The Surgical Treatment of Headache

Cranial decompression and expansion surgery for the treatment of refractory idiopathic intracranial hypertension: case report and systematic review

OBJECTIVE

The purpose of this study is to systematically review the literature on the clinical outcomes following different surgical techniques in patients with refractory idiopathic intracranial hypertension (IIH).

BACKGROUND

IIH is a condition characterised by increased cranial pressure (ICP) in the absence of an intracranial lesion that does not adequately respond to different medical and surgical therapies. Cranial decompression or expansion surgeries are a last resort therapy for patients with refractory IIH.

METHODS

A systematic literature search of the databases of PubMed, Embase and Medline from inception to 2019 was performed. Searches were limited to the English language and to clinical studies. Studies were included if clinical outcomes following different cranial decompression or expansion techniques were reported. We also add one case of our own experience with performing a bilateral frontoparietal expansion craniotomy and subtemporal craniectomy.

RESULTS

Five manuscripts, describing 38 procedures, met the inclusion criteria. Thirty-one patients were female (82%). The mean age was 26.2 years. The techniques studied included subtemporal craniectomy (27/38, 71%), internal cranial expansion (10/38, 26%), and cranial morcellation decompression (1/38, 3%). Thirty-five patients presented with headaches of which 17 noted postoperative improvement or resolution (49%). Visual deficits were documented in 30 patients and 25 reported postoperative improvement (83%). Papilledema disappeared in 23 of 32 patients with this sign at presentation (72%). In our patient, symptoms completely resolved postoperatively and a 6% increase in intracranial volume was measured.

CONCLUSIONS

Cranial vault decompression or expansion surgeries may be an effective last resort therapy for patients with refractory IIH. These surgeries expand the intracranial volume, and thus may normalise ICP, leading to clinical improvement.

Chiari Headache

PURPOSE OF REVIEW

Chiari malformations (CM) are a group of neuroanatomical pathologies resulting from overcrowding of the hindbrain. The purpose of this review is to characterize Chiari headache (CH) and describe diagnosis and treatment of the condition.

RECENT FINDINGS

Recent research has helped solidify the criteria for diagnosis of CH. Imaging studies have expanded our understanding of the morphological features producing them and helped to better characterize the pathophysiology. Additionally, identifying this unusual headache disorder accurately has helped with specific treatment options. CH is a disabling condition which can effect multiple domains of a patient's life. The diagnostic criteria has improved, and we now have a better understanding of the pathophysiology and imaging findings associated with CH. Future research is warranted to find new treatment options for individuals suffering from this condition.

[Diagnosis of refractory forms of chronic primary headache]

A number of patients with primary headaches remain insensitive or refractory to treatment despite correctly selected drugs, adequate therapeutic dose and duration of therapy. The importance of refractory problem is determined by the fact that patients are completely maladjusted, disabled, and keeping these patients is very difficult even for seasoned professionals. Determination of the correct tactics and success of the treatment depends, in the first place, on the correct diagnosis. This article discusses the diagnostic criteria for the most important forms such as refractory chronic migraine or refractory chronic cluster headache presented by experts of the European Headache Federation in two separate Consensus.