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Korsbæk JJ, Jensen RH, Beier D, Wibroe EA, Hagen SM, Molander LD, Gillum MP, Svart K, Hansen TF, Kogelman LJA, Westgate CSJ. Metabolic Dysfunction in New-Onset Idiopathic Intracranial Hypertension: Identification of Novel Biomarkers. Ann Neurol 2024; 96:595-607. [PMID: 39140399 DOI: 10.1002/ana.27010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2024] [Revised: 05/30/2024] [Accepted: 05/31/2024] [Indexed: 08/15/2024]
Abstract
OBJECTIVE Idiopathic intracranial hypertension (IIH) is a neurometabolic disease with an increasing incidence. The pathophysiology is unknown, but improvement of diagnosis and management requires discovery of novel biomarkers. Our objective was to identify such candidate biomarkers in IIH, and secondarily, test for associations between identified metabolites and disease severity. METHODS This is a prospective case-control study with collection of cerebrospinal fluid (CSF), serum, and clinical data from new-onset, treatment-naïve patients with IIH (n = 60). Patients were included consecutively from 2 tertiary headache centers in Denmark, and age, sex, and body mass index (BMI) -matched healthy controls (n = 35) were recruited. Clinical data were retrieved at ocular remission (n = 55). Samples were analyzed using non-targeted mass spectrometry. RESULTS Serum sphingosine 1-phosphate (S1P), adenosine, and glutamate were 0.46-fold (q < 0.0001), 0.25-fold (q = 0.0048), and 0.44-fold (q < 0.0001) lower, respectively, in IIH. CSF stearoyl-lysophosphatidylcholine (LysoPC-18) and 2-palmitoyl-lysophosphatidylcholine (LysoPC-16) were 0.42 (q = 0.0025) and 0.37 (q < 0.001) -fold lower. LysoPC-18 was higher in patients with moderate-severe versus mild papilledema (p = 0.022). LysoPC-18 correlated positively with retinal nerve fiber layer thickness (p = 0.0012, r = 0.42) and inversely with mean deviation on automated perimetry (p = 0.01, r = -0.35). Higher baseline serum S1P (p = 0.018) and lower CSF LysoPC-16 (p = 0.003) were associated with optic nerve atrophy at ocular remission. Pathway analysis suggests dysregulated lipid metabolism and redox disturbances in new-onset IIH. INTERPRETATION We identify perturbed metabolism in new-onset IIH. S1P and LysoPC-16 demonstrate potential prognostic value due to association with subsequent optic nerve atrophy. This association between specific, differential metabolites and outcome provides substantial evidence for novel biomarkers of clinical significance that should be the focus of further targeted studies. ANN NEUROL 2024;96:595-607.
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Affiliation(s)
- Johanne Juhl Korsbæk
- Danish Headache Center, Department of Neurology, Rigshospitalet, Glostrup, Denmark
| | - Rigmor Højland Jensen
- Danish Headache Center, Department of Neurology, Rigshospitalet, Glostrup, Denmark
- Translational Research Centre, Rigshospitalet, Glostrup, Denmark
| | - Dagmar Beier
- Headache Clinic, Department of Neurology, Odense University Hospital, Odense, Denmark
- Department of Clinical Research, University of Southern Denmark, Odense, Denmark
- OPEN, Odense Patient data Explorative Network, Odense University Hospital, Odense, Denmark
| | | | | | | | - Matthew Paul Gillum
- Department of Obesity and Liver Pharmacology, Novo Nordisk A/S, Novo Nordisk, Denmark
| | - Katrine Svart
- Danish Headache Center, Department of Neurology, Rigshospitalet, Glostrup, Denmark
| | - Thomas Folkmann Hansen
- Danish Headache Center, Department of Neurology, Rigshospitalet, Glostrup, Denmark
- Translational Research Centre, Rigshospitalet, Glostrup, Denmark
- Novo Nordisk Foundation Center for Protein Research, Copenhagen University, København, Denmark
| | - Lisette J A Kogelman
- Danish Headache Center, Department of Neurology, Rigshospitalet, Glostrup, Denmark
- Translational Research Centre, Rigshospitalet, Glostrup, Denmark
- Department of Health Science and Technology, Genomic Medicine Group, Aalborg University, Aalborg, Denmark
| | - Connar Stanley James Westgate
- Danish Headache Center, Department of Neurology, Rigshospitalet, Glostrup, Denmark
- Translational Research Centre, Rigshospitalet, Glostrup, Denmark
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Bonelli L, Menon V, Arnold AC, Mollan SP. Managing idiopathic intracranial hypertension in the eye clinic. Eye (Lond) 2024; 38:2472-2481. [PMID: 38789788 PMCID: PMC11306398 DOI: 10.1038/s41433-024-03140-y] [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: 04/02/2024] [Revised: 04/30/2024] [Accepted: 05/07/2024] [Indexed: 05/26/2024] Open
Abstract
Idiopathic intracranial hypertension (IIH) is a neuro-ophthalmological condition characterised by a raised intracranial pressure and papilloedema that causes disabling headaches. The main risk factors of female sex and living with obesity have been known for some time, however the knowledge of the underlying pathophysiology is evolving. Papilloedema can impact the visual function, and the majority of people are offered acetazolamide. Those with sight threatening disease need urgent management, though there is little high quality evidence to recommend any particular surgical intervention. Headache treatment is an unmet clinical need and simple medication overuse advice has the potential to reduce the chronification of migraine-like headaches. IIH is emerging as a systemic metabolic disease distinct from people living with obesity alone. While weight loss is the main stay of disease modifying therapy this is challenging to access and many healthcare professionals that manage the condition have no formal training or accessible pathways for weight management. The aim of this "how to do it" article is to present the latest advances in knowledge of IIH that we pragmatically included in routine clinical care for people living with the condition.
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Affiliation(s)
- Laura Bonelli
- Department of Ophthalmology, University of California, Los Angeles, Stein Eye Institute, Los Angeles, CA, USA
| | - Vaishnavi Menon
- Birmingham Neuro-Ophthalmology, University Hospitals Birmingham NHS Foundation Trust, Birmingham, B15 2GW, UK
| | - Anthony C Arnold
- Department of Ophthalmology, University of California, Los Angeles, Stein Eye Institute, Los Angeles, CA, USA
| | - Susan P Mollan
- Translational Brain Science, Institute of Metabolism and Systems Research, University of Birmingham, Edgbaston, B15 2TT, UK.
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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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Heckel B. Idiopathic Intracranial Hypertension After Abrupt Cessation of Medication: A Case Report of Abrupt Glucagon-Like Peptide-1 (GLP-1) Receptor Agonist Cessation and Review of the Literature. Curr Pain Headache Rep 2024; 28:453-456. [PMID: 38573570 PMCID: PMC11156736 DOI: 10.1007/s11916-024-01215-9] [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] [Accepted: 01/20/2024] [Indexed: 04/05/2024]
Abstract
PURPOSE OF REVIEW The purpose of this review is two-fold: (1) to discuss a case report of idiopathic intracranial hypertension (IIH) after abrupt cessation of a glucagon-like peptide-1 (GLP-1) receptor agonist with resultant rapid weight gain and (2) to review the literature regarding the potential role of GLP-1 receptor agonists in the treatment of IIH as well as potential pitfalls. RECENT FINDINGS GLP-1 receptor agonists have become widely used to treat obesity. Obesity is a known risk factor for the development of IIH, though the precise pathophysiology is unclear. GLP-1 receptor agonists may help treat IIH by promoting weight loss, lipolysis of adipose tissue, and potentially decreasing the secretion of CSF, as was seen in rat models. Abrupt cessation of GLP-1 receptor agonists can result in regaining lost weight rapidly. In the case that we present, the patient stopped duraglutide abruptly due to lack of insurance coverage and regained the weight she had lost within a month. She subsequently developed IIH. GLP-1 receptor agonists have the potential to help treat IIH; however, this class of medication needs to be used carefully, as cessation of the medication and resultant rapid weight gain can result in IIH.
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Affiliation(s)
- Brittany Heckel
- Jefferson Headache Center, Department of Neurology, Thomas Jefferson University, Philadelphia, PA, USA.
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Colman BD, Boonstra F, Nguyen MN, Raviskanthan S, Sumithran P, White O, Hutton EJ, Fielding J, van der Walt A. Understanding the pathophysiology of idiopathic intracranial hypertension (IIH): a review of recent developments. J Neurol Neurosurg Psychiatry 2024; 95:375-383. [PMID: 37798095 DOI: 10.1136/jnnp-2023-332222] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/17/2023] [Accepted: 09/15/2023] [Indexed: 10/07/2023]
Abstract
Idiopathic intracranial hypertension (IIH) is a condition of significant morbidity and rising prevalence. It typically affects young people living with obesity, mostly women of reproductive age, and can present with headaches, visual abnormalities, tinnitus and cognitive dysfunction. Raised intracranial pressure without a secondary identified cause remains a key diagnostic feature of this condition, however, the underlying pathophysiological mechanisms that drive this increase are poorly understood. Previous theories have focused on cerebrospinal fluid (CSF) hypersecretion or impaired reabsorption, however, the recent characterisation of the glymphatic system in many other neurological conditions necessitates a re-evaluation of these hypotheses. Further, the impact of metabolic dysfunction and hormonal dysregulation in this population group must also be considered. Given the emerging evidence, it is likely that IIH is triggered by the interaction of multiple aetiological factors that ultimately results in the disruption of CSF dynamics. This review aims to provide a comprehensive update on the current theories regarding the pathogenesis of IIH.
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Affiliation(s)
- Blake D Colman
- Department of Neuroscience, Monash University Faculty of Medicine Nursing and Health Sciences, Clayton, Victoria, Australia
- Department of Neurology, Alfred Hospital, Melbourne, Victoria, Australia
| | - Frederique Boonstra
- Department of Neuroscience, Monash University Faculty of Medicine Nursing and Health Sciences, Clayton, Victoria, Australia
| | - Minh Nl Nguyen
- Department of Neuroscience, Monash University Faculty of Medicine Nursing and Health Sciences, Clayton, Victoria, Australia
- Department of Neurology, Alfred Hospital, Melbourne, Victoria, Australia
| | | | - Priya Sumithran
- Department of Surgery, Monash University Faculty of Medicine Nursing and Health Sciences, Clayton, Victoria, Australia
- Department of Endocrinology, Alfred Hospital, Melbourne, Victoria, Australia
| | - Owen White
- Department of Neurology, Alfred Hospital, Melbourne, Victoria, Australia
- Department of Neuroscience, Monash University Central Clinical School, Clayton, Victoria, Australia
| | - Elspeth J Hutton
- Department of Neuroscience, Monash University Faculty of Medicine Nursing and Health Sciences, Clayton, Victoria, Australia
- Department of Neurology, Alfred Hospital, Melbourne, Victoria, Australia
| | - Joanne Fielding
- Department of Neuroscience, Monash University Faculty of Medicine Nursing and Health Sciences, Clayton, Victoria, Australia
| | - Anneke van der Walt
- Department of Neuroscience, Monash University Faculty of Medicine Nursing and Health Sciences, Clayton, Victoria, Australia
- Department of Neurology, Alfred Hospital, Melbourne, Victoria, Australia
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Thaller M, Homer V, Sassani M, Mollan SP, Sinclair AJ. Longitudinal prospective cohort study evaluating prognosis in idiopathic intracranial hypertension patients with and without comorbid polycystic ovarian syndrome. Eye (Lond) 2023; 37:3621-3628. [PMID: 37225826 PMCID: PMC10686374 DOI: 10.1038/s41433-023-02569-x] [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: 09/20/2022] [Revised: 04/06/2023] [Accepted: 04/26/2023] [Indexed: 05/26/2023] Open
Abstract
INTRODUCTION Idiopathic intracranial hypertension (IIH) and polycystic ovary syndrome (PCOS) are hyperandrogenic metabolic disorders that affect women of reproductive age living with obesity. The previously reported prevalence of comorbid PCOS in IIH patients is highly variable and the longitudinal impact on visual and headache outcomes are unknown. METHODS In this prospective longitudinal cohort study patients were identified from the IIH: Life database over a nine-year period (2012-2021). Data collected included demographics and PCOS questionnaire data. Key visual and detailed headache outcomes were recorded. We analysed the key variables for influential outcomes of vision and headache. Logistical regression methods were used to model long term visual and headache outcomes. RESULTS Overall 398 women with IIH and documented PCOS questionnaires were followed up for a median of 10 months (range 0-87). Prevalence of PCOS in IIH was 20% (78/398) diagnosed by the Rotterdam criteria. Patients with IIH and comorbid PCOS reported higher self-reported fertility problems (3.2-fold increased risk) and increased need for medical help in becoming pregnant (4.4-fold increased risk). Comorbid PCOS in IIH patients does not adversely impact long-term vision or headache outcomes. The headache burden was high in both cohorts studied. CONCLUSIONS The study demonstrated that comorbid PCOS in IIH is common (20%). Diagnosing comorbid PCOS is important as it can impact on fertility and is known to have long-term adverse cardiovascular risks. Our data suggest that a diagnosis of PCOS in those with IIH does not significantly exacerbate long-term vision or headache prognosis.
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Affiliation(s)
- Mark Thaller
- Translational Brain Science, Institute of Metabolism and Systems Research, University of Birmingham, Edgbaston, 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
| | - Matilde Sassani
- Translational Brain Science, Institute of Metabolism and Systems Research, University of Birmingham, Edgbaston, Birmingham, B15 2TT, UK
- Centre for Endocrinology, Diabetes and Metabolism, Birmingham Health Partners, Birmingham, B15 2TH, UK
| | - Susan P Mollan
- Translational Brain Science, Institute of Metabolism and Systems Research, University of Birmingham, Edgbaston, 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, Edgbaston, 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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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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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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Khatkar P, Hubbard JC, Hill L, Sinclair AJ, Mollan SP. Experimental drugs for the treatment of idiopathic intracranial hypertension (IIH): shedding light on phase I and II trials. Expert Opin Investig Drugs 2023; 32:1123-1131. [PMID: 38006580 DOI: 10.1080/13543784.2023.2288073] [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: 10/03/2023] [Accepted: 11/22/2023] [Indexed: 11/27/2023]
Abstract
INTRODUCTION Idiopathic intracranial hypertension is a neurological condition characterized by a raised intracranial pressure and papilledema that causes debilitating headaches. While the extent of the pathophysiology is being discovered, the condition is emerging as a systemic metabolic disease distinct to people living with obesity alone. Idiopathic intracranial hypertension is becoming more common and therefore establishing licensed therapeutics is a key priority. AREA COVERED The translation of preclinical work in idiopathic intracranial hypertension is evident by the two early phase trials evaluating 11-β-hydroxysteroid dehydrogenase inhibitor, AZD4017, and a glucagon like peptide-1 receptor agonist, Exenatide. This review summarizes these two early phase trials evaluating targeted medicines for the treatment of intracranial pressure. The modulation of these two distinct mechanisms have potential for therapeutic intervention in people living with idiopathic intracranial hypertension. EXPERT OPINION The clinical trial landscape in idiopathic intracranial hypertension is a challenge due to the rarity of the disease and the lack of agreed meaningful trial outcomes. Further preclinical work to fully understand the pathogenesis is required to enable personalized targeted drug treatment.
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Affiliation(s)
- Pavan Khatkar
- Medical school Imperial College London, UK
- Birmingham Neuro-Ophthalmology, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Jess C Hubbard
- School of Biomedical Sciences, Institute of Clinical Sciences, University of Birmingham, Birmingham, UK
- Translational Brain Science, Institute of Metabolism and Systems Research, University of Birmingham, Edgbaston, UK
| | - Lisa Hill
- School of Biomedical Sciences, Institute of Clinical Sciences, University of Birmingham, Birmingham, UK
- Translational Brain Science, Institute of Metabolism and Systems Research, University of Birmingham, Edgbaston, UK
| | - Alexandra J Sinclair
- Translational Brain Science, Institute of Metabolism and Systems Research, University of Birmingham, Edgbaston, UK
- Centre for Endocrinology, Diabetes and Metabolism, Birmingham Health Partners, Birmingham, UK
- Department of Neurology, 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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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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11
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Mollan SP, Sinclair AJ, Tsermoulas G. Letter: Cerebrospinal Fluid Shunting for Idiopathic Intracranial Hypertension: A Systematic Review, Meta-Analysis, and Implications for a Modern Management Protocol. Neurosurgery 2023; 92:e59-e60. [PMID: 36700758 DOI: 10.1227/neu.0000000000002316] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2022] [Accepted: 10/25/2022] [Indexed: 01/27/2023] Open
Affiliation(s)
- Susan P Mollan
- Translational Brain Science, Institute of Metabolism and Systems Research, University of Birmingham, Edgbaston, UK
- Birmingham Neuro-Ophthalmology, University Hospitals Birmingham NHS Foundation Trust, UK
| | - Alexandra J Sinclair
- Translational Brain Science, Institute of Metabolism and Systems Research, University of Birmingham, Edgbaston, UK
- Department of Neurology, University Hospitals Birmingham NHS Foundation Trust, UK
- Centre for Endocrinology, Diabetes and Metabolism, Birmingham Health Partners, UK
| | - Georgios Tsermoulas
- Institute of Metabolism and Systems Research, University of Birmingham, Edgbaston, UK
- Department of Neurosurgery, University Hospitals Birmingham NHS Foundation Trust, UK
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12
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Thaller M, Adderley NJ, Subramanian A, Mollan SP, Sinclair AJ. Co-morbid Polycystic Ovarian Syndrome with Idiopathic Intracranial Hypertension. Neuroophthalmology 2023; 47:49-52. [PMID: 36798860 PMCID: PMC9928479 DOI: 10.1080/01658107.2022.2162089] [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: 10/26/2022] [Revised: 11/23/2022] [Accepted: 12/12/2022] [Indexed: 01/11/2023] Open
Abstract
The link between polycystic ovarian syndrome (PCOS) and idiopathic intracranial hypertension (IIH) has long been debated. Historically, there is a wide range of reported occurrence of both conditions, being between 15% and 64%. Both conditions share a common phenotype. The awareness that in a new large data study that there is a 1.5-fold increased prevalence of diagnosed PCOS in participants with IIH as compared to the controls is important. Assessment for the potential of co-morbid PCOS in women with IIH is important as this may enable optimisation of weight and fertility management.
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Affiliation(s)
- Mark Thaller
- Translational Brain Science, Institute of Metabolism and Systems Research, University of Birmingham, Birmingham, UK
- Department of Neurology, University Hospitals Birmingham, Queen Elizabeth Hospital, Birmingham, UK
- Centre for Endocrinology, Diabetes, and Metabolism, Birmingham Health Partners, Birmingham, UK
| | - Nicola J. Adderley
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | | | - Susan P. Mollan
- Translational Brain Science, Institute of Metabolism and Systems Research, University of Birmingham, Birmingham, UK
- Birmingham Neuro-Ophthalmology, Queen Elizabeth Hospital, 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, Queen Elizabeth Hospital, Birmingham, UK
- Centre for Endocrinology, Diabetes, and Metabolism, Birmingham Health Partners, Birmingham, UK
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13
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Alimajstorovic Z, Mollan SP, Grech O, Mitchell JL, Yiangou A, Thaller M, Lyons H, Sassani M, Seneviratne S, Hancox T, Jankevics A, Najdekr L, Dunn W, Sinclair AJ. Dysregulation of Amino Acid, Lipid, and Acylpyruvate Metabolism in Idiopathic Intracranial Hypertension: A Non-targeted Case Control and Longitudinal Metabolomic Study. J Proteome Res 2022; 22:1127-1137. [PMID: 36534069 PMCID: PMC10088035 DOI: 10.1021/acs.jproteome.2c00449] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Background: Idiopathic intracranial hypertension (IIH) is characterized by increased intracranial pressure occurring predominantly in women with obesity. The pathogenesis is not understood. We have applied untargeted metabolomic analysis using ultrahigh-performance liquid chromatography-mass spectrometry to characterize the cerebrospinal fluid (CSF) and serum in IIH compared to control subjects. Methods and findings: Samples were collected from IIH patients (n = 66) with active disease at baseline and again at 12 months following therapeutic weight loss. Control samples were collected from gender- and weight-matched healthy controls (n = 20). We identified annotated metabolites in CSF, formylpyruvate and maleylpyruvate/fumarylpyruvate, which were present at lower concentrations in IIH compared to control subjects and returned to values observed in controls following weight loss. These metabolites showed the opposite trend in serum at baseline. Multiple amino acid metabolic pathways and lipid classes were perturbed in serum and CSF in IIH alone. Serum lipid metabolite pathways were significantly increased in IIH. Conclusions: We observed a number of differential metabolic pathways related to amino acid, lipid, and acylpyruvate metabolism, in IIH compared to controls. These pathways were associated with clinical measures and normalized with disease remission. Perturbation of these metabolic pathways provides initial understanding of disease dysregulation in IIH.
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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, U.K
| | - Susan P. Mollan
- Birmingham Neuro-Ophthalmology, Queen Elizabeth Hospital, University Hospitals Birmingham, Birmingham B15 2WB, U.K
| | - Olivia Grech
- Institute of Metabolism and Systems Research, College of Medical and Dental Sciences, University of Birmingham, Birmingham B15 2TT, U.K
| | - James L. Mitchell
- Institute of Metabolism and Systems Research, College of Medical and Dental Sciences, University of Birmingham, Birmingham B15 2TT, U.K
- Department of Neurology, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham B15 2WB, U.K
| | - Andreas Yiangou
- Institute of Metabolism and Systems Research, College of Medical and Dental Sciences, University of Birmingham, Birmingham B15 2TT, U.K
- Department of Neurology, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham B15 2WB, U.K
| | - Mark Thaller
- Institute of Metabolism and Systems Research, College of Medical and Dental Sciences, University of Birmingham, Birmingham B15 2TT, U.K
- Department of Neurology, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham B15 2WB, U.K
| | - Hannah Lyons
- Institute of Metabolism and Systems Research, College of Medical and Dental Sciences, University of Birmingham, Birmingham B15 2TT, U.K
- Department of Neurology, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham B15 2WB, U.K
| | - Matilde Sassani
- Institute of Metabolism and Systems Research, College of Medical and Dental Sciences, University of Birmingham, Birmingham B15 2TT, U.K
- Department of Neurology, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham B15 2WB, U.K
| | - Senali Seneviratne
- Institute of Metabolism and Systems Research, College of Medical and Dental Sciences, University of Birmingham, Birmingham B15 2TT, U.K
| | - Thomas Hancox
- School of Biosciences, University of Birmingham, Birmingham B15 2TT, U.K
| | - Andris Jankevics
- School of Biosciences, University of Birmingham, Birmingham B15 2TT, U.K
- Phenome Centre Birmingham, University of Birmingham, Birmingham B15 2TT, U.K
| | - Lukáš Najdekr
- School of Biosciences, University of Birmingham, Birmingham B15 2TT, U.K
- Phenome Centre Birmingham, University of Birmingham, Birmingham B15 2TT, U.K
- Institute of Molecular and Translational Medicine, Palacký University Olomouc, Hněvotínská 5, Olomouc 77900, Czech Republic
| | - Warwick Dunn
- Institute of Metabolism and Systems Research, College of Medical and Dental Sciences, University of Birmingham, Birmingham B15 2TT, U.K
- School of Biosciences, University of Birmingham, Birmingham B15 2TT, U.K
- Phenome Centre Birmingham, University of Birmingham, Birmingham B15 2TT, U.K
- Department of Biochemistry and Systems Biology, Institute of Systems, Molecular, and Integrative Biology, University of Liverpool, Liverpool L69 7ZB, U.K
| | - Alexandra J. Sinclair
- Institute of Metabolism and Systems Research, College of Medical and Dental Sciences, University of Birmingham, Birmingham B15 2TT, U.K
- Department of Neurology, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham B15 2WB, U.K
- Centre for Endocrinology, Diabetes and Metabolism, Birmingham Health Partners, Birmingham B15 2TT, U.K
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14
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Thaller M, Mytton J, Wakerley BR, Mollan SP, Sinclair AJ. Idiopathic intracranial hypertension: Evaluation of births and fertility through the Hospital Episode Statistics dataset. BJOG 2022; 129:2019-2027. [PMID: 35620863 PMCID: PMC9796176 DOI: 10.1111/1471-0528.17241] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2021] [Revised: 05/05/2022] [Accepted: 05/19/2022] [Indexed: 01/01/2023]
Abstract
OBJECTIVE Idiopathic intracranial hypertension (IIH) predominantly affects women of reproductive age with obesity, and these women have a distinct profile of hyperandrogenism and insulin resistance. Polycystic ovary syndrome (PCOS) has an established adverse fertility phenotype that typically affects obese women. As IIH may impact reproductive health, we sought to evaluate fertility, gestational complications and pregnancy outcome in IIH. DESIGN Prospective cohort study from English Hospital Episode Statistics dataset. SETTING English hospitals, UK. POPULATION Women aged 18-45 years seen in English hospitals between 1 April 2002 and 31 March 2019. Patients were required to have an IIH diagnosis and were compared with those with PCOS and general population female controls. MAIN OUTCOME MEASURES Pregnancies resulting in live births, complications of gestational diabetes and pre-eclampsia, and method of delivery. RESULTS Data was collected from 17 587 IIH, 199633 PCOS and 10 947 012 women in the general population. The live birth rate, adjusted for age, was significantly lower among women with IIH (54.1%) than PCOS (67.9%), p < 0.0001 and the general population (57.7%), p < 0.0001. Pre-eclampsia and gestational diabetes risks were higher following a diagnosis of IIH (5.3-fold and 2.7-fold, respectively, p < 0.0001) compared with the general population controls. Following a diagnosis of IIH, elective caesarean section rates were more than twice that of general population (odds ratio [OR] 2.4) and prior to a diagnosis of IIH (OR 2.2). CONCLUSIONS These data indicate there are lower age-adjusted total pregnancy rates, increased risk of pre-eclampsia and gestational diabetes, and a doubling of elective caesarean section rates in those with a diagnosis of IIH.
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Affiliation(s)
- Mark Thaller
- Metabolic NeurologyInstitute of Metabolism and Systems ResearchUniversity of BirminghamBirminghamUK,Department of NeurologyUniversity Hospitals Birmingham NHS Foundation TrustBirminghamUK
| | - Jemma Mytton
- InformaticsUniversity Hospitals Birmingham NHS Foundation TrustBirminghamUK
| | - Benjamin R. Wakerley
- Metabolic NeurologyInstitute of Metabolism and Systems ResearchUniversity of BirminghamBirminghamUK,Department of NeurologyUniversity Hospitals Birmingham NHS Foundation TrustBirminghamUK
| | - Susan P. Mollan
- Birmingham Neuro‐OphthalmologyUniversity Hospitals Birmingham NHS Foundation TrustBirminghamUK
| | - Alexandra J. Sinclair
- Metabolic NeurologyInstitute of Metabolism and Systems ResearchUniversity of BirminghamBirminghamUK,Department of NeurologyUniversity Hospitals Birmingham NHS Foundation TrustBirminghamUK,Centre for Endocrinology, Diabetes and Metabolism, Birmingham Health PartnersBirminghamUK
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15
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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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16
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Grech O, Seneviratne SY, Alimajstorovic Z, Yiangou A, Mitchell JL, Smith TB, Mollan SP, Lavery GG, Ludwig C, Sinclair AJ. Nuclear Magnetic Resonance Spectroscopy Metabolomics in Idiopathic Intracranial Hypertension to Identify Markers of Disease and Headache. Neurology 2022; 99:e1702-e1714. [PMID: 36240084 PMCID: PMC9620805 DOI: 10.1212/wnl.0000000000201007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2022] [Accepted: 06/09/2022] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND AND OBJECTIVE We evaluated the metabolomic profile in the CSF, serum, and urine of participants with idiopathic intracranial hypertension (IIH) compared with that in controls and measured changes in metabolism associated with clinical markers of disease activity and treatment. METHODS A case-control study compared women aged 18-55 years with active IIH (Friedman diagnostic criteria) with a sex-matched, age-matched, and body mass index-matched control group. IIH participants were identified from neurology and ophthalmology clinics from National Health Service hospitals and underwent a prospective intervention to induce disease remission through weight loss with reevaluation at 12 months. Clinical assessments included lumbar puncture, headache, papilledema, and visual measurements. Spectra of the CSF, serum, and urine metabolites were acquired using proton nuclear magnetic resonance spectroscopy. RESULTS Urea was lower in IIH participants (CSF, controls median ± IQR 0.196 ± 0.008, IIH 0.058 ± 0.059, p < 0.001; urine, controls 5971.370 ± 3021.831, IIH 4691.363 ± 1955.774, p = 0.009), correlated with ICP (urine p = 0.019) and headache severity (CSF p = 0.031), and increased by 12 months (CSF 12 months; 0.175 ± 0.043, p = 0.004, urine; 5210.874 ± 1825.302, p = 0.043). The lactate:pyruvate ratio was increased in IIH participants compared with that in controls (CSF, controls 49.739 ± 19.523, IIH 113.114 ± 117.298, p = 0.023; serum, controls 38.187 ± 13.392, IIH 54.547 ± 18.471, p = 0.004) and decreased at 12 months (CSF, 113.114 ± 117.298, p < 0.001). Baseline acetate was higher in IIH participants (CSF, controls 0.128 ± 0.041, IIH 0.192 ± 0.151, p = 0.008), correlated with headache severity (p = 0.030) and headache disability (p = 0.003), and was reduced at 12 months (0.160 ± 0.060, p = 0.007). Ketones, 3-hydroxybutyrate and acetoacetate, were altered in the CSF at baseline in IIH participants (3-hydroxybutyrate, controls 0.074 ± 0.063, IIH 0.049 ± 0.055, p = 0.019; acetoacetate, controls 0.013 ± 0.007, IIH 0.017 ± 0.010, p = 0.013) and normalized at 12 months (0.112 ± 0.114, p = 0.019, 0.029 ± 0.017, p = 0.015, respectively). DISCUSSION We observed metabolic disturbances that are evident in the CSF, serum, and urine of IIH participants, suggesting global metabolic dysregulation. Altered ketone body metabolites normalized after therapeutic weight loss. CSF:serum urea ratio was altered, which may influence ICP dynamics and headache. Elevated CSF acetate, known to stimulate trigeminal sensitization, was associated with headache morbidity. These alterations of metabolic pathways specific to IIH provide biological insight and warrant mechanistic evaluation. TRIAL REGISTRATION INFORMATION Registered on ClinicalTrials.gov, NCT02124486 (submitted April 22, 2014) and NCT02017444 (submitted December 16, 2013).
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Affiliation(s)
- Olivia Grech
- Metabolic Neurology (O.G., S.Y.S., Z.A., A.Y., J.L.M., A.J.S.), Institute of Metabolism and Systems Research, College of Medical and Dental Sciences, University of Birmingham; Department of Neurology (A.Y., J.L.M., A.J.S.), University Hospitals Birmingham NHS Foundation Trust; Department of Surgery (T.B.S.), Addenbrooke's Hospital, The University of Cambridge; Birmingham Neuro-Ophthalmology (S.P.M), Queen Elizabeth Hospital, University Hospitals Birmingham; Institute of Metabolism and Systems Research (G.G.L., C.L.), College of Medical and Dental Sciences, University of Birmingham; and Department of Biosciences (G.G.L.), School of Science and Technology, Nottingham Trent University, Clifton Campus, UK
| | - Senali Y Seneviratne
- Metabolic Neurology (O.G., S.Y.S., Z.A., A.Y., J.L.M., A.J.S.), Institute of Metabolism and Systems Research, College of Medical and Dental Sciences, University of Birmingham; Department of Neurology (A.Y., J.L.M., A.J.S.), University Hospitals Birmingham NHS Foundation Trust; Department of Surgery (T.B.S.), Addenbrooke's Hospital, The University of Cambridge; Birmingham Neuro-Ophthalmology (S.P.M), Queen Elizabeth Hospital, University Hospitals Birmingham; Institute of Metabolism and Systems Research (G.G.L., C.L.), College of Medical and Dental Sciences, University of Birmingham; and Department of Biosciences (G.G.L.), School of Science and Technology, Nottingham Trent University, Clifton Campus, UK
| | - Zerin Alimajstorovic
- Metabolic Neurology (O.G., S.Y.S., Z.A., A.Y., J.L.M., A.J.S.), Institute of Metabolism and Systems Research, College of Medical and Dental Sciences, University of Birmingham; Department of Neurology (A.Y., J.L.M., A.J.S.), University Hospitals Birmingham NHS Foundation Trust; Department of Surgery (T.B.S.), Addenbrooke's Hospital, The University of Cambridge; Birmingham Neuro-Ophthalmology (S.P.M), Queen Elizabeth Hospital, University Hospitals Birmingham; Institute of Metabolism and Systems Research (G.G.L., C.L.), College of Medical and Dental Sciences, University of Birmingham; and Department of Biosciences (G.G.L.), School of Science and Technology, Nottingham Trent University, Clifton Campus, UK
| | - Andreas Yiangou
- Metabolic Neurology (O.G., S.Y.S., Z.A., A.Y., J.L.M., A.J.S.), Institute of Metabolism and Systems Research, College of Medical and Dental Sciences, University of Birmingham; Department of Neurology (A.Y., J.L.M., A.J.S.), University Hospitals Birmingham NHS Foundation Trust; Department of Surgery (T.B.S.), Addenbrooke's Hospital, The University of Cambridge; Birmingham Neuro-Ophthalmology (S.P.M), Queen Elizabeth Hospital, University Hospitals Birmingham; Institute of Metabolism and Systems Research (G.G.L., C.L.), College of Medical and Dental Sciences, University of Birmingham; and Department of Biosciences (G.G.L.), School of Science and Technology, Nottingham Trent University, Clifton Campus, UK
| | - James L Mitchell
- Metabolic Neurology (O.G., S.Y.S., Z.A., A.Y., J.L.M., A.J.S.), Institute of Metabolism and Systems Research, College of Medical and Dental Sciences, University of Birmingham; Department of Neurology (A.Y., J.L.M., A.J.S.), University Hospitals Birmingham NHS Foundation Trust; Department of Surgery (T.B.S.), Addenbrooke's Hospital, The University of Cambridge; Birmingham Neuro-Ophthalmology (S.P.M), Queen Elizabeth Hospital, University Hospitals Birmingham; Institute of Metabolism and Systems Research (G.G.L., C.L.), College of Medical and Dental Sciences, University of Birmingham; and Department of Biosciences (G.G.L.), School of Science and Technology, Nottingham Trent University, Clifton Campus, UK
| | - Thomas B Smith
- Metabolic Neurology (O.G., S.Y.S., Z.A., A.Y., J.L.M., A.J.S.), Institute of Metabolism and Systems Research, College of Medical and Dental Sciences, University of Birmingham; Department of Neurology (A.Y., J.L.M., A.J.S.), University Hospitals Birmingham NHS Foundation Trust; Department of Surgery (T.B.S.), Addenbrooke's Hospital, The University of Cambridge; Birmingham Neuro-Ophthalmology (S.P.M), Queen Elizabeth Hospital, University Hospitals Birmingham; Institute of Metabolism and Systems Research (G.G.L., C.L.), College of Medical and Dental Sciences, University of Birmingham; and Department of Biosciences (G.G.L.), School of Science and Technology, Nottingham Trent University, Clifton Campus, UK
| | - Susan P Mollan
- Metabolic Neurology (O.G., S.Y.S., Z.A., A.Y., J.L.M., A.J.S.), Institute of Metabolism and Systems Research, College of Medical and Dental Sciences, University of Birmingham; Department of Neurology (A.Y., J.L.M., A.J.S.), University Hospitals Birmingham NHS Foundation Trust; Department of Surgery (T.B.S.), Addenbrooke's Hospital, The University of Cambridge; Birmingham Neuro-Ophthalmology (S.P.M), Queen Elizabeth Hospital, University Hospitals Birmingham; Institute of Metabolism and Systems Research (G.G.L., C.L.), College of Medical and Dental Sciences, University of Birmingham; and Department of Biosciences (G.G.L.), School of Science and Technology, Nottingham Trent University, Clifton Campus, UK
| | - Gareth G Lavery
- Metabolic Neurology (O.G., S.Y.S., Z.A., A.Y., J.L.M., A.J.S.), Institute of Metabolism and Systems Research, College of Medical and Dental Sciences, University of Birmingham; Department of Neurology (A.Y., J.L.M., A.J.S.), University Hospitals Birmingham NHS Foundation Trust; Department of Surgery (T.B.S.), Addenbrooke's Hospital, The University of Cambridge; Birmingham Neuro-Ophthalmology (S.P.M), Queen Elizabeth Hospital, University Hospitals Birmingham; Institute of Metabolism and Systems Research (G.G.L., C.L.), College of Medical and Dental Sciences, University of Birmingham; and Department of Biosciences (G.G.L.), School of Science and Technology, Nottingham Trent University, Clifton Campus, UK
| | - Christian Ludwig
- Metabolic Neurology (O.G., S.Y.S., Z.A., A.Y., J.L.M., A.J.S.), Institute of Metabolism and Systems Research, College of Medical and Dental Sciences, University of Birmingham; Department of Neurology (A.Y., J.L.M., A.J.S.), University Hospitals Birmingham NHS Foundation Trust; Department of Surgery (T.B.S.), Addenbrooke's Hospital, The University of Cambridge; Birmingham Neuro-Ophthalmology (S.P.M), Queen Elizabeth Hospital, University Hospitals Birmingham; Institute of Metabolism and Systems Research (G.G.L., C.L.), College of Medical and Dental Sciences, University of Birmingham; and Department of Biosciences (G.G.L.), School of Science and Technology, Nottingham Trent University, Clifton Campus, UK
| | - Alexandra J Sinclair
- Metabolic Neurology (O.G., S.Y.S., Z.A., A.Y., J.L.M., A.J.S.), Institute of Metabolism and Systems Research, College of Medical and Dental Sciences, University of Birmingham; Department of Neurology (A.Y., J.L.M., A.J.S.), University Hospitals Birmingham NHS Foundation Trust; Department of Surgery (T.B.S.), Addenbrooke's Hospital, The University of Cambridge; Birmingham Neuro-Ophthalmology (S.P.M), Queen Elizabeth Hospital, University Hospitals Birmingham; Institute of Metabolism and Systems Research (G.G.L., C.L.), College of Medical and Dental Sciences, University of Birmingham; and Department of Biosciences (G.G.L.), School of Science and Technology, Nottingham Trent University, Clifton Campus, UK.
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Mollan SP, Mitchell JL, Yiangou A, Ottridge RS, Alimajstorovic Z, Cartwright DM, Hickman SJ, Markey KA, Singhal R, Tahrani AA, Frew E, Brock K, Sinclair AJ. Association of Amount of Weight Lost After Bariatric Surgery With Intracranial Pressure in Women With Idiopathic Intracranial Hypertension. Neurology 2022; 99:e1090-e1099. [PMID: 35790425 PMCID: PMC9536743 DOI: 10.1212/wnl.0000000000200839] [Citation(s) in RCA: 18] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2021] [Accepted: 04/22/2022] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND AND OBJECTIVES The idiopathic intracranial hypertension randomized controlled weight trial (IIH:WT) established that weight loss through bariatric surgery significantly reduced intracranial pressure when compared with a community weight management intervention. This substudy aimed to evaluate the amount of weight loss required to reduce intracranial pressure and to explore the effect of different bariatric surgical approaches. METHODS IIH:WT was a multicenter randomized controlled trial. Adult women with active idiopathic intracranial hypertension and a body mass index ≥35 kg/m2 were randomized to bariatric surgery or a community weight management intervention (1:1). This per-protocol analysis evaluated the relationship between intracranial pressure, weight loss, and the weight loss methods. A linear hierarchical regression model was used to fit the trial outcomes, adjusted for time, treatment arm, and weight. RESULTS Sixty-six women were included, of whom 23 had received bariatric surgery by 12 months; the mean age was 31 (SD 8.7) years in the bariatric surgery group and 33.2 (SD 7.4) years in the dietary group. Baseline weight and intracranial pressure were similar in both groups with a mean weight of 119.5 (SD 24.1) and 117.9 (SD 19.5) kg and mean lumbar puncture opening pressure of 34.4 (SD 6.3) and 34.9 (SD 5.3) cmCSF in the bariatric surgery and dietary groups, respectively. Weight loss was significantly associated with reduction in intracranial pressure (R2 = 0.4734, p ≤ 0.0001). Twenty-four percentage of weight loss (weight loss of 13.3 kg [SD 1.76]) was associated with disease remission (intracranial pressure [ICP] ≤ 25 cmCSF). Roux-en-Y gastric bypass achieved greater, more rapid, and sustained ICP reduction compared with other methods. DISCUSSION The greater the weight loss, the greater the reduction in ICP was documented. Twenty four percentage of weight loss was associated with disease remission. Such magnitude of weight loss was unlikely to be achieved without bariatric surgery, and hence, consideration of referral to a bariatric surgery program early for those with active idiopathic intracranial hypertension may be appropriate. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT02124486; ISRCTN registry number ISRCTN40152829; doi.org/10.1186/ISRCTN40152829. CLASSIFICATION OF EVIDENCE This study provides Class II evidence that weight loss after bariatric surgery results in reduction in intracranial pressure in adult women with idiopathic intracranial hypertension. This study is Class II because of the use of a per-protocol analysis.
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Affiliation(s)
- Susan P Mollan
- From the Birmingham Neuro-Ophthalmology (S.P.M.), University Hospitals Birmingham NHS Foundation Trust, Queen Elizabeth Hospital; Metabolic Neurology (J.L.M., A.Y., Z.A., K.A.M., A.J.S.), Institute of Metabolism and Systems Research, College of Medical and Dental Sciences, University of Birmingham; Department of Neurology (J.L.M., A.Y., A.J.S.), University Hospitals Birmingham NHS Foundation Trust, Queen Elizabeth Hospital; Centre for Endocrinology (J.L.M., A.Y., A.A.T., A.J.S.), Diabetes and Metabolism, Birmingham Health Partners; Birmingham Clinical Trials Unit (R.S.O.); Institute of Metabolism and Systems Research (Z.A., D.M.C., A.A.T., A.J.S.), College of Medical and Dental Sciences, University of Birmingham, Birmingham, United Kingdom; Department of Neurology (S.J.H.), Royal Hallamshire Hospital, Sheffield, United Kingdom; Upper GI Unit and Minimally Invasive Unit (R.S.), Birmingham Heartlands Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham; Institute of Cancer and Genomic Sciences (R.S.), University of Birmingham; Department of Endocrinology (A.A.T.), University Hospitals Birmingham NHS Foundation Trust, Queen Elizabeth Hospital; Health Economics Unit (E.F.), Institute of Applied Health Research, University of Birmingham; and Cancer Research UK Clinical Trials Unit (K.B.), University of Birmingham, Birmingham, United Kingdom.
| | - James L Mitchell
- From the Birmingham Neuro-Ophthalmology (S.P.M.), University Hospitals Birmingham NHS Foundation Trust, Queen Elizabeth Hospital; Metabolic Neurology (J.L.M., A.Y., Z.A., K.A.M., A.J.S.), Institute of Metabolism and Systems Research, College of Medical and Dental Sciences, University of Birmingham; Department of Neurology (J.L.M., A.Y., A.J.S.), University Hospitals Birmingham NHS Foundation Trust, Queen Elizabeth Hospital; Centre for Endocrinology (J.L.M., A.Y., A.A.T., A.J.S.), Diabetes and Metabolism, Birmingham Health Partners; Birmingham Clinical Trials Unit (R.S.O.); Institute of Metabolism and Systems Research (Z.A., D.M.C., A.A.T., A.J.S.), College of Medical and Dental Sciences, University of Birmingham, Birmingham, United Kingdom; Department of Neurology (S.J.H.), Royal Hallamshire Hospital, Sheffield, United Kingdom; Upper GI Unit and Minimally Invasive Unit (R.S.), Birmingham Heartlands Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham; Institute of Cancer and Genomic Sciences (R.S.), University of Birmingham; Department of Endocrinology (A.A.T.), University Hospitals Birmingham NHS Foundation Trust, Queen Elizabeth Hospital; Health Economics Unit (E.F.), Institute of Applied Health Research, University of Birmingham; and Cancer Research UK Clinical Trials Unit (K.B.), University of Birmingham, Birmingham, United Kingdom
| | - Andreas Yiangou
- From the Birmingham Neuro-Ophthalmology (S.P.M.), University Hospitals Birmingham NHS Foundation Trust, Queen Elizabeth Hospital; Metabolic Neurology (J.L.M., A.Y., Z.A., K.A.M., A.J.S.), Institute of Metabolism and Systems Research, College of Medical and Dental Sciences, University of Birmingham; Department of Neurology (J.L.M., A.Y., A.J.S.), University Hospitals Birmingham NHS Foundation Trust, Queen Elizabeth Hospital; Centre for Endocrinology (J.L.M., A.Y., A.A.T., A.J.S.), Diabetes and Metabolism, Birmingham Health Partners; Birmingham Clinical Trials Unit (R.S.O.); Institute of Metabolism and Systems Research (Z.A., D.M.C., A.A.T., A.J.S.), College of Medical and Dental Sciences, University of Birmingham, Birmingham, United Kingdom; Department of Neurology (S.J.H.), Royal Hallamshire Hospital, Sheffield, United Kingdom; Upper GI Unit and Minimally Invasive Unit (R.S.), Birmingham Heartlands Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham; Institute of Cancer and Genomic Sciences (R.S.), University of Birmingham; Department of Endocrinology (A.A.T.), University Hospitals Birmingham NHS Foundation Trust, Queen Elizabeth Hospital; Health Economics Unit (E.F.), Institute of Applied Health Research, University of Birmingham; and Cancer Research UK Clinical Trials Unit (K.B.), University of Birmingham, Birmingham, United Kingdom
| | - Ryan S Ottridge
- From the Birmingham Neuro-Ophthalmology (S.P.M.), University Hospitals Birmingham NHS Foundation Trust, Queen Elizabeth Hospital; Metabolic Neurology (J.L.M., A.Y., Z.A., K.A.M., A.J.S.), Institute of Metabolism and Systems Research, College of Medical and Dental Sciences, University of Birmingham; Department of Neurology (J.L.M., A.Y., A.J.S.), University Hospitals Birmingham NHS Foundation Trust, Queen Elizabeth Hospital; Centre for Endocrinology (J.L.M., A.Y., A.A.T., A.J.S.), Diabetes and Metabolism, Birmingham Health Partners; Birmingham Clinical Trials Unit (R.S.O.); Institute of Metabolism and Systems Research (Z.A., D.M.C., A.A.T., A.J.S.), College of Medical and Dental Sciences, University of Birmingham, Birmingham, United Kingdom; Department of Neurology (S.J.H.), Royal Hallamshire Hospital, Sheffield, United Kingdom; Upper GI Unit and Minimally Invasive Unit (R.S.), Birmingham Heartlands Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham; Institute of Cancer and Genomic Sciences (R.S.), University of Birmingham; Department of Endocrinology (A.A.T.), University Hospitals Birmingham NHS Foundation Trust, Queen Elizabeth Hospital; Health Economics Unit (E.F.), Institute of Applied Health Research, University of Birmingham; and Cancer Research UK Clinical Trials Unit (K.B.), University of Birmingham, Birmingham, United Kingdom
| | - Zerin Alimajstorovic
- From the Birmingham Neuro-Ophthalmology (S.P.M.), University Hospitals Birmingham NHS Foundation Trust, Queen Elizabeth Hospital; Metabolic Neurology (J.L.M., A.Y., Z.A., K.A.M., A.J.S.), Institute of Metabolism and Systems Research, College of Medical and Dental Sciences, University of Birmingham; Department of Neurology (J.L.M., A.Y., A.J.S.), University Hospitals Birmingham NHS Foundation Trust, Queen Elizabeth Hospital; Centre for Endocrinology (J.L.M., A.Y., A.A.T., A.J.S.), Diabetes and Metabolism, Birmingham Health Partners; Birmingham Clinical Trials Unit (R.S.O.); Institute of Metabolism and Systems Research (Z.A., D.M.C., A.A.T., A.J.S.), College of Medical and Dental Sciences, University of Birmingham, Birmingham, United Kingdom; Department of Neurology (S.J.H.), Royal Hallamshire Hospital, Sheffield, United Kingdom; Upper GI Unit and Minimally Invasive Unit (R.S.), Birmingham Heartlands Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham; Institute of Cancer and Genomic Sciences (R.S.), University of Birmingham; Department of Endocrinology (A.A.T.), University Hospitals Birmingham NHS Foundation Trust, Queen Elizabeth Hospital; Health Economics Unit (E.F.), Institute of Applied Health Research, University of Birmingham; and Cancer Research UK Clinical Trials Unit (K.B.), University of Birmingham, Birmingham, United Kingdom
| | - David M Cartwright
- From the Birmingham Neuro-Ophthalmology (S.P.M.), University Hospitals Birmingham NHS Foundation Trust, Queen Elizabeth Hospital; Metabolic Neurology (J.L.M., A.Y., Z.A., K.A.M., A.J.S.), Institute of Metabolism and Systems Research, College of Medical and Dental Sciences, University of Birmingham; Department of Neurology (J.L.M., A.Y., A.J.S.), University Hospitals Birmingham NHS Foundation Trust, Queen Elizabeth Hospital; Centre for Endocrinology (J.L.M., A.Y., A.A.T., A.J.S.), Diabetes and Metabolism, Birmingham Health Partners; Birmingham Clinical Trials Unit (R.S.O.); Institute of Metabolism and Systems Research (Z.A., D.M.C., A.A.T., A.J.S.), College of Medical and Dental Sciences, University of Birmingham, Birmingham, United Kingdom; Department of Neurology (S.J.H.), Royal Hallamshire Hospital, Sheffield, United Kingdom; Upper GI Unit and Minimally Invasive Unit (R.S.), Birmingham Heartlands Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham; Institute of Cancer and Genomic Sciences (R.S.), University of Birmingham; Department of Endocrinology (A.A.T.), University Hospitals Birmingham NHS Foundation Trust, Queen Elizabeth Hospital; Health Economics Unit (E.F.), Institute of Applied Health Research, University of Birmingham; and Cancer Research UK Clinical Trials Unit (K.B.), University of Birmingham, Birmingham, United Kingdom
| | - Simon J Hickman
- From the Birmingham Neuro-Ophthalmology (S.P.M.), University Hospitals Birmingham NHS Foundation Trust, Queen Elizabeth Hospital; Metabolic Neurology (J.L.M., A.Y., Z.A., K.A.M., A.J.S.), Institute of Metabolism and Systems Research, College of Medical and Dental Sciences, University of Birmingham; Department of Neurology (J.L.M., A.Y., A.J.S.), University Hospitals Birmingham NHS Foundation Trust, Queen Elizabeth Hospital; Centre for Endocrinology (J.L.M., A.Y., A.A.T., A.J.S.), Diabetes and Metabolism, Birmingham Health Partners; Birmingham Clinical Trials Unit (R.S.O.); Institute of Metabolism and Systems Research (Z.A., D.M.C., A.A.T., A.J.S.), College of Medical and Dental Sciences, University of Birmingham, Birmingham, United Kingdom; Department of Neurology (S.J.H.), Royal Hallamshire Hospital, Sheffield, United Kingdom; Upper GI Unit and Minimally Invasive Unit (R.S.), Birmingham Heartlands Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham; Institute of Cancer and Genomic Sciences (R.S.), University of Birmingham; Department of Endocrinology (A.A.T.), University Hospitals Birmingham NHS Foundation Trust, Queen Elizabeth Hospital; Health Economics Unit (E.F.), Institute of Applied Health Research, University of Birmingham; and Cancer Research UK Clinical Trials Unit (K.B.), University of Birmingham, Birmingham, United Kingdom
| | - Keira A Markey
- From the Birmingham Neuro-Ophthalmology (S.P.M.), University Hospitals Birmingham NHS Foundation Trust, Queen Elizabeth Hospital; Metabolic Neurology (J.L.M., A.Y., Z.A., K.A.M., A.J.S.), Institute of Metabolism and Systems Research, College of Medical and Dental Sciences, University of Birmingham; Department of Neurology (J.L.M., A.Y., A.J.S.), University Hospitals Birmingham NHS Foundation Trust, Queen Elizabeth Hospital; Centre for Endocrinology (J.L.M., A.Y., A.A.T., A.J.S.), Diabetes and Metabolism, Birmingham Health Partners; Birmingham Clinical Trials Unit (R.S.O.); Institute of Metabolism and Systems Research (Z.A., D.M.C., A.A.T., A.J.S.), College of Medical and Dental Sciences, University of Birmingham, Birmingham, United Kingdom; Department of Neurology (S.J.H.), Royal Hallamshire Hospital, Sheffield, United Kingdom; Upper GI Unit and Minimally Invasive Unit (R.S.), Birmingham Heartlands Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham; Institute of Cancer and Genomic Sciences (R.S.), University of Birmingham; Department of Endocrinology (A.A.T.), University Hospitals Birmingham NHS Foundation Trust, Queen Elizabeth Hospital; Health Economics Unit (E.F.), Institute of Applied Health Research, University of Birmingham; and Cancer Research UK Clinical Trials Unit (K.B.), University of Birmingham, Birmingham, United Kingdom
| | - Rishi Singhal
- From the Birmingham Neuro-Ophthalmology (S.P.M.), University Hospitals Birmingham NHS Foundation Trust, Queen Elizabeth Hospital; Metabolic Neurology (J.L.M., A.Y., Z.A., K.A.M., A.J.S.), Institute of Metabolism and Systems Research, College of Medical and Dental Sciences, University of Birmingham; Department of Neurology (J.L.M., A.Y., A.J.S.), University Hospitals Birmingham NHS Foundation Trust, Queen Elizabeth Hospital; Centre for Endocrinology (J.L.M., A.Y., A.A.T., A.J.S.), Diabetes and Metabolism, Birmingham Health Partners; Birmingham Clinical Trials Unit (R.S.O.); Institute of Metabolism and Systems Research (Z.A., D.M.C., A.A.T., A.J.S.), College of Medical and Dental Sciences, University of Birmingham, Birmingham, United Kingdom; Department of Neurology (S.J.H.), Royal Hallamshire Hospital, Sheffield, United Kingdom; Upper GI Unit and Minimally Invasive Unit (R.S.), Birmingham Heartlands Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham; Institute of Cancer and Genomic Sciences (R.S.), University of Birmingham; Department of Endocrinology (A.A.T.), University Hospitals Birmingham NHS Foundation Trust, Queen Elizabeth Hospital; Health Economics Unit (E.F.), Institute of Applied Health Research, University of Birmingham; and Cancer Research UK Clinical Trials Unit (K.B.), University of Birmingham, Birmingham, United Kingdom
| | - Abd A Tahrani
- From the Birmingham Neuro-Ophthalmology (S.P.M.), University Hospitals Birmingham NHS Foundation Trust, Queen Elizabeth Hospital; Metabolic Neurology (J.L.M., A.Y., Z.A., K.A.M., A.J.S.), Institute of Metabolism and Systems Research, College of Medical and Dental Sciences, University of Birmingham; Department of Neurology (J.L.M., A.Y., A.J.S.), University Hospitals Birmingham NHS Foundation Trust, Queen Elizabeth Hospital; Centre for Endocrinology (J.L.M., A.Y., A.A.T., A.J.S.), Diabetes and Metabolism, Birmingham Health Partners; Birmingham Clinical Trials Unit (R.S.O.); Institute of Metabolism and Systems Research (Z.A., D.M.C., A.A.T., A.J.S.), College of Medical and Dental Sciences, University of Birmingham, Birmingham, United Kingdom; Department of Neurology (S.J.H.), Royal Hallamshire Hospital, Sheffield, United Kingdom; Upper GI Unit and Minimally Invasive Unit (R.S.), Birmingham Heartlands Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham; Institute of Cancer and Genomic Sciences (R.S.), University of Birmingham; Department of Endocrinology (A.A.T.), University Hospitals Birmingham NHS Foundation Trust, Queen Elizabeth Hospital; Health Economics Unit (E.F.), Institute of Applied Health Research, University of Birmingham; and Cancer Research UK Clinical Trials Unit (K.B.), University of Birmingham, Birmingham, United Kingdom
| | - Emma Frew
- From the Birmingham Neuro-Ophthalmology (S.P.M.), University Hospitals Birmingham NHS Foundation Trust, Queen Elizabeth Hospital; Metabolic Neurology (J.L.M., A.Y., Z.A., K.A.M., A.J.S.), Institute of Metabolism and Systems Research, College of Medical and Dental Sciences, University of Birmingham; Department of Neurology (J.L.M., A.Y., A.J.S.), University Hospitals Birmingham NHS Foundation Trust, Queen Elizabeth Hospital; Centre for Endocrinology (J.L.M., A.Y., A.A.T., A.J.S.), Diabetes and Metabolism, Birmingham Health Partners; Birmingham Clinical Trials Unit (R.S.O.); Institute of Metabolism and Systems Research (Z.A., D.M.C., A.A.T., A.J.S.), College of Medical and Dental Sciences, University of Birmingham, Birmingham, United Kingdom; Department of Neurology (S.J.H.), Royal Hallamshire Hospital, Sheffield, United Kingdom; Upper GI Unit and Minimally Invasive Unit (R.S.), Birmingham Heartlands Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham; Institute of Cancer and Genomic Sciences (R.S.), University of Birmingham; Department of Endocrinology (A.A.T.), University Hospitals Birmingham NHS Foundation Trust, Queen Elizabeth Hospital; Health Economics Unit (E.F.), Institute of Applied Health Research, University of Birmingham; and Cancer Research UK Clinical Trials Unit (K.B.), University of Birmingham, Birmingham, United Kingdom
| | - Kristian Brock
- From the Birmingham Neuro-Ophthalmology (S.P.M.), University Hospitals Birmingham NHS Foundation Trust, Queen Elizabeth Hospital; Metabolic Neurology (J.L.M., A.Y., Z.A., K.A.M., A.J.S.), Institute of Metabolism and Systems Research, College of Medical and Dental Sciences, University of Birmingham; Department of Neurology (J.L.M., A.Y., A.J.S.), University Hospitals Birmingham NHS Foundation Trust, Queen Elizabeth Hospital; Centre for Endocrinology (J.L.M., A.Y., A.A.T., A.J.S.), Diabetes and Metabolism, Birmingham Health Partners; Birmingham Clinical Trials Unit (R.S.O.); Institute of Metabolism and Systems Research (Z.A., D.M.C., A.A.T., A.J.S.), College of Medical and Dental Sciences, University of Birmingham, Birmingham, United Kingdom; Department of Neurology (S.J.H.), Royal Hallamshire Hospital, Sheffield, United Kingdom; Upper GI Unit and Minimally Invasive Unit (R.S.), Birmingham Heartlands Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham; Institute of Cancer and Genomic Sciences (R.S.), University of Birmingham; Department of Endocrinology (A.A.T.), University Hospitals Birmingham NHS Foundation Trust, Queen Elizabeth Hospital; Health Economics Unit (E.F.), Institute of Applied Health Research, University of Birmingham; and Cancer Research UK Clinical Trials Unit (K.B.), University of Birmingham, Birmingham, United Kingdom
| | - Alexandra Jean Sinclair
- From the Birmingham Neuro-Ophthalmology (S.P.M.), University Hospitals Birmingham NHS Foundation Trust, Queen Elizabeth Hospital; Metabolic Neurology (J.L.M., A.Y., Z.A., K.A.M., A.J.S.), Institute of Metabolism and Systems Research, College of Medical and Dental Sciences, University of Birmingham; Department of Neurology (J.L.M., A.Y., A.J.S.), University Hospitals Birmingham NHS Foundation Trust, Queen Elizabeth Hospital; Centre for Endocrinology (J.L.M., A.Y., A.A.T., A.J.S.), Diabetes and Metabolism, Birmingham Health Partners; Birmingham Clinical Trials Unit (R.S.O.); Institute of Metabolism and Systems Research (Z.A., D.M.C., A.A.T., A.J.S.), College of Medical and Dental Sciences, University of Birmingham, Birmingham, United Kingdom; Department of Neurology (S.J.H.), Royal Hallamshire Hospital, Sheffield, United Kingdom; Upper GI Unit and Minimally Invasive Unit (R.S.), Birmingham Heartlands Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham; Institute of Cancer and Genomic Sciences (R.S.), University of Birmingham; Department of Endocrinology (A.A.T.), University Hospitals Birmingham NHS Foundation Trust, Queen Elizabeth Hospital; Health Economics Unit (E.F.), Institute of Applied Health Research, University of Birmingham; and Cancer Research UK Clinical Trials Unit (K.B.), University of Birmingham, Birmingham, United Kingdom
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Westgate CSJ, Markey K, Mitchell JL, Yiangou A, Singhal R, Stewart P, Tomlinson JW, Lavery GG, Mollan SP, Sinclair AJ. Increased systemic and adipose 11β-HSD1 activity in idiopathic intracranial hypertension. Eur J Endocrinol 2022; 187:323-333. [PMID: 35584002 PMCID: PMC9346265 DOI: 10.1530/eje-22-0108] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/2022] [Accepted: 05/18/2022] [Indexed: 11/09/2022]
Abstract
Context Idiopathic intracranial hypertension (IIH) is a disease of raised intracranial pressure (ICP) of unknown etiology. Reductions in glucocorticoid metabolism are associated with improvements in IIH disease activity. The basal IIH glucocorticoid metabolism is yet to be assessed. Objective The objective of this study was to determine the basal glucocorticoid phenotype in IIH and assess the effects of weight loss on the IIH glucocorticoid phenotype. Design A retrospective case-control study and a separate exploratory analysis of a prospective randomized intervention study were carried out. Methods The case-control study compared female IIH patients to BMI, age, and sex-matched controls. In the randomized intervention study, different IIH patients were randomized to either a community weight management intervention or bariatric surgery, with patients assessed at baseline and 12 months. Glucocorticoid levels were determined utilizing 24-h urinary steroid profiles alongside the measurement of adipose tissue 11β-HSD1 activity. Results Compared to control subjects, patients with active IIH had increased systemic 11β-hydroxysteroid dehydrogenase (11β-HSD1) and 5α-reductase activity. The intervention study demonstrated that weight loss following bariatric surgery reduced systemic 11β-HSD1 and 5α-reductase activity. Reductions in these were associated with reduced ICP. Subcutaneous adipose tissue explants demonstrated elevated 11β-HSD1 activity compared to samples from matched controls. Conclusion The study demonstrates that in IIH, there is a phenotype of elevated systemic and adipose 11β-HSD1 activity in excess to that mediated by obesity. Bariatric surgery to induce weight loss was associated with reductions in 11β-HSD1 activity and decreased ICP. These data reflect new insights into the IIH phenotype and further point toward metabolic dysregulation as a feature of IIH.
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Affiliation(s)
- Connar S J Westgate
- Metabolic Neurology, Institute of Metabolism and Systems Research, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
| | - Keira Markey
- Metabolic Neurology, Institute of Metabolism and Systems Research, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
| | - James L Mitchell
- Metabolic Neurology, 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
| | - Andreas Yiangou
- Metabolic Neurology, 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
| | - Rishi Singhal
- Upper GI Unit and Minimally Invasive Unit, Birmingham Heartlands Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | | | - Jeremy W Tomlinson
- Oxford Centre for Diabetes, Endocrinology & Metabolism (OCDEM), NIHR Oxford Biomedical Research Centre, University of Oxford, Churchill Hospital, Headington, Oxford, UK
| | - Gareth G Lavery
- Metabolic Neurology, Institute of Metabolism and Systems Research, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
- Department of Biosciences, Nottingham Trent University, Nottingham, UK
| | - Susan P Mollan
- Birmingham Neuro-Ophthalmology, University Hospitals Birmingham NHS Foundation Trust, Queen Elizabeth Hospital, Birmingham, UK
| | - Alexandra J Sinclair
- Metabolic Neurology, 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
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Korsbæk JJ, Beier D, Hagen SM, Molander LD, Jensen RH. Psychiatric Comorbidities in Patients With Idiopathic Intracranial Hypertension: A Prospective Cohort Study. Neurology 2022; 99:e199-e208. [PMID: 35473759 DOI: 10.1212/wnl.0000000000200548] [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: 11/12/2021] [Accepted: 03/02/2022] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND AND OBJECTIVES Psychiatric disease is a frequent comorbidity in idiopathic intracranial hypertension (IIH) and has been associated with a poor subjective outcome. No prospective studies have investigated psychiatric comorbidities in new-onset IIH. Our primary aim was to investigate disease severity in IIH depending on comorbid psychiatric disease. Important secondary outcomes were disease severity after 6 months and prevalence of psychiatric diseases in IIH. METHODS This prospective, observational cohort study consecutively included patients with clinically suspected, new-onset IIH from 2 headache centers. A standardized diagnostic workup was completed to confirm or exclude IIH according to the revised Friedman criteria: semi-structured interview, neurologic and neuro-ophthalmologic examination, lumbar puncture with opening pressure (OP), and neuroimaging. Exclusion criteria were known IIH, secondary intracranial hypertension, missing data, and pregnancy. Disease severity was evaluated based on papilledema, visual fields, OP, and headache in patients with IIH without psychiatric disease (IIH-P) compared with patients with IIH with psychiatric disease (IIH+P). A blinded neuro-ophthalmologist assessed visual outcomes. Age- and sex-matched prevalence rates of psychiatric diseases in the general population were found in national reports. RESULTS A total of 258 patients were screened; 69 were excluded. A total of 189 patients with clinically suspected IIH were then evaluated with the diagnostic workup and IIH was confirmed in 111 patients (58.7%). A total of 45% of patients with IIH had a psychiatric comorbidity. Visual fields were worse in patients with IIH+P at baseline (-8.0 vs -6.0 dB; p = 0.04) and after 6 months (-5.5 vs -4.0 dB; p < 0.01) compared with IIH-P. Highly prevalent psychiatric disorders were major depressive disorder (24.3%; n = 27), anxiety or stress-related disorders (24.3%; n = 27), and emotionally unstable personality disorder (6.3%; n = 7). Substance abuse (1.8%), schizophrenia (0.9%), and bipolar disorder (0.9%) were rare. In the general population, prevalence estimates of major depressive disorder and emotionally unstable personality disorder were 1.8%-3.3% and 2%, respectively. DISCUSSION Visual fields were significantly worse at baseline and 6 months in IIH+P compared with IIH-P. Psychiatric comorbidities, particularly depression and emotionally unstable personality disorder, were highly prevalent in IIH. Increased awareness of psychiatric disease as a marker for worse visual status may improve patient care.
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Affiliation(s)
- Johanne Juhl Korsbæk
- From the Department of Neurology, Danish Headache Center, Rigshospitalet-Glostrup (J.J.K., R.H.J.), and Department of Ophthalmology, Rigshospitalet (S.M.H.), University of Copenhagen; Departments of Neurology (D.B.) and Ophthalmology (L.D.M.) and OPEN, Odense Patient Data Explorative Network (D.B.), Odense University Hospital; and Department of Clinical Research (D.B.), University of Southern Denmark
| | - Dagmar Beier
- From the Department of Neurology, Danish Headache Center, Rigshospitalet-Glostrup (J.J.K., R.H.J.), and Department of Ophthalmology, Rigshospitalet (S.M.H.), University of Copenhagen; Departments of Neurology (D.B.) and Ophthalmology (L.D.M.) and OPEN, Odense Patient Data Explorative Network (D.B.), Odense University Hospital; and Department of Clinical Research (D.B.), University of Southern Denmark
| | - Snorre Malm Hagen
- From the Department of Neurology, Danish Headache Center, Rigshospitalet-Glostrup (J.J.K., R.H.J.), and Department of Ophthalmology, Rigshospitalet (S.M.H.), University of Copenhagen; Departments of Neurology (D.B.) and Ophthalmology (L.D.M.) and OPEN, Odense Patient Data Explorative Network (D.B.), Odense University Hospital; and Department of Clinical Research (D.B.), University of Southern Denmark
| | - Laleh Dehghani Molander
- From the Department of Neurology, Danish Headache Center, Rigshospitalet-Glostrup (J.J.K., R.H.J.), and Department of Ophthalmology, Rigshospitalet (S.M.H.), University of Copenhagen; Departments of Neurology (D.B.) and Ophthalmology (L.D.M.) and OPEN, Odense Patient Data Explorative Network (D.B.), Odense University Hospital; and Department of Clinical Research (D.B.), University of Southern Denmark
| | - Rigmor Højland Jensen
- From the Department of Neurology, Danish Headache Center, Rigshospitalet-Glostrup (J.J.K., R.H.J.), and Department of Ophthalmology, Rigshospitalet (S.M.H.), University of Copenhagen; Departments of Neurology (D.B.) and Ophthalmology (L.D.M.) and OPEN, Odense Patient Data Explorative Network (D.B.), Odense University Hospital; and Department of Clinical Research (D.B.), University of Southern Denmark.
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20
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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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21
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Oliveira BBRD, Coelho CG, Barreto SM, Giatti L, Araújo LF. Body fat distribution and its risk for cardiovascular events in 10 years: Brazilian Longitudinal Study of Adult Health (ELSA-Brasil). CAD SAUDE PUBLICA 2022; 38:e00346520. [DOI: 10.1590/0102-311x00346520] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2020] [Accepted: 04/26/2021] [Indexed: 12/23/2022] Open
Abstract
Body fat distribution seems to have different effects in cardiovascular diseases (CVD). We aimed to estimate the associations between lower limbs and trunk fat ratio and the 10-year CVD risk, and isolated risk factors in men and women. A total of 10,917 participants from ELSA-Brasil were eligible for this cross-sectional study. Associations between lower limb/trunk fat ratio with the percentage of 10-year CVD risk - according to the Framingham Risk Score - and its risk factors (systolic blood pressure, total cholesterol and HDL-cholesterol, diabetes, and use of antihypertensive medication) were performed using generalized linear models, linear and logistic regressions. All analyses were stratified by gender and adjustments were made by age, self-reported skin color, educational attainment, alcohol consumption, leisure physical activity, hypolipidemic drug use and, for women, menopausal status. In this study, 55.91% were women, with a mean age of 52.68 (SD = 6.57) years. A higher lower limb/trunk fat ratio was related to lower 10-year CVD risk, as well as a reduction in systolic blood pressure, total cholesterol, and antihypertensive drug use, also an increasing HDL-cholesterol in both genders, but this relationship was stronger in women. Besides, a protective relationship to diabetes was observed in women. Higher fat accumulation in the lower body, when compared to the trunk, seems to have a lower risk of CVD and associated risk factors - even in the presence of fat in the abdominal region - with women presenting lower risks than men.
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22
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Westgate CSJ, Israelsen IME, Jensen RH, Eftekhari S. Understanding the link between obesity and headache- with focus on migraine and idiopathic intracranial hypertension. J Headache Pain 2021; 22:123. [PMID: 34629054 PMCID: PMC8504002 DOI: 10.1186/s10194-021-01337-0] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2021] [Accepted: 09/26/2021] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Obesity confers adverse effects to every system in the body including the central nervous system. Obesity is associated with both migraine and idiopathic intracranial hypertension (IIH). The mechanisms underlying the association between obesity and these headache diseases remain unclear. METHODS We conducted a narrative review of the evidence in both humans and rodents, for the putative mechanisms underlying the link between obesity, migraine and IIH. RESULTS Truncal adiposity, a key feature of obesity, is associated with increased migraine morbidity and disability through increased headache severity, frequency and more severe cutaneous allodynia. Obesity may also increase intracranial pressure and could contribute to headache morbidity in migraine and be causative in IIH headache. Weight loss can improve both migraine and IIH headache. Preclinical research highlights that obesity increases the sensitivity of the trigeminovascular system to noxious stimuli including inflammatory stimuli, but the underlying molecular mechanisms remain unelucidated. CONCLUSIONS This review highlights that at the epidemiological and clinical level, obesity increases morbidity in migraine and IIH headache, where weight loss can improve headache morbidity. However, further research is required to understand the molecular underpinnings of obesity related headache in order to generate novel treatments.
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Affiliation(s)
- Connar Stanley James Westgate
- Danish Headache Center, Department of Neurology, Rigshospitalet- Glostrup, Glostrup Research Institute, University of Copenhagen, Nordstjernevej 42, 2600, Glostrup, Denmark
| | - Ida Marchen Egerod Israelsen
- Danish Headache Center, Department of Neurology, Rigshospitalet- Glostrup, Glostrup Research Institute, University of Copenhagen, Nordstjernevej 42, 2600, Glostrup, Denmark
| | - Rigmor Højland Jensen
- Danish Headache Center, Department of Neurology, Rigshospitalet- Glostrup, Glostrup Research Institute, University of Copenhagen, Nordstjernevej 42, 2600, Glostrup, Denmark
| | - Sajedeh Eftekhari
- Danish Headache Center, Department of Neurology, Rigshospitalet- Glostrup, Glostrup Research Institute, University of Copenhagen, Nordstjernevej 42, 2600, Glostrup, Denmark.
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23
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Galli J, Morelli F, Rigante M, Paludetti G. Management of cerebrospinal fluid leak: the importance of multidisciplinary approach. ACTA ACUST UNITED AC 2021; 41:S18-S29. [PMID: 34060517 PMCID: PMC8172102 DOI: 10.14639/0392-100x-suppl.1-41-2021-02] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2020] [Accepted: 01/08/2021] [Indexed: 01/20/2023]
Abstract
Cerebrospinal fluid (CSF) leak remains a rare condition, characterized by serious complications and potentially fatal. According to different etiologies, CSF leaks may be classified into two main categories: traumatic and spontaneous. Spontaneous fistulas seem to be mainly related to obesity and idiopathic intracranial hypertension. Diagnosis is both clinical and radiological. During the last three decades, surgical treatment has mostly shifted to endonasal endoscopic approach, which widely demonstrated to be more effective than invasive intracranial ones. Post-operative complications, long-term sequelae and hospital stay are strongly reduced thanks to endoscopic approach. The diagnosis and treatment of CSF leaks represent a difficult and challenge task. The main effort seems to be related to the precise localization of the leak. An accurate assessment of both predisposing factors and comorbidities is mandatory in case of spontaneous leaks. However, a clinical multidisciplinary evaluation as well as treatment, is essential to decrease the rate of failure of surgery. The presence of a dedicated instruments, the Skull Base Team, the knowledge of reconstructive materials and techniques represents a decisive result in therapeutical management even if for each patient an effective therapeutic algorithm can be obtained considering the correct leak detection and characteristics. In conclusion the strict teamwork with neurosurgeons, neuroradiologists, ophtalmologists will enable the development also of innovative biomaterials, which could spread and standardize multi-layer techniques, nowadays still related to surgeon preferences.
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Affiliation(s)
- Jacopo Galli
- Otorhinolaryngology, Head and Neck Surgery, "A. Gemelli" Hospital Foundation IRCCS, Catholic University of the Sacred Heart, Rome, Italy
| | - Francesco Morelli
- Otorhinolaryngology, Head and Neck Surgery, "A. Gemelli" Hospital Foundation IRCCS, Catholic University of the Sacred Heart, Rome, Italy
| | - Mario Rigante
- Otorhinolaryngology, Head and Neck Surgery, "A. Gemelli" Hospital Foundation IRCCS, Catholic University of the Sacred Heart, Rome, Italy
| | - Gaetano Paludetti
- Otorhinolaryngology, Head and Neck Surgery, "A. Gemelli" Hospital Foundation IRCCS, Catholic University of the Sacred Heart, Rome, Italy
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24
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Mollan SP, Grech O, Sinclair AJ. Headache attributed to idiopathic intracranial hypertension and persistent post-idiopathic intracranial hypertension headache: A narrative review. Headache 2021; 61:808-816. [PMID: 34106464 DOI: 10.1111/head.14125] [Citation(s) in RCA: 34] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2021] [Accepted: 04/12/2021] [Indexed: 01/01/2023]
Abstract
OBJECTIVE Headache is a near-universal sequela of idiopathic intracranial hypertension (IIH). The aim of this paper is to report current knowledge of headache in IIH and to identify therapeutic options. BACKGROUND Disability in IIH is predominantly driven by headache; thus, headache management is an urgent and unmet clinical need. At present, there is currently no scientific evidence for the directed use of abortive or preventative headache therapy. METHODS A detailed search of the scientific literature and narrative review was performed. RESULTS Headache in IIH is driven by raised intracranial pressure (ICP) and reduction of ICP has been reported in some studies to reduce headache. Despite resolution of papilledema and normalization of raised ICP, a majority suffer persistent post-IIH headache. The lack of evidence-based management approaches leaves many untreated. Where clinicians attempt to manage IIH headache, they use off-label therapies to target the prevailing headache phenotype. A recent prospective open-label study demonstrated the effective use of a calcitonin gene-related peptide monoclonal antibody therapy in IIH for persistent post-IIH headache. CONCLUSIONS There is overwhelming evidence of the headache burden in IIH. Studies are required to investigate the biological foundations of headache related to ICP and to develop treatments specifically directed to manage headache in IIH.
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Affiliation(s)
- Susan P Mollan
- Birmingham Neuro-Ophthalmology, Queen Elizabeth Hospital, Birmingham, UK
| | - Olivia Grech
- 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
| | - Alexandra J Sinclair
- Birmingham Neuro-Ophthalmology, Queen Elizabeth Hospital, Birmingham, 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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25
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Elevated Intracranial Pressure Associated With Exogenous Hormonal Therapy Used for Gender Affirmation. J Neuroophthalmol 2021; 41:217-223. [PMID: 32235230 DOI: 10.1097/wno.0000000000000926] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
BACKGROUND Addison disease, corticosteroid withdrawal, and taking synthetic growth hormone have been linked with development of intracranial hypertension, but there is still debate on whether administration of other exogenous hormones plays a role in precipitating elevated pressure. The growing use of hormonal therapy for gender affirmation provides an opportunity to explore this possibility. METHODS All transgender patients taking exogenous hormones for female-to-male (FTM) and male-to-female (MTF) transitions who were diagnosed with intracranial hypertension at Massachusetts Eye and Ear Infirmary, Massachusetts General Hospital and Beth Israel Deaconess Medical Center between August 2014 and November 2018 were included in a retrospective review. Visual acuity, type, and dose of exogenous hormone, visual field testing, clinical exam, results of neuroimaging and lumbar puncture, and treatment modalities were catalogued and analyzed. RESULTS Six transgender individuals were identified. Five were FTM, with an average hormone treatment time of 18.4 months, and one was MTF who had been treated with hormones for 4 years. The average age of all patients was 23.5 years. The average time between onset of symptoms and presentation was 5 months. Fifty percent of the patients reported pulse-synchronous tinnitus, 83% reported positional headache, 33% reported transient visual obscurations, and 16% reported diplopia. Lumbar punctures performed on 4 of the patients revealed elevated opening pressures and normal cerebrospinal fluid constituents. MRI findings consistent with elevated intracranial pressure (ICP) were present in the other 2 patients in whom lumbar puncture was unsuccessful. Four patients were treated with acetazolamide and one was treated with topiramate, with an average follow-up time of 15.7 months. All patients demonstrated bilateral optic disc swelling, and all maintained normal acuity and color vision. Performance on visual field testing was not significantly affected in any patient. CONCLUSIONS This is the largest reported series to date of gender-transitioning patients with intracranial hypertension, including one novel MTF conversion. These observations warrant further investigation into the possible link of exogenous hormonal therapy and elevated ICP and any mechanisms or confounders underlying this potential association.
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26
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Westgate CS, Botfield HF, Alimajstorovic Z, Yiangou A, Walsh M, Smith G, Singhal R, Mitchell JL, Grech O, Markey KA, Hebenstreit D, Tennant DA, Tomlinson JW, Mollan SP, Ludwig C, Akerman I, Lavery GG, Sinclair AJ. Systemic and adipocyte transcriptional and metabolic dysregulation in idiopathic intracranial hypertension. JCI Insight 2021; 6:145346. [PMID: 33848268 PMCID: PMC8262372 DOI: 10.1172/jci.insight.145346] [Citation(s) in RCA: 34] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2020] [Accepted: 04/07/2021] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Idiopathic intracranial hypertension (IIH) is a condition predominantly affecting obese women of reproductive age. Recent evidence suggests that IIH is a disease of metabolic dysregulation, androgen excess, and an increased risk of cardiovascular morbidity. Here we evaluate systemic and adipose specific metabolic determinants of the IIH phenotype. METHODS In fasted, matched IIH (n = 97) and control (n = 43) patients, we assessed glucose and insulin homeostasis and leptin levels. Body composition was assessed along with an interrogation of adipose tissue function via nuclear magnetic resonance metabolomics and RNA sequencing in paired omental and subcutaneous biopsies in a case-control study. RESULTS We demonstrate an insulin- and leptin-resistant phenotype in IIH in excess of that driven by obesity. Adiposity in IIH is preferentially centripetal and is associated with increased disease activity and insulin resistance. IIH adipocytes appear transcriptionally and metabolically primed toward depot-specific lipogenesis. CONCLUSION These data show that IIH is a metabolic disorder in which adipose tissue dysfunction is a feature of the disease. Managing IIH as a metabolic disease could reduce disease morbidity and improve cardiovascular outcomes. FUNDING This study was supported by the UK NIHR (NIHR-CS-011-028), the UK Medical Research Council (MR/K015184/1), Diabetes UK, Wellcome Trust (104612/Z/14/Z), the Sir Jules Thorn Award, and the Midlands Neuroscience Teaching and Research Fund.
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Affiliation(s)
- Connar Sj Westgate
- Institute of Metabolism and Systems Research, College of Medical and Dental Sciences, University of Birmingham, Birmingham, United Kingdom.,Centre for Endocrinology, Diabetes and Metabolism, Birmingham Health Partners, Birmingham, United Kingdom
| | - Hannah F Botfield
- Institute of Inflammation and Ageing, College of Medical and Dental Sciences, University of Birmingham, Birmingham, United Kingdom
| | - Zerin Alimajstorovic
- Institute of Metabolism and Systems Research, College of Medical and Dental Sciences, University of Birmingham, Birmingham, United Kingdom.,Centre for Endocrinology, Diabetes and Metabolism, Birmingham Health Partners, Birmingham, United Kingdom
| | - Andreas Yiangou
- Institute of Metabolism and Systems Research, College of Medical and Dental Sciences, University of Birmingham, Birmingham, United Kingdom.,Department of Neurology, University Hospitals Birmingham National Health Service (NHS) Foundation Trust, Queen Elizabeth Hospital, Birmingham, United Kingdom
| | - Mark Walsh
- School of Life Sciences, University of Warwick, Coventry, United Kingdom
| | - Gabrielle Smith
- Institute of Metabolism and Systems Research, College of Medical and Dental Sciences, University of Birmingham, Birmingham, United Kingdom.,Centre for Endocrinology, Diabetes and Metabolism, Birmingham Health Partners, Birmingham, United Kingdom
| | - Rishi Singhal
- Upper GI Unit and Minimally Invasive Unit, Heartlands Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham United Kingdom
| | - James L Mitchell
- Institute of Metabolism and Systems Research, College of Medical and Dental Sciences, University of Birmingham, Birmingham, United Kingdom.,Centre for Endocrinology, Diabetes and Metabolism, Birmingham Health Partners, Birmingham, United Kingdom
| | - Olivia Grech
- Institute of Metabolism and Systems Research, College of Medical and Dental Sciences, University of Birmingham, Birmingham, United Kingdom.,Centre for Endocrinology, Diabetes and Metabolism, Birmingham Health Partners, Birmingham, United Kingdom
| | - Keira A Markey
- Institute of Metabolism and Systems Research, College of Medical and Dental Sciences, University of Birmingham, Birmingham, United Kingdom.,Department of Neurology, University Hospitals Birmingham National Health Service (NHS) Foundation Trust, Queen Elizabeth Hospital, Birmingham, United Kingdom
| | - Daniel Hebenstreit
- School of Life Sciences, University of Warwick, Coventry, United Kingdom
| | - Daniel A Tennant
- Institute of Metabolism and Systems Research, College of Medical and Dental Sciences, University of Birmingham, Birmingham, United Kingdom
| | - Jeremy W Tomlinson
- Oxford Centre for Diabetes, Endocrinology & Metabolism, National Institute for Health Research (NIHR) Oxford Biomedical Research Centre, University of Oxford, Churchill Hospital, Headington, Oxford, United Kingdom
| | - Susan P Mollan
- Birmingham Neuro-Ophthalmology, Ophthalmology Department, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham, United Kingdom
| | - Christian Ludwig
- Institute of Metabolism and Systems Research, College of Medical and Dental Sciences, University of Birmingham, Birmingham, United Kingdom.,Centre for Endocrinology, Diabetes and Metabolism, Birmingham Health Partners, Birmingham, United Kingdom
| | - Ildem Akerman
- Institute of Metabolism and Systems Research, College of Medical and Dental Sciences, University of Birmingham, Birmingham, United Kingdom.,Centre for Endocrinology, Diabetes and Metabolism, Birmingham Health Partners, Birmingham, United Kingdom
| | - Gareth G Lavery
- Institute of Metabolism and Systems Research, College of Medical and Dental Sciences, University of Birmingham, Birmingham, United Kingdom.,Centre for Endocrinology, Diabetes and Metabolism, Birmingham Health Partners, Birmingham, United Kingdom
| | - Alexandra J Sinclair
- Institute of Metabolism and Systems Research, College of Medical and Dental Sciences, University of Birmingham, Birmingham, United Kingdom.,Centre for Endocrinology, Diabetes and Metabolism, Birmingham Health Partners, Birmingham, United Kingdom.,Department of Neurology, University Hospitals Birmingham National Health Service (NHS) Foundation Trust, Queen Elizabeth Hospital, Birmingham, United Kingdom
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27
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Dural venous sinus stenting in the treatment of idiopathic intracranial hypertension: A systematic review and critique of literature. Surv Ophthalmol 2021; 67:271-287. [PMID: 34004224 DOI: 10.1016/j.survophthal.2021.05.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2020] [Revised: 04/23/2021] [Accepted: 05/03/2021] [Indexed: 12/19/2022]
Abstract
Idiopathic intracranial hypertension (IIH) is increased intracranial pressure without a known cause. Dural venous sinus stenting (DVSS) is a relatively new intervention for treatment of IIH refractory to medical therapy and lifestyle modifications. In this review, we outline various hypotheses of IIH pathogenesis and describe the role of venous sinus stenosis and the technical details of DVSS. We also present a summary and critique of the available evidence describing the outcomes of DVSS in IIH and review the evidence-based guidelines for this procedure. We conclude that, although many studies have shown generally favorable outcomes of DVSS in patients with IIH, most have serious limitations, the most common one being paucity of pre- and postprocedure ophthalmological data. Thus, there is not enough available evidence to conclude whether DVSS is an effective procedure for treatment of IIH. We also present the most commonly used indications for DVSS as described in the literature and stress the importance of neuro-ophthalmological assessment before and after the procedure to monitor response and potential complications.
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28
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Aguiar M, Frew E, Mollan SP, Mitchell JL, Ottridge RS, Alimajstorovic Z, Yiangou A, Singhal R, Tahrani AA, Sinclair AJ. The Health Economic Evaluation of Bariatric Surgery Versus a Community Weight Management Intervention Analysis from the Idiopathic Intracranial Hypertension Weight Trial (IIH:WT). Life (Basel) 2021; 11:409. [PMID: 33946177 PMCID: PMC8146846 DOI: 10.3390/life11050409] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2021] [Revised: 04/26/2021] [Accepted: 04/27/2021] [Indexed: 01/10/2023] Open
Abstract
BACKGROUND The Idiopathic Intracranial Hypertension Weight Trial (IIH:WT) established the efficacy of bariatric surgery as compared to a community weight management intervention in reducing intracranial pressure in active IIH. The aim of this cost-effectiveness analysis was to evaluate the economic impact of these weight loss treatments for IIH. METHODS IIH:WT was a five-year randomised, controlled, parallel group, multicentre trial in the United Kingdom, where participants with active IIH and a body mass index ≥35 kg/m2 were randomly assigned (1:1) to receive access to bariatric surgery or a community weight management intervention. All clinical and quality of life data was recorded at baseline, 12 and 24 months. Economic evaluation was performed to assess health-care costs and cost-effectiveness. Evaluations were established on an intention to treat principle, followed by a sensitivity analysis using a per protocol analysis. RESULTS The mean total health care costs were GBP 1353 for the community weight management arm and GBP 5400 for the bariatric surgery arm over 24 months. The majority of costs for the bariatric surgery arm relate to the surgical procedure itself. The 85% who underwent bariatric surgery achieved a 12.5% reduction in intracranial pressure at 24 months as compared to 39% in the community weight management arm; a mean difference of 45% in favour of bariatric surgery. The cost effectiveness of bariatric surgery improved over time. CONCLUSIONS The IIH:WT was the first to compare the efficacy and cost-effectiveness of bariatric surgery with community weight management interventions in the setting of a randomised control trial. The cost-effectiveness of bariatric surgery improved over time and therefore the incremental cost of surgery when offset against the incremental reduction of intracranial pressure improved after 24 months, as compared with 12 months follow up.
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Affiliation(s)
- Magda Aguiar
- Health Economics Unit, Institute of Applied Health Research, University of Birmingham, Birmingham B12 2TT, UK; (M.A.); (E.F.)
| | - Emma Frew
- Health Economics Unit, Institute of Applied Health Research, University of Birmingham, Birmingham B12 2TT, UK; (M.A.); (E.F.)
| | - Susan P. Mollan
- Birmingham Neuro-Ophthalmology, University Hospitals Birmingham NHS Foundation Trust, Queen Elizabeth Hospital, Birmingham B15 2WB, UK
| | - James L. Mitchell
- Institute of Metabolism and Systems Research, College of Medical and Dental Sciences, University of Birmingham, Birmingham B15 2TT, UK; (J.L.M.); (Z.A.); (A.Y.); (A.A.T.); (A.J.S.)
- Department of Neurology, University Hospitals Birmingham NHS Foundation Trust, Queen Elizabeth Hospital, Birmingham B15 2WB, UK
| | - Ryan S. Ottridge
- Birmingham Clinical Trials Unit, College of Medical and Dental Sciences, University of Birmingham, Birmingham B15 2TT, UK;
| | - Zerin Alimajstorovic
- Institute of Metabolism and Systems Research, College of Medical and Dental Sciences, University of Birmingham, Birmingham B15 2TT, UK; (J.L.M.); (Z.A.); (A.Y.); (A.A.T.); (A.J.S.)
- Upper GI Unit and Minimally Invasive Unit, Birmingham Heartlands Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham B9 5SS, UK;
| | - Andreas Yiangou
- Institute of Metabolism and Systems Research, College of Medical and Dental Sciences, University of Birmingham, Birmingham B15 2TT, UK; (J.L.M.); (Z.A.); (A.Y.); (A.A.T.); (A.J.S.)
- Department of Neurology, University Hospitals Birmingham NHS Foundation Trust, Queen Elizabeth Hospital, Birmingham B15 2WB, UK
| | - Rishi Singhal
- Upper GI Unit and Minimally Invasive Unit, Birmingham Heartlands Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham B9 5SS, UK;
- Institute of Cancer and Genomic Sciences, College of Medical and Dental Sciences, University of Birmingham, Birmingham B15 2TT, UK
| | - Abd A. Tahrani
- Institute of Metabolism and Systems Research, College of Medical and Dental Sciences, University of Birmingham, Birmingham B15 2TT, UK; (J.L.M.); (Z.A.); (A.Y.); (A.A.T.); (A.J.S.)
- Centre for Endocrinology, Diabetes and Metabolism, Birmingham Health Partners, Birmingham B15 2GW, UK
- Department of Endocrinology, University Hospitals Birmingham NHS Foundation Trust, Queen Elizabeth Hospital, Birmingham B15 2WB, UK
| | - Alex J. Sinclair
- Institute of Metabolism and Systems Research, College of Medical and Dental Sciences, University of Birmingham, Birmingham B15 2TT, UK; (J.L.M.); (Z.A.); (A.Y.); (A.A.T.); (A.J.S.)
- Department of Neurology, University Hospitals Birmingham NHS Foundation Trust, Queen Elizabeth Hospital, Birmingham B15 2WB, UK
- Centre for Endocrinology, Diabetes and Metabolism, Birmingham Health Partners, Birmingham B15 2GW, UK
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29
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Mollan SP, Tahrani AA, Sinclair AJ. The Potentially Modifiable Risk Factor in Idiopathic Intracranial Hypertension: Body Weight. Neurol Clin Pract 2021; 11:e504-e507. [PMID: 34484948 DOI: 10.1212/cpj.0000000000001063] [Citation(s) in RCA: 30] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2020] [Accepted: 01/06/2021] [Indexed: 01/07/2023]
Abstract
Purpose of Review Idiopathic intracranial hypertension (IIH) prevalence increased in conjunction with rising obesity rates. Here, we highlight the importance of weight management in IIH and introduce glucagon-like peptide 1 (GLP-1) receptor agonists (RAs) as potential treatment strategy for IIH. Recent Findings Weight gain is a risk factor for IIH, and weight loss (via any treatment strategy) plays a key role in IIH management. GLP-1 is an incretin secreted by the distal small intestine in response to a meal. GLP-1 RAs have been shown to improve glycaemic control (no hypoglycaemia) and lower body weight in patients with and without type 2 diabetes. The choroid plexus has been found to express GLP-1 receptors, and treatment with a GLP-1 RA significantly reduces CSF secretion in vitro and intracranial pressure (ICP) in rodents. Summary New research evaluating the pathophysiology of IIH supports GLP-1 RA as a potential treatment for IIH via weight loss dependent and independent mechanism to directly reduce ICP.
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Affiliation(s)
- Susan P Mollan
- Birmingham Neuro-Ophthalmology (SPM), Queen Elizabeth Hospital; Institute of Metabolism and Systems Research (AAT), College of Medical and Dental Sciences, University of Birmingham; Department of Diabetes and Endocrinology (AAT), Queen Elizabeth Hospital, Birmingham; Metabolic Neurology (AJS), Institute of Metabolism and Systems Research, College of Medical and Dental Sciences, University of Birmingham; and Department of Neurology (AJS), University Hospitals Birmingham NHS Foundation Trust, Queen Elizabeth Hospital, United Kingdom
| | - Abd A Tahrani
- Birmingham Neuro-Ophthalmology (SPM), Queen Elizabeth Hospital; Institute of Metabolism and Systems Research (AAT), College of Medical and Dental Sciences, University of Birmingham; Department of Diabetes and Endocrinology (AAT), Queen Elizabeth Hospital, Birmingham; Metabolic Neurology (AJS), Institute of Metabolism and Systems Research, College of Medical and Dental Sciences, University of Birmingham; and Department of Neurology (AJS), University Hospitals Birmingham NHS Foundation Trust, Queen Elizabeth Hospital, United Kingdom
| | - Alexandra J Sinclair
- Birmingham Neuro-Ophthalmology (SPM), Queen Elizabeth Hospital; Institute of Metabolism and Systems Research (AAT), College of Medical and Dental Sciences, University of Birmingham; Department of Diabetes and Endocrinology (AAT), Queen Elizabeth Hospital, Birmingham; Metabolic Neurology (AJS), Institute of Metabolism and Systems Research, College of Medical and Dental Sciences, University of Birmingham; and Department of Neurology (AJS), University Hospitals Birmingham NHS Foundation Trust, Queen Elizabeth Hospital, United Kingdom
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Miah L, Strafford H, Fonferko-Shadrach B, Hollinghurst J, Sawhney IMS, Hadjikoutis S, Rees MI, Powell R, Lacey A, Pickrell WO. Incidence, Prevalence, and Health Care Outcomes in Idiopathic Intracranial Hypertension: A Population Study. Neurology 2021; 96:e1251-e1261. [PMID: 33472926 PMCID: PMC8055349 DOI: 10.1212/wnl.0000000000011463] [Citation(s) in RCA: 33] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2020] [Accepted: 10/23/2020] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE To characterize trends in incidence, prevalence, and health care outcomes in the idiopathic intracranial hypertension (IIH) population in Wales using routinely collected health care data. METHODS We used and validated primary and secondary care IIH diagnosis codes within the Secure Anonymised Information Linkage databank to ascertain IIH cases and controls in a retrospective cohort study between 2003 and 2017. We recorded body mass index (BMI), deprivation quintile, CSF diversion surgery, and unscheduled hospital admissions in case and control cohorts. RESULTS We analyzed 35 million patient-years of data. There were 1,765 cases of IIH in 2017 (85% female). The prevalence and incidence of IIH in 2017 was 76/100,000 and 7.8/100,000/y, a significant increase from 2003 (corresponding figures = 12/100,000 and 2.3/100,000/y) (p < 0.001). IIH prevalence is associated with increasing BMI and increasing deprivation. The odds ratio for developing IIH in the least deprived quintile compared to the most deprived quintile, adjusted for sex and BMI, was 0.65 (95% confidence interval 0.55 to 0.76). Nine percent of IIH cases had CSF shunts with less than 0.2% having bariatric surgery. Unscheduled hospital admissions were higher in the IIH cohort compared to controls (rate ratio 5.28, p < 0.001) and in individuals with IIH and CSF shunts compared to those without shunts (rate ratio 2.02, p < 0.01). CONCLUSIONS IIH incidence and prevalence is increasing considerably, corresponding to population increases in BMI, and is associated with increased deprivation. This has important implications for health care professionals and policy makers given the comorbidities, complications, and increased health care utilization associated with IIH.
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Affiliation(s)
- Latif Miah
- From Swansea University Medical School (L.M., H.S., B.F.-S., J.H., I.M.S.S., M.I.R., R.P., A.L., W.O.P.), Swansea University; Neurology Department (I.M.S.S., S.H., R.P., W.O.P.), Morriston Hospital, Swansea Bay University Health Board; and Faculty of Medicine and Health (M.I.R.), University of Sydney, Australia
| | - Huw Strafford
- From Swansea University Medical School (L.M., H.S., B.F.-S., J.H., I.M.S.S., M.I.R., R.P., A.L., W.O.P.), Swansea University; Neurology Department (I.M.S.S., S.H., R.P., W.O.P.), Morriston Hospital, Swansea Bay University Health Board; and Faculty of Medicine and Health (M.I.R.), University of Sydney, Australia
| | - Beata Fonferko-Shadrach
- From Swansea University Medical School (L.M., H.S., B.F.-S., J.H., I.M.S.S., M.I.R., R.P., A.L., W.O.P.), Swansea University; Neurology Department (I.M.S.S., S.H., R.P., W.O.P.), Morriston Hospital, Swansea Bay University Health Board; and Faculty of Medicine and Health (M.I.R.), University of Sydney, Australia
| | - Joe Hollinghurst
- From Swansea University Medical School (L.M., H.S., B.F.-S., J.H., I.M.S.S., M.I.R., R.P., A.L., W.O.P.), Swansea University; Neurology Department (I.M.S.S., S.H., R.P., W.O.P.), Morriston Hospital, Swansea Bay University Health Board; and Faculty of Medicine and Health (M.I.R.), University of Sydney, Australia
| | - Inder M S Sawhney
- From Swansea University Medical School (L.M., H.S., B.F.-S., J.H., I.M.S.S., M.I.R., R.P., A.L., W.O.P.), Swansea University; Neurology Department (I.M.S.S., S.H., R.P., W.O.P.), Morriston Hospital, Swansea Bay University Health Board; and Faculty of Medicine and Health (M.I.R.), University of Sydney, Australia
| | - Savvas Hadjikoutis
- From Swansea University Medical School (L.M., H.S., B.F.-S., J.H., I.M.S.S., M.I.R., R.P., A.L., W.O.P.), Swansea University; Neurology Department (I.M.S.S., S.H., R.P., W.O.P.), Morriston Hospital, Swansea Bay University Health Board; and Faculty of Medicine and Health (M.I.R.), University of Sydney, Australia
| | - Mark I Rees
- From Swansea University Medical School (L.M., H.S., B.F.-S., J.H., I.M.S.S., M.I.R., R.P., A.L., W.O.P.), Swansea University; Neurology Department (I.M.S.S., S.H., R.P., W.O.P.), Morriston Hospital, Swansea Bay University Health Board; and Faculty of Medicine and Health (M.I.R.), University of Sydney, Australia
| | - Rob Powell
- From Swansea University Medical School (L.M., H.S., B.F.-S., J.H., I.M.S.S., M.I.R., R.P., A.L., W.O.P.), Swansea University; Neurology Department (I.M.S.S., S.H., R.P., W.O.P.), Morriston Hospital, Swansea Bay University Health Board; and Faculty of Medicine and Health (M.I.R.), University of Sydney, Australia
| | - Arron Lacey
- From Swansea University Medical School (L.M., H.S., B.F.-S., J.H., I.M.S.S., M.I.R., R.P., A.L., W.O.P.), Swansea University; Neurology Department (I.M.S.S., S.H., R.P., W.O.P.), Morriston Hospital, Swansea Bay University Health Board; and Faculty of Medicine and Health (M.I.R.), University of Sydney, Australia
| | - William O Pickrell
- From Swansea University Medical School (L.M., H.S., B.F.-S., J.H., I.M.S.S., M.I.R., R.P., A.L., W.O.P.), Swansea University; Neurology Department (I.M.S.S., S.H., R.P., W.O.P.), Morriston Hospital, Swansea Bay University Health Board; and Faculty of Medicine and Health (M.I.R.), University of Sydney, Australia.
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Hardy RS, Botfield H, Markey K, Mitchell JL, Alimajstorovic Z, Westgate CSJ, Sagmeister M, Fairclough RJ, Ottridge RS, Yiangou A, Storbeck KHH, Taylor AE, Gilligan LC, Arlt W, Stewart PM, Tomlinson JW, Mollan SP, Lavery GG, Sinclair AJ. 11βHSD1 Inhibition with AZD4017 Improves Lipid Profiles and Lean Muscle Mass in Idiopathic Intracranial Hypertension. J Clin Endocrinol Metab 2021; 106:174-187. [PMID: 33098644 PMCID: PMC7765633 DOI: 10.1210/clinem/dgaa766] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2020] [Indexed: 02/02/2023]
Abstract
BACKGROUND The enzyme 11β-hydroxysteroid dehydrogenase type 1 (11β-HSD1) determines prereceptor metabolism and activation of glucocorticoids within peripheral tissues. Its dysregulation has been implicated in a wide array of metabolic diseases, leading to the development of selective 11β-HSD1 inhibitors. We examined the impact of the reversible competitive 11β-HSD1 inhibitor, AZD4017, on the metabolic profile in an overweight female cohort with idiopathic intracranial hypertension (IIH). METHODS We conducted a UK multicenter phase II randomized, double-blind, placebo-controlled trial of 12-week treatment with AZD4017. Serum markers of glucose homeostasis, lipid metabolism, renal and hepatic function, inflammation and androgen profiles were determined and examined in relation to changes in fat and lean mass by dual-energy X-ray absorptiometry. RESULTS Patients receiving AZD4017 showed significant improvements in lipid profiles (decreased cholesterol, increased high-density lipoprotein [HDL] and cholesterol/HDL ratio), markers of hepatic function (decreased alkaline phosphatase and gamma-glutamyl transferase), and increased lean muscle mass (1.8%, P < .001). No changes in body mass index, fat mass, and markers of glucose metabolism or inflammation were observed. Patients receiving AZD4017 demonstrated increased levels of circulating androgens, positively correlated with changes in total lean muscle mass. CONCLUSIONS These beneficial metabolic changes represent a reduction in risk factors associated with raised intracranial pressure and represent further beneficial therapeutic outcomes of 11β-HSD1 inhibition by AZD4017 in this overweight IIH cohort. In particular, beneficial changes in lean muscle mass associated with AZD4017 may reflect new applications for this nature of inhibitor in the management of conditions such as sarcopenia.
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Affiliation(s)
- Rowan S Hardy
- Institute of Metabolism and Systems Research, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
- Institute of Inflammation and Ageing, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
- Institute of Clinical Sciences, College of Medical and Dental Sciences, University of Birmingham, UK
| | - Hannah Botfield
- Institute of Inflammation and Ageing, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
| | - Keira Markey
- Institute of Metabolism and Systems Research, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
| | - James L Mitchell
- 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
| | - Zerin Alimajstorovic
- 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
| | - Connar S J Westgate
- Institute of Metabolism and Systems Research, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
| | - Michael Sagmeister
- Institute of Metabolism and Systems Research, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
| | - Rebecca J Fairclough
- Emerging Innovations Unit, Discovery Sciences. BioPharmaceuticals R&D, AstraZeneca, Cambridge, UK
| | - Ryan S Ottridge
- Birmingham Clinical Trials Unit, Institute of Applied Health Research, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
| | - Andreas Yiangou
- 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
| | - Karl-Heinz H Storbeck
- Institute of Metabolism and Systems Research, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
- Department of Biochemistry, Stellenbosch University, Stellenbosch, Matieland, South Africa
| | - Angela E Taylor
- 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
| | - Lorna C Gilligan
- 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
| | - Wiebke Arlt
- 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
- NIHR Birmingham Biomedical Research Centre, University of Birmingham and University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | | | - Jeremy W Tomlinson
- Oxford Centre for Diabetes, Endocrinology & Metabolism (OCDEM), NIHR Oxford Biomedical Research Centre, University of Oxford, Churchill Hospital, Oxford, UK
| | - Susan P Mollan
- 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
| | - Gareth G Lavery
- 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
| | - Alexandra J Sinclair
- 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
- Correspondence and Reprint Requests: Alexandra Sinclair, Institute of Metabolism and Systems Research, College of Medical and Dental Sciences, University of Birmingham, Birmingham B15 2TT, UK. E-mail:
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Mollan SP, Grech O, Alimajstorovic Z, Wakerley BR, Sinclair AJ. New horizons for idiopathic intracranial hypertension: advances and challenges. Br Med Bull 2020; 136:118-126. [PMID: 33200788 DOI: 10.1093/bmb/ldaa034] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/28/2020] [Indexed: 02/05/2023]
Abstract
INTRODUCTION Idiopathic intracranial hypertension (IIH) is becoming a recognized condition due to the increasing incidence linked to a global obesity epidemic. SOURCES OF DATA All English papers on PubMed, Cochrane and Scholar between inception until 1 March 2020 were considered. AREAS OF AGREEMENT Studies suggest central adiposity has a pathogenic role. Recent weight gain is a risk factor and weight loss has a key role in management. AREAS OF CONTROVERSY Interpretation of abnormal lumbar puncture opening pressure is debated. There is an increasing recognition of obesity stigma and how this should be approached. GROWING POINTS Further evidence is required for the choice of surgical intervention for fulminant IIH. Education regarding IIH should be evidence based. AREAS TIMELY FOR DEVELOPING RESEARCH Novel research of the pathology of IIH is influencing development of therapies such as glucagon-like peptide-1 receptor agonists and targeting unique androgen signatures. The newly discovered cardiovascular risk requires further attention.
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Affiliation(s)
- Susan P Mollan
- Birmingham Neuro-Ophthalmology, Queen Elizabeth Hospital, Birmingham, UK
| | - Olivia Grech
- 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
| | - Zerin Alimajstorovic
- 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
| | | | - 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, Queen Elizabeth Hospital, Birmingham B15 2WB, UK
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33
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Virdee J, Larcombe S, Vijay V, Sinclair AJ, Dayan M, Mollan SP. Reviewing the Recent Developments in Idiopathic Intracranial Hypertension. Ophthalmol Ther 2020; 9:767-781. [PMID: 32902722 PMCID: PMC7708542 DOI: 10.1007/s40123-020-00296-0] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2019] [Indexed: 02/07/2023] Open
Abstract
There is increasing evidence and appreciation of idiopathic intracranial hypertension (IIH) in medicine. The pathological processes underlying raised intracranial pressure are being studied, with new insights found in both hormonal dysregulation and the metabolic neuroendocrine axis. These will potentially lead to novel therapeutic targets for IIH. The first consensus guidelines have been published on the investigation and management of adult IIH, and the International Headache Society criteria for headache attributable to IIH have been modified to reflect our evolving understanding of IIH. Randomized clinical trials have been published, and a number of studies in this disease area are ongoing.
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Affiliation(s)
- Jasvir Virdee
- Ophthalmology, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | | | - Vivek Vijay
- Metabolic Neurology, Institute of Metabolism and Systems Research, University of Birmingham, Birmingham, UK.,Centre for Endocrinology, Diabetes and Metabolism, Birmingham Health Partners, Birmingham, UK
| | - Alex J Sinclair
- Metabolic Neurology, Institute of Metabolism and Systems Research, University of Birmingham, Birmingham, UK.,Centre for Endocrinology, Diabetes and Metabolism, Birmingham Health Partners, Birmingham, UK.,Birmingham Neuro-Ophthalmology, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Margaret Dayan
- Newcastle Eye Centre, The Newcastle Upon Tyne Hospitals NHS Foundation Trust, Royal Victoria Infirmary, Newcastle upon Tyne, UK
| | - Susan P Mollan
- Birmingham Neuro-Ophthalmology, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK.
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Alimajstorovic Z, Westgate CSJ, Jensen RH, Eftekhari S, Mitchell J, Vijay V, Seneviratne SY, Mollan SP, Sinclair AJ. Guide to preclinical models used to study the pathophysiology of idiopathic intracranial hypertension. Eye (Lond) 2020; 34:1321-1333. [PMID: 31896803 PMCID: PMC7376028 DOI: 10.1038/s41433-019-0751-1] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2019] [Revised: 10/24/2019] [Accepted: 11/29/2019] [Indexed: 12/21/2022] Open
Abstract
Idiopathic intracranial hypertension (IIH) is characterised by raised intracranial pressure (ICP) and papilloedema in the absence of an identifiable secondary cause typically occurring in young women with obesity. The impact is considerable with the potential for blindness, chronic disabling headaches, future risk of cardiovascular disease and marked healthcare utilisation. There have been marked advances in our understanding the pathophysiology of IIH including the role of androgen excess. Insight into pathophysiological underpinnings has arisen from astute clinical observations, studies, and an array of preclinical models. This article summarises the current literature pertaining to the pathophysiology of IIH. The current preclinical models relevant to gaining mechanistic insights into IIH are then discussed. In vitro and in vivo models which study CSF secretion and the effect of potentially pathogenic molecules have started to glean important mechanistic insights. These models are also useful to evaluate novel therapeutic targets to abrogate CSF secretion. Importantly, in vitro CSF secretion assays translate into relevant changes in ICP in vivo. Models of CSF absorption pertinent to IIH, are less well established but highly relevant and of future interest. There is no fully developed in vivo model of IIH but this remains an area of importance. Progress is being made to improve our understanding of the underlying aetiology in IIH including the characterisation of disease biomarkers and their mechanistic role in driving disease pathology. Preclinical models, used to evaluate IIH mechanisms are yielding important mechanistic insights. Further work to refine these techniques will provide translatable insights into disease aetiology.
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Affiliation(s)
- Zerin Alimajstorovic
- Metabolic Neurology, Institute of Metabolism and Systems Research, College of Medical and Dental Sciences, University of Birmingham, Birmingham, B15 2TT, UK
| | - Connar S J Westgate
- Metabolic Neurology, Institute of Metabolism and Systems Research, College of Medical and Dental Sciences, University of Birmingham, Birmingham, B15 2TT, UK
- Department of Neurology, Danish Headache Centre, Rigshospitalet-Glostrup, Glostrup Research Institute, Valdemar Hansens Vej 5, 2600, Glostrup, Denmark
| | - Rigmor H Jensen
- Department of Neurology, Danish Headache Centre, Rigshospitalet-Glostrup, Glostrup Research Institute, Valdemar Hansens Vej 5, 2600, Glostrup, Denmark
| | - Sajedeh Eftekhari
- Department of Neurology, Danish Headache Centre, Rigshospitalet-Glostrup, Glostrup Research Institute, Valdemar Hansens Vej 5, 2600, Glostrup, Denmark
| | - James Mitchell
- Metabolic Neurology, Institute of Metabolism and Systems Research, College of Medical and Dental Sciences, University of Birmingham, Birmingham, B15 2TT, UK
| | - Vivek Vijay
- Metabolic Neurology, Institute of Metabolism and Systems Research, College of Medical and Dental Sciences, University of Birmingham, Birmingham, B15 2TT, UK
| | - Senali Y Seneviratne
- Metabolic Neurology, Institute of Metabolism and Systems Research, College of Medical and Dental Sciences, University of Birmingham, Birmingham, B15 2TT, UK
| | - Susan P Mollan
- Birmingham Neuro-Ophthalmology, Queen Elizabeth Hospital, Birmingham, 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.
- Birmingham Neuro-Ophthalmology, Queen Elizabeth Hospital, Birmingham, UK.
- Centre for Endocrinology, Diabetes and Metabolism, Birmingham Health Partners, Birmingham, B15 2TH, UK.
- Department of Neurology, University Hospitals Birmingham NHS Foundation Trust, Queen Elizabeth Hospital, Birmingham, B15 2WB, UK.
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Long-term monitoring of intracranial pressure in freely-moving rats; impact of different physiological states. Fluids Barriers CNS 2020; 17:39. [PMID: 32517699 PMCID: PMC7285467 DOI: 10.1186/s12987-020-00199-z] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2020] [Accepted: 05/27/2020] [Indexed: 12/17/2022] Open
Abstract
Background Elevated intracranial pressure (ICP) is observed in association with a range of brain disorders. There is limited insight into the regulatory mechanisms of ICP under physiological conditions, and consequently also under pathological conditions. Thereby, to understand the mechanisms underlying ICP dynamics, precise, valid and long-term ICP recordings are of importance in the preclinical setting. Herein, we used a novel telemetric system for ICP recordings which allowed for long-term recordings in freely-moving rats. The aim was to investigate ICP dynamics under different physiological states and investigate how factors such as surgery/recovery, body position, light–dark, co-housing, weight and anesthesia may influence ICP and its waveforms. Methods A telemetric device was implanted epidurally in rats and signals were recorded continuously for up to 50 days (n = 14). Recording was divided into three experimental periods: a surgical recovery period (RP), a physiological period (PP) and an experimental period (EP). Histology was performed to study the morphology of implanted rats and non-implanted rats (n = 17). Results For the first time, we can demonstrate continuous ICP recordings in freely-moving and co-housed rats for up to 50 days with a high degree of stability. The mean ICP in the recording periods were; RP: 3.2 ± 0.6 mmHg, PP: 5.0 ± 0.6 mmHg and EP: 4.7 ± 0.6 mmHg. In the RP, the ICP was significantly lower compared to the PP (P = 0.0034). Significant light–dark difference in ICP with 21% increase in respiratory slow-wave amplitude was observed in the co-housed animals but not in single-housed animals. The ICP signal was raised during the dark period relative to the light (Δ0.3 ± 0.07 mmHg, P = 0.0043). Administration of anesthesia gave a short-term increase in ICP followed by a significant decrease in ICP. No signs of tissue damage or inflammation were found in the implanted brains. Conclusions ICP dynamics were influenced by several factors such as, use of anesthesia, light–dark difference and housing conditions. Our study demonstrates the importance of performing ICP physiological measurements in freely-moving animals. This has significant implications for moving the preclinical research field forward in order to properly study ICP physiology during disease development and to explore drug targets for alleviating increased ICP.
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Metabolic Concepts in Idiopathic Intracranial Hypertension and Their Potential for Therapeutic Intervention. J Neuroophthalmol 2020; 38:522-530. [PMID: 29985799 PMCID: PMC6215484 DOI: 10.1097/wno.0000000000000684] [Citation(s) in RCA: 70] [Impact Index Per Article: 17.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND Traditional risk factors associated with idiopathic intracranial hypertension (IIH) include obesity, weight gain, and female sex. The incidence of IIH is increasing and yet the underlying trigger and the fueling pathological mechanisms are still poorly understood. EVIDENCE ACQUISITION Review of ophthalmology, neurology, general surgery, obesity, endocrinology, nutrition, and neurosurgery literature was made. RESULTS The facts that implicate sex and obesity in IIH and headache are examined. The role of fat distribution in IIH is questioned, and the concept of adipose tissue functioning as an endocrine organ driving IIH is discussed. The impact of androgen metabolism in IIH is reviewed as is the emerging role of glucagon-like-peptide-1 analogues in modulating intracranial pressure. This introduces the concept of developing targeted disease-modifying therapeutic strategies for IIH. CONCLUSIONS This review will discuss the possible role of the adipose/gut/brain metabolism axis in IIH and speculate how this may impact the pathogenesis of IIH and therapeutic opportunities.
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Gurney SP, Ramalingam S, Thomas A, Sinclair AJ, Mollan SP. Exploring The Current Management Idiopathic Intracranial Hypertension, And Understanding The Role Of Dural Venous Sinus Stenting. Eye Brain 2020; 12:1-13. [PMID: 32021528 PMCID: PMC6969694 DOI: 10.2147/eb.s193027] [Citation(s) in RCA: 33] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2019] [Accepted: 11/05/2019] [Indexed: 12/12/2022] Open
Abstract
Idiopathic Intracranial Hypertension (IIH) is a debilitating disorder characterised by raised intracranial pressure (ICP), papilloedema with the potential risk of permanent visual loss, and headaches that are profoundly disabling and reduce the quality of life. The first consensus guidelines have been published on investigation and management of adult IIH and one key area of uncertainty is the utility of dural venous sinus stenting for the management of headache and visual loss. There are an increasing number of series published and to help understand the successes and complications. During a patient physician priority setting, the understanding of the best type of intervention to treat IIH was assigned to the top 10 of most desired research questions for the disease. Ultimately randomised clinical trials (RCTs) in neurovascular stenting for IIH would be instructive, as the literature to date may suffer from publication bias. Due to the increasing incidence of IIH, there is no better time to systematically investigate interventions that may reverse the disease process and achieve remission. In this review we discuss the pathophysiology of IIH in relation to venous sinus stenosis, the role of venous sinus stenting with a review of the relevant literature, the advantages and disadvantages of stenting compared with other surgical interventions, and the future of stenting in the treatment of IIH.
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Affiliation(s)
- Sam P Gurney
- Birmingham Neuro-Ophthalmology, Queen Elizabeth Hospital, University Hospitals Birmingham, BirminghamB15 2WB, UK
| | - Sateesh Ramalingam
- Neuroradiology Department, Queen Elizabeth Hospital, University Hospitals Birmingham, BirminghamB15 2WB, UK
| | - Alan Thomas
- Neuroradiology Department, Queen Elizabeth Hospital, University Hospitals Birmingham, BirminghamB15 2WB, UK
| | - Alex J Sinclair
- Metabolic Neurology, Institute of Metabolism and Systems Research, College of Medical and Dental Sciences, University of Birmingham, BirminghamB15 2TT, UK
- Centre for Endocrinology, Diabetes and Metabolism, Birmingham Health Partners, BirminghamB15 2TH, UK
- Department of Neurology, University Hospitals Birmingham NHS Foundation Trust, Queen Elizabeth Hospital, BirminghamB15 2WB, UK
| | - Susan P Mollan
- Birmingham Neuro-Ophthalmology, Queen Elizabeth Hospital, University Hospitals Birmingham, BirminghamB15 2WB, UK
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Wakerley B, Warner R, Cole M, Stone K, Foy C, Sittampalam M. Cerebrospinal fluid opening pressure: The effect of body mass index and body composition. Clin Neurol Neurosurg 2020; 188:105597. [DOI: 10.1016/j.clineuro.2019.105597] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2019] [Revised: 11/10/2019] [Accepted: 11/11/2019] [Indexed: 10/25/2022]
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Eftekhari S, Westgate CSJ, Uldall MS, Jensen RH. Preclinical update on regulation of intracranial pressure in relation to idiopathic intracranial hypertension. Fluids Barriers CNS 2019; 16:35. [PMID: 31767019 PMCID: PMC6878629 DOI: 10.1186/s12987-019-0155-4] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2019] [Accepted: 11/13/2019] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Elevated intracranial pressure (ICP) is observed in association with a range of brain disorders. One of these challenging disorders is idiopathic intracranial hypertension (IIH), characterized by raised ICP of unknown cause with significant morbidity and limited therapeutic options. In this review, special focus is put on the preclinical research performed in order to understand the pathophysiology behind ICP regulation and IIH. This includes cerebrospinal fluid dynamics, molecular mechanisms underlying disturbances in brain fluids leading to elevated ICP, role of obesity in IIH, development of an IIH model and ICP measurements in rodents. The review also discusses existing and new drug targets for IIH that have been evaluated in vivo. CONCLUSIONS ICP monitoring in rodents is challenging and different methods have been applied. Some of these methods are invasive, depend on use of anesthesia and only allow short-term monitoring. Long-term ICP recordings are needed to study IIH but existing methods are hampered by several limitations. As obesity is one of the most common risk factors for IIH, a rodent obese model has been developed that mimics some key aspects of IIH. The most commonly used drugs for IIH have been evaluated in vivo for their efficacy at lowering ICP in the existing animal models. These studies suggest these drugs, including acetazolamide, might have limited or no reducing effect on ICP. Two drug targets that can impact ICP in healthy rodents are topiramate and a glucagon-like peptide-1 receptor (GLP-1R) agonist. However, it remains to evaluate their effect in an IIH model with more precise and valid ICP monitoring system. Therefore, continued evaluation in the preclinical research with refined tools is of great importance to further understand the pathophysiology behind disorders with raised ICP and to explore new drug targets.
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Affiliation(s)
- Sajedeh Eftekhari
- Danish Headache Center, Department of Neurology, Glostrup Research Institute, Rigshospitalet-Glostrup, University of Copenhagen, Nordstjernevej 42, 2600 Glostrup, Denmark
| | - Connar Stanley James Westgate
- Danish Headache Center, Department of Neurology, Glostrup Research Institute, Rigshospitalet-Glostrup, University of Copenhagen, Nordstjernevej 42, 2600 Glostrup, Denmark
| | - Maria Schmidt Uldall
- Danish Headache Center, Department of Neurology, Glostrup Research Institute, Rigshospitalet-Glostrup, University of Copenhagen, Nordstjernevej 42, 2600 Glostrup, Denmark
| | - Rigmor Hoejland Jensen
- Danish Headache Center, Department of Neurology, Glostrup Research Institute, Rigshospitalet-Glostrup, University of Copenhagen, Nordstjernevej 42, 2600 Glostrup, Denmark
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Investigation of Skull-Based Cerebrospinal Fluid Leak Repair: A Single-Institution Comprehensive Study of 116 Cases Over 10 Years. World Neurosurg 2019; 135:e1-e11. [PMID: 31604132 DOI: 10.1016/j.wneu.2019.09.133] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2019] [Revised: 09/24/2019] [Accepted: 09/25/2019] [Indexed: 12/26/2022]
Abstract
BACKGROUND Cerebrospinal fluid (CSF) leaks have been historically difficult to diagnose and treat because their cause can widely vary. There are insufficient diagnostic predictors and no clinically accepted standards for their treatment. This large institutional study reports on the diagnosis, management, and outcomes of patients presenting with CSF leak over 10 years and aims to identify potential comorbidities and risk factors for primary and recurrent leaks. METHODS Patients diagnosed with CSF leak from 2007 to 2017 were analyzed retrospectively. The data included medical history, body mass index, surgical treatment, and postoperative outcomes. RESULTS A total of 116 cases were identified. The location of leaks was 91 CSF rhinorrhea and 28 CSF otorrhea (3 both). The average BMI for females was greater than that of males (P = 0.01). Causes of leak were 64 noniatrogenic, 47 iatrogenic, and 9 traumatic. A total of 108 patients underwent surgical treatment. Sixty-nine were treated by endoscopic approaches, 42 involved open approaches, and 83 involved the placement of a lumbar drain. Eighteen patients had a ventriculoperitoneal shunt and 6 had a lumbar-peritoneal shunt. A total of 78 patients (72.22%) had an associated encephalocele with the CSF leak. The average length of stay was 7.73 days (0.76). The average length of follow-up was 1.58 years (0.22). The primary repair rate was 80.17% (n = 93) and the overall repair outcome was 99.14% (n = 115). CONCLUSIONS The overall CSF repair outcome was 99.14% over 10 years at a single institution. Despite this high percentage, CSF leaks continue to be a complex problem and require vigorous multidisciplinary work with close follow-up and use of multiple imaging strategies.
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Adderley NJ, Subramanian A, Nirantharakumar K, Yiangou A, Gokhale KM, Mollan SP, Sinclair AJ. Association Between Idiopathic Intracranial Hypertension and Risk of Cardiovascular Diseases in Women in the United Kingdom. JAMA Neurol 2019; 76:1088-1098. [PMID: 31282950 PMCID: PMC6618853 DOI: 10.1001/jamaneurol.2019.1812] [Citation(s) in RCA: 77] [Impact Index Per Article: 15.4] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2019] [Accepted: 04/26/2019] [Indexed: 12/30/2022]
Abstract
IMPORTANCE Cardiovascular disease (CVD) risk has not been previously evaluated in a large matched cohort study in idiopathic intracranial hypertension (IIH). OBJECTIVES To estimate the risk of composite cardiovascular events, heart failure, ischemic heart disease, stroke/transient ischemic attack (TIA), type 2 diabetes, and hypertension in women with idiopathic intracranial hypertension and compare it with the risk in women, matched on body mass index (BMI) and age, without the condition; and to evaluate the prevalence and incidence of IIH. DESIGN, SETTING, AND PARTICIPANTS This population-based matched controlled cohort study used 28 years of data, from January 1, 1990, to January 17, 2018, from The Health Improvement Network (THIN), an anonymized, nationally representative electronic medical records database in the United Kingdom. All female patients aged 16 years or older were eligible for inclusion. Female patients with IIH (n = 2760) were included and randomly matched with up to 10 control patients (n = 27 125) by BMI and age. MAIN OUTCOMES AND MEASURES Adjusted hazard ratios (aHRs) of cardiovascular outcomes were calculated using Cox regression models. The primary outcome was a composite of any CVD (heart failure, ischemic heart disease, and stroke/TIA), and the secondary outcomes were each CVD outcome, type 2 diabetes, and hypertension. RESULTS In total, 2760 women with IIH and 27 125 women without IIH were included. Age and BMI were similar between the 2 groups, with a median (interquartile range) age of 32.1 (25.6-42.0) years in the exposed group and 32.1 (25.7-42.1) years in the control group; in the exposed group 1728 women (62.6%) were obese, and in the control group 16514 women (60.9%) were obese. Higher absolute risks for all cardiovascular outcomes were observed in women with IIH compared with control patients. The aHRs were as follows: composite cardiovascular events, 2.10 (95% CI, 1.61-2.74; P < .001); heart failure, 1.97 (95% CI, 1.16-3.37; P = .01); ischemic heart disease, 1.94 (95% CI, 1.27-2.94; P = .002); stroke/TIA, 2.27 (95% CI, 1.61-3.21; P < .001); type 2 diabetes, 1.30 (95% CI, 1.07-1.57; P = .009); and hypertension, 1.55 (95% CI, 1.30-1.84; P < .001). The incidence of IIH in female patients more than tripled between 2005 and 2017, from 2.5 to 9.3 per 100 000 person-years. Similarly, IIH prevalence increased in the same period, from 26 to 79 per 100 000 women. Incidence increased markedly with BMI higher than 30. CONCLUSIONS AND RELEVANCE Idiopathic intracranial hypertension in women appeared to be associated with a 2-fold increase in CVD risk; change in patient care to modify risk factors for CVD may reduce long-term morbidity for women with IIH and warrants further evaluation.
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Affiliation(s)
- Nicola J Adderley
- Institute of Applied Health Research, University of Birmingham, Birmingham, United Kingdom
| | - Anuradhaa Subramanian
- Institute of Applied Health Research, University of Birmingham, Birmingham, United Kingdom
| | - Krishnarajah Nirantharakumar
- Institute of Applied Health Research, University of Birmingham, Birmingham, United Kingdom
- Centre for Endocrinology, Diabetes, and Metabolism, Birmingham Health Partners, Birmingham, United Kingdom
- Health Data Research UK, Birmingham, United Kingdom
| | - Andreas Yiangou
- Metabolic Neurology, Institute of Metabolism and Systems Research, University of Birmingham, Birmingham, United Kingdom
- Department of Neurology, University Hospitals Birmingham, Queen Elizabeth Hospital, Birmingham, United Kingdom
| | - Krishna M Gokhale
- Institute of Applied Health Research, University of Birmingham, Birmingham, United Kingdom
| | - Susan P Mollan
- Metabolic Neurology, Institute of Metabolism and Systems Research, University of Birmingham, Birmingham, United Kingdom
- Birmingham Neuro-Ophthalmology, Queen Elizabeth Hospital, Birmingham, United Kingdom
| | - Alexandra J Sinclair
- Metabolic Neurology, Institute of Metabolism and Systems Research, University of Birmingham, Birmingham, United Kingdom
- Department of Neurology, University Hospitals Birmingham, Queen Elizabeth Hospital, Birmingham, United Kingdom
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Blanch RJ, Vasseneix C, Liczkowski A, Yiangou A, Aojula A, Micieli JA, Mollan SP, Newman NJ, Biousse V, Bruce BB, Sinclair A. Differing presenting features of idiopathic intracranial hypertension in the UK and US. Eye (Lond) 2019; 33:1014-1019. [PMID: 30783258 DOI: 10.1038/s41433-019-0359-5] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2018] [Revised: 11/27/2018] [Accepted: 12/05/2018] [Indexed: 11/09/2022] Open
Abstract
AIM Demographic factors potentially influencing the presentation and severity of idiopathic intracranial hypertension (IIH) in the US vs. UK populations include obesity and ethnicity. We aimed to compare the presenting features of IIH between populations in the UK and US tertiary referral centres, to assess what population differences exist and whether these cause different presentations and impact on visual function. METHODS Clinical data were collected on 243 consecutive UK IIH patients and 469 consecutive US IIH patients seen after 2012 in two tertiary centres. Visual function was defined as severe visual loss when Humphrey visual field mean deviation was <-15 dB, when Goldmann visual fields showed constriction or when visual acuity was <20/200. RESULTS US patients were more commonly of self-reported black race (58.9% vs. 7.1%) than UK patients, but had a similar mean body mass index (38.3 ± 0.63kg/m2 UK vs. 37.7 ± 0.42kg/m2 US; p = 0.626). The UK cohort had lower presenting Frisén grade (median 1 vs. 2; p < 0.001) and severe visual loss less frequently (15.4% vs. 5%; p = 0.014), but there was no difference in mean cerebrospinal fluid-opening pressure (CSF-OP) (35.8 ± 0.88cmH2O UK vs. 36.3 ± 0.52cmH2O US; p = 0.582). African Americans had poorer visual outcomes compared with US whites (19.4% vs. 10% severe visual loss; p = 0.011). Visual function was weakly associated with CSF-OP (R2 = 0.059; p = 0.001), which was similar between UK and US patients. CONCLUSIONS The UK and the US cohorts had a similar average presenting BMI. However, the worse presenting visual function in the US IIH cohort was partially attributable to differences in the black populations in the two countries.
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Affiliation(s)
- R J Blanch
- Department of Ophthalmology, Emory University, Atlanta, GA, USA. .,Neuroscience and Ophthalmology, Institute of Inflammation and Ageing, University of Birmingham, Birmingham, UK. .,Academic Department of Military Surgery and Trauma, Royal Centre for Defence Medicine, Birmingham, UK. .,Department of Ophthalmology, University Hospital Birmingham NHS Trust, Birmingham, UK.
| | - C Vasseneix
- Department of Ophthalmology, Emory University, Atlanta, GA, USA
| | - A Liczkowski
- Metabolic Neurology, Institute of Metabolism and Systems Research, University of Birmingham, Birmingham, UK
| | - A Yiangou
- Metabolic Neurology, Institute of Metabolism and Systems Research, University of Birmingham, Birmingham, UK.,Department of Neurology, University Hospital Birmingham NHS Trust, Birmingham, UK
| | - A Aojula
- Metabolic Neurology, Institute of Metabolism and Systems Research, University of Birmingham, Birmingham, UK.,Department of Neurology, University Hospital Birmingham NHS Trust, Birmingham, UK
| | - J A Micieli
- Department of Ophthalmology, Emory University, Atlanta, GA, USA
| | - S P Mollan
- Department of Ophthalmology, University Hospital Birmingham NHS Trust, Birmingham, UK
| | - N J Newman
- Department of Ophthalmology, Emory University, Atlanta, GA, USA.,Department of Neurological Surgery, Emory University, Atlanta, GA, USA.,Department of Neurology, Emory University, Atlanta, GA, USA
| | - V Biousse
- Department of Ophthalmology, Emory University, Atlanta, GA, USA.,Department of Neurology, Emory University, Atlanta, GA, USA
| | - B B Bruce
- Department of Ophthalmology, Emory University, Atlanta, GA, USA.,Department of Neurology, Emory University, Atlanta, GA, USA
| | - A Sinclair
- Metabolic Neurology, Institute of Metabolism and Systems Research, University of Birmingham, Birmingham, UK. .,Department of Neurology, University Hospital Birmingham NHS Trust, Birmingham, UK.
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