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Friedman DI. The Pseudotumor Cerebri Syndrome. Neurol Clin 2024; 42:433-471. [PMID: 38575259 DOI: 10.1016/j.ncl.2024.02.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/06/2024]
Abstract
Pseudotumor cerebri syndrome is a syndrome of increased cerebrospinal fluid pressure without ventriculomegaly, mass lesion, or meningeal abnormality. It is either primary (idiopathic intracranial hypertension, IIH) or secondary. A secondary cause is unlikely when adhering to the diagnostic criteria. Permanent visual loss occurs if undetected or untreated, and the associated headaches may be debilitating. Fulminant disease may result in blindness despite aggressive treatment. This study addresses the diagnosis and management of IIH including new insights into the pathobiology of IIH, updates in therapeutics and causes of overdiagnosis.
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Corecha Santos R, Gupta B, Santiago RB, Sabahi M, Kaye B, Dabecco R, Obrzut M, Adada B, Velasquez N, Borghei-Razavi H. Endoscopic endonasal optic nerve sheath decompression (EONSD) for idiopathic intracranial hypertension: Technical details and meta-analysis. Clin Neurol Neurosurg 2023; 229:107750. [PMID: 37146367 DOI: 10.1016/j.clineuro.2023.107750] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2023] [Revised: 04/24/2023] [Accepted: 04/26/2023] [Indexed: 05/07/2023]
Abstract
BACKGROUND The neurosurgical management of idiopathic intracranial hypertension (IIH) remains controversial. Although shunting and newer endovascular stenting techniques are part of the neurosurgical armamentarium to treat medically refractory IIH symptoms, optic nerve sheath fenestration has traditionally been performed by ophthalmologists. OBJECTIVE We present a detailed cadaveric dissection that simulates the endoscopic endonasal optic nerve sheath decompression (EONSD) technique along with the literature review. METHODS EONSD was performed in four freshly injected cadaveric specimens. Additionally, a systematic review from different electronic databases has been done. RESULTS Bilateral EONSD was performed in all specimens without significant technical difficulties. Based on our experience, there is no need to expose the periorbita or orbital apex. The primary anatomic landmarks were the optic canal, the lateral opticocarotid recess, the tuberculum, the limbus, and the clinoid segment of the internal carotid artery. Based on the systematic review, 68 patients (77.9% female) underwent EONSD, with a mean age of 33.4 ± 6.9 years in adult patients. Follow-up ranged from 3 to 58 months across different studies. The pooled meta-analysis showed headache, papilledema, and visual disturbance improvement in 78% [95%CI 0.65-0.90], 72% [95%CI 0.61-0.83], and 88% [95%CI 0.80-0.96] of cases who underwent EONSD, respectively. The subgroup analysis showed there was no statistically significant difference between unilateral and bilateral EONSD in terms of different measured outcomes. CONCLUSION EONSD is a feasible surgical procedure that may obviate the need for shunting in patients with IIH. Although clinical studies showed that EONSD is a safe and effective technique, further studies are required to establish the preferences of either unilateral or bilateral approaches.
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Affiliation(s)
- Romel Corecha Santos
- Department of Neurosurgery, Cleveland Clinic Florida, 2950 Cleveland Clinic Blvd., Weston, FL 33331, USA
| | - Bhavika Gupta
- Department of Neurosurgery, Cleveland Clinic Florida, 2950 Cleveland Clinic Blvd., Weston, FL 33331, USA
| | - Raphael Bastianon Santiago
- Department of Neurosurgery, Cleveland Clinic Florida, 2950 Cleveland Clinic Blvd., Weston, FL 33331, USA
| | - Mohammadmahdi Sabahi
- Department of Neurosurgery, Cleveland Clinic Florida, 2950 Cleveland Clinic Blvd., Weston, FL 33331, USA
| | - Brandon Kaye
- Department of Neurosurgery, Cleveland Clinic Florida, 2950 Cleveland Clinic Blvd., Weston, FL 33331, USA
| | - Rocco Dabecco
- Department of Neurosurgery, Cleveland Clinic Florida, 2950 Cleveland Clinic Blvd., Weston, FL 33331, USA
| | - Michal Obrzut
- Department of Neurosurgery, Cleveland Clinic Florida, 2950 Cleveland Clinic Blvd., Weston, FL 33331, USA
| | - Badih Adada
- Department of Neurosurgery, Cleveland Clinic Florida, 2950 Cleveland Clinic Blvd., Weston, FL 33331, USA
| | - Nathalia Velasquez
- Department of Otolaryngology, Cleveland Clinic Florida, 2950 Cleveland Clinic Blvd., Weston, FL 33331, USA
| | - Hamid Borghei-Razavi
- Department of Neurosurgery, Cleveland Clinic Florida, 2950 Cleveland Clinic Blvd., Weston, FL 33331, USA.
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Mombaerts I, Allen RC. The transconjunctival orbitotomy: A versatile approach to the orbit and beyond. Surv Ophthalmol 2023; 68:265-279. [PMID: 36372115 DOI: 10.1016/j.survophthal.2022.11.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2022] [Revised: 11/06/2022] [Accepted: 11/07/2022] [Indexed: 11/13/2022]
Abstract
In the management of orbital disorders and defects, minimally invasive surgical approaches have become increasingly efficient for their reduction of operative trauma and access without compromise of therapeutic benefit or diagnostic yield. Various approaches have focused on bone- and canthal-sparing techniques and concealed and small skin incisions. We review the current state of knowledge of procedures to enter the orbit via the conjunctiva. Any quadrant of the orbit can be accessed via the conjunctiva. Surgical incisions involve the orbital palpebral, forniceal, and bulbar conjunctiva. According to the location, nature, and size of the lesion, the transconjunctival orbitotomy can be used as a single procedure, in combination with a caruncular approach or as an adjunct in a multidisciplinary procedure for lesions extending deep into or outside the orbit. The working space and field of operating view can be expanded by releasing the horizontal tension of the eyelid with a lateral cantholysis, lateral paracanthal blepharotomy, or medial lid split procedure. Complications related to the conjunctival incision are reduced to dry eye disease.
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Affiliation(s)
- Ilse Mombaerts
- Department of Ophthalmology, University Hospitals Leuven, Leuven, Belgium; Department of Neurosciences, Faculty of Medicine, Catholic University Leuven, Leuven, Belgium.
| | - Richard C Allen
- Department of Ophthalmology, Baylor College of Medicine, Houston, TX, USA.; Department of Ophthalmology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
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Optic nerve sheath fenestration: Current status in France and comparison of 6 different surgical approaches. J Fr Ophtalmol 2023; 46:137-147. [PMID: 36564304 DOI: 10.1016/j.jfo.2022.07.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2022] [Accepted: 07/01/2022] [Indexed: 12/24/2022]
Abstract
PURPOSE Optic nerve sheath fenestration (ONSF) is a surgical procedure commonly performed in the Anglo-Saxon countries for the treatment of medically refractory idiopathic intracranial hypertension (IIH). We chose to compare 6 different trans-orbital surgical approaches to ONSF. We also desired to determine the number of optic nerve decompression procedures performed in France in 2019 and 2020. METHODS Four fresh frozen orbits were dissected at the University of Nice anatomy laboratory. We performed the following surgical approaches: (i) eyelid crease, (ii) lid-split, (iii) medial transconjunctival with medial rectus disinsertion, (iv) medial transconjunctival without rectus disinsertion, (v) lateral transconjunctival and (vi) lateral orbitotomy. For each surgical approach, we measured the distance between the incision and the optic nerve dura mater. We also extracted data from the French National PMSI (Programme de Médicalisation des Systèmes d' Information) database from January 2019 through December 2020 to determine the annual number of optic nerve decompression procedures. RESULTS The lid crease and medial transconjunctival approaches provided the shortest distance to the optic nerve (average 21mm and 24mm, respectively) and the lowest levels of difficulty compared to the other surgical routes. A total of 23 and 45 optic nerve decompressions were performed in France in 2019 and 2020, respectively. Among them, only 2 and 7 procedures, respectively, were performed through a trans-orbital approach. CONCLUSION Upper lid crease incision and medial transconjunctival approaches are the most direct and easiest surgical routes when performing an ONSF. We found that ONSF was rarely performed in France. We strongly recommend close cooperation between ophthalmologists, neurologists, neurosurgeons and interventional radiologists.
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Xue X, Zhou C, Gao Y, Ji X, Zhang X. Optic nerve sheath fenestration for visual impairment in cerebral venous diseases. Front Neurol 2023; 14:1065315. [PMID: 36761350 PMCID: PMC9902767 DOI: 10.3389/fneur.2023.1065315] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2022] [Accepted: 01/06/2023] [Indexed: 01/26/2023] Open
Abstract
Objective Visual impairment is the most common clinical feature of cerebral venous sinus occlusion or cerebral venous thrombosis-induced intracranial hypertension, which can result in optic atrophy, leading to irreversible vision loss, visual field defections, and finally, permanent blindness. Papilledema is a typical early pathophysiological alteration in visual impairment. Optic nerve sheath fenestration (ONSF) has become increasingly accepted as an option to prevent or halt progressive visual loss owing to its low risk and complications. The objective of this study is to review the latest research progress on ONSF for the treatment of visual impairment related to cerebral venous diseases. Methods Study were searched following PRISMA guidelines based on three electronic databases (Pubmed, Embase and Medline-Ovid). We used the following keywords and variations as keywords to identify studies: "optic nerve sheath fenestration, papilledema, cerebral venous diseases, cerebral venous stenosis, cerebral venous thrombosis, idiopathic intracranial hypertension". The publication date of studies was restricted between 1,872.1.1 and 2,021.12.31. The application of ONSF in papilledema due to cerebral venous diseases is reviewed. Additionally, the common surgical approaches as well as advantages and disadvantages are also described graphically. Results With the improvement of specific details of the ONSF procedure and surgical instruments, complications of ONSF have reduced and its safety has been significantly improved, although the number of clinically investigated cases in the literature remains low. Conclusion We recommend that ONSF should be considered as an imperative alternative to reduce or delay the visual morbidity of cerebral venous diseases, although there is yet no consensus on the optimal surgical timing.
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Affiliation(s)
- Xiao Xue
- Department of Ophthalmology, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Chen Zhou
- Department of Neurology, Xuanwu Hospital, Capital Medical University, Beijing, China
- Laboratory of Brain Disorders, Ministry of Science and Technology, Beijing Institute of Brain Disorders of Capital Medical University, Beijing, China
| | - Yuan Gao
- Department of Biomedical Engineering, School of Biological Science and Medical Engineering, Beihang University, Beijing, China
| | - Xunming Ji
- Laboratory of Brain Disorders, Ministry of Science and Technology, Beijing Institute of Brain Disorders of Capital Medical University, Beijing, China
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Xuxiang Zhang
- Department of Ophthalmology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
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Alternative Path for Optic Nerve Decompression in Pseudotumor Cerebri With Full Endoscopic Lateral Transorbital Approach. J Craniofac Surg 2022; 34:1089-1092. [PMID: 36730888 DOI: 10.1097/scs.0000000000009096] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2022] [Accepted: 09/04/2022] [Indexed: 02/04/2023] Open
Abstract
Endonasal endoscopic approaches are the most preferred surgical methods in patients with pseudotumor cerebri because of easy access to the optic nerve, but the choice of this technique may not apply to all endoscopic endonasal cases. Moreover, there may be difficulties in practice in some cases, including the coronavirus disease 2019 pandemic. This study aimed to suggest an alternative endoscopic approach by lateral orbitotomy for optic nerve decompression in patients with pseudotumor cerebri. The study was performed using 5 fresh-frozen cadaver heads (bilaterally, total of 10 sides) injected intravenously with colored silicone preserved in the cold chain. An average of 2.5 cm skin incision was made to fit the lateral orbitotomy. The lengths of the recurrent meningeal artery (mm), the meningo-orbital band (mm), and the optic nerve (mm) to the orbital margin were measured. After these morphometric measurements, optic nerve decompression was performed endoscopically, and the length of the decompression was measured (mm). The average length (mm) between the orbital rim and meningeal recurrent artery (or meningolacrimal branch) was 16.2 mm, between the orbital rim and the meningo-orbital band was 18.5 mm, and between the orbital rim and optic nerve was 44.1 mm. The average optic nerve decompression length was 4.4 mm. The endoscopic lateral orbitotomy approach provides easy access to the optic nerve by anatomically following the recurrent meningeal artery and the meningo-orbital band. It can be a safe second-line approach after endonasal approaches for optic nerve decompression in pseudotumor cerebri.
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Hagen SM, Wegener M, Toft PB, Fugleholm K, Jensen RH, Hamann S. Unilateral Optic Nerve Sheath Fenestration in Idiopathic Intracranial Hypertension: A 6-Month Follow-Up Study on Visual Outcome and Prognostic Markers. Life (Basel) 2021; 11:778. [PMID: 34440522 PMCID: PMC8400184 DOI: 10.3390/life11080778] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2021] [Revised: 07/27/2021] [Accepted: 07/28/2021] [Indexed: 11/17/2022] Open
Abstract
Loss of vision is a feared consequence of idiopathic intracranial hypertension (IIH). Optic nerve sheath fenestration (ONSF) may be an effective surgical approach to protect visual function in medically refractory IIH. In this study, we evaluate the impact of unilateral superomedial transconjunctival ONSF on bilateral visual outcome using a comprehensive follow-up program. A retrospective chart review of IIH patients who underwent unilateral ONSF between January 2016 and March 2021 was conducted. Patients fulfilling the revised Friedman criteria for IIH and who had exclusively received ONSF as a surgical treatment were included. Main outcomes were visual acuity (VA); perimetric mean deviation (PMD); papilledema grade; and optic nerve head elevation (maxONHE) 1 week, 2 weeks, and 1, 3, and 6 months after surgery. VA (p < 0.05), PMD (p < 0.05), papilledema grade (p < 0.01), and maxOHNE (p < 0.001) were improved after 6 months on both the operated and non-operated eye. Prolonged surgical delay impedes PMD improvement (r = -0.78, p < 0.01), and an increasing opening pressure initiates a greater ganglion cell loss (r = -0.79, p < 0.01). In this small case series, we demonstrate that unilateral superonasal transconjunctival ONSF is a safe procedure with an effect on both eyes. Optic nerve head elevation and PMD are feasible biomarkers for assessing early treatment efficacy after ONSF.
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Affiliation(s)
- Snorre Malm Hagen
- Department of Ophthalmology, Rigshospitalet, University of Copenhagen, 2600 Glostrup, Denmark; (M.W.); (P.B.T.); (S.H.)
| | - Marianne Wegener
- Department of Ophthalmology, Rigshospitalet, University of Copenhagen, 2600 Glostrup, Denmark; (M.W.); (P.B.T.); (S.H.)
| | - Peter Bjerre Toft
- Department of Ophthalmology, Rigshospitalet, University of Copenhagen, 2600 Glostrup, Denmark; (M.W.); (P.B.T.); (S.H.)
| | - Kåre Fugleholm
- Department of Neurosurgery, Rigshospitalet, University of Copenhagen, 2100 Copenhagen Ø, Denmark;
| | - Rigmor Højland Jensen
- Danish Headache Center, Department of Neurology, Rigshospitalet-Glostrup, University of Copenhagen, 2600 Glostrup, Denmark;
| | - Steffen Hamann
- Department of Ophthalmology, Rigshospitalet, University of Copenhagen, 2600 Glostrup, Denmark; (M.W.); (P.B.T.); (S.H.)
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Malik AI, Xu J, Lee AG. Outcomes of optic nerve sheath fenestration from superomedial eyelid crease approach. Orbit 2021; 41:413-421. [PMID: 33588671 DOI: 10.1080/01676830.2021.1880444] [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] [Indexed: 10/22/2022]
Abstract
Purpose: The purpose of this study is to report the safety and outcomes of optic nerve sheath fenestration (ONSF) performed via superomedial eyelid crease approach.Methods: A retrospective chart review was performed on patients undergoing superomedial eyelid crease ONSF at a single institution between 2014-2019. Data obtained included preoperative visual acuity (VA), mean deviation (MD) on visual field (VF), papilledema grade, intraoperative time, estimated blood loss, intraoperative complications and optic nerve sheath biopsy results. Postoperative month 6 (POM6) data collected included VA, MD, papilledema grade, and lid contour. Outcome measures included overall change in VA, MD, and papilledema grade at POM6. Statistical analysis was performed using STATA version 16 statistical software. Data analysis was done comparing all patients pre- and postoperatively. Additional subgroup analysis was performed on patients undergoing ONSF for IIH vs other indications, and on the contralateral unoperated eye.Results: A total of 31 eyes of 24 patients were identified, four of whom were excluded due to being lost to follow-up. At POM6, improvement was seen in VA (p<0.001) across all groups. There was improvement in POM6 median papilledema grade and MD, but these did not reach statistical significance. Additional subgroup analysis on patients with IIH showed statistically significant improvement in POM 6 VA (p=0.009), papilledema (p=0.009) and MD (p<0.001), as well as VA improvement in the contralateral unoperated eye (p<0.001).Conclusions: Superomedial eyelid crease approach for ONSF is a safe and effective surgery in IIH and other conditions of excess pressure within the optic nerve sheath.
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Affiliation(s)
- Amina I Malik
- Department of Ophthalmology, Blanton Eye Institute, Houston Methodist Hospital, Houston, Texas, USA.,Deparment of Ophthalmology, The Houston Methodist Research Institute, Houston Methodist Hospital, Houston, Texas, USA.,Departments of Ophthalmology, Neurology, and Neurosurgery, Weill Cornell Medicine, New York, New York state, USA.,Deparment of Ophthalmology, Texas A and M College of Medicine, Bryan, Texas, USA
| | - Jiaqiong Xu
- Center for Outcomes Research, Houston Methodist DeBakey Heart & Vascular Center, Houston Methodist Research Institute, Houston Methodist Hospital, Houston, Texas, USA
| | - Andrew G Lee
- Department of Ophthalmology, Blanton Eye Institute, Houston Methodist Hospital, Houston, Texas, USA.,Deparment of Ophthalmology, The Houston Methodist Research Institute, Houston Methodist Hospital, Houston, Texas, USA.,Departments of Ophthalmology, Neurology, and Neurosurgery, Weill Cornell Medicine, New York, New York state, USA.,Deparment of Ophthalmology, Texas A and M College of Medicine, Bryan, Texas, USA.,Department of Ophthalmology, University of Texas Medical Branch, Galveston, Texas, USA.,Deparment of Ophthalmology, Baylor College of Medicine, Houston, Texas, USA.,Deparment of Ophthalmology, University of Texas MD Anderson Cancer Center, Houston, Texas, USA.,Department of Ophthalmology, The University of Iowa Hospitals and Clinics, Iowa City, Iowa, USA
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Jefferis JM, Littlewood RA, Pepper IM, Hickman SJ, Salvi SM. Optic nerve sheath fenestration via a supero-medial eyelid skin crease approach for the treatment of idiopathic intracranial hypertension in a UK population. Eye (Lond) 2020; 35:1418-1426. [PMID: 32555545 DOI: 10.1038/s41433-020-1024-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2020] [Revised: 06/02/2020] [Accepted: 06/04/2020] [Indexed: 11/09/2022] Open
Abstract
BACKGROUND/AIMS Optic nerve sheath fenestration (ONSF) is a surgical intervention in the management of idiopathic intracranial hypertension (IIH) infrequently performed in the United Kingdom. Numerous surgical approaches have been described, including medial transconjunctival, lateral and endoscopic. We describe our outcomes and complications from ONSF via a supero-medial eyelid skin crease incision in patients with IIH. METHODS We performed a retrospective review of consecutive patients undergoing ONSF for IIH between January 2011 and December 2017 by a single surgeon. RESULTS Thirty patients were included in the analysis with a median follow-up of 14.5 months. Bilateral ONSFs were undertaken in 27 (90%). The data from one eye per patient were analysed. The mean kinetic perimetry score in mean radial degrees of the I4e isopter improved from 27.3° to 35.7°, p = 0.04. After removing cases with optic atrophy, the median modified Frisén grade of papilloedema improved from 2.5 to 1.0, p = 0.007. A total of 5/30 (17%) patients had complications: two (7%) had recurrence/late failure (one managed medically and one with cerebrospinal fluid [CSF] diversion surgery), one had transient cotton wool spots post-operatively, one had transient retinal haemorrhages and one patient had a transiently oval pupil. No patients had repeat ONSF, but CSF diversion surgery was subsequently carried out in 4/30 (13%) patients. CONCLUSIONS ONSF via a supero-medial eyelid skin crease approach is effective at improving visual function in patients with IIH. The complication rates are low when compared with CSF diversion surgery and other surgical approaches for ONSF.
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Affiliation(s)
- J M Jefferis
- Department of Ophthalmology, Royal Hallamshire Hospital, Sheffield, S10 2JF, UK. .,The University of Sheffield, Sheffield, S10 2TN, UK.
| | - R A Littlewood
- Department of Ophthalmology, Royal Hallamshire Hospital, Sheffield, S10 2JF, UK
| | - I M Pepper
- Department of Ophthalmology, Royal Hallamshire Hospital, Sheffield, S10 2JF, UK.,The University of Sheffield, Sheffield, S10 2TN, UK
| | - S J Hickman
- The University of Sheffield, Sheffield, S10 2TN, UK.,Department of Neurology, Royal Hallamshire Hospital, Sheffield, S10 2JF, UK
| | - S M Salvi
- Department of Ophthalmology, Royal Hallamshire Hospital, Sheffield, S10 2JF, UK.,The University of Sheffield, Sheffield, S10 2TN, UK
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