
| | - Hang Wang
- Department of Neurology, West China HospitalSichuan UniversityChengduChina
| | - Chen Ye
- Department of Neurology, West China HospitalSichuan UniversityChengduChina
| | - Wendan Tao
- Department of Neurology, West China HospitalSichuan UniversityChengduChina
| | - Junfeng Liu
- Department of Neurology, West China HospitalSichuan UniversityChengduChina
| | - Bo Wu
- Department of Neurology, West China HospitalSichuan UniversityChengduChina
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Dinkin M, Oliveira C. Bilateral Optic Disc Edema in Multisystem Inflammatory Syndrome in Children (MIS-C) Associated With COVID-19: The Value and Limitations of Optical Coherence Tomography: Response. J Neuroophthalmol 2023; 43:e358. [PMID: 35020704 DOI: 10.1097/wno.0000000000001510] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Affiliation(s)
- Marc Dinkin
- Department of Ophthalmology, Weill Cornell Medicine, New York Hospital, New York, New York, Department of Neurology, Weill Cornell Medicine, New York, New York; and Department of Neurology, Weill Cornell Medicine, New York, New York
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Alimajstorovic Z, Mitchell JL, Yiangou A, Hancox T, Southam AD, Grech O, Ottridge R, Winder CL, Tahrani AA, Tan TM, Mollan SP, Dunn WB, Sinclair AJ. Determining the role of novel metabolic pathways in driving intracranial pressure reduction after weight loss. Brain Commun 2023; 5:fcad272. [PMID: 37901040 PMCID: PMC10608960 DOI: 10.1093/braincomms/fcad272] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2023] [Revised: 08/07/2023] [Accepted: 10/17/2023] [Indexed: 10/31/2023] Open
Abstract
Idiopathic intracranial hypertension, a disease classically occurring in women with obesity, is characterized by raised intracranial pressure. Weight loss leads to the reduction in intracranial pressure. Additionally, pharmacological glucagon-like peptide-1 agonism reduces cerebrospinal fluid secretion and intracranial pressure. The potential mechanisms by which weight loss reduces intracranial pressure are unknown and were the focus of this study. Meal stimulation tests (fasted plasma sample, then samples at 15, 30, 60, 90 and 120 min following a standardized meal) were conducted pre- and post-bariatric surgery [early (2 weeks) and late (12 months)] in patients with active idiopathic intracranial hypertension. Dynamic changes in gut neuropeptides (glucagon-like peptide-1, gastric inhibitory polypeptide and ghrelin) and metabolites (untargeted ultra-high performance liquid chromatography-mass spectrometry) were evaluated. We determined the relationship between gut neuropeptides, metabolites and intracranial pressure. Eighteen idiopathic intracranial hypertension patients were included [Roux-en-Y gastric bypass (RYGB) n = 7, gastric banding n = 6 or sleeve gastrectomy n = 5]. At 2 weeks post-bariatric surgery, despite similar weight loss, RYGB had a 2-fold (50%) greater reduction in intracranial pressure compared to sleeve. Increased meal-stimulated glucagon-like peptide-1 secretion was observed after RYGB (+600%) compared to sleeve (+319%). There was no change in gastric inhibitory polypeptide and ghrelin. Dynamic changes in meal-stimulated metabolites after bariatric surgery consistently identified changes in lipid metabolites, predominantly ceramides, glycerophospholipids and lysoglycerophospholipids, which correlated with intracranial pressure. A greater number of differential lipid metabolites were observed in the RYGB cohort at 2 weeks, and these also correlated with intracranial pressure. In idiopathic intracranial hypertension, we identified novel changes in lipid metabolites and meal-stimulated glucagon-like peptide-1 levels following bariatric surgery which were associated with changes in intracranial pressure. RYGB was most effective at reducing intracranial pressure despite analogous weight loss to gastric sleeve at 2 weeks post-surgery and was associated with more pronounced changes in these metabolite pathways. We suggest that these novel perturbations in lipid metabolism and glucagon-like peptide-1 secretion are mechanistically important in driving a reduction in intracranial pressure following weight loss in patients with idiopathic intracranial hypertension. Therapeutic targeting of these pathways, for example with glucagon-like peptide-1 agonist infusion, could represent a therapeutic strategy.
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Affiliation(s)
- Zerin Alimajstorovic
- Institute of Metabolism and Systems Research, College of Medical and Dental Sciences, University of Birmingham, Birmingham B15 2TT, UK
| | - James L Mitchell
- Institute of Metabolism and Systems Research, College of Medical and Dental Sciences, University of Birmingham, Birmingham B15 2TT, UK
- Department of Neurology, University Hospitals Birmingham NHS Foundation Trust, Queen Elizabeth Hospital, Birmingham B15 2GW, UK
| | - Andreas Yiangou
- Institute of Metabolism and Systems Research, College of Medical and Dental Sciences, University of Birmingham, Birmingham B15 2TT, UK
- Department of Neurology, University Hospitals Birmingham NHS Foundation Trust, Queen Elizabeth Hospital, Birmingham B15 2GW, UK
| | - Thomas Hancox
- School of Biosciences, College of Life and Environmental Sciences, University of Birmingham, Birmingham B15 2TT, UK
| | - Andrew D Southam
- School of Biosciences, College of Life and Environmental Sciences, University of Birmingham, Birmingham B15 2TT, UK
| | - Olivia Grech
- Institute of Metabolism and Systems Research, College of Medical and Dental Sciences, University of Birmingham, Birmingham B15 2TT, UK
| | - Ryan Ottridge
- Birmingham Clinical Trials Unit, College of Medical and Dental Sciences, University of Birmingham, Birmingham B15 2TT, UK
| | - Catherine L Winder
- School of Biosciences, College of Life and Environmental Sciences, University of Birmingham, Birmingham B15 2TT, UK
- Department of Biochemistry and Systems Biology, Institute of Systems, Molecular, and Integrative Biology, University of Liverpool, Liverpool L3 5TR, UK
| | - Abd A Tahrani
- Institute of Metabolism and Systems Research, College of Medical and Dental Sciences, University of Birmingham, Birmingham B15 2TT, UK
- Centre for Endocrinology, Diabetes and Metabolism, Birmingham Health Partners, Birmingham B15 2TT, UK
| | - Tricia M Tan
- Section of Endocrinology and Investigative Medicine, Department of Metabolism, Digestion and Reproduction, Faculty of Medicine, Imperial College London, London SW7 2BX, UK
| | - Susan P Mollan
- Institute of Metabolism and Systems Research, College of Medical and Dental Sciences, University of Birmingham, Birmingham B15 2TT, UK
- Birmingham Neuro-Ophthalmology, University Hospitals Birmingham, Queen Elizabeth Hospital, Birmingham B15 2GW, UK
| | - Warwick B Dunn
- Institute of Metabolism and Systems Research, College of Medical and Dental Sciences, University of Birmingham, Birmingham B15 2TT, UK
- School of Biosciences, College of Life and Environmental Sciences, University of Birmingham, Birmingham B15 2TT, UK
- Department of Biochemistry and Systems Biology, Institute of Systems, Molecular, and Integrative Biology, University of Liverpool, Liverpool L3 5TR, UK
| | - Alexandra J Sinclair
- Institute of Metabolism and Systems Research, College of Medical and Dental Sciences, University of Birmingham, Birmingham B15 2TT, UK
- Centre for Endocrinology, Diabetes and Metabolism, Birmingham Health Partners, Birmingham B15 2TT, UK
- Birmingham Neuro-Ophthalmology, University Hospitals Birmingham, Queen Elizabeth Hospital, Birmingham B15 2GW, UK
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14
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Wagner SK, Romero-Bascones D, Cortina-Borja M, Williamson DJ, Struyven RR, Zhou Y, Patel S, Weil RS, Antoniades CA, Topol EJ, Korot E, Foster PJ, Balaskas K, Ayala U, Barrenechea M, Gabilondo I, Schapira AHV, Khawaja AP, Patel PJ, Rahi JS, Denniston AK, Petzold A, Keane PA. Retinal Optical Coherence Tomography Features Associated With Incident and Prevalent Parkinson Disease. Neurology 2023; 101:e1581-e1593. [PMID: 37604659 PMCID: PMC10585674 DOI: 10.1212/wnl.0000000000207727] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2023] [Accepted: 06/14/2023] [Indexed: 08/23/2023] Open
Abstract
BACKGROUND AND OBJECTIVES Cadaveric studies have shown disease-related neurodegeneration and other morphological abnormalities in the retina of individuals with Parkinson disease (PD); however, it remains unclear whether this can be reliably detected with in vivo imaging. We investigated inner retinal anatomy, measured using optical coherence tomography (OCT), in prevalent PD and subsequently assessed the association of these markers with the development of PD using a prospective research cohort. METHODS This cross-sectional analysis used data from 2 studies. For the detection of retinal markers in prevalent PD, we used data from AlzEye, a retrospective cohort of 154,830 patients aged 40 years and older attending secondary care ophthalmic hospitals in London, United Kingdom, between 2008 and 2018. For the evaluation of retinal markers in incident PD, we used data from UK Biobank, a prospective population-based cohort where 67,311 volunteers aged 40-69 years were recruited between 2006 and 2010 and underwent retinal imaging. Macular retinal nerve fiber layer (mRNFL), ganglion cell-inner plexiform layer (GCIPL), and inner nuclear layer (INL) thicknesses were extracted from fovea-centered OCT. Linear mixed-effects models were fitted to examine the association between prevalent PD and retinal thicknesses. Hazard ratios for the association between time to PD diagnosis and retinal thicknesses were estimated using frailty models. RESULTS Within the AlzEye cohort, there were 700 individuals with prevalent PD and 105,770 controls (mean age 65.5 ± 13.5 years, 51.7% female). Individuals with prevalent PD had thinner GCIPL (-2.12 μm, 95% CI -3.17 to -1.07, p = 8.2 × 10-5) and INL (-0.99 μm, 95% CI -1.52 to -0.47, p = 2.1 × 10-4). The UK Biobank included 50,405 participants (mean age 56.1 ± 8.2 years, 54.7% female), of whom 53 developed PD at a mean of 2,653 ± 851 days. Thinner GCIPL (hazard ratio [HR] 0.62 per SD increase, 95% CI 0.46-0.84, p = 0.002) and thinner INL (HR 0.70, 95% CI 0.51-0.96, p = 0.026) were also associated with incident PD. DISCUSSION Individuals with PD have reduced thickness of the INL and GCIPL of the retina. Involvement of these layers several years before clinical presentation highlight a potential role for retinal imaging for at-risk stratification of PD.
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Affiliation(s)
- Siegfried Karl Wagner
- From the Institute of Ophthalmology (S.K.W., D.J.W., R.R.S., Y.Z., P.J.F., K.B., A.P.K., P.J.P., J.S.R., A.P., P.A.K.), University College London; NIHR Biomedical Research Centre at Moorfields Eye Hospital and UCL Institute of Ophthalmology (S.K.W., D.R.-B., D.J.W., R.R.S., Y.Z., E.K., P.J.F., K.B., A.P.K., P.J.P., J.S.R., A.K.D., A.P., P.A.K.), London, United Kingdom; Biomedical Engineering Department (D.R.-B., E.K., U.A., M.B.), Faculty of Engineering (MU-ENG), Mondragon Unibertsitatea, Spain; Great Ormond Street Institute of Child Health (M.C.-B., J.S.R.), and Centre for Medical Image Computing (D.J.W., R.R.S., Y.Z.), Department of Computer Science, University College London; NeuroMetrology Lab (S.P., C.A.A.), Nuffield Department of Clinical Neurosciences, University of Oxford; Dementia Research Centre (R.S.W.), University College London, United Kingdom; Department of Molecular Medicine (E.J.T.), Scripps Research, La Jolla, CA; Byers Eye Institute (E.K.), Stanford University, Palo Alto, CA; Biocruces Bizkaia Health Research Institute (I.G.), Barakaldo; IKERBASQUE: The Basque Foundation for Science (I.G.), Bilbao, Spain; Department of Clinical and Movement Neurosciences (A.H.V.S.), UCL Queen Square Institute of Neurology; Great Ormond Street Hospital NHS Foundation Trust (J.S.R.); Ulverscroft Vision Research Group (J.S.R.), University College London; NIHR Biomedical Research Centre at UCL Great Ormond Street Institute of Child Health and Great Ormond Street Hospital (J.S.R.), London; University of Birmingham (A.K.D.); University Hospitals Birmingham NHS Foundation Trust (A.K.D.); NIHR Birmingham Biomedical Research Centre (A.K.D.), University of Birmingham; and Queen Square Institute of Neurology (A.P.), University College London, United Kingdom.
| | - David Romero-Bascones
- From the Institute of Ophthalmology (S.K.W., D.J.W., R.R.S., Y.Z., P.J.F., K.B., A.P.K., P.J.P., J.S.R., A.P., P.A.K.), University College London; NIHR Biomedical Research Centre at Moorfields Eye Hospital and UCL Institute of Ophthalmology (S.K.W., D.R.-B., D.J.W., R.R.S., Y.Z., E.K., P.J.F., K.B., A.P.K., P.J.P., J.S.R., A.K.D., A.P., P.A.K.), London, United Kingdom; Biomedical Engineering Department (D.R.-B., E.K., U.A., M.B.), Faculty of Engineering (MU-ENG), Mondragon Unibertsitatea, Spain; Great Ormond Street Institute of Child Health (M.C.-B., J.S.R.), and Centre for Medical Image Computing (D.J.W., R.R.S., Y.Z.), Department of Computer Science, University College London; NeuroMetrology Lab (S.P., C.A.A.), Nuffield Department of Clinical Neurosciences, University of Oxford; Dementia Research Centre (R.S.W.), University College London, United Kingdom; Department of Molecular Medicine (E.J.T.), Scripps Research, La Jolla, CA; Byers Eye Institute (E.K.), Stanford University, Palo Alto, CA; Biocruces Bizkaia Health Research Institute (I.G.), Barakaldo; IKERBASQUE: The Basque Foundation for Science (I.G.), Bilbao, Spain; Department of Clinical and Movement Neurosciences (A.H.V.S.), UCL Queen Square Institute of Neurology; Great Ormond Street Hospital NHS Foundation Trust (J.S.R.); Ulverscroft Vision Research Group (J.S.R.), University College London; NIHR Biomedical Research Centre at UCL Great Ormond Street Institute of Child Health and Great Ormond Street Hospital (J.S.R.), London; University of Birmingham (A.K.D.); University Hospitals Birmingham NHS Foundation Trust (A.K.D.); NIHR Birmingham Biomedical Research Centre (A.K.D.), University of Birmingham; and Queen Square Institute of Neurology (A.P.), University College London, United Kingdom
| | - Mario Cortina-Borja
- From the Institute of Ophthalmology (S.K.W., D.J.W., R.R.S., Y.Z., P.J.F., K.B., A.P.K., P.J.P., J.S.R., A.P., P.A.K.), University College London; NIHR Biomedical Research Centre at Moorfields Eye Hospital and UCL Institute of Ophthalmology (S.K.W., D.R.-B., D.J.W., R.R.S., Y.Z., E.K., P.J.F., K.B., A.P.K., P.J.P., J.S.R., A.K.D., A.P., P.A.K.), London, United Kingdom; Biomedical Engineering Department (D.R.-B., E.K., U.A., M.B.), Faculty of Engineering (MU-ENG), Mondragon Unibertsitatea, Spain; Great Ormond Street Institute of Child Health (M.C.-B., J.S.R.), and Centre for Medical Image Computing (D.J.W., R.R.S., Y.Z.), Department of Computer Science, University College London; NeuroMetrology Lab (S.P., C.A.A.), Nuffield Department of Clinical Neurosciences, University of Oxford; Dementia Research Centre (R.S.W.), University College London, United Kingdom; Department of Molecular Medicine (E.J.T.), Scripps Research, La Jolla, CA; Byers Eye Institute (E.K.), Stanford University, Palo Alto, CA; Biocruces Bizkaia Health Research Institute (I.G.), Barakaldo; IKERBASQUE: The Basque Foundation for Science (I.G.), Bilbao, Spain; Department of Clinical and Movement Neurosciences (A.H.V.S.), UCL Queen Square Institute of Neurology; Great Ormond Street Hospital NHS Foundation Trust (J.S.R.); Ulverscroft Vision Research Group (J.S.R.), University College London; NIHR Biomedical Research Centre at UCL Great Ormond Street Institute of Child Health and Great Ormond Street Hospital (J.S.R.), London; University of Birmingham (A.K.D.); University Hospitals Birmingham NHS Foundation Trust (A.K.D.); NIHR Birmingham Biomedical Research Centre (A.K.D.), University of Birmingham; and Queen Square Institute of Neurology (A.P.), University College London, United Kingdom
| | - Dominic J Williamson
- From the Institute of Ophthalmology (S.K.W., D.J.W., R.R.S., Y.Z., P.J.F., K.B., A.P.K., P.J.P., J.S.R., A.P., P.A.K.), University College London; NIHR Biomedical Research Centre at Moorfields Eye Hospital and UCL Institute of Ophthalmology (S.K.W., D.R.-B., D.J.W., R.R.S., Y.Z., E.K., P.J.F., K.B., A.P.K., P.J.P., J.S.R., A.K.D., A.P., P.A.K.), London, United Kingdom; Biomedical Engineering Department (D.R.-B., E.K., U.A., M.B.), Faculty of Engineering (MU-ENG), Mondragon Unibertsitatea, Spain; Great Ormond Street Institute of Child Health (M.C.-B., J.S.R.), and Centre for Medical Image Computing (D.J.W., R.R.S., Y.Z.), Department of Computer Science, University College London; NeuroMetrology Lab (S.P., C.A.A.), Nuffield Department of Clinical Neurosciences, University of Oxford; Dementia Research Centre (R.S.W.), University College London, United Kingdom; Department of Molecular Medicine (E.J.T.), Scripps Research, La Jolla, CA; Byers Eye Institute (E.K.), Stanford University, Palo Alto, CA; Biocruces Bizkaia Health Research Institute (I.G.), Barakaldo; IKERBASQUE: The Basque Foundation for Science (I.G.), Bilbao, Spain; Department of Clinical and Movement Neurosciences (A.H.V.S.), UCL Queen Square Institute of Neurology; Great Ormond Street Hospital NHS Foundation Trust (J.S.R.); Ulverscroft Vision Research Group (J.S.R.), University College London; NIHR Biomedical Research Centre at UCL Great Ormond Street Institute of Child Health and Great Ormond Street Hospital (J.S.R.), London; University of Birmingham (A.K.D.); University Hospitals Birmingham NHS Foundation Trust (A.K.D.); NIHR Birmingham Biomedical Research Centre (A.K.D.), University of Birmingham; and Queen Square Institute of Neurology (A.P.), University College London, United Kingdom
| | - Robbert R Struyven
- From the Institute of Ophthalmology (S.K.W., D.J.W., R.R.S., Y.Z., P.J.F., K.B., A.P.K., P.J.P., J.S.R., A.P., P.A.K.), University College London; NIHR Biomedical Research Centre at Moorfields Eye Hospital and UCL Institute of Ophthalmology (S.K.W., D.R.-B., D.J.W., R.R.S., Y.Z., E.K., P.J.F., K.B., A.P.K., P.J.P., J.S.R., A.K.D., A.P., P.A.K.), London, United Kingdom; Biomedical Engineering Department (D.R.-B., E.K., U.A., M.B.), Faculty of Engineering (MU-ENG), Mondragon Unibertsitatea, Spain; Great Ormond Street Institute of Child Health (M.C.-B., J.S.R.), and Centre for Medical Image Computing (D.J.W., R.R.S., Y.Z.), Department of Computer Science, University College London; NeuroMetrology Lab (S.P., C.A.A.), Nuffield Department of Clinical Neurosciences, University of Oxford; Dementia Research Centre (R.S.W.), University College London, United Kingdom; Department of Molecular Medicine (E.J.T.), Scripps Research, La Jolla, CA; Byers Eye Institute (E.K.), Stanford University, Palo Alto, CA; Biocruces Bizkaia Health Research Institute (I.G.), Barakaldo; IKERBASQUE: The Basque Foundation for Science (I.G.), Bilbao, Spain; Department of Clinical and Movement Neurosciences (A.H.V.S.), UCL Queen Square Institute of Neurology; Great Ormond Street Hospital NHS Foundation Trust (J.S.R.); Ulverscroft Vision Research Group (J.S.R.), University College London; NIHR Biomedical Research Centre at UCL Great Ormond Street Institute of Child Health and Great Ormond Street Hospital (J.S.R.), London; University of Birmingham (A.K.D.); University Hospitals Birmingham NHS Foundation Trust (A.K.D.); NIHR Birmingham Biomedical Research Centre (A.K.D.), University of Birmingham; and Queen Square Institute of Neurology (A.P.), University College London, United Kingdom
| | - Yukun Zhou
- From the Institute of Ophthalmology (S.K.W., D.J.W., R.R.S., Y.Z., P.J.F., K.B., A.P.K., P.J.P., J.S.R., A.P., P.A.K.), University College London; NIHR Biomedical Research Centre at Moorfields Eye Hospital and UCL Institute of Ophthalmology (S.K.W., D.R.-B., D.J.W., R.R.S., Y.Z., E.K., P.J.F., K.B., A.P.K., P.J.P., J.S.R., A.K.D., A.P., P.A.K.), London, United Kingdom; Biomedical Engineering Department (D.R.-B., E.K., U.A., M.B.), Faculty of Engineering (MU-ENG), Mondragon Unibertsitatea, Spain; Great Ormond Street Institute of Child Health (M.C.-B., J.S.R.), and Centre for Medical Image Computing (D.J.W., R.R.S., Y.Z.), Department of Computer Science, University College London; NeuroMetrology Lab (S.P., C.A.A.), Nuffield Department of Clinical Neurosciences, University of Oxford; Dementia Research Centre (R.S.W.), University College London, United Kingdom; Department of Molecular Medicine (E.J.T.), Scripps Research, La Jolla, CA; Byers Eye Institute (E.K.), Stanford University, Palo Alto, CA; Biocruces Bizkaia Health Research Institute (I.G.), Barakaldo; IKERBASQUE: The Basque Foundation for Science (I.G.), Bilbao, Spain; Department of Clinical and Movement Neurosciences (A.H.V.S.), UCL Queen Square Institute of Neurology; Great Ormond Street Hospital NHS Foundation Trust (J.S.R.); Ulverscroft Vision Research Group (J.S.R.), University College London; NIHR Biomedical Research Centre at UCL Great Ormond Street Institute of Child Health and Great Ormond Street Hospital (J.S.R.), London; University of Birmingham (A.K.D.); University Hospitals Birmingham NHS Foundation Trust (A.K.D.); NIHR Birmingham Biomedical Research Centre (A.K.D.), University of Birmingham; and Queen Square Institute of Neurology (A.P.), University College London, United Kingdom
| | - Salil Patel
- From the Institute of Ophthalmology (S.K.W., D.J.W., R.R.S., Y.Z., P.J.F., K.B., A.P.K., P.J.P., J.S.R., A.P., P.A.K.), University College London; NIHR Biomedical Research Centre at Moorfields Eye Hospital and UCL Institute of Ophthalmology (S.K.W., D.R.-B., D.J.W., R.R.S., Y.Z., E.K., P.J.F., K.B., A.P.K., P.J.P., J.S.R., A.K.D., A.P., P.A.K.), London, United Kingdom; Biomedical Engineering Department (D.R.-B., E.K., U.A., M.B.), Faculty of Engineering (MU-ENG), Mondragon Unibertsitatea, Spain; Great Ormond Street Institute of Child Health (M.C.-B., J.S.R.), and Centre for Medical Image Computing (D.J.W., R.R.S., Y.Z.), Department of Computer Science, University College London; NeuroMetrology Lab (S.P., C.A.A.), Nuffield Department of Clinical Neurosciences, University of Oxford; Dementia Research Centre (R.S.W.), University College London, United Kingdom; Department of Molecular Medicine (E.J.T.), Scripps Research, La Jolla, CA; Byers Eye Institute (E.K.), Stanford University, Palo Alto, CA; Biocruces Bizkaia Health Research Institute (I.G.), Barakaldo; IKERBASQUE: The Basque Foundation for Science (I.G.), Bilbao, Spain; Department of Clinical and Movement Neurosciences (A.H.V.S.), UCL Queen Square Institute of Neurology; Great Ormond Street Hospital NHS Foundation Trust (J.S.R.); Ulverscroft Vision Research Group (J.S.R.), University College London; NIHR Biomedical Research Centre at UCL Great Ormond Street Institute of Child Health and Great Ormond Street Hospital (J.S.R.), London; University of Birmingham (A.K.D.); University Hospitals Birmingham NHS Foundation Trust (A.K.D.); NIHR Birmingham Biomedical Research Centre (A.K.D.), University of Birmingham; and Queen Square Institute of Neurology (A.P.), University College London, United Kingdom
| | - Rimona S Weil
- From the Institute of Ophthalmology (S.K.W., D.J.W., R.R.S., Y.Z., P.J.F., K.B., A.P.K., P.J.P., J.S.R., A.P., P.A.K.), University College London; NIHR Biomedical Research Centre at Moorfields Eye Hospital and UCL Institute of Ophthalmology (S.K.W., D.R.-B., D.J.W., R.R.S., Y.Z., E.K., P.J.F., K.B., A.P.K., P.J.P., J.S.R., A.K.D., A.P., P.A.K.), London, United Kingdom; Biomedical Engineering Department (D.R.-B., E.K., U.A., M.B.), Faculty of Engineering (MU-ENG), Mondragon Unibertsitatea, Spain; Great Ormond Street Institute of Child Health (M.C.-B., J.S.R.), and Centre for Medical Image Computing (D.J.W., R.R.S., Y.Z.), Department of Computer Science, University College London; NeuroMetrology Lab (S.P., C.A.A.), Nuffield Department of Clinical Neurosciences, University of Oxford; Dementia Research Centre (R.S.W.), University College London, United Kingdom; Department of Molecular Medicine (E.J.T.), Scripps Research, La Jolla, CA; Byers Eye Institute (E.K.), Stanford University, Palo Alto, CA; Biocruces Bizkaia Health Research Institute (I.G.), Barakaldo; IKERBASQUE: The Basque Foundation for Science (I.G.), Bilbao, Spain; Department of Clinical and Movement Neurosciences (A.H.V.S.), UCL Queen Square Institute of Neurology; Great Ormond Street Hospital NHS Foundation Trust (J.S.R.); Ulverscroft Vision Research Group (J.S.R.), University College London; NIHR Biomedical Research Centre at UCL Great Ormond Street Institute of Child Health and Great Ormond Street Hospital (J.S.R.), London; University of Birmingham (A.K.D.); University Hospitals Birmingham NHS Foundation Trust (A.K.D.); NIHR Birmingham Biomedical Research Centre (A.K.D.), University of Birmingham; and Queen Square Institute of Neurology (A.P.), University College London, United Kingdom
| | - Chrystalina A Antoniades
- From the Institute of Ophthalmology (S.K.W., D.J.W., R.R.S., Y.Z., P.J.F., K.B., A.P.K., P.J.P., J.S.R., A.P., P.A.K.), University College London; NIHR Biomedical Research Centre at Moorfields Eye Hospital and UCL Institute of Ophthalmology (S.K.W., D.R.-B., D.J.W., R.R.S., Y.Z., E.K., P.J.F., K.B., A.P.K., P.J.P., J.S.R., A.K.D., A.P., P.A.K.), London, United Kingdom; Biomedical Engineering Department (D.R.-B., E.K., U.A., M.B.), Faculty of Engineering (MU-ENG), Mondragon Unibertsitatea, Spain; Great Ormond Street Institute of Child Health (M.C.-B., J.S.R.), and Centre for Medical Image Computing (D.J.W., R.R.S., Y.Z.), Department of Computer Science, University College London; NeuroMetrology Lab (S.P., C.A.A.), Nuffield Department of Clinical Neurosciences, University of Oxford; Dementia Research Centre (R.S.W.), University College London, United Kingdom; Department of Molecular Medicine (E.J.T.), Scripps Research, La Jolla, CA; Byers Eye Institute (E.K.), Stanford University, Palo Alto, CA; Biocruces Bizkaia Health Research Institute (I.G.), Barakaldo; IKERBASQUE: The Basque Foundation for Science (I.G.), Bilbao, Spain; Department of Clinical and Movement Neurosciences (A.H.V.S.), UCL Queen Square Institute of Neurology; Great Ormond Street Hospital NHS Foundation Trust (J.S.R.); Ulverscroft Vision Research Group (J.S.R.), University College London; NIHR Biomedical Research Centre at UCL Great Ormond Street Institute of Child Health and Great Ormond Street Hospital (J.S.R.), London; University of Birmingham (A.K.D.); University Hospitals Birmingham NHS Foundation Trust (A.K.D.); NIHR Birmingham Biomedical Research Centre (A.K.D.), University of Birmingham; and Queen Square Institute of Neurology (A.P.), University College London, United Kingdom
| | - Eric J Topol
- From the Institute of Ophthalmology (S.K.W., D.J.W., R.R.S., Y.Z., P.J.F., K.B., A.P.K., P.J.P., J.S.R., A.P., P.A.K.), University College London; NIHR Biomedical Research Centre at Moorfields Eye Hospital and UCL Institute of Ophthalmology (S.K.W., D.R.-B., D.J.W., R.R.S., Y.Z., E.K., P.J.F., K.B., A.P.K., P.J.P., J.S.R., A.K.D., A.P., P.A.K.), London, United Kingdom; Biomedical Engineering Department (D.R.-B., E.K., U.A., M.B.), Faculty of Engineering (MU-ENG), Mondragon Unibertsitatea, Spain; Great Ormond Street Institute of Child Health (M.C.-B., J.S.R.), and Centre for Medical Image Computing (D.J.W., R.R.S., Y.Z.), Department of Computer Science, University College London; NeuroMetrology Lab (S.P., C.A.A.), Nuffield Department of Clinical Neurosciences, University of Oxford; Dementia Research Centre (R.S.W.), University College London, United Kingdom; Department of Molecular Medicine (E.J.T.), Scripps Research, La Jolla, CA; Byers Eye Institute (E.K.), Stanford University, Palo Alto, CA; Biocruces Bizkaia Health Research Institute (I.G.), Barakaldo; IKERBASQUE: The Basque Foundation for Science (I.G.), Bilbao, Spain; Department of Clinical and Movement Neurosciences (A.H.V.S.), UCL Queen Square Institute of Neurology; Great Ormond Street Hospital NHS Foundation Trust (J.S.R.); Ulverscroft Vision Research Group (J.S.R.), University College London; NIHR Biomedical Research Centre at UCL Great Ormond Street Institute of Child Health and Great Ormond Street Hospital (J.S.R.), London; University of Birmingham (A.K.D.); University Hospitals Birmingham NHS Foundation Trust (A.K.D.); NIHR Birmingham Biomedical Research Centre (A.K.D.), University of Birmingham; and Queen Square Institute of Neurology (A.P.), University College London, United Kingdom
| | - Edward Korot
- From the Institute of Ophthalmology (S.K.W., D.J.W., R.R.S., Y.Z., P.J.F., K.B., A.P.K., P.J.P., J.S.R., A.P., P.A.K.), University College London; NIHR Biomedical Research Centre at Moorfields Eye Hospital and UCL Institute of Ophthalmology (S.K.W., D.R.-B., D.J.W., R.R.S., Y.Z., E.K., P.J.F., K.B., A.P.K., P.J.P., J.S.R., A.K.D., A.P., P.A.K.), London, United Kingdom; Biomedical Engineering Department (D.R.-B., E.K., U.A., M.B.), Faculty of Engineering (MU-ENG), Mondragon Unibertsitatea, Spain; Great Ormond Street Institute of Child Health (M.C.-B., J.S.R.), and Centre for Medical Image Computing (D.J.W., R.R.S., Y.Z.), Department of Computer Science, University College London; NeuroMetrology Lab (S.P., C.A.A.), Nuffield Department of Clinical Neurosciences, University of Oxford; Dementia Research Centre (R.S.W.), University College London, United Kingdom; Department of Molecular Medicine (E.J.T.), Scripps Research, La Jolla, CA; Byers Eye Institute (E.K.), Stanford University, Palo Alto, CA; Biocruces Bizkaia Health Research Institute (I.G.), Barakaldo; IKERBASQUE: The Basque Foundation for Science (I.G.), Bilbao, Spain; Department of Clinical and Movement Neurosciences (A.H.V.S.), UCL Queen Square Institute of Neurology; Great Ormond Street Hospital NHS Foundation Trust (J.S.R.); Ulverscroft Vision Research Group (J.S.R.), University College London; NIHR Biomedical Research Centre at UCL Great Ormond Street Institute of Child Health and Great Ormond Street Hospital (J.S.R.), London; University of Birmingham (A.K.D.); University Hospitals Birmingham NHS Foundation Trust (A.K.D.); NIHR Birmingham Biomedical Research Centre (A.K.D.), University of Birmingham; and Queen Square Institute of Neurology (A.P.), University College London, United Kingdom
| | - Paul J Foster
- From the Institute of Ophthalmology (S.K.W., D.J.W., R.R.S., Y.Z., P.J.F., K.B., A.P.K., P.J.P., J.S.R., A.P., P.A.K.), University College London; NIHR Biomedical Research Centre at Moorfields Eye Hospital and UCL Institute of Ophthalmology (S.K.W., D.R.-B., D.J.W., R.R.S., Y.Z., E.K., P.J.F., K.B., A.P.K., P.J.P., J.S.R., A.K.D., A.P., P.A.K.), London, United Kingdom; Biomedical Engineering Department (D.R.-B., E.K., U.A., M.B.), Faculty of Engineering (MU-ENG), Mondragon Unibertsitatea, Spain; Great Ormond Street Institute of Child Health (M.C.-B., J.S.R.), and Centre for Medical Image Computing (D.J.W., R.R.S., Y.Z.), Department of Computer Science, University College London; NeuroMetrology Lab (S.P., C.A.A.), Nuffield Department of Clinical Neurosciences, University of Oxford; Dementia Research Centre (R.S.W.), University College London, United Kingdom; Department of Molecular Medicine (E.J.T.), Scripps Research, La Jolla, CA; Byers Eye Institute (E.K.), Stanford University, Palo Alto, CA; Biocruces Bizkaia Health Research Institute (I.G.), Barakaldo; IKERBASQUE: The Basque Foundation for Science (I.G.), Bilbao, Spain; Department of Clinical and Movement Neurosciences (A.H.V.S.), UCL Queen Square Institute of Neurology; Great Ormond Street Hospital NHS Foundation Trust (J.S.R.); Ulverscroft Vision Research Group (J.S.R.), University College London; NIHR Biomedical Research Centre at UCL Great Ormond Street Institute of Child Health and Great Ormond Street Hospital (J.S.R.), London; University of Birmingham (A.K.D.); University Hospitals Birmingham NHS Foundation Trust (A.K.D.); NIHR Birmingham Biomedical Research Centre (A.K.D.), University of Birmingham; and Queen Square Institute of Neurology (A.P.), University College London, United Kingdom
| | - Konstantinos Balaskas
- From the Institute of Ophthalmology (S.K.W., D.J.W., R.R.S., Y.Z., P.J.F., K.B., A.P.K., P.J.P., J.S.R., A.P., P.A.K.), University College London; NIHR Biomedical Research Centre at Moorfields Eye Hospital and UCL Institute of Ophthalmology (S.K.W., D.R.-B., D.J.W., R.R.S., Y.Z., E.K., P.J.F., K.B., A.P.K., P.J.P., J.S.R., A.K.D., A.P., P.A.K.), London, United Kingdom; Biomedical Engineering Department (D.R.-B., E.K., U.A., M.B.), Faculty of Engineering (MU-ENG), Mondragon Unibertsitatea, Spain; Great Ormond Street Institute of Child Health (M.C.-B., J.S.R.), and Centre for Medical Image Computing (D.J.W., R.R.S., Y.Z.), Department of Computer Science, University College London; NeuroMetrology Lab (S.P., C.A.A.), Nuffield Department of Clinical Neurosciences, University of Oxford; Dementia Research Centre (R.S.W.), University College London, United Kingdom; Department of Molecular Medicine (E.J.T.), Scripps Research, La Jolla, CA; Byers Eye Institute (E.K.), Stanford University, Palo Alto, CA; Biocruces Bizkaia Health Research Institute (I.G.), Barakaldo; IKERBASQUE: The Basque Foundation for Science (I.G.), Bilbao, Spain; Department of Clinical and Movement Neurosciences (A.H.V.S.), UCL Queen Square Institute of Neurology; Great Ormond Street Hospital NHS Foundation Trust (J.S.R.); Ulverscroft Vision Research Group (J.S.R.), University College London; NIHR Biomedical Research Centre at UCL Great Ormond Street Institute of Child Health and Great Ormond Street Hospital (J.S.R.), London; University of Birmingham (A.K.D.); University Hospitals Birmingham NHS Foundation Trust (A.K.D.); NIHR Birmingham Biomedical Research Centre (A.K.D.), University of Birmingham; and Queen Square Institute of Neurology (A.P.), University College London, United Kingdom
| | - Unai Ayala
- From the Institute of Ophthalmology (S.K.W., D.J.W., R.R.S., Y.Z., P.J.F., K.B., A.P.K., P.J.P., J.S.R., A.P., P.A.K.), University College London; NIHR Biomedical Research Centre at Moorfields Eye Hospital and UCL Institute of Ophthalmology (S.K.W., D.R.-B., D.J.W., R.R.S., Y.Z., E.K., P.J.F., K.B., A.P.K., P.J.P., J.S.R., A.K.D., A.P., P.A.K.), London, United Kingdom; Biomedical Engineering Department (D.R.-B., E.K., U.A., M.B.), Faculty of Engineering (MU-ENG), Mondragon Unibertsitatea, Spain; Great Ormond Street Institute of Child Health (M.C.-B., J.S.R.), and Centre for Medical Image Computing (D.J.W., R.R.S., Y.Z.), Department of Computer Science, University College London; NeuroMetrology Lab (S.P., C.A.A.), Nuffield Department of Clinical Neurosciences, University of Oxford; Dementia Research Centre (R.S.W.), University College London, United Kingdom; Department of Molecular Medicine (E.J.T.), Scripps Research, La Jolla, CA; Byers Eye Institute (E.K.), Stanford University, Palo Alto, CA; Biocruces Bizkaia Health Research Institute (I.G.), Barakaldo; IKERBASQUE: The Basque Foundation for Science (I.G.), Bilbao, Spain; Department of Clinical and Movement Neurosciences (A.H.V.S.), UCL Queen Square Institute of Neurology; Great Ormond Street Hospital NHS Foundation Trust (J.S.R.); Ulverscroft Vision Research Group (J.S.R.), University College London; NIHR Biomedical Research Centre at UCL Great Ormond Street Institute of Child Health and Great Ormond Street Hospital (J.S.R.), London; University of Birmingham (A.K.D.); University Hospitals Birmingham NHS Foundation Trust (A.K.D.); NIHR Birmingham Biomedical Research Centre (A.K.D.), University of Birmingham; and Queen Square Institute of Neurology (A.P.), University College London, United Kingdom
| | - Maitane Barrenechea
- From the Institute of Ophthalmology (S.K.W., D.J.W., R.R.S., Y.Z., P.J.F., K.B., A.P.K., P.J.P., J.S.R., A.P., P.A.K.), University College London; NIHR Biomedical Research Centre at Moorfields Eye Hospital and UCL Institute of Ophthalmology (S.K.W., D.R.-B., D.J.W., R.R.S., Y.Z., E.K., P.J.F., K.B., A.P.K., P.J.P., J.S.R., A.K.D., A.P., P.A.K.), London, United Kingdom; Biomedical Engineering Department (D.R.-B., E.K., U.A., M.B.), Faculty of Engineering (MU-ENG), Mondragon Unibertsitatea, Spain; Great Ormond Street Institute of Child Health (M.C.-B., J.S.R.), and Centre for Medical Image Computing (D.J.W., R.R.S., Y.Z.), Department of Computer Science, University College London; NeuroMetrology Lab (S.P., C.A.A.), Nuffield Department of Clinical Neurosciences, University of Oxford; Dementia Research Centre (R.S.W.), University College London, United Kingdom; Department of Molecular Medicine (E.J.T.), Scripps Research, La Jolla, CA; Byers Eye Institute (E.K.), Stanford University, Palo Alto, CA; Biocruces Bizkaia Health Research Institute (I.G.), Barakaldo; IKERBASQUE: The Basque Foundation for Science (I.G.), Bilbao, Spain; Department of Clinical and Movement Neurosciences (A.H.V.S.), UCL Queen Square Institute of Neurology; Great Ormond Street Hospital NHS Foundation Trust (J.S.R.); Ulverscroft Vision Research Group (J.S.R.), University College London; NIHR Biomedical Research Centre at UCL Great Ormond Street Institute of Child Health and Great Ormond Street Hospital (J.S.R.), London; University of Birmingham (A.K.D.); University Hospitals Birmingham NHS Foundation Trust (A.K.D.); NIHR Birmingham Biomedical Research Centre (A.K.D.), University of Birmingham; and Queen Square Institute of Neurology (A.P.), University College London, United Kingdom
| | - Iñigo Gabilondo
- From the Institute of Ophthalmology (S.K.W., D.J.W., R.R.S., Y.Z., P.J.F., K.B., A.P.K., P.J.P., J.S.R., A.P., P.A.K.), University College London; NIHR Biomedical Research Centre at Moorfields Eye Hospital and UCL Institute of Ophthalmology (S.K.W., D.R.-B., D.J.W., R.R.S., Y.Z., E.K., P.J.F., K.B., A.P.K., P.J.P., J.S.R., A.K.D., A.P., P.A.K.), London, United Kingdom; Biomedical Engineering Department (D.R.-B., E.K., U.A., M.B.), Faculty of Engineering (MU-ENG), Mondragon Unibertsitatea, Spain; Great Ormond Street Institute of Child Health (M.C.-B., J.S.R.), and Centre for Medical Image Computing (D.J.W., R.R.S., Y.Z.), Department of Computer Science, University College London; NeuroMetrology Lab (S.P., C.A.A.), Nuffield Department of Clinical Neurosciences, University of Oxford; Dementia Research Centre (R.S.W.), University College London, United Kingdom; Department of Molecular Medicine (E.J.T.), Scripps Research, La Jolla, CA; Byers Eye Institute (E.K.), Stanford University, Palo Alto, CA; Biocruces Bizkaia Health Research Institute (I.G.), Barakaldo; IKERBASQUE: The Basque Foundation for Science (I.G.), Bilbao, Spain; Department of Clinical and Movement Neurosciences (A.H.V.S.), UCL Queen Square Institute of Neurology; Great Ormond Street Hospital NHS Foundation Trust (J.S.R.); Ulverscroft Vision Research Group (J.S.R.), University College London; NIHR Biomedical Research Centre at UCL Great Ormond Street Institute of Child Health and Great Ormond Street Hospital (J.S.R.), London; University of Birmingham (A.K.D.); University Hospitals Birmingham NHS Foundation Trust (A.K.D.); NIHR Birmingham Biomedical Research Centre (A.K.D.), University of Birmingham; and Queen Square Institute of Neurology (A.P.), University College London, United Kingdom
| | - Anthony H V Schapira
- From the Institute of Ophthalmology (S.K.W., D.J.W., R.R.S., Y.Z., P.J.F., K.B., A.P.K., P.J.P., J.S.R., A.P., P.A.K.), University College London; NIHR Biomedical Research Centre at Moorfields Eye Hospital and UCL Institute of Ophthalmology (S.K.W., D.R.-B., D.J.W., R.R.S., Y.Z., E.K., P.J.F., K.B., A.P.K., P.J.P., J.S.R., A.K.D., A.P., P.A.K.), London, United Kingdom; Biomedical Engineering Department (D.R.-B., E.K., U.A., M.B.), Faculty of Engineering (MU-ENG), Mondragon Unibertsitatea, Spain; Great Ormond Street Institute of Child Health (M.C.-B., J.S.R.), and Centre for Medical Image Computing (D.J.W., R.R.S., Y.Z.), Department of Computer Science, University College London; NeuroMetrology Lab (S.P., C.A.A.), Nuffield Department of Clinical Neurosciences, University of Oxford; Dementia Research Centre (R.S.W.), University College London, United Kingdom; Department of Molecular Medicine (E.J.T.), Scripps Research, La Jolla, CA; Byers Eye Institute (E.K.), Stanford University, Palo Alto, CA; Biocruces Bizkaia Health Research Institute (I.G.), Barakaldo; IKERBASQUE: The Basque Foundation for Science (I.G.), Bilbao, Spain; Department of Clinical and Movement Neurosciences (A.H.V.S.), UCL Queen Square Institute of Neurology; Great Ormond Street Hospital NHS Foundation Trust (J.S.R.); Ulverscroft Vision Research Group (J.S.R.), University College London; NIHR Biomedical Research Centre at UCL Great Ormond Street Institute of Child Health and Great Ormond Street Hospital (J.S.R.), London; University of Birmingham (A.K.D.); University Hospitals Birmingham NHS Foundation Trust (A.K.D.); NIHR Birmingham Biomedical Research Centre (A.K.D.), University of Birmingham; and Queen Square Institute of Neurology (A.P.), University College London, United Kingdom
| | - Anthony P Khawaja
- From the Institute of Ophthalmology (S.K.W., D.J.W., R.R.S., Y.Z., P.J.F., K.B., A.P.K., P.J.P., J.S.R., A.P., P.A.K.), University College London; NIHR Biomedical Research Centre at Moorfields Eye Hospital and UCL Institute of Ophthalmology (S.K.W., D.R.-B., D.J.W., R.R.S., Y.Z., E.K., P.J.F., K.B., A.P.K., P.J.P., J.S.R., A.K.D., A.P., P.A.K.), London, United Kingdom; Biomedical Engineering Department (D.R.-B., E.K., U.A., M.B.), Faculty of Engineering (MU-ENG), Mondragon Unibertsitatea, Spain; Great Ormond Street Institute of Child Health (M.C.-B., J.S.R.), and Centre for Medical Image Computing (D.J.W., R.R.S., Y.Z.), Department of Computer Science, University College London; NeuroMetrology Lab (S.P., C.A.A.), Nuffield Department of Clinical Neurosciences, University of Oxford; Dementia Research Centre (R.S.W.), University College London, United Kingdom; Department of Molecular Medicine (E.J.T.), Scripps Research, La Jolla, CA; Byers Eye Institute (E.K.), Stanford University, Palo Alto, CA; Biocruces Bizkaia Health Research Institute (I.G.), Barakaldo; IKERBASQUE: The Basque Foundation for Science (I.G.), Bilbao, Spain; Department of Clinical and Movement Neurosciences (A.H.V.S.), UCL Queen Square Institute of Neurology; Great Ormond Street Hospital NHS Foundation Trust (J.S.R.); Ulverscroft Vision Research Group (J.S.R.), University College London; NIHR Biomedical Research Centre at UCL Great Ormond Street Institute of Child Health and Great Ormond Street Hospital (J.S.R.), London; University of Birmingham (A.K.D.); University Hospitals Birmingham NHS Foundation Trust (A.K.D.); NIHR Birmingham Biomedical Research Centre (A.K.D.), University of Birmingham; and Queen Square Institute of Neurology (A.P.), University College London, United Kingdom
| | - Praveen J Patel
- From the Institute of Ophthalmology (S.K.W., D.J.W., R.R.S., Y.Z., P.J.F., K.B., A.P.K., P.J.P., J.S.R., A.P., P.A.K.), University College London; NIHR Biomedical Research Centre at Moorfields Eye Hospital and UCL Institute of Ophthalmology (S.K.W., D.R.-B., D.J.W., R.R.S., Y.Z., E.K., P.J.F., K.B., A.P.K., P.J.P., J.S.R., A.K.D., A.P., P.A.K.), London, United Kingdom; Biomedical Engineering Department (D.R.-B., E.K., U.A., M.B.), Faculty of Engineering (MU-ENG), Mondragon Unibertsitatea, Spain; Great Ormond Street Institute of Child Health (M.C.-B., J.S.R.), and Centre for Medical Image Computing (D.J.W., R.R.S., Y.Z.), Department of Computer Science, University College London; NeuroMetrology Lab (S.P., C.A.A.), Nuffield Department of Clinical Neurosciences, University of Oxford; Dementia Research Centre (R.S.W.), University College London, United Kingdom; Department of Molecular Medicine (E.J.T.), Scripps Research, La Jolla, CA; Byers Eye Institute (E.K.), Stanford University, Palo Alto, CA; Biocruces Bizkaia Health Research Institute (I.G.), Barakaldo; IKERBASQUE: The Basque Foundation for Science (I.G.), Bilbao, Spain; Department of Clinical and Movement Neurosciences (A.H.V.S.), UCL Queen Square Institute of Neurology; Great Ormond Street Hospital NHS Foundation Trust (J.S.R.); Ulverscroft Vision Research Group (J.S.R.), University College London; NIHR Biomedical Research Centre at UCL Great Ormond Street Institute of Child Health and Great Ormond Street Hospital (J.S.R.), London; University of Birmingham (A.K.D.); University Hospitals Birmingham NHS Foundation Trust (A.K.D.); NIHR Birmingham Biomedical Research Centre (A.K.D.), University of Birmingham; and Queen Square Institute of Neurology (A.P.), University College London, United Kingdom
| | - Jugnoo S Rahi
- From the Institute of Ophthalmology (S.K.W., D.J.W., R.R.S., Y.Z., P.J.F., K.B., A.P.K., P.J.P., J.S.R., A.P., P.A.K.), University College London; NIHR Biomedical Research Centre at Moorfields Eye Hospital and UCL Institute of Ophthalmology (S.K.W., D.R.-B., D.J.W., R.R.S., Y.Z., E.K., P.J.F., K.B., A.P.K., P.J.P., J.S.R., A.K.D., A.P., P.A.K.), London, United Kingdom; Biomedical Engineering Department (D.R.-B., E.K., U.A., M.B.), Faculty of Engineering (MU-ENG), Mondragon Unibertsitatea, Spain; Great Ormond Street Institute of Child Health (M.C.-B., J.S.R.), and Centre for Medical Image Computing (D.J.W., R.R.S., Y.Z.), Department of Computer Science, University College London; NeuroMetrology Lab (S.P., C.A.A.), Nuffield Department of Clinical Neurosciences, University of Oxford; Dementia Research Centre (R.S.W.), University College London, United Kingdom; Department of Molecular Medicine (E.J.T.), Scripps Research, La Jolla, CA; Byers Eye Institute (E.K.), Stanford University, Palo Alto, CA; Biocruces Bizkaia Health Research Institute (I.G.), Barakaldo; IKERBASQUE: The Basque Foundation for Science (I.G.), Bilbao, Spain; Department of Clinical and Movement Neurosciences (A.H.V.S.), UCL Queen Square Institute of Neurology; Great Ormond Street Hospital NHS Foundation Trust (J.S.R.); Ulverscroft Vision Research Group (J.S.R.), University College London; NIHR Biomedical Research Centre at UCL Great Ormond Street Institute of Child Health and Great Ormond Street Hospital (J.S.R.), London; University of Birmingham (A.K.D.); University Hospitals Birmingham NHS Foundation Trust (A.K.D.); NIHR Birmingham Biomedical Research Centre (A.K.D.), University of Birmingham; and Queen Square Institute of Neurology (A.P.), University College London, United Kingdom
| | - Alastair K Denniston
- From the Institute of Ophthalmology (S.K.W., D.J.W., R.R.S., Y.Z., P.J.F., K.B., A.P.K., P.J.P., J.S.R., A.P., P.A.K.), University College London; NIHR Biomedical Research Centre at Moorfields Eye Hospital and UCL Institute of Ophthalmology (S.K.W., D.R.-B., D.J.W., R.R.S., Y.Z., E.K., P.J.F., K.B., A.P.K., P.J.P., J.S.R., A.K.D., A.P., P.A.K.), London, United Kingdom; Biomedical Engineering Department (D.R.-B., E.K., U.A., M.B.), Faculty of Engineering (MU-ENG), Mondragon Unibertsitatea, Spain; Great Ormond Street Institute of Child Health (M.C.-B., J.S.R.), and Centre for Medical Image Computing (D.J.W., R.R.S., Y.Z.), Department of Computer Science, University College London; NeuroMetrology Lab (S.P., C.A.A.), Nuffield Department of Clinical Neurosciences, University of Oxford; Dementia Research Centre (R.S.W.), University College London, United Kingdom; Department of Molecular Medicine (E.J.T.), Scripps Research, La Jolla, CA; Byers Eye Institute (E.K.), Stanford University, Palo Alto, CA; Biocruces Bizkaia Health Research Institute (I.G.), Barakaldo; IKERBASQUE: The Basque Foundation for Science (I.G.), Bilbao, Spain; Department of Clinical and Movement Neurosciences (A.H.V.S.), UCL Queen Square Institute of Neurology; Great Ormond Street Hospital NHS Foundation Trust (J.S.R.); Ulverscroft Vision Research Group (J.S.R.), University College London; NIHR Biomedical Research Centre at UCL Great Ormond Street Institute of Child Health and Great Ormond Street Hospital (J.S.R.), London; University of Birmingham (A.K.D.); University Hospitals Birmingham NHS Foundation Trust (A.K.D.); NIHR Birmingham Biomedical Research Centre (A.K.D.), University of Birmingham; and Queen Square Institute of Neurology (A.P.), University College London, United Kingdom
| | - Axel Petzold
- From the Institute of Ophthalmology (S.K.W., D.J.W., R.R.S., Y.Z., P.J.F., K.B., A.P.K., P.J.P., J.S.R., A.P., P.A.K.), University College London; NIHR Biomedical Research Centre at Moorfields Eye Hospital and UCL Institute of Ophthalmology (S.K.W., D.R.-B., D.J.W., R.R.S., Y.Z., E.K., P.J.F., K.B., A.P.K., P.J.P., J.S.R., A.K.D., A.P., P.A.K.), London, United Kingdom; Biomedical Engineering Department (D.R.-B., E.K., U.A., M.B.), Faculty of Engineering (MU-ENG), Mondragon Unibertsitatea, Spain; Great Ormond Street Institute of Child Health (M.C.-B., J.S.R.), and Centre for Medical Image Computing (D.J.W., R.R.S., Y.Z.), Department of Computer Science, University College London; NeuroMetrology Lab (S.P., C.A.A.), Nuffield Department of Clinical Neurosciences, University of Oxford; Dementia Research Centre (R.S.W.), University College London, United Kingdom; Department of Molecular Medicine (E.J.T.), Scripps Research, La Jolla, CA; Byers Eye Institute (E.K.), Stanford University, Palo Alto, CA; Biocruces Bizkaia Health Research Institute (I.G.), Barakaldo; IKERBASQUE: The Basque Foundation for Science (I.G.), Bilbao, Spain; Department of Clinical and Movement Neurosciences (A.H.V.S.), UCL Queen Square Institute of Neurology; Great Ormond Street Hospital NHS Foundation Trust (J.S.R.); Ulverscroft Vision Research Group (J.S.R.), University College London; NIHR Biomedical Research Centre at UCL Great Ormond Street Institute of Child Health and Great Ormond Street Hospital (J.S.R.), London; University of Birmingham (A.K.D.); University Hospitals Birmingham NHS Foundation Trust (A.K.D.); NIHR Birmingham Biomedical Research Centre (A.K.D.), University of Birmingham; and Queen Square Institute of Neurology (A.P.), University College London, United Kingdom
| | - Pearse Andrew Keane
- From the Institute of Ophthalmology (S.K.W., D.J.W., R.R.S., Y.Z., P.J.F., K.B., A.P.K., P.J.P., J.S.R., A.P., P.A.K.), University College London; NIHR Biomedical Research Centre at Moorfields Eye Hospital and UCL Institute of Ophthalmology (S.K.W., D.R.-B., D.J.W., R.R.S., Y.Z., E.K., P.J.F., K.B., A.P.K., P.J.P., J.S.R., A.K.D., A.P., P.A.K.), London, United Kingdom; Biomedical Engineering Department (D.R.-B., E.K., U.A., M.B.), Faculty of Engineering (MU-ENG), Mondragon Unibertsitatea, Spain; Great Ormond Street Institute of Child Health (M.C.-B., J.S.R.), and Centre for Medical Image Computing (D.J.W., R.R.S., Y.Z.), Department of Computer Science, University College London; NeuroMetrology Lab (S.P., C.A.A.), Nuffield Department of Clinical Neurosciences, University of Oxford; Dementia Research Centre (R.S.W.), University College London, United Kingdom; Department of Molecular Medicine (E.J.T.), Scripps Research, La Jolla, CA; Byers Eye Institute (E.K.), Stanford University, Palo Alto, CA; Biocruces Bizkaia Health Research Institute (I.G.), Barakaldo; IKERBASQUE: The Basque Foundation for Science (I.G.), Bilbao, Spain; Department of Clinical and Movement Neurosciences (A.H.V.S.), UCL Queen Square Institute of Neurology; Great Ormond Street Hospital NHS Foundation Trust (J.S.R.); Ulverscroft Vision Research Group (J.S.R.), University College London; NIHR Biomedical Research Centre at UCL Great Ormond Street Institute of Child Health and Great Ormond Street Hospital (J.S.R.), London; University of Birmingham (A.K.D.); University Hospitals Birmingham NHS Foundation Trust (A.K.D.); NIHR Birmingham Biomedical Research Centre (A.K.D.), University of Birmingham; and Queen Square Institute of Neurology (A.P.), University College London, United Kingdom
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Mollan SP, Momin SNA, Khatkar PS, Grech O, Sinclair AJ, Tsermoulas G. A Neuro-Ophthalmologist's Guide to Advances in Intracranial Pressure Measurements. Eye Brain 2023; 15:113-124. [PMID: 37790122 PMCID: PMC10543929 DOI: 10.2147/eb.s404642] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2023] [Accepted: 09/15/2023] [Indexed: 10/05/2023] Open
Abstract
Cerebrospinal fluid disorders have a wide-ranging impact on vision, headache, cognition and a person's quality of life. Due to advances in technology and accessibility, intracranial pressure measurement and monitoring, usually managed by neurosurgeons, are being employed more widely in clinical practice. These developments are of direct importance for Ophthalmologists and Neurologists because the ability to readily measure intracranial pressure can aide management decisions. The aim of this review is to present the emerging evidence for intracranial pressure measurement methods and interpretation that is relevant to Neuro-ophthalmologists.
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Affiliation(s)
- Susan P Mollan
- Birmingham Neuro-Ophthalmology, Queen Elizabeth Hospital, University Hospitals Birmingham, Birmingham, UK
- Translational Brain Science, Institute of Metabolism and Systems Research; Birmingham, University of Birmingham, Birmingham, UK
| | - Sehrish N A Momin
- Ophthalmology Department, The Aga Khan University Hospital, Karachi, Pakistan
| | | | - Olivia Grech
- Translational Brain Science, Institute of Metabolism and Systems Research; Birmingham, University of Birmingham, Birmingham, UK
| | - Alex J Sinclair
- Translational Brain Science, Institute of Metabolism and Systems Research; Birmingham, University of Birmingham, Birmingham, UK
- Department of Neurology, Queen Elizabeth Hospital, University Hospitals Birmingham, Birmingham, UK
| | - Georgios Tsermoulas
- Translational Brain Science, Institute of Metabolism and Systems Research; Birmingham, University of Birmingham, Birmingham, UK
- Department of Neurosurgery, Queen Elizabeth Hospital, University Hospitals Birmingham, Birmingham, UK
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16
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El-Masri S, Wilson M, Goh J, Sanfilippo P, Fok A, Hardy T, Chakrabarti R, Van Der Walt A. A 20-year multicentre retrospective review of optic nerve sheath fenestration outcomes. Ther Adv Neurol Disord 2023; 16:17562864231197994. [PMID: 37719666 PMCID: PMC10501074 DOI: 10.1177/17562864231197994] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2023] [Accepted: 07/31/2023] [Indexed: 09/19/2023] Open
Abstract
Background Optic nerve sheath fenestration (ONSF) longitudinal outcomes remain unclear and are vital in the assessment of vision failure in patients with raised intracranial pressure (ICP). Furthermore, limited observational data exists regarding its use in other causes of raised ICP. Objective To determine the efficacy and safety of ONSF for idiopathic intracranial hypertension (IIH), cerebral venous sinus thrombosis (CVST), and other indications. Method Multicentre study from a tertiary hospital and specialty eye referral hospital in Melbourne, Australia, from July 2000 to December 2020. A total of 116 eyes from 70 patients undergoing ONSF were retrospectively reviewed with patient demographics, surgery indications, visual acuity (VA), visual fields, fundus photos of optic discs, retinal nerve fibre layer (RNFL) thickness, average thickness of optic discs on optical coherence tomography (OCT), and complications recorded. Parametric tests were used to compare the treatment groups pre- and post-operatively. Results A total of 116 eyes from 70 patients underwent ONSF, which involved 92 eyes with IIH, 9 eyes with CVST, and 15 eyes with other aetiologies ('Other'). Post ONSF, there was a best corrected visual acuity (BCVA) improvement or stabilisation in 84% of patients in all groups, with 50% achieving a BCVA of 6/6 or better at the final follow-up. RNFL, visual fields, and fundus grades all trended towards improvement, with most improvement noted by day 360. Common complications included transient diplopia (n = 29, 25%) and worsening of visual function requiring further cerebrospinal fluid (CSF) diversion procedures (n = 20, 17%). Complications were most significant in the 'Other' group with 1/3 of eyes requiring further CSF diversion procedures. Conclusion Our data demonstrates effectiveness in the use of ONSF in papilloedema with visual failure due to IIH or CVST and when other CSF diversion procedures or medical therapies have failed.
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Affiliation(s)
- Shaddy El-Masri
- Royal Melbourne Hospital, Hospital City Campus, Grattan Street, Parkville, VIC 3050, Australia
- Royal Adelaide Hospital, Adelaide, SA, Australia
| | - Matthew Wilson
- Royal Victorian Eye and Ear Hospital, Melbourne, VIC, Australia
| | - Jonathan Goh
- Royal Victorian Eye and Ear Hospital, Melbourne, VIC, Australia
| | - Paul Sanfilippo
- Neuroscience Department, The Alfred Hospital, Melbourne, VIC, Australia
| | - Anthony Fok
- Royal Melbourne Hospital, Parkville, VIC, Australia
| | - Thomas Hardy
- Royal Victorian Eye and Ear Hospital, Melbourne, VIC, Australia
| | | | - Anneke Van Der Walt
- Royal Victorian Eye and Ear Hospital, Melbourne, VIC, Australia
- Neuroscience Department, The Alfred Hospital, Melbourne, VIC, Australia
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17
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Mollan SP, Fraser CL, Digre KB, Diener HC, Lipton RB, Juhler M, Miller NR, Pozo-Rosich P, Togha M, Brock K, Dinkin MJ, Chan CKM, Tassorelli C, Sinclair AJ, Terwindt GM, Jensen RH. Guidelines of the International Headache Society for Controlled Clinical Trials in Idiopathic Intracranial Hypertension. Cephalalgia 2023; 43:3331024231197118. [PMID: 37661711 DOI: 10.1177/03331024231197118] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/05/2023]
Abstract
The quality of clinical trials is essential to advance treatment, inform regulatory decisions and meta-analysis. With the increased incidence of idiopathic intracranial hypertension and the emergence of clinical trials for novel therapies in this condition, the International Headache Society Guidelines for Controlled Clinical Trials in Idiopathic Intracranial Hypertension aims to establish guidelines for designing state-of-the-art controlled clinical trials for idiopathic intracranial hypertension.
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Affiliation(s)
- Susan P Mollan
- Neuro-ophthalmology, Queen Elizabeth Hospital, University Hospital Birmingham NHS Foundation Trust, Birmingham, Birmingham, UK
- Translational Brain Science, Institute of Metabolism and Systems Research, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
| | - Clare L Fraser
- Save Sight Institute, University of Sydney, Sydney, NSW, Australia
| | - Kathleen B Digre
- Neuro-ophthalmology Division, John A. Moran Eye Center, University of Utah, Salt Lake City, USA
| | - Hans-Christoph Diener
- Institut für Medizinische Informatik, Biometrie undEpidemiologie (IMIBE), Medizinische Fakultät der Universität Duisburg-Essen, Essen, Germany
| | - Richard B Lipton
- The Saul R. Korey Department of Neurology, and the Montefiore Headache Center, Albert Einstein College of Medicine, Bronx, New York, USA
| | - Marianne Juhler
- Department of Neurosurgery, Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark
- Institute of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Neil R Miller
- Wilmer Eye Institute and Departments of Ophthalmology, Neurology, and Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Patricia Pozo-Rosich
- Headache Unit, Neurology Department, Hospital Universitari Vall d'Hebron, Barcelona, Spain
- Headache and Neurological Pain Research Group, Vall d'Hebron Research Institute, Department of Medicine, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Mansoureh Togha
- Headache Department, Iranian Centre of Neurological Research, Neuroscience Institute, Tehran University of Medical Sciences, Tehran, Iran
- Headache Department, Neurology Ward, Sina Hospital, School of Medicine, Tehran University of Medical Sciences, Tehran, Iran
| | - Kristian Brock
- Cancer Research Clinical Trials Unit, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
| | - Marc J Dinkin
- Department of Ophthalmology, Weill Cornell Medical College, NY Presbyterian Hospital, New York, New York, USA
- Department of Neurology, Weill Cornell Medical College, NY Presbyterian Hospital, New York, New York, USA
| | - Carmen K M Chan
- Department of Ophthalmology and Visual Sciences, The Chinese University of Hong Kong, Hong Kong SAR, China
- Hong Kong Eye Hospital, Hong Kong SAR, China
| | - Cristina Tassorelli
- Unit of Translational Neurovascular Research, IRCCS Mondino Foundation, 27100, Pavia, Italy
- Department of Brain and Behavioural Sciences, University of Pavia, 27100, Pavia, Italy
| | - Alex J Sinclair
- Translational Brain Science, Institute of Metabolism and Systems Research, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
- Department of Neurology, University Hospitals Birmingham, Queen Elizabeth Hospital, Birmingham, UK
| | - Gisela M Terwindt
- Department of Neurology, Leiden University Medical Center, Leiden, the Netherlands
| | - Rigmor H Jensen
- Department of Neurology, Danish Headache Center, Rigshospitalet-Glostrup, University of Copenhagen, Copenhagen, Denmark
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18
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Beare NAV. Cerebral malaria-using the retina to study the brain. Eye (Lond) 2023; 37:2379-2384. [PMID: 36788363 PMCID: PMC10397347 DOI: 10.1038/s41433-023-02432-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2022] [Revised: 01/14/2023] [Accepted: 01/30/2023] [Indexed: 02/16/2023] Open
Abstract
Cerebral malaria (CM) remains a common cause of death of children in Africa with annual mortality of 400 000. Malarial retinopathy is a unique set of fundus signs which has diagnostic and prognostic value in CM. Assessment of malarial retinopathy is now widely utilised in clinical care, and routinely incorporated into clinical studies to refine entry criteria. As a visible part of the central nervous system, the retina provides insights into the pathophysiology of this infectious small-vessel vasculitis with adherent parasitised red blood cells. Fluorescein angiography and optical coherence tomography (OCT) have shown that patchy capillary non-perfusion is common and causes ischaemic changes in the retina in CM. It is likely this is mirrored in the brain and may cause global neurological impairments evident on developmental follow up. Three types of blood-retina barrier breakdown are evident: large focal, punctate, and vessel leak. Punctate and large focal leak (haemorrhage in formation) are associated with severe brain swelling and fatal outcome. Vessel leak and capillary non-perfusion are associated with moderate brain swelling and neurological sequelae. These findings imply that death and neurological sequelae have separate mechanisms and are not a continuum of severity. Each haemorrhage causes a temporary uncontrolled outflow of fluid into the tissue. The rapid accumulation of haemorrhages, as evidenced by multiple focal leaks, is a proposed mechanism of severe brain swelling, and death. Current studies aim to use optic nerve head OCT to identify patients with severe brain swelling, and macula OCT to identify those at risk of neurological sequelae.
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Affiliation(s)
- Nicholas A V Beare
- Department of Eye and Vision Science, University of Liverpool, Liverpool, L7 8TX, UK.
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19
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Waisberg E, Ong J, Paladugu P, Kamran SA, Zaman N, Tavakkoli A, Lee AG. Applying generative adversarial network techniques to portable ophthalmic imaging. Eye (Lond) 2023; 37:2580-2581. [PMID: 36509995 PMCID: PMC10397179 DOI: 10.1038/s41433-022-02353-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2022] [Revised: 11/10/2022] [Accepted: 12/02/2022] [Indexed: 12/14/2022] Open
Affiliation(s)
- Ethan Waisberg
- University College Dublin School of Medicine, Belfield, Dublin, Ireland
| | - Joshua Ong
- Michigan Medicine, University of Michigan, Ann Arbor, MI, USA
| | - Phani Paladugu
- Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Sharif Amit Kamran
- Human-Machine Perception Laboratory, Department of Computer Science and Engineering, University of Nevada, Reno, Reno, NV, USA
| | - Nasif Zaman
- Human-Machine Perception Laboratory, Department of Computer Science and Engineering, University of Nevada, Reno, Reno, NV, USA
| | - Alireza Tavakkoli
- Human-Machine Perception Laboratory, Department of Computer Science and Engineering, University of Nevada, Reno, Reno, NV, USA
| | - Andrew G Lee
- Center for Space Medicine, Baylor College of Medicine, Houston, TX, USA.
- Department of Ophthalmology, Blanton Eye Institute, Houston Methodist Hospital, Houston, TX, USA.
- The Houston Methodist Research Institute, Houston Methodist Hospital, Houston, TX, USA.
- Departments of Ophthalmology, Neurology, and Neurosurgery, Weill Cornell Medicine, New York, NY, USA.
- Department of Ophthalmology, University of Texas Medical Branch, Galveston, TX, USA.
- University of Texas MD Anderson Cancer Center, Houston, TX, USA.
- Texas A&M College of Medicine, Bryan, TX, USA.
- Department of Ophthalmology, The University of Iowa Hospitals and Clinics, Iowa City, IA, USA.
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20
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Hyder YF, Homer V, Thaller M, Byrne M, Tsermoulas G, Piccus R, Mollan SP, Sinclair AJ. Defining the Phenotype and Prognosis of People With Idiopathic Intracranial Hypertension After Cerebrospinal Fluid Diversion Surgery. Am J Ophthalmol 2023; 250:70-81. [PMID: 36682516 DOI: 10.1016/j.ajo.2023.01.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2022] [Revised: 01/11/2023] [Accepted: 01/12/2023] [Indexed: 01/22/2023]
Abstract
PURPOSE To characterize the phenotype of patients with idiopathic intracranial hypertension (IIH) who received cerebrospinal (CSF) diversion surgery and to detail the trajectory of recovery. DESIGN Prospective cohort registry study. METHODS Patients with IIH with sight-threatening papilledema presenting to a single United Kingdom neuroscience center between 2019 and 2021 were included. Outcomes consisted of perimetric mean deviation (PMD) and optical coherence tomography measures of papilledema (retinal nerve fiber layer [RNFL]) and macular ganglion cell layer (GCL) in both eyes. Headache outcomes included monthly headache days (MHD). Logistic regression methods were used to model long-term outcomes. RESULTS Fifty-one patients without previous surgical interventions were included (92% female, mean age 28.1 years [SD 8.4], body mass index 37.4 kg/m2 [SD 9.7], mean days of follow-up 330 [SD 209]). Measurements before surgery showed mean PMD -11.4 dB (SD 9.7), RNFL 364 µm (SD 128), Frisén grade papilledema 4.3 (SD 0.9). and MHD 23 (SD 10.6). At 1 month postoperatively, RNFL and PMD had improved by 38% and 4%, respectively. At 4 months postoperatively, papilledema had resolved. GCL declined by 13% over 12 months. MHD reduced by 75% 3 months postoperatively before returning to baseline levels by 12 months. Five patients (9.8%) required revision surgeries. CONCLUSIONS Detailed characteristics of patients with sight-threatening IIH who received CSF diversion surgery and their typical postoperative recovery are presented. These parameters should guide physicians as to when patients with IIH may require surgery and enable the early identification of outliers who fail to respond. Papilledema and PMD recovered but GCL atrophy continued for 12 months. The implication of this delayed atrophy is unknown.
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Affiliation(s)
- Yousef F Hyder
- From the Translational Brain Science (Y.F.H., M.T., S.P.M., A.J.S.), Institute of Metabolism and Systems Research, University of Birmingham, Birmingham, United Kingdom; Department of Neurology (Y.F.H., M.T., A.J.S.), University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK; Centre for Endocrinology, Diabetes and Metabolism (Y.F.H., M.T., A.J.S.), Birmingham Health Partners, Birmingham, UK
| | - Victoria Homer
- Cancer Research (UK) Clinical Trials Unit (V.H.), University of Birmingham, Birmingham, Birmingham, UK
| | - Mark Thaller
- From the Translational Brain Science (Y.F.H., M.T., S.P.M., A.J.S.), Institute of Metabolism and Systems Research, University of Birmingham, Birmingham, United Kingdom; Department of Neurology (Y.F.H., M.T., A.J.S.), University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK; Centre for Endocrinology, Diabetes and Metabolism (Y.F.H., M.T., A.J.S.), Birmingham Health Partners, Birmingham, UK
| | - Marian Byrne
- Department of Neurosurgery (M.B., G.T.), Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Georgios Tsermoulas
- Department of Neurosurgery (M.B., G.T.), Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Rachel Piccus
- and Birmingham Neuro-Ophthalmology (R.P., S.P.M.), Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Susan P Mollan
- From the Translational Brain Science (Y.F.H., M.T., S.P.M., A.J.S.), Institute of Metabolism and Systems Research, University of Birmingham, Birmingham, United Kingdom; and Birmingham Neuro-Ophthalmology (R.P., S.P.M.), Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Alexandra J Sinclair
- From the Translational Brain Science (Y.F.H., M.T., S.P.M., A.J.S.), Institute of Metabolism and Systems Research, University of Birmingham, Birmingham, United Kingdom; Department of Neurology (Y.F.H., M.T., A.J.S.), University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK; Centre for Endocrinology, Diabetes and Metabolism (Y.F.H., M.T., A.J.S.), Birmingham Health Partners, Birmingham, UK.
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21
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Piccus R, Thaller M, Sinclair AJ, Mollan SP. Current and emerging diagnostic and management approaches for idiopathic intracranial hypertension. Expert Rev Neurother 2023; 23:457-466. [PMID: 37114519 DOI: 10.1080/14737175.2023.2206567] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/29/2023]
Abstract
INTRODUCTION Idiopathic intracranial hypertension is characterized by raised intracranial pressure that triggers disabling headaches and can cause permanent visual loss. There is an increased incidence and prevalence of the condition linked to location-specific obesity rates. There are no licensed treatments for the condition. The majority of approaches to managing the disease prioritize resolution of papilledema. However, evidence is emerging that idiopathic intracranial hypertension is a systemic metabolic disease. AREAS COVERED The aim of this review is to present the emerging pathophysiology evidence which is leading to novel targeted therapeutics. The diagnostic pathway is outlined. The current and potential management approaches for idiopathic intracranial hypertension are also discussed. EXPERT OPINION Idiopathic intracranial hypertension is a condition with metabolic dysregulation with systemic manifestations that are present over and above what can be expl.ained by obesity alone. While most of the current management of this condition focuses on the eyes, future management needs to address the disabling headaches and the systemic risks of preeclampsia, gestational diabetes, and major cardiovascular events.
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Affiliation(s)
- Ravi Piccus
- Medical school, University of Birmingham, Birmingham, UK
| | - Mark Thaller
- Translational Brain Science, Institute of Metabolism and Systems Research, University of Birmingham, Birmingham, UK
- Department of Neurology, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
- Centre for Endocrinology, Diabetes and Metabolism, Birmingham Health Partners, Birmingham, UK
| | - Alexandra J Sinclair
- Translational Brain Science, Institute of Metabolism and Systems Research, University of Birmingham, Birmingham, UK
- Department of Neurology, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
- Centre for Endocrinology, Diabetes and Metabolism, Birmingham Health Partners, Birmingham, UK
| | - Susan P Mollan
- Translational Brain Science, Institute of Metabolism and Systems Research, University of Birmingham, Birmingham, UK
- Birmingham Neuro-Ophthalmology, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
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22
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Thaller M, Homer V, Mollan SP, Sinclair AJ. Disease Course and Long-term Outcomes in Pregnant Women With Idiopathic Intracranial Hypertension: The IIH Prospective Maternal Health Study. Neurology 2023; 100:e1598-e1610. [PMID: 36750388 PMCID: PMC10103118 DOI: 10.1212/wnl.0000000000206854] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2022] [Accepted: 12/07/2022] [Indexed: 02/09/2023] Open
Abstract
BACKGROUND AND OBJECTIVES Idiopathic intracranial hypertension (IIH) most typically occurs in women of childbearing age with increased weight as a key risk factor for development or exacerbation of the disease. Pregnancy is common in this group of patients. The longer-term effect of pregnancy on IIH has not been established and was the aim of this study. METHODS A prospective cohort study (IIH Life) recruited consecutive patients with IIH between 2012 and 2021 and evaluated outcomes including vision (logarithm of the minimum angle of resolution visual acuity, Humphrey visual field perimetric mean deviation, and optical coherence tomography [OCT] imaging) and headache. Four cohorts were evaluated: those with IIH diagnosed for the first time while pregnant, those with established IIH who became pregnant, those with a pregnancy prior to their diagnosis of IIH, and those with IIH who never became pregnant. RESULTS Three hundred seventy-seven people with IIH agreed to participate in the IIH Life maternal health study. Mean follow-up was 17.5 months (SD 20.5). IIH diagnosed in pregnancy was rare. Patients diagnosed with IIH while pregnant had greater papilledema (mean OCT total retinal thickness +11.59 µm/mo [95% CI 1.25-21.93]), although they had comparable visual field and acuity measures compared with those with established IIH who became pregnant during their disease course (-1.2 µm/mo [95% CI -2.6 to 0.21]). In those with established IIH, pregnancy did not adversely affect visual or headache outcomes over time, and the trajectory was akin to those with IIH who never had a pregnancy. Headache outcomes showed variability reflecting the IIH cohort as a whole. DISCUSSION A diagnosis of IIH while pregnant was rare but associated with more severe papilledema. Long-term visual outcomes in IIH were analogous irrespective of the timing of the pregnancy. These data are reassuring; however, close vigilance of IIH clinical features during pregnancy is recommended.
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Affiliation(s)
- Mark Thaller
- From the Translational Brain Science (M.T., S.P.M., A.J.S.), Institute of Metabolism and Systems Research, and Cancer Research (UK) Clinical Trials Unit (V.H.), University of Birmingham; Department of Neurology (M.T., A.J.S.) and Birmingham Neuro-Ophthalmology (S.P.M.), University Hospitals Birmingham NHS Foundation Trust; Centre for Endocrinology (M.T., A.J.S.), Diabetes and Metabolism, Birmingham Health Partners, UK
| | - Victoria Homer
- From the Translational Brain Science (M.T., S.P.M., A.J.S.), Institute of Metabolism and Systems Research, and Cancer Research (UK) Clinical Trials Unit (V.H.), University of Birmingham; Department of Neurology (M.T., A.J.S.) and Birmingham Neuro-Ophthalmology (S.P.M.), University Hospitals Birmingham NHS Foundation Trust; Centre for Endocrinology (M.T., A.J.S.), Diabetes and Metabolism, Birmingham Health Partners, UK
| | - Susan P Mollan
- From the Translational Brain Science (M.T., S.P.M., A.J.S.), Institute of Metabolism and Systems Research, and Cancer Research (UK) Clinical Trials Unit (V.H.), University of Birmingham; Department of Neurology (M.T., A.J.S.) and Birmingham Neuro-Ophthalmology (S.P.M.), University Hospitals Birmingham NHS Foundation Trust; Centre for Endocrinology (M.T., A.J.S.), Diabetes and Metabolism, Birmingham Health Partners, UK
| | - Alexandra Jean Sinclair
- From the Translational Brain Science (M.T., S.P.M., A.J.S.), Institute of Metabolism and Systems Research, and Cancer Research (UK) Clinical Trials Unit (V.H.), University of Birmingham; Department of Neurology (M.T., A.J.S.) and Birmingham Neuro-Ophthalmology (S.P.M.), University Hospitals Birmingham NHS Foundation Trust; Centre for Endocrinology (M.T., A.J.S.), Diabetes and Metabolism, Birmingham Health Partners, UK.
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23
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Bouthour W, Biousse V, Newman NJ. Diagnosis of Optic Disc Oedema: Fundus Features, Ocular Imaging Findings, and Artificial Intelligence. Neuroophthalmology 2023; 47:177-192. [PMID: 37434667 PMCID: PMC10332214 DOI: 10.1080/01658107.2023.2176522] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2022] [Revised: 01/12/2023] [Accepted: 01/29/2023] [Indexed: 02/18/2023] Open
Abstract
Optic disc swelling is a manifestation of a broad range of processes affecting the optic nerve head and/or the anterior segment of the optic nerve. Accurately diagnosing optic disc oedema, grading its severity, and recognising its cause, is crucial in order to treat patients in a timely manner and limit vision loss. Some ocular fundus features, in light of a patient's history and visual symptoms, may suggest a specific mechanism or aetiology of the visible disc oedema, but current criteria can at most enable an educated guess as to the most likely cause. In many cases only the clinical evolution and ancillary testing can inform the exact diagnosis. The development of ocular fundus imaging, including colour fundus photography, fluorescein angiography, optical coherence tomography, and multimodal imaging, has provided assistance in quantifying swelling, distinguishing true optic disc oedema from pseudo-optic disc oedema, and differentiating among the numerous causes of acute optic disc oedema. However, the diagnosis of disc oedema is often delayed or not made in busy emergency departments and outpatient neurology clinics. Indeed, most non-eye care providers are not able to accurately perform ocular fundus examination, increasing the risk of diagnostic errors in acute neurological settings. The implementation of non-mydriatic fundus photography and artificial intelligence technology in the diagnostic process addresses these important gaps in clinical practice.
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Affiliation(s)
- Walid Bouthour
- Department of Ophthalmology, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Valérie Biousse
- Department of Ophthalmology, Emory University School of Medicine, Atlanta, Georgia, USA
- Department of Neurology, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Nancy J. Newman
- Department of Ophthalmology, Emory University School of Medicine, Atlanta, Georgia, USA
- Department of Neurology, Emory University School of Medicine, Atlanta, Georgia, USA
- Department of Neurological Surgery, Emory University School of Medicine, Atlanta, Georgia, USA
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24
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Thaller M, Homer V, Hyder Y, Yiangou A, Liczkowski A, Fong AW, Virdee J, Piccus R, Roque M, Mollan SP, Sinclair AJ. The idiopathic intracranial hypertension prospective cohort study: evaluation of prognostic factors and outcomes. J Neurol 2023; 270:851-863. [PMID: 36242625 PMCID: PMC9886634 DOI: 10.1007/s00415-022-11402-6] [Citation(s) in RCA: 16] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2022] [Revised: 09/22/2022] [Accepted: 09/23/2022] [Indexed: 02/03/2023]
Abstract
BACKGROUND There are limited longitudinal data evaluating outcomes in idiopathic intracranial hypertension (IIH). We aimed to evaluate the long-term outcomes in a real-world cohort of patients with IIH and sought to establish the prognostic factors. METHODS A longitudinal prospective cohort study was conducted over 9 years (2012-2021). Data included demographics and disease status. All consenting patients with IIH were recruited. Visual outcomes included visual acuity, Humphrey visual field and optical coherence tomography (OCT) imaging measurements. Headache frequency, severity, and impact were noted. We analysed the key variables impacting visual and headache outcomes. RESULTS The cohort contained 490 patients with a confirmed IIH diagnosis. 98% were female with a mean body mass index (BMI) of 38 kg/m2. Those with the highest OCT retinal nerve fibre layer had the worst visual outcomes. We noted a delayed decline, in the visual field and OCT ganglion cell layer after 12 months. In the medically managed cohort (n = 426), we found that disease duration and change in BMI had the greatest influence on visual outcomes. There was a high burden of headache, with a daily headache at presentation and prior migraine history influencing long-term headache prognosis. CONCLUSIONS There is a delayed decline in visual outcomes in those with the most severe papilloedema. Disease duration and change in BMI were the key visual prognostic factors, therefore those with the more acute disease may require closer monitoring. Improving prognosis in IIH should focus on the potentially modifiable factor of weight management.
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Affiliation(s)
- Mark Thaller
- Translational Brain Science, Institute of Metabolism and Systems Research, University of Birmingham, Birmingham, B15 2TT, UK.,Department of Neurology, University Hospitals Birmingham NHS Foundation Trust, Birmingham, B15 2TH, UK.,Centre for Endocrinology, Diabetes and Metabolism, Birmingham Health Partners, Birmingham, B15 2TH, UK
| | - Victoria Homer
- Cancer Research (UK) Clinical Trials Unit, University of Birmingham, Birmingham, B15 2TT, UK
| | - Yousef Hyder
- Translational Brain Science, Institute of Metabolism and Systems Research, University of Birmingham, Birmingham, B15 2TT, UK.,Department of Neurology, University Hospitals Birmingham NHS Foundation Trust, Birmingham, B15 2TH, UK.,Centre for Endocrinology, Diabetes and Metabolism, Birmingham Health Partners, Birmingham, B15 2TH, UK
| | - Andreas Yiangou
- Translational Brain Science, Institute of Metabolism and Systems Research, University of Birmingham, Birmingham, B15 2TT, UK.,Department of Neurology, University Hospitals Birmingham NHS Foundation Trust, Birmingham, B15 2TH, UK.,Centre for Endocrinology, Diabetes and Metabolism, Birmingham Health Partners, Birmingham, B15 2TH, UK
| | - Anthony Liczkowski
- Translational Brain Science, Institute of Metabolism and Systems Research, University of Birmingham, Birmingham, B15 2TT, UK.,Emergency Medicine, Hull University Teaching Hospitals NHS Trust, Anlaby Rd, Hull, HU3 2JZ, UK
| | - Anthony W Fong
- Birmingham Neuro-Ophthalmology, University Hospitals Birmingham NHS Foundation Trust, Birmingham, B15 2TH, UK.,Ophthalmology, School of Medicine, University of Queensland, Queensland, 4006, Australia
| | - Jasvir Virdee
- Birmingham Neuro-Ophthalmology, University Hospitals Birmingham NHS Foundation Trust, Birmingham, B15 2TH, UK
| | - Rachel Piccus
- Birmingham Neuro-Ophthalmology, University Hospitals Birmingham NHS Foundation Trust, Birmingham, B15 2TH, UK
| | - Marianne Roque
- Birmingham Neuro-Ophthalmology, University Hospitals Birmingham NHS Foundation Trust, Birmingham, B15 2TH, UK
| | - Susan P Mollan
- Translational Brain Science, Institute of Metabolism and Systems Research, University of Birmingham, Birmingham, B15 2TT, UK.,Birmingham Neuro-Ophthalmology, University Hospitals Birmingham NHS Foundation Trust, Birmingham, B15 2TH, UK
| | - Alexandra J Sinclair
- Translational Brain Science, Institute of Metabolism and Systems Research, University of Birmingham, Birmingham, B15 2TT, UK. .,Department of Neurology, University Hospitals Birmingham NHS Foundation Trust, Birmingham, B15 2TH, UK. .,Centre for Endocrinology, Diabetes and Metabolism, Birmingham Health Partners, Birmingham, B15 2TH, UK.
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25
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Dattilo M. Noninvasive methods to monitor intracranial pressure. Curr Opin Neurol 2023; 36:1-9. [PMID: 36630209 DOI: 10.1097/wco.0000000000001126] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
PURPOSE OF REVIEW Intracranial pressure (ICP) is determined by the production of and outflow facility of cerebrospinal fluid. Since alterations in ICP are implicated in several vision-threatening and life-threatening diseases, measurement of ICP is necessary and common. All current clinical methods to measure ICP are invasive and carry the risk for significant side effects. Therefore, the development of accurate, reliable, objective, and portal noninvasive devices to measure ICP has the potential to change the practice of medicine. This review discusses recent advances and barriers to the clinical implementation of noninvasive devices to determine ICP. RECENT FINDINGS Many noninvasive methods to determine ICP have been developed. Although most have significant limitations limiting their clinical utility, several noninvasive methods have shown strong correlations with invasively obtained ICP and have excellent potential to be developed further to accurately quantify ICP and ICP changes. SUMMARY Although invasive methods remain the mainstay for ICP determination and monitoring, several noninvasive biomarkers have shown promise to quantitatively assess and monitor ICP. With further refinement and advancement of these techniques, it is highly possible that noninvasive methods will become more commonplace and may complement or even supplant invasively obtained methods to determine ICP in certain situations.
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Affiliation(s)
- Michael Dattilo
- Emory Eye Center, Neuro-Ophthalmology Division, Emory University School of Medicine, Atlanta, Georgia, USA
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26
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Mitchell JL, Buckham R, Lyons H, Walker JK, Yiangou A, Sassani M, Thaller M, Grech O, Alimajstorovic Z, Julher M, Tsermoulas G, Brock K, Mollan SP, Sinclair AJ. Evaluation of diurnal and postural intracranial pressure employing telemetric monitoring in idiopathic intracranial hypertension. Fluids Barriers CNS 2022; 19:85. [PMID: 36320018 PMCID: PMC9628104 DOI: 10.1186/s12987-022-00384-2] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2022] [Accepted: 10/12/2022] [Indexed: 11/07/2022] Open
Abstract
OBJECTIVES Intracranial pressure (ICP) has been thought to vary diurnally. This study evaluates diurnal ICP measurements and quantifies changes in ICP occurring with changes in body posture in active idiopathic intracranial hypertension (IIH). METHODS This prospective observational study utilized telemetric ICP monitoring in people with active IIH. Participants had the Raumedic p-Tel ICP intraparenchymal device (Raumedic, Hembrechts, Germany) surgically inserted. Changes in ICP in the supine position were evaluated. Then, the ICP was measured in the standing, sitting, supine, left lateral decubitus positions and with coughing and bending. Ultimately, changes in ICP over the course of 24 h were recorded. ISRCTN registration number 12678718. RESULTS 15 women were included, mean (standard deviation) age 29.5 (9.5) years, body mass index 38.1 (6.2) kg/m2, and baseline mean ICP of 21.2 (4.8) mmHg (equivalent to 28.8 (6.5) cmCSF). Mean ICP rose with the duration in the supine position 1.2 (3.3) mmHg over 5-minutes (p = 0.175), 3.5 (2.8) mmHg over 30-minutes (p = 0.0002) and by a further 2.1 (2.2) mmHg over 3 h (p = 0.042). Mean ICP decreased by 51% when moving from the supine position to standing (21.2 (4.8) mmHg to 10.3 (3.7) mmHg respectively, p = 0.0001). Mean ICP increased by 13% moving from supine to the left lateral decubitus position (21.2 (4.8) mmHg to 24.0 (3.8) mmHg, p = 0.028). There was no significant difference in ICP measurements at any point during the daytime, or between 5-minute standing or supine recordings and prolonged ambulatory daytime and end of night supine recordings respectively. ICP, following an initial drop, increased progressively in conjunction with lying supine position from 23:00 h to 07:00 h by 34% (5.2 (1.9) mmHg, p = 0.026). CONCLUSION This analysis demonstrated that ICP does not appear to have a diurnal variation in IIH, but varies by position and duration in the supine position. ICP rose at night whilst the patient was continuously supine. Furthermore, brief standing and supine ICP measures in the day predicted daytime prolonged ambulatory measures and end of night peak ICP respectively. This knowledge gives reassurance that ICP can be accurately measured and compared at any time of day in an ambulant IIH patient. These are useful findings to inform clinical measurements and in the interpretation of ICP analyses in IIH. TRIAL REGISTRATION ISTCRN (12678718).
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Affiliation(s)
- James L Mitchell
- grid.6572.60000 0004 1936 7486Institute of Metabolism and Systems Research, College of Medical and Dental Sciences, University of Birmingham, B15 2TT Birmingham, UK ,Centre for Endocrinology, Diabetes and Metabolism, Birmingham Health Partners, B15 2TH Birmingham, UK ,grid.415490.d0000 0001 2177 007XDepartment of Neurology, University Hospitals Birmingham NHS Foundation Trust, Queen Elizabeth Hospital, B15 2WB Birmingham, UK ,Academic Department of Military Rehabilitation, Defence Medical Rehabilitation Centre, Stanford Hall, LE12 5BL Loughborough, UK
| | - Rebecca Buckham
- grid.6572.60000 0004 1936 7486Institute of Metabolism and Systems Research, College of Medical and Dental Sciences, University of Birmingham, B15 2TT Birmingham, UK ,Centre for Endocrinology, Diabetes and Metabolism, Birmingham Health Partners, B15 2TH Birmingham, UK
| | - Hannah Lyons
- grid.6572.60000 0004 1936 7486Institute of Metabolism and Systems Research, College of Medical and Dental Sciences, University of Birmingham, B15 2TT Birmingham, UK ,Centre for Endocrinology, Diabetes and Metabolism, Birmingham Health Partners, B15 2TH Birmingham, UK ,grid.415490.d0000 0001 2177 007XDepartment of Neurology, University Hospitals Birmingham NHS Foundation Trust, Queen Elizabeth Hospital, B15 2WB Birmingham, UK
| | - Jessica K Walker
- grid.6572.60000 0004 1936 7486Institute of Metabolism and Systems Research, College of Medical and Dental Sciences, University of Birmingham, B15 2TT Birmingham, UK ,Centre for Endocrinology, Diabetes and Metabolism, Birmingham Health Partners, B15 2TH Birmingham, UK
| | - Andreas Yiangou
- grid.6572.60000 0004 1936 7486Institute of Metabolism and Systems Research, College of Medical and Dental Sciences, University of Birmingham, B15 2TT Birmingham, UK ,Centre for Endocrinology, Diabetes and Metabolism, Birmingham Health Partners, B15 2TH Birmingham, UK ,grid.415490.d0000 0001 2177 007XDepartment of Neurology, University Hospitals Birmingham NHS Foundation Trust, Queen Elizabeth Hospital, B15 2WB Birmingham, UK
| | - Matilde Sassani
- grid.6572.60000 0004 1936 7486Institute of Metabolism and Systems Research, College of Medical and Dental Sciences, University of Birmingham, B15 2TT Birmingham, UK ,Centre for Endocrinology, Diabetes and Metabolism, Birmingham Health Partners, B15 2TH Birmingham, UK ,grid.415490.d0000 0001 2177 007XDepartment of Neurology, University Hospitals Birmingham NHS Foundation Trust, Queen Elizabeth Hospital, B15 2WB Birmingham, UK
| | - Mark Thaller
- grid.6572.60000 0004 1936 7486Institute of Metabolism and Systems Research, College of Medical and Dental Sciences, University of Birmingham, B15 2TT Birmingham, UK ,Centre for Endocrinology, Diabetes and Metabolism, Birmingham Health Partners, B15 2TH Birmingham, UK ,grid.415490.d0000 0001 2177 007XDepartment of Neurology, University Hospitals Birmingham NHS Foundation Trust, Queen Elizabeth Hospital, B15 2WB Birmingham, UK
| | - Olivia Grech
- grid.6572.60000 0004 1936 7486Institute of Metabolism and Systems Research, College of Medical and Dental Sciences, University of Birmingham, B15 2TT Birmingham, UK ,Centre for Endocrinology, Diabetes and Metabolism, Birmingham Health Partners, B15 2TH Birmingham, UK
| | - Zerin Alimajstorovic
- grid.6572.60000 0004 1936 7486Institute of Metabolism and Systems Research, College of Medical and Dental Sciences, University of Birmingham, B15 2TT Birmingham, UK ,Centre for Endocrinology, Diabetes and Metabolism, Birmingham Health Partners, B15 2TH Birmingham, UK
| | - Marianne Julher
- grid.475435.4Department of Neurosurgery, Rigshospitalet, Copenhagen, Denmark
| | - Georgios Tsermoulas
- grid.6572.60000 0004 1936 7486Institute of Metabolism and Systems Research, College of Medical and Dental Sciences, University of Birmingham, B15 2TT Birmingham, UK ,Centre for Endocrinology, Diabetes and Metabolism, Birmingham Health Partners, B15 2TH Birmingham, UK ,grid.412563.70000 0004 0376 6589Department of Neurosurgery, Queen Elizabeth Hospital Birmingham, University Hospitals of Birmingham, Birmingham, UK
| | - Kristian Brock
- grid.6572.60000 0004 1936 7486Cancer Research Clinical Trials Unit, University of Birmingham, Birmingham, UK
| | - Susan P Mollan
- grid.6572.60000 0004 1936 7486Institute of Metabolism and Systems Research, College of Medical and Dental Sciences, University of Birmingham, B15 2TT Birmingham, UK ,Centre for Endocrinology, Diabetes and Metabolism, Birmingham Health Partners, B15 2TH Birmingham, UK ,grid.415490.d0000 0001 2177 007XBirmingham Neuro-Ophthalmology, University Hospitals Birmingham NHS Foundation Trust, Queen Elizabeth Hospital, B15 2WB Birmingham, UK
| | - Alexandra J Sinclair
- grid.6572.60000 0004 1936 7486Institute of Metabolism and Systems Research, College of Medical and Dental Sciences, University of Birmingham, B15 2TT Birmingham, UK ,Centre for Endocrinology, Diabetes and Metabolism, Birmingham Health Partners, B15 2TH Birmingham, UK ,grid.415490.d0000 0001 2177 007XDepartment of Neurology, University Hospitals Birmingham NHS Foundation Trust, Queen Elizabeth Hospital, B15 2WB Birmingham, UK
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27
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Bilton EJ, Sinclair AJ, Mollan SP. The UK CSF Disorders Day 2022. Neuroophthalmology 2022; 47:35-41. [PMID: 36798861 PMCID: PMC9928467 DOI: 10.1080/01658107.2022.2133149] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2022] [Accepted: 09/30/2022] [Indexed: 10/17/2022] Open
Abstract
The annual United Kingdom cerebrospinal fluid disorders meeting made its return to the University of Birmingham, United Kingdom, following the break in proceedings due to the coronavirus pandemic. Cerebrospinal fluid disorders require a multi-disciplinary approach with inputs from the neurological, neuro-ophthalmological, neuroradiological, and neurosurgical specialities. The annual meeting presented the newest concepts underpinning idiopathic intracranial hypertension pathophysiology and the advances in intracranial pressure monitoring and treatment.
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Affiliation(s)
- Edward J Bilton
- Birmingham Neuro-Ophthalmology, Queen Elizabeth Hospital,University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Alexandra J Sinclair
- Translational Brain Science, Institute of Metabolism and Systems Research, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
- Department of Neurology, University Hospitals Birmingham NHS Foundation Trust, Queen Elizabeth Hospital, Birmingham, UK
- Centre for Endocrinology, Diabetes and Metabolism, Birmingham Health Partners, Birmingham, UK
| | - Susan P Mollan
- Birmingham Neuro-Ophthalmology, Queen Elizabeth Hospital,University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
- Translational Brain Science, Institute of Metabolism and Systems Research, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
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28
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Abdul-Rahman A, Morgan W, Yu DY. A machine learning approach in the non-invasive prediction of intracranial pressure using Modified Photoplethysmography. PLoS One 2022; 17:e0275417. [PMID: 36174066 PMCID: PMC9521929 DOI: 10.1371/journal.pone.0275417] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2022] [Accepted: 09/16/2022] [Indexed: 11/19/2022] Open
Abstract
The ideal Intracranial pressure (ICP) estimation method should be accurate, reliable, cost-effective, compact, and associated with minimal morbidity/mortality. To this end several described non-invasive methods in ICP estimation have yielded promising results, however the reliability of these techniques have yet to supersede invasive methods of ICP measurement. Over several publications, we described a novel imaging method of Modified Photoplethysmography in the evaluation of the retinal vascular pulse parameters decomposed in the Fourier domain, which enables computationally efficient information filtering of the retinal vascular pulse wave. We applied this method in a population of 21 subjects undergoing lumbar puncture manometry. A regression model was derived by applying an Extreme Gradient Boost (XGB) machine learning algorithm using retinal vascular pulse harmonic regression waveform amplitude (HRWa), first and second harmonic cosine and sine coefficients (an1,2, bn1,2) among other features. Gain and SHapley Additive exPlanation (SHAP) values ranked feature importance in the model. Agreement between the predicted ICP mean, median and peak density with measured ICP was assessed using Bland-Altman bias±standard error. Feature gain of intraocular pressure (IOPi) (arterial = 0.6092, venous = 0.5476), and of the Fourier coefficients, an1 (arterial = 0.1000, venous = 0.1024) ranked highest in the XGB model for both vascular systems. The arterial model SHAP values demonstrated the importance of the laterality of the tested eye (1.2477), which was less prominent in the venous model (0.8710). External validation was achieved using seven hold-out test cases, where the median venous predicted ICP showed better agreement with measured ICP. Although the Bland-Altman bias from the venous model (0.034±1.8013 cm water (p<0.99)) was lower compared to that of the arterial model (0.139±1.6545 cm water (p<0.94)), the arterial model provided a potential avenue for internal validation of the prediction. This approach can potentially be integrated into a neurological clinical decision algorithm to evaluate the indication for lumbar puncture.
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Affiliation(s)
- Anmar Abdul-Rahman
- Department of Ophthalmology, Counties Manukau District Health Board, Auckland, New Zealand
- * E-mail:
| | - William Morgan
- Centre for Ophthalmology and Visual Science, The University of Western Australia, Perth, Australia
- Lions Eye Institute, University of Western Australia, Perth, Australia
| | - Dao-Yi Yu
- Centre for Ophthalmology and Visual Science, The University of Western Australia, Perth, Australia
- Lions Eye Institute, University of Western Australia, Perth, Australia
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29
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Biousse V, Danesh-Meyer HV, Saindane AM, Lamirel C, Newman NJ. Imaging of the optic nerve: technological advances and future prospects. Lancet Neurol 2022; 21:1135-1150. [DOI: 10.1016/s1474-4422(22)00173-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2021] [Revised: 04/06/2022] [Accepted: 04/13/2022] [Indexed: 01/02/2023]
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30
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Korsbæk JJ, Hagen SM, Schytz HW, Vukovic-Cvetkovic V, Wibroe EA, Hamann S, Jensen RH. Transorbital sonography: A non-invasive bedside screening tool for detection of pseudotumor cerebri syndrome. Cephalalgia 2022; 42:1116-1126. [PMID: 35469442 DOI: 10.1177/03331024221094293] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Our objective was to assess optic nerve sheath diameter (a marker of elevated intracranial pressure) and optic disc elevation (a marker of papilledema) in pseudotumor cerebri syndrome using transorbital sonography. METHODS The study was a prospective case-control study. We included patients with new-onset pseudotumor cerebri syndrome and matched healthy controls. All had fundoscopy, lumbar puncture with opening pressure and transorbital sonography. Sonography was assessed by a blinded observer. RESULTS We evaluated 45 patients and included 23 cases. We recruited 35 controls. Optic nerve sheath diameter was larger in pseudotumor cerebri syndrome compared to controls (6.3 ± 0.9 mm versus 5.0 ± 0.5 mm, p < 0.001) and so was optic disc elevation (0.9 ± 0.4 mm versus 0.4 ± 0.1 mm, p < 0.001). The optimal cut-off point for optic nerve sheath diameter was 6 mm with a sensitivity of 74% for prediction of pseudotumor cerebri syndrome and 68% for prediction of elevated opening pressure. Specificity was 94%. The optimal cut-off point for optic disc elevation was 0.6 mm. Sensitivity was 100% and specificity 83% for prediction of pseudotumor cerebri syndrome. CONCLUSION Optic disc elevation and optic nerve sheath diameter are increased in new-onset pseudotumor cerebri syndrome. Optic disc elevation achieved high specificity and excellent sensitivity for diagnosis of pseudotumor cerebri syndrome. Transorbital sonography (TOS) is a potential, non-invasive screening tool for pseudotumor cerebri syndrome in headache clinics.
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Affiliation(s)
- Johanne Juhl Korsbæk
- Danish Headache Center, Department of Neurology, Rigshospitalet, University of Copenhagen
| | - Snorre Malm Hagen
- Department of Ophthalmology, Rigshospitalet, University of Copenhagen
| | - Henrik W Schytz
- Danish Headache Center, Department of Neurology, Rigshospitalet, University of Copenhagen
| | | | | | - Steffen Hamann
- Department of Ophthalmology, Rigshospitalet, University of Copenhagen
| | - Rigmor H Jensen
- Danish Headache Center, Department of Neurology, Rigshospitalet, University of Copenhagen
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31
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Thaller M, Wakerley BR, Abbott S, Tahrani AA, Mollan SP, Sinclair AJ. Managing idiopathic intracranial hypertension in pregnancy: practical advice. Pract Neurol 2022; 22:295-300. [PMID: 35450962 PMCID: PMC9304112 DOI: 10.1136/practneurol-2021-003152] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/09/2022] [Indexed: 01/18/2023]
Abstract
Idiopathic intracranial hypertension (IIH) is more common in women of reproductive age who have obesity, yet there is little information on its management specifically in pregnancy. Women with IIH should plan their pregnancy including discussing contraception before pregnancy, recognising that hormonal contraceptives are not contraindicated. Potentially teratogenic medications including acetazolamide and topiramate are not recommended during pregnancy or in those with immediate plans to conceive; prescribing acetazolamide in pregnancy must only follow discussion with the patient and their obstetrician. Ideally, patients should aim to achieve disease remission or control before pregnancy, through optimising their weight. Although weight gain is expected in pregnancy, excessive weight gain may exacerbate IIH and increase maternal and fetal complications; evidence-based recommendations for non-IIH pregnancies may help in guiding optimal gestational weight gain. The vast majority of women with IIH can have a normal vaginal delivery, with spinal or epidural anaesthesia if needed, provided the papilloedema is stable or the IIH is in remission.
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Affiliation(s)
- Mark Thaller
- Metabolic Neurology, University of Birmingham Institute of Metabolism and Systems Research, Birmingham, UK .,Neurology, Queen Elizabeth Hospital, Birmingham, UK
| | - Benjamin R Wakerley
- Metabolic Neurology, University of Birmingham Institute of Metabolism and Systems Research, Birmingham, UK.,Neurology, Queen Elizabeth Hospital, Birmingham, UK
| | - Sally Abbott
- Faculty of Health and Life Sciences, Coventry University, Coventry, UK.,University Hospitals Coventry and Warwickshire NHS Trust, Coventry, UK
| | - Abd A Tahrani
- Institute of Metabolism and Systems Research, University of Birmingham, Birmingham, UK.,Diabetes and Endocrinology, Queen Elizabeth Hospital, Birmingham, UK
| | - Susan P Mollan
- Metabolic Neurology, University of Birmingham Institute of Metabolism and Systems Research, Birmingham, UK.,Birmingham Neuro-Ophthalmology Unit, Ophthalmology Department, Queen Elizabeth Hospital, Birmingham, UK
| | - Alexandra J Sinclair
- Metabolic Neurology, University of Birmingham Institute of Metabolism and Systems Research, Birmingham, UK .,Neurology, Queen Elizabeth Hospital, Birmingham, UK
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32
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Jacobsen HH, Jørstad ØK, Moe MC, Petrovski G, Pripp AH, Sandell T, Eide PK. Noninvasive Estimation of Pulsatile and Static Intracranial Pressure by Optical Coherence Tomography. Transl Vis Sci Technol 2022; 11:31. [PMID: 35050344 PMCID: PMC8787623 DOI: 10.1167/tvst.11.1.31] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Purpose To explore the ability of optical coherence tomography (OCT) to noninvasively estimate pulsatile and static intracranial pressure (ICP). Methods An OCT examination was performed in patients who underwent continuous overnight monitoring of the pulsatile and static ICP for diagnostic purpose. We included two patient groups, patients with idiopathic intracranial hypertension (IIH; n = 20) and patients with no verified cerebrospinal fluid disturbances (reference; n = 12). Several OCT parameters were acquired using spectral-domain OCT (RS-3000 Advance; NIDEK, Singapore). The ICP measurements were obtained using a parenchymal sensor (Codman ICP MicroSensor; Johnson & Johnson, Raynham, MA, USA). The pulsatile ICP was determined as the mean ICP wave amplitude (MWA), and the static ICP was determined as the mean ICP. Results The peripapillary Bruch's membrane angle (pBA) and the optic nerve head height (ONHH) differed between the IIH and reference groups and correlated with both MWA and mean ICP. Both OCT parameters predicted elevated MWA. Area under the curve and cutoffs were 0.82 (95% confidence interval [CI], 0.66–0.98) and -0.65° (sensitivity/specificity; 0.75/0.92) for pBA and 0.84 (95% CI, 0.70–0.99) and 405 µm (0.88/0.67) for ONHH. Adjusting for age and body mass index resulted in nonsignificant predictive values for mean ICP, whereas the predictive value for MWA remained significant. Conclusions This study provides evidence that the OCT parameters pBA and ONHH noninvasively can predict elevated pulsatile ICP, represented by the MWA. Translational Relevance OCT shows promise as a method for noninvasive estimation of ICP.
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Affiliation(s)
- Henrik Holvin Jacobsen
- Department of Ophthalmology, Oslo University Hospital-Ullevål, Oslo, Norway.,Institute of Clinical Medicine, Faculty of Medicine, University of Oslo, Oslo, Norway
| | - Øystein Kalsnes Jørstad
- Department of Ophthalmology, Oslo University Hospital-Ullevål, Oslo, Norway.,Institute of Clinical Medicine, Faculty of Medicine, University of Oslo, Oslo, Norway
| | - Morten C Moe
- Department of Ophthalmology, Oslo University Hospital-Ullevål, Oslo, Norway.,Institute of Clinical Medicine, Faculty of Medicine, University of Oslo, Oslo, Norway
| | - Goran Petrovski
- Department of Ophthalmology, Oslo University Hospital-Ullevål, Oslo, Norway.,Institute of Clinical Medicine, Faculty of Medicine, University of Oslo, Oslo, Norway.,Department of Ophthalmology, University of Split School of Medicine, Split, Croatia
| | - Are Hugo Pripp
- Oslo Centre of Biostatistics and Epidemiology, Research Support Services, Oslo University Hospital, Oslo, Norway
| | - Tiril Sandell
- Department of Ophthalmology, Oslo University Hospital-Ullevål, Oslo, Norway.,Department of Ophthalmology, Vestre Viken Hospital, Drammen, Norway
| | - Per Kristian Eide
- Institute of Clinical Medicine, Faculty of Medicine, University of Oslo, Oslo, Norway.,Department of Neurosurgery, Oslo University Hospital-Rikshospitalet, Oslo, Norway
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33
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Wang MTM, Bhatti MT, Danesh-Meyer HV. Idiopathic intracranial hypertension: Pathophysiology, diagnosis and management. J Clin Neurosci 2021; 95:172-179. [PMID: 34929642 DOI: 10.1016/j.jocn.2021.11.029] [Citation(s) in RCA: 26] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2021] [Revised: 11/12/2021] [Accepted: 11/26/2021] [Indexed: 12/13/2022]
Abstract
Idiopathic intracranial hypertension (IIH) is characterized by increased intracranial pressure, manifested by papilledema and radiological findings, in the absence of an identifiable casual factor. The primary symptoms include headache, vision loss, and pulsatile tinnitus, and are recognized to have profound impacts on quality of life and visual function. IIH demonstrates a strong predilection towards obese women of reproductive age, and the population incidence is rising with the growing prevalence of obesity worldwide. The pathophysiology involves dysregulation of cerebrospinal fluid (CSF) dynamics and venous sinus pressure, and recent studies highlighting the pathogenic role of metabolic and hormonal factors have led to the identification of several pharmacological targets and development of novel therapeutic agents. The overarching treatment goals include symptomatic alleviation and prevention of permanent vision loss. The Idiopathic Intracranial Hypertension Treatment Trial, the first of its kind randomized controlled trial on IIH, provides class I evidence for treatment with weight loss and acetazolamide. In medically refractive or fulminant cases, optic nerve sheath fenestration, CSF diversion, and venous sinus stenting, have been successfully implemented. However, there are few high-quality prospective studies investigating the treatment and natural history of IIH, highlighting the compelling need for further research to determine the optimal treatment regimen.
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Affiliation(s)
- Michael T M Wang
- Department of Ophthalmology, New Zealand National Eye Centre, University of Auckland, Auckland, New Zealand
| | - M Tariq Bhatti
- Departments of Ophthalmology and Neurology, Mayo Clinic College of Medicine, Rochester, MN, United States
| | - Helen V Danesh-Meyer
- Department of Ophthalmology, New Zealand National Eye Centre, University of Auckland, Auckland, New Zealand.
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34
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Grech O, Clouter A, Mitchell JL, Alimajstorovic Z, Ottridge RS, Yiangou A, Roque M, Tahrani AA, Nicholls M, Taylor AE, Shaheen F, Arlt W, Lavery GG, Shapiro K, Mollan SP, Sinclair AJ. Cognitive performance in idiopathic intracranial hypertension and relevance of intracranial pressure. Brain Commun 2021; 3:fcab202. [PMID: 34704028 PMCID: PMC8421706 DOI: 10.1093/braincomms/fcab202] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/17/2021] [Indexed: 12/03/2022] Open
Abstract
Cognitive impairments have been reported in idiopathic intracranial hypertension; however, evidence supporting these deficits is scarce and contributing factors have not been defined. Using a case-control prospective study, we identified multiple domains of deficiency in a cohort of 66 female adult idiopathic intracranial hypertension patients. We identified significantly impaired attention networks (executive function) and sustained attention compared to a body mass index and age matched control group of 25 healthy female participants. We aimed to investigate how cognitive function changed over time and demonstrated that deficits were not permanent. Participants exhibited improvement in several domains including executive function, sustained attention and verbal short-term memory over 12-month follow-up. Improved cognition over time was associated with reduction in intracranial pressure but not body weight. We then evaluated cognition before and after a lumbar puncture with acute reduction in intracranial pressure and noted significant improvement in sustained attention to response task performance. The impact of comorbidities (headache, depression, adiposity and obstructive sleep apnoea) was also explored. We observed that body mass index and the obesity associated cytokine interleukin-6 (serum and cerebrospinal fluid) were not associated with cognitive performance. Headache severity during cognitive testing, co-morbid depression and markers of obstructive sleep apnoea were adversely associated with cognitive performance. Dysregulation of the cortisol generating enzyme 11β hydroxysteroid dehydrogenase type 1 has been observed in idiopathic intracranial hypertension. Elevated cortisol has been associated with impaired cognition. Here, we utilized liquid chromatography-tandem mass spectrometry for multi-steroid profiling in serum and cerebrospinal fluid in idiopathic intracranial hypertension patients. We noted that reduction in the serum cortisol:cortisone ratio in those undergoing bariatric surgery at 12 months was associated with improving verbal working memory. The clinical relevance of cognitive deficits was noted in their significant association with impaired reliability to perform visual field tests, the cornerstone of monitoring vision in idiopathic intracranial hypertension. Our findings propose that cognitive impairment should be accepted as a clinical manifestation of idiopathic intracranial hypertension and impairs the ability to perform visual field testing reliably. Importantly, cognitive deficits can improve over time and with reduction of intracranial pressure. Treating comorbid depression, obstructive sleep apnoea and headache could improve cognitive performance in idiopathic intracranial hypertension.
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Affiliation(s)
- Olivia Grech
- Metabolic Neurology, Institute of Metabolism and Systems Research, University of Birmingham, Edgbaston B15 2TT, UK
| | - Andrew Clouter
- Department of Psychology, Nottingham Trent University, Nottingham NG1 5LT, UK
| | - James L Mitchell
- Metabolic Neurology, Institute of Metabolism and Systems Research, University of Birmingham, Edgbaston B15 2TT, UK
| | - Zerin Alimajstorovic
- Metabolic Neurology, Institute of Metabolism and Systems Research, University of Birmingham, Edgbaston B15 2TT, UK
| | - Ryan S Ottridge
- Birmingham Clinical Trials Unit, College of Medical and Dental Sciences, University of Birmingham, Birmingham B15 2TT, UK
| | - Andreas Yiangou
- Metabolic Neurology, Institute of Metabolism and Systems Research, University of Birmingham, Edgbaston B15 2TT, UK
| | - Marianne Roque
- Birmingham Neuro-Ophthalmology Unit, University Hospitals Birmingham NHS Foundation Trust, Birmingham B15 2TH, UK
| | - Abd A Tahrani
- Centre for Endocrinology, Diabetes and Metabolism, Birmingham Health Partners, Birmingham B15 2TH, UK
| | - Matthew Nicholls
- Centre for Endocrinology, Diabetes and Metabolism, Birmingham Health Partners, Birmingham B15 2TH, UK
| | - Angela E Taylor
- Centre for Endocrinology, Diabetes and Metabolism, Birmingham Health Partners, Birmingham B15 2TH, UK
| | - Fozia Shaheen
- Centre for Endocrinology, Diabetes and Metabolism, Birmingham Health Partners, Birmingham B15 2TH, UK
| | - Wiebke Arlt
- Centre for Endocrinology, Diabetes and Metabolism, Birmingham Health Partners, Birmingham B15 2TH, UK
| | - Gareth G Lavery
- Centre for Endocrinology, Diabetes and Metabolism, Birmingham Health Partners, Birmingham B15 2TH, UK
| | - Kimron Shapiro
- Centre for Human Brain Health, School of Psychology, University of Birmingham, Birmingham B15 2TT, UK
| | - Susan P Mollan
- Birmingham Neuro-Ophthalmology Unit, University Hospitals Birmingham NHS Foundation Trust, Birmingham B15 2TH, UK
| | - Alexandra J Sinclair
- Metabolic Neurology, Institute of Metabolism and Systems Research, University of Birmingham, Edgbaston B15 2TT, UK
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35
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Hasırcı Bayır BR, Vanlı Yavuz EN, Baykan B. Idiopathic intracranial hypertension: Do we diagnose and manage it appropriately in the light of current data? Clin Neurol Neurosurg 2021; 208:106879. [PMID: 34418707 DOI: 10.1016/j.clineuro.2021.106879] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2021] [Revised: 08/03/2021] [Accepted: 08/04/2021] [Indexed: 10/20/2022]
Abstract
BACKGROUND AND OBJECTIVE Idiopathic intracranial hypertension (IIH) is an increase of intracranial pressure without a known cause, which usually presented with headache. This study aimed to evaluate the changing diagnosis and management approaches of neurologists for IIH in light of recent data. METHODS An online questionnaire about IIH was developed covering 28 questions, and five sections: demographic data, diagnosis, examination, treatment, and follow-up. We compared the approach of neurologists with 1-9 years of experience (group-A) with that of neurologists with more than 10 years' experience (group-B). RESULTS A total of 517 neurologists (group A: n = 252, group B: n = 265) participated in the study. Responder rate of questionarre is 18.3%. The approach to IIH in diagnosis, examination, treatment, and follow-up processes was similar in both groups. The younger group (group A) recognized all neuro-radiologic findings, especially flattening of the posterior aspect of the globe (p = 0.001) and tortuosity of the optic nerve (p < 0.001) at higher rates compared with group B. The most commonly used medical treatment was acetazolamide (99%); corticosteroids were used more frequently by group B (p < 0.001). Optic nerve sheath fenestration (88.3%) was the first-line and ventriculo-peritoneal shunt (70.5%) was the second preferred surgical approach. It was observed that serial lumbar puncture applications (57.0%) were preferred more frequently than venous sinus stenting (19.0%) and bariatric surgery (10.0%). CONCLUSIONS The changing information in the last decade about IIH was more closely followed by younger neurologists despite their lesser experience, but classic methods were preferred in surgical approaches in both groups. Our findings indicated that post-graduate education and guidelines should be disseminated for IIH.
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Affiliation(s)
| | | | - Betül Baykan
- Istanbul University, Istanbul Faculty of Medicine, Department of Neurology, Istanbul, Turkey
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36
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Yiangou A, Mitchell JL, Nicholls M, Chong YJ, Vijay V, Wakerley BR, Lavery GG, Tahrani AA, Mollan SP, Sinclair AJ. Obstructive sleep apnoea in women with idiopathic intracranial hypertension: a sub-study of the idiopathic intracranial hypertension weight randomised controlled trial (IIH: WT). J Neurol 2021; 269:1945-1956. [PMID: 34420064 PMCID: PMC8940816 DOI: 10.1007/s00415-021-10700-9] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2021] [Revised: 07/02/2021] [Accepted: 07/03/2021] [Indexed: 12/15/2022]
Abstract
Objective Obesity is a risk factor for idiopathic intracranial hypertension (IIH) and obstructive sleep apnoea (OSA). We aimed to determine the prevalence of OSA in IIH and evaluate the diagnostic performance of OSA screening tools in IIH. Additionally, we evaluated the relationship between weight loss, OSA and IIH over 12 months. Methods A sub-study of a multi-centre, randomised controlled parallel group trial comparing the impact of bariatric surgery vs. community weight management intervention (CWI) on IIH-related outcomes over 12 months (IIH:WT). OSA was assessed using home-based polygraphy (ApneaLink Air, ResMed) at baseline and 12 months. OSA was defined as an apnoea–hypopnoea index (AHI) ≥ 15 or ≥ 5 with excessive daytime sleepiness (Epworth Sleepiness Scale ≥11 ). Results Of the 66 women in the IIH: WT trial, 46 were included in the OSA sub-study. OSA prevalence was 47% (n = 19). The STOP-BANG had the highest sensitivity (84%) compared to the Epworth Sleepiness Scale (69%) and Berlin (68%) to detect OSA. Bariatric surgery resulted in greater reductions in AHI vs. CWI (median [95%CI] AHI reduction of – 2.8 [ – 11.9, 0.7], p = 0.017). Over 12 months there was a positive association between changes in papilloedema and AHI (r = 0.543, p = 0.045), despite adjustment for changes in the body mass index (R2 = 0.522, p = 0.017). Conclusion OSA is common in IIH and the STOP-BANG questionnaire was the most sensitive screening tool. Bariatric surgery improved OSA in patients with IIH. The improvement in AHI was associated with improvement in papilloedema independent of weight loss. Whether OSA treatment has beneficial impact on papilloedema warrants further evaluation. Trial registration number IIH: WT is registered as ISRCTN40152829 and on ClinicalTrials.gov as NCT02124486 (28/04/2014). Supplementary Information The online version contains supplementary material available at 10.1007/s00415-021-10700-9.
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Affiliation(s)
- Andreas Yiangou
- Metabolic Neurology, Institute of Metabolism and Systems Research, College of Medical and Dental Sciences, University of Birmingham, Birmingham, B15 2TT, UK.,Centre for Endocrinology, Diabetes and Metabolism, Birmingham Health Partners, Birmingham, B15 2TH, UK.,Department of Neurology, University Hospitals Birmingham NHS Foundation Trust, Birmingham, B15 2TH, UK
| | - James L Mitchell
- Metabolic Neurology, Institute of Metabolism and Systems Research, College of Medical and Dental Sciences, University of Birmingham, Birmingham, B15 2TT, UK.,Centre for Endocrinology, Diabetes and Metabolism, Birmingham Health Partners, Birmingham, B15 2TH, UK.,Department of Neurology, University Hospitals Birmingham NHS Foundation Trust, Birmingham, B15 2TH, UK
| | - Matthew Nicholls
- Metabolic Neurology, Institute of Metabolism and Systems Research, College of Medical and Dental Sciences, University of Birmingham, Birmingham, B15 2TT, UK.,Centre for Endocrinology, Diabetes and Metabolism, Birmingham Health Partners, Birmingham, B15 2TH, UK
| | - Yu Jeat Chong
- Birmingham Neuro-Ophthalmology, Ophthalmology Department, University Hospitals Birmingham NHS Foundation Trust, Birmingham, Birmingham, B15 2TH, UK
| | - Vivek Vijay
- Metabolic Neurology, Institute of Metabolism and Systems Research, College of Medical and Dental Sciences, University of Birmingham, Birmingham, B15 2TT, UK.,Centre for Endocrinology, Diabetes and Metabolism, Birmingham Health Partners, Birmingham, B15 2TH, UK.,Department of Neurology, University Hospitals Birmingham NHS Foundation Trust, Birmingham, B15 2TH, UK
| | - Benjamin R Wakerley
- Department of Neurology, University Hospitals Birmingham NHS Foundation Trust, Birmingham, B15 2TH, UK
| | - Gareth G Lavery
- Metabolic Neurology, Institute of Metabolism and Systems Research, College of Medical and Dental Sciences, University of Birmingham, Birmingham, B15 2TT, UK.,Centre for Endocrinology, Diabetes and Metabolism, Birmingham Health Partners, Birmingham, B15 2TH, UK.,Department of Neurology, University Hospitals Birmingham NHS Foundation Trust, Birmingham, B15 2TH, UK
| | - Abd A Tahrani
- Metabolic Neurology, Institute of Metabolism and Systems Research, College of Medical and Dental Sciences, University of Birmingham, Birmingham, B15 2TT, UK.,Centre for Endocrinology, Diabetes and Metabolism, Birmingham Health Partners, Birmingham, B15 2TH, UK.,Department of Endocrinology, University Hospitals Birmingham NHS Foundation Trust, Birmingham, B15 2TH, UK
| | - Susan P Mollan
- Birmingham Neuro-Ophthalmology, Ophthalmology Department, University Hospitals Birmingham NHS Foundation Trust, Birmingham, Birmingham, B15 2TH, UK
| | - Alexandra J Sinclair
- Metabolic Neurology, Institute of Metabolism and Systems Research, College of Medical and Dental Sciences, University of Birmingham, Birmingham, B15 2TT, UK. .,Centre for Endocrinology, Diabetes and Metabolism, Birmingham Health Partners, Birmingham, B15 2TH, UK. .,Department of Neurology, University Hospitals Birmingham NHS Foundation Trust, Birmingham, B15 2TH, UK.
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Hagen SM, Wegener M, Toft PB, Fugleholm K, Jensen RH, Hamann S. Unilateral Optic Nerve Sheath Fenestration in Idiopathic Intracranial Hypertension: A 6-Month Follow-Up Study on Visual Outcome and Prognostic Markers. Life (Basel) 2021; 11:778. [PMID: 34440522 PMCID: PMC8400184 DOI: 10.3390/life11080778] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2021] [Revised: 07/27/2021] [Accepted: 07/28/2021] [Indexed: 11/17/2022] Open
Abstract
Loss of vision is a feared consequence of idiopathic intracranial hypertension (IIH). Optic nerve sheath fenestration (ONSF) may be an effective surgical approach to protect visual function in medically refractory IIH. In this study, we evaluate the impact of unilateral superomedial transconjunctival ONSF on bilateral visual outcome using a comprehensive follow-up program. A retrospective chart review of IIH patients who underwent unilateral ONSF between January 2016 and March 2021 was conducted. Patients fulfilling the revised Friedman criteria for IIH and who had exclusively received ONSF as a surgical treatment were included. Main outcomes were visual acuity (VA); perimetric mean deviation (PMD); papilledema grade; and optic nerve head elevation (maxONHE) 1 week, 2 weeks, and 1, 3, and 6 months after surgery. VA (p < 0.05), PMD (p < 0.05), papilledema grade (p < 0.01), and maxOHNE (p < 0.001) were improved after 6 months on both the operated and non-operated eye. Prolonged surgical delay impedes PMD improvement (r = -0.78, p < 0.01), and an increasing opening pressure initiates a greater ganglion cell loss (r = -0.79, p < 0.01). In this small case series, we demonstrate that unilateral superonasal transconjunctival ONSF is a safe procedure with an effect on both eyes. Optic nerve head elevation and PMD are feasible biomarkers for assessing early treatment efficacy after ONSF.
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Affiliation(s)
- Snorre Malm Hagen
- Department of Ophthalmology, Rigshospitalet, University of Copenhagen, 2600 Glostrup, Denmark; (M.W.); (P.B.T.); (S.H.)
| | - Marianne Wegener
- Department of Ophthalmology, Rigshospitalet, University of Copenhagen, 2600 Glostrup, Denmark; (M.W.); (P.B.T.); (S.H.)
| | - Peter Bjerre Toft
- Department of Ophthalmology, Rigshospitalet, University of Copenhagen, 2600 Glostrup, Denmark; (M.W.); (P.B.T.); (S.H.)
| | - Kåre Fugleholm
- Department of Neurosurgery, Rigshospitalet, University of Copenhagen, 2100 Copenhagen Ø, Denmark;
| | - Rigmor Højland Jensen
- Danish Headache Center, Department of Neurology, Rigshospitalet-Glostrup, University of Copenhagen, 2600 Glostrup, Denmark;
| | - Steffen Hamann
- Department of Ophthalmology, Rigshospitalet, University of Copenhagen, 2600 Glostrup, Denmark; (M.W.); (P.B.T.); (S.H.)
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Abstract
First described in 1991 and introduced into clinical practice in 1996, optical coherence tomography (OCT) now has a very extensive role in many different areas of ophthalmological practice. It is non-invasive, cheap, highly reproducible, widely available and easy to perform. OCT also has a role in managing patients with neurological disorders, particularly idiopathic intracranial hypertension. This review provides an overview of the technology underlying OCT and the information it can provide that is relevant to the practising neurologist. Particular conditions discussed include papilloedema, optic disc drusen, multiple sclerosis and neuromyelitis optica, other optic neuropathies, compression of the anterior visual pathway and various neurodegenerative conditions.
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39
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Mollan SP, Sinclair AJ. Outcomes measures in idiopathic intracranial hypertension. Expert Rev Neurother 2021; 21:687-700. [PMID: 34047224 DOI: 10.1080/14737175.2021.1931127] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Introduction: Idiopathic intracranial hypertension is a condition characterized by raised intracranial pressure, papilledema, and normal neuroimaging (aside from radiological signs of raised intracranial pressure). Symptoms of idiopathic intracranial hypertension include chronic headaches and for some, visual loss. New treatments are unmet clinical needs.Areas covered: The aim of this review is to present the evidence base and considered opinion on outcome measures to determine successful management of idiopathic intracranial hypertension.Expert opinion: Less invasive measures of disease activity such as optical coherence tomography will continue to grow in this field, both as a measure of papilledema, and potentially as a surrogate for intracranial pressure and visual function. As a highly disabling aspect of the disease is headache, treatment outcomes for headache morbidity need to be appropriately chosen and standardized to allow comparison between trials.
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Affiliation(s)
- Susan P Mollan
- Birmingham Neuro-Ophthalmology, Queen Elizabeth Hospital, Birmingham, United Kingdom (UK)
| | - Alexandra J Sinclair
- Birmingham Neuro-Ophthalmology, Queen Elizabeth Hospital, Birmingham, United Kingdom (UK).,Metabolic Neurology, Institute of Metabolism and Systems Research, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK.,Centre for Endocrinology, Diabetes and Metabolism, Birmingham Health Partners, Birmingham, UK.,Department of Neurology, University Hospitals Birmingham NHS Foundation Trust, Queen Elizabeth Hospital, Birmingham, UK
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40
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Li J, Wan C. Non-invasive detection of intracranial pressure related to the optic nerve. Quant Imaging Med Surg 2021; 11:2823-2836. [PMID: 34079745 DOI: 10.21037/qims-20-1188] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Intracranial pressure (ICP) is associated with a variety of diseases. Early diagnosis and the timely intervention of elevated ICP are effective means to clinically reduce the morbidity and mortality of some diseases. The detection and judgment of reduced ICP are beneficial to glaucoma doctor and neuro ophthalmologist to diagnose optic nerve disease earlier. It is important to evaluate and monitor ICP clinically. Although invasive ICP detection is the gold standard, it can have complications. Most non-invasive ICP tests are related to the optic nerve and surrounding tissues due to their anatomical characteristics. Ultrasound, magnetic resonance imaging, transcranial Doppler, papilledema on optical coherence tomography, visual evoked potential, ophthalmodynamometry, the assessment of spontaneous retinal venous pulsations, and eye-tracking have potential for application. Although none of these methods can completely replace invasive technology; however, its repeatable, low risk, high accuracy, gradually attracted people's attention. This review summarizes the non-invasive ICP detection methods related to the optic nerve and the role of the diagnosis and prognosis of neurological disorders and glaucoma. We discuss the advantages and challenges and predict possible areas of development in the future.
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Affiliation(s)
- Jian Li
- Department of Radiology, the First Hospital of China Medical University, Shenyang, China
| | - Chao Wan
- Department of Ophthalmology, the First Hospital of China Medical University, Shenyang, China
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41
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Mollan SP, Chong YJ, Grech O, Sinclair AJ, Wakerley BR. Current Perspectives on Idiopathic Intracranial Hypertension without Papilloedema. Life (Basel) 2021; 11:472. [PMID: 34073844 PMCID: PMC8225003 DOI: 10.3390/life11060472] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2021] [Revised: 05/16/2021] [Accepted: 05/18/2021] [Indexed: 02/07/2023] Open
Abstract
The pseudotumor cerebri syndrome embraces disorders characterised by raised intracranial pressure, where the commonest symptom is headache (90%). Idiopathic intracranial hypertension without papilloedema (IIHWOP) is increasingly recognised as a source of refractory headache symptoms and resultant neurological disability. Although the majority of patients with IIHWOP are phenotypically similar to those with idiopathic intracranial hypertension (IIH), it remains uncertain as to whether IIHWOP is nosologically distinct from IIH. The incidence, prevalence, and the degree of association with the world-wide obesity epidemic is unknown. Establishing a diagnosis of IIHWOP can be challenging, as often lumbar puncture is not routinely part of the work-up for refractory headaches. There are published diagnostic criteria for IIHWOP; however, some report uncertainty regarding a pathologically acceptable cut off for a raised lumbar puncture opening pressure, which is a key criterion. The literature provides little information to help guide clinicians in managing patients with IIHWOP. Further research is therefore needed to better understand the mechanisms that drive the development of chronic daily headaches and a relationship to intracranial pressure; and indeed, whether such patients would benefit from therapies to lower intracranial pressure. The aim of this narrative review was to perform a detailed search of the scientific literature and provide a summary of historic and current opinion regarding IIHWOP.
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Affiliation(s)
- Susan P. Mollan
- Birmingham Neuro-Ophthalmology Unit, University Hospitals Birmingham NHS Foundation Trust, Birmingham B15 2TH, UK;
| | - Yu Jeat Chong
- Birmingham Neuro-Ophthalmology Unit, University Hospitals Birmingham NHS Foundation Trust, Birmingham B15 2TH, UK;
| | - Olivia Grech
- Metabolic Neurology, Institute of Metabolism and Systems Research, University of Birmingham, Edgbaston B15 2TT, UK; (O.G.); (A.J.S.); (B.R.W.)
- Centre for Endocrinology, Diabetes and Metabolism, Birmingham Health Partners, Birmingham B15 2TH, UK
| | - Alex J. Sinclair
- Metabolic Neurology, Institute of Metabolism and Systems Research, University of Birmingham, Edgbaston B15 2TT, UK; (O.G.); (A.J.S.); (B.R.W.)
- Centre for Endocrinology, Diabetes and Metabolism, Birmingham Health Partners, Birmingham B15 2TH, UK
- Department of Neurology, University Hospitals Birmingham NHS Foundation Trust, Birmingham B15 2TH, UK
| | - Benjamin R. Wakerley
- Metabolic Neurology, Institute of Metabolism and Systems Research, University of Birmingham, Edgbaston B15 2TT, UK; (O.G.); (A.J.S.); (B.R.W.)
- Centre for Endocrinology, Diabetes and Metabolism, Birmingham Health Partners, Birmingham B15 2TH, UK
- Department of Neurology, University Hospitals Birmingham NHS Foundation Trust, Birmingham B15 2TH, UK
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