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Emekli AS, Hines DA, Miller NJ, Schulte A, Kaufman D. Idiopathic intracranial hypertension without papilledema maybe underdiagnosed. Neurol Sci 2024; 45:5077-5081. [PMID: 38831165 DOI: 10.1007/s10072-024-07563-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2024] [Accepted: 04/25/2024] [Indexed: 06/05/2024]
Affiliation(s)
- Ahmed Serkan Emekli
- Department of Neurology, Istanbul Faculty of Medicine, Istanbul University, Istanbul, Türkiye.
- Department of Neurology and Ophthalmology, Michigan State University, East Lansing, MI, USA.
| | - Dustin A Hines
- Department of Neurology and Ophthalmology, Michigan State University, East Lansing, MI, USA
- University of Michigan Health - Sparrow, Lansing, MI, USA
| | - Neysa J Miller
- Department of Neurology and Ophthalmology, Michigan State University, East Lansing, MI, USA
| | - Alexandra Schulte
- Department of Neurology and Ophthalmology, Michigan State University, East Lansing, MI, USA
- Department of Ophthalmology, Ascension Macomb Oakland Hospital, Warren, MI, USA
| | - David Kaufman
- Department of Neurology and Ophthalmology, Michigan State University, East Lansing, MI, USA
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Abstract
Background Accumulating evidence suggests various specific triggers may lead to new daily persistent headache (NDPH)-like presentations, suggesting that new daily persistent headache is a heterogenous syndrome, and challenging the concept that new daily persistent headache is a primary headache disorder.Method We searched the PubMed database up to August 2022 for keywords including persistent daily headache with both primary and secondary etiologies. We summarized the literature and provided a narrative review of the clinical presentation, diagnostic work-ups, possible pathophysiology, treatment response, and clinical outcomes.Results and conclusion New daily persistent headache is a controversial but clinically important topic. New daily persistent headache is likely not a single entity but a syndrome with different etiologies. The issue with past studies of new daily persistent headache is that patients with different etiologies/subtypes were pooled together. Different studies may investigate distinct subsets of patients, which renders the inter-study comparison, both positive and negative results, difficult. The identification (and removal) of a specific trigger might provide the opportunity for clinical improvement in certain patients, even when the disease has lasted for months or years. Nonetheless, if there is a specific trigger, it remains unknown or unidentified for a great proportion of the patients. We need to continue to study this unique headache population to better understand underlying pathogenesis and, most importantly, to establish effective treatment strategies that hopefully resolve the continuous cycle of pain.
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Affiliation(s)
- Kuan-Po Peng
- Department of Systems Neuroscience, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Todd D Rozen
- Department of Neurology, Mayo Clinic, Florida, USA
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Eide PK, Hansson HA. A New Perspective on the Pathophysiology of Idiopathic Intracranial Hypertension: Role of the Glia-Neuro-Vascular Interface. Front Mol Neurosci 2022; 15:900057. [PMID: 35903170 PMCID: PMC9315230 DOI: 10.3389/fnmol.2022.900057] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2022] [Accepted: 06/07/2022] [Indexed: 11/13/2022] Open
Abstract
Idiopathic intracranial hypertension (IIH) is a neurological disease characterized by symptoms and signs of increased intracranial pressure (ICP) of unknown cause. Most attention has been given to the role of cerebrospinal fluid (CSF) disturbance and intracranial venous hypertension caused by sinus vein stenosis. We previously proposed that key pathophysiological processes take place within the brain at the glia-neuro-vascular interface. However, the relative importance of the proposed mechanisms in IIH disease remains unknown. Modern treatment regimens aim to reduce intracranial CSF and venous pressures, but a substantial proportion of patients experience lasting complaints. In 2010, the first author established a database for the prospective collection of information from individuals being assessed for IIH. The database incorporates clinical, imaging, physiological, and biological data, and information about treatment/outcome. This study retrieved information from the database, asking the following research questions: In IIH subjects responding to shunt surgery, what is the occurrence of signs of CSF disturbance, sinus vein stenosis, intracranial hypertension, and microscopic evidence of structural abnormalities at the glia-neuro-vascular interface? Secondarily, do semi-quantitative measures of abnormal ultrastructure at the glia-neurovascular differ between subjects with definite IIH and non-IIH (reference) subjects? The study included 13 patients with IIH who fulfilled the diagnostic criteria and who improved following shunt surgery, i.e., patients with definite IIH. Comparisons were done regarding magnetic resonance imaging (MRI) findings, pulsatile and static ICP scores, and immune-histochemistry microscopy. Among these 13 IIH subjects, 6/13 (46%) of patients presented with magnetic resonance imaging (MRI) signs of CSF disturbance (empty sella and/or distended perioptic subarachnoid spaces), 0/13 (0%) of patients with IIH had MRI signs of sinus vein stenosis, 13/13 (100%) of patients with IIH presented with abnormal preoperative pulsatile ICP [overnight mean ICP wave amplitude (MWA) above thresholds], 3/13 (23%) patients showed abnormal static ICP (overnight mean ICP above threshold), and 12/13 (92%) of patients with IIH showed abnormal structural changes at the glia-neuro-vascular interface. Comparisons of semi-quantitative structural variables between IIH and aged- and gender-matched reference (REF) subjects showed IIH abnormalities in glial cells, neurons, and capillaries. The present data suggest a key role of disease processes affecting the glia-neuro-vascular interface.
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Affiliation(s)
- Per Kristian Eide
- Department of Neurosurgery, Oslo University Hospital—Rikshospitalet, Oslo, Norway
- Institute of Clinical Medicine, Faculty of Medicine, University of Oslo, Oslo, Norway
- *Correspondence: Per Kristian Eide
| | - Hans-Arne Hansson
- Institute of Biomedicine, University of Gothenburg, Göteborg, Sweden
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Raggi A, Bianchi Marzoli S, Ciasca P, Cammarata G, Melzi L, Chiapparini L, Erbetta A, Ciceri E, Faragò G, Gioppo A, Usai S, D'Amico D. The Pre-Lumbar puncture Intracranial Hypertension Scale (PLIHS): A practical scale to identify subjects with normal cerebrospinal fluid pressure in the management of idiopathic intracranial hypertension. J Neurol Sci 2021; 429:118058. [PMID: 34461550 DOI: 10.1016/j.jns.2021.118058] [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: 07/05/2021] [Revised: 08/05/2021] [Accepted: 08/24/2021] [Indexed: 10/20/2022]
Abstract
BACKGROUND Idiopathic Intracranial Hypertension (IIH) diagnosis requires lumbar puncture to measure cerebrospinal fluid (CSF) pressure. The Pre-Lumbar puncture Intracranial Hypertension Scale (PLIHS) is aimed to detect cases that will show raised or normal CSF opening pressure. METHODS Retrospective analysis of records of patients who underwent lumbar puncture for suspect IIH. The target was CSF opening pressure ≥ 250 mmH2O, whereas a set of known neurological, neuro-ophthalmological and neuro-radiological parameters, plus obesity, were used as predictors in a logistic regression model. The PLIHS was based on significant predictors and a cut-off was validated using chi-squared test around CSF opening pressure ≥ 250 and < 200 mmH2O. RESULTS Records of 162 patients were included: CSF opening pressure was <200 mmH2O in 40 and ≥ 250 mmH2O in 95 patients; 85 fulfilled IIH diagnosis. PLIHS is based on Frisén grade 2 or higher papilledema, tinnitus, empty sella, perioptic subarachnoid space distension, and obesity. Score range is 0-7: correlation with CSF opening pressure is 0.508 (p < .001), and PLIHS score is different between subjects not diagnosed with IIH, and those diagnosed with IIH both with and without papilledema (p < .001). PLIHS score ≤ 2 identifies cerebrospinal fluid pressure < 200 mmH2O; PLIHS score ≥ 3 identifies CSF opening pressure ≥ 250 mmH2O, IIH diagnosis, visual acuity ≤0.7, and optic nerve atrophy. CONCLUSIONS The PLIHS, can be used to identify patients who will particularly need LP, thus helping with the organization of the diagnostic work-up by optimising healthcare resources and potentially limit the likelihood to incur in LP-related adverse events.
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Affiliation(s)
- Alberto Raggi
- Fondazione IRCCS Istituto Neurologico Carlo Besta, Neurology, Public Health and Disability Unit, Milano, Italy.
| | - Stefania Bianchi Marzoli
- Istituto Auxologico Italiano IRCCS, Neuro-ophthalmology Center - Scientific Institute Capitanio Hospital, Milano, Italy.
| | - Paola Ciasca
- Istituto Auxologico Italiano IRCCS, Neuro-ophthalmology Center - Scientific Institute Capitanio Hospital, Milano, Italy.
| | - Gabriella Cammarata
- Istituto Auxologico Italiano IRCCS, Neuro-ophthalmology Center - Scientific Institute Capitanio Hospital, Milano, Italy.
| | - Lisa Melzi
- Istituto Auxologico Italiano IRCCS, Neuro-ophthalmology Center - Scientific Institute Capitanio Hospital, Milano, Italy.
| | - Luisa Chiapparini
- Fondazione IRCCS Istituto Neurologico Carlo Besta, Neuroradiology Unit, Milano, Italy.
| | - Alessandra Erbetta
- Fondazione IRCCS Istituto Neurologico Carlo Besta, Neuroradiology Unit, Milano, Italy.
| | - Elisa Ciceri
- Fondazione IRCCS Istituto Neurologico Carlo Besta, Radiodiagnostic and Interventional Neuroradiology, Milano, Italy.
| | - Giuseppe Faragò
- Papa Giovanni XXII Hospital, Neuroradiology Department, Bergamo, Italy.
| | - Andrea Gioppo
- ASST Santi Paolo e Carlo, P.O San Carlo, Radiologia II - Neurodiagnostica-Neurointerventistica, Milano, Italy.
| | - Susanna Usai
- Fondazione IRCCS Istituto Neurologico Carlo Besta, Neuroalgology Unit, Milano, Italy.
| | - Domenico D'Amico
- Fondazione IRCCS Istituto Neurologico Carlo Besta, Neuroalgology Unit, Milano, Italy.
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Sansone M, De Angelis M, Bilo L, Bonavita V, De Simone R. Idiopathic Intracranial Hypertension Without Intracranial Hypertension. Neurol Clin Pract 2021; 11:e350-e352. [PMID: 34484911 DOI: 10.1212/cpj.0000000000001022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2020] [Accepted: 09/22/2020] [Indexed: 11/15/2022]
Affiliation(s)
- Mattia Sansone
- Department of Neuroscience (MS, LB, RDS), Reproductive Sciences and Odontostomatology, Headache Centre, University Federico II of Naples; Department of Neurosurgery (MDA), IRCCS "Neuromed," Pozzilli (IS); and Istituto di Diagnosi e Cura Hermitage Capodimonte (VB), Naples, Italy
| | - Michelangelo De Angelis
- Department of Neuroscience (MS, LB, RDS), Reproductive Sciences and Odontostomatology, Headache Centre, University Federico II of Naples; Department of Neurosurgery (MDA), IRCCS "Neuromed," Pozzilli (IS); and Istituto di Diagnosi e Cura Hermitage Capodimonte (VB), Naples, Italy
| | - Leonilda Bilo
- Department of Neuroscience (MS, LB, RDS), Reproductive Sciences and Odontostomatology, Headache Centre, University Federico II of Naples; Department of Neurosurgery (MDA), IRCCS "Neuromed," Pozzilli (IS); and Istituto di Diagnosi e Cura Hermitage Capodimonte (VB), Naples, Italy
| | - Vincenzo Bonavita
- Department of Neuroscience (MS, LB, RDS), Reproductive Sciences and Odontostomatology, Headache Centre, University Federico II of Naples; Department of Neurosurgery (MDA), IRCCS "Neuromed," Pozzilli (IS); and Istituto di Diagnosi e Cura Hermitage Capodimonte (VB), Naples, Italy
| | - Roberto De Simone
- Department of Neuroscience (MS, LB, RDS), Reproductive Sciences and Odontostomatology, Headache Centre, University Federico II of Naples; Department of Neurosurgery (MDA), IRCCS "Neuromed," Pozzilli (IS); and Istituto di Diagnosi e Cura Hermitage Capodimonte (VB), Naples, Italy
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Mollan SP, Chong YJ, Grech O, Sinclair AJ, Wakerley BR. Current Perspectives on Idiopathic Intracranial Hypertension without Papilloedema. Life (Basel) 2021; 11:472. [PMID: 34073844 PMCID: PMC8225003 DOI: 10.3390/life11060472] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2021] [Revised: 05/16/2021] [Accepted: 05/18/2021] [Indexed: 02/07/2023] Open
Abstract
The pseudotumor cerebri syndrome embraces disorders characterised by raised intracranial pressure, where the commonest symptom is headache (90%). Idiopathic intracranial hypertension without papilloedema (IIHWOP) is increasingly recognised as a source of refractory headache symptoms and resultant neurological disability. Although the majority of patients with IIHWOP are phenotypically similar to those with idiopathic intracranial hypertension (IIH), it remains uncertain as to whether IIHWOP is nosologically distinct from IIH. The incidence, prevalence, and the degree of association with the world-wide obesity epidemic is unknown. Establishing a diagnosis of IIHWOP can be challenging, as often lumbar puncture is not routinely part of the work-up for refractory headaches. There are published diagnostic criteria for IIHWOP; however, some report uncertainty regarding a pathologically acceptable cut off for a raised lumbar puncture opening pressure, which is a key criterion. The literature provides little information to help guide clinicians in managing patients with IIHWOP. Further research is therefore needed to better understand the mechanisms that drive the development of chronic daily headaches and a relationship to intracranial pressure; and indeed, whether such patients would benefit from therapies to lower intracranial pressure. The aim of this narrative review was to perform a detailed search of the scientific literature and provide a summary of historic and current opinion regarding IIHWOP.
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Affiliation(s)
- Susan P. Mollan
- Birmingham Neuro-Ophthalmology Unit, University Hospitals Birmingham NHS Foundation Trust, Birmingham B15 2TH, UK;
| | - Yu Jeat Chong
- Birmingham Neuro-Ophthalmology Unit, University Hospitals Birmingham NHS Foundation Trust, Birmingham B15 2TH, UK;
| | - Olivia Grech
- Metabolic Neurology, Institute of Metabolism and Systems Research, University of Birmingham, Edgbaston B15 2TT, UK; (O.G.); (A.J.S.); (B.R.W.)
- Centre for Endocrinology, Diabetes and Metabolism, Birmingham Health Partners, Birmingham B15 2TH, UK
| | - Alex J. Sinclair
- Metabolic Neurology, Institute of Metabolism and Systems Research, University of Birmingham, Edgbaston B15 2TT, UK; (O.G.); (A.J.S.); (B.R.W.)
- Centre for Endocrinology, Diabetes and Metabolism, Birmingham Health Partners, Birmingham B15 2TH, UK
- Department of Neurology, University Hospitals Birmingham NHS Foundation Trust, Birmingham B15 2TH, UK
| | - Benjamin R. Wakerley
- Metabolic Neurology, Institute of Metabolism and Systems Research, University of Birmingham, Edgbaston B15 2TT, UK; (O.G.); (A.J.S.); (B.R.W.)
- Centre for Endocrinology, Diabetes and Metabolism, Birmingham Health Partners, Birmingham B15 2TH, UK
- Department of Neurology, University Hospitals Birmingham NHS Foundation Trust, Birmingham B15 2TH, UK
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7
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Headache in idiopathic intracranial hypertension. A CGRP-dependent head pain? Neurol Sci 2020; 41:417-421. [DOI: 10.1007/s10072-020-04641-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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An update on idiopathic intracranial hypertension in adults: a look at pathophysiology, diagnostic approach and management. J Neurol 2020; 268:3249-3268. [PMID: 32462350 DOI: 10.1007/s00415-020-09943-9] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2020] [Revised: 05/18/2020] [Accepted: 05/20/2020] [Indexed: 02/06/2023]
Abstract
Idiopathic intracranial hypertension is a neurological syndrome determined by a rise in intracranial pressure without a detectable cause. Course and prognosis may be changeable, requiring a multidisciplinary approach for its diagnosis and management. Although its precise pathogenesis is still unknown, many studies have been carried out to define the possible causal and associated factors, such as retinoids, steroid hormones, body mass index and recent weight gains, cytokines and adipokines levels. The clinical presentation can be variable including chronic headache, disturbance of vision, diplopia and tinnitus. Even if papilloedema is considered the most specific sign, it could not be observed in more than 5% of patients during the evaluation of the fundus oculi. Neuroradiological signs acquire greater importance in patients who do not present papilloedema and may suggest the diagnosis of idiopathic intracranial hypertension. Other assessments can be useful in the diagnostic process, such as optical coherence tomography, visual evoked potentials, ocular ultrasonography and fundus fluorescein angiography and autofluorescence. Nonetheless, cerebrospinal fluid pressure measurement is required to establish a definite diagnosis. Management may be different, since surgical procedures or lumbar punctures are often required when symptoms develop rapidly leading to a loss of visual function. Apart from these cases, patients can be treated with a pharmacological approach and low-calorie diet, but they also need to be monitored over time since relapses years later are not uncommon.
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Levendowski DJ, Gamaldo C, St Louis EK, Ferini-Strambi L, Hamilton JM, Salat D, Westbrook PR, Berka C. Head Position During Sleep: Potential Implications for Patients with Neurodegenerative Disease. J Alzheimers Dis 2020; 67:631-638. [PMID: 30614805 PMCID: PMC6398535 DOI: 10.3233/jad-180697] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
BACKGROUND The characterization of sleep in those with neurodegenerative disease (NDD) is essential in understanding the potential neurobiological mechanisms that underlie the connection between sleep disruption and NDD manifestations and progression. OBJECTIVE Explore the inter-relationships between NDD and age, sex, diagnosis of obstructive sleep apnea, snoring, and duration of sleep time with the head in the supine and non-supine positions. METHODS A case-control design was used to evaluate differences in sleep position obtained from multi-night, in-home Sleep Profiler recordings in 45 patients with diagnosed NDD (24 with mild cognitive impairment, 15 with Alzheimer's disease, and 6 with Lewy Body, Parkinson's, or other dementias) and 120 age-sex matched controls with normal cognition (NC). RESULTS The frequency of supine sleep >2 h/night was significantly greater in the NDD than in the NC group (p < 0.001, odds ratio = 3.7), and remained significant after controlling for age, sex, snoring, and obstructive sleep apnea diagnosis (p = 0.01). There were no group differences in nocturnal mobility i.e., number of head position changes/h. CONCLUSION This study demonstrates the utility of in-home measurements of sleep in defining the association of supine sleep position with neurodegenerative disorders. Our findings warrant further investigation, particularly in light of the recent evidence suggesting that sleep may an active role in the brain's ability to clear CNS neurotoxins and metabolites.
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Affiliation(s)
| | - Charlene Gamaldo
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Erik K St Louis
- Center for Sleep Medicine, Departments of Neurology and Medicine, Mayo Clinic College of Medicine and Science, Rochester, MN, USA
| | - Luigi Ferini-Strambi
- Department of Clinical Neurosciences, San Raffaele Scientific Institute, Sleep Disorders Center Università Vita-Salute San Raffaele, Milan, Italy
| | | | - David Salat
- Harvard Medical School, Boston, MA, USA.,Massachusetts General Hospital, Boston, MA, USA
| | | | - Chris Berka
- Advanced Brain Monitoring, Carlsbad, CA, USA
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De Simone R, Ranieri A, Sansone M, Marano E, Russo CV, Saccà F, Bonavita V. Dural sinus collapsibility, idiopathic intracranial hypertension, and the pathogenesis of chronic migraine. Neurol Sci 2019; 40:59-70. [PMID: 30838545 DOI: 10.1007/s10072-019-03775-w] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
Available evidences suggest that a number of known assumption on idiopathic intracranial hypertension (IIH) with or without papilledema might be discussed. These include (1) the primary pathogenetic role of an excessive dural sinus collapsibility in IIH, allowing a new relatively stable intracranial fluids pressure balance at higher values; (2) the non-mandatory role of papilledema for a definite diagnosis; (3) the possibly much higher prevalence of IIH without papilledema than currently considered; (4) the crucial role of the cerebral compliance exhaustion that precede the raise in intracranial pressure and that may already be pathologic in cases showing a moderately elevated opening pressure; (5) the role as "intracranial pressure sensor" played by the trigeminovascular innervation of dural sinuses and cortical bridge veins, which could represent a major source of CGRP and may explain the high comorbidity and the emerging causative link between IIHWOP and chronic migraine (CM). Accordingly, the control of intracranial pressure is to be considered a promising new therapeutic target in CM.
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Affiliation(s)
- Roberto De Simone
- Department of Neuroscience, Reproductive Sciences and Odontostomatology, Headache Centre, University Federico II of Naples, Via Pansini, 5, 80122, Naples, Italy.
| | - Angelo Ranieri
- Division of Neurology and Stroke Unit, Hospital A. Cardarelli, Naples, Italy
| | - Mattia Sansone
- Department of Neuroscience, Reproductive Sciences and Odontostomatology, Headache Centre, University Federico II of Naples, Via Pansini, 5, 80122, Naples, Italy
| | - Enrico Marano
- Department of Neuroscience, Reproductive Sciences and Odontostomatology, Headache Centre, University Federico II of Naples, Via Pansini, 5, 80122, Naples, Italy
| | - Cinzia Valeria Russo
- Department of Neuroscience, Reproductive Sciences and Odontostomatology, Headache Centre, University Federico II of Naples, Via Pansini, 5, 80122, Naples, Italy
| | - Francesco Saccà
- Department of Neuroscience, Reproductive Sciences and Odontostomatology, Headache Centre, University Federico II of Naples, Via Pansini, 5, 80122, Naples, Italy
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Rusbridge C, McFadyen AK, Knower SP. Behavioral and clinical signs of Chiari-like malformation-associated pain and syringomyelia in Cavalier King Charles spaniels. J Vet Intern Med 2019; 33:2138-2150. [PMID: 31290195 PMCID: PMC6766577 DOI: 10.1111/jvim.15552] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2018] [Accepted: 06/19/2019] [Indexed: 02/02/2023] Open
Abstract
Background Diagnosis of Chiari‐like malformation‐associated pain (CM‐P) or clinically relevant syringomyelia (SM) is challenging. We sought to determine common signs. Animals One hundred thirty client‐owned Cavalier King Charles spaniels with neuroaxis magnetic resonance imaging (MRI) and diagnosis of CM‐P/SM. Dogs with comorbidities causing similar signs were excluded with exception of otitis media with effusion (OME). Methods Retrospective study of medical records relating signalment, signs, and MRI findings. Dogs were grouped by SM maximum transverse diameter (1 = no SM; 2 = 0.5‐1.99 mm; 3 = 2‐3.9 mm: 4 = ≥4 mm). Differences between all groups—groups 1 versus 2‐4 and groups 1‐3 versus 4—were investigated. Continuous variables were analyzed using 2‐sample t‐tests and analysis of variance. Associations between categorical variables were analyzed using Fisher's exact or chi‐square tests. Results Common signs were vocalization (65.4%), spinal pain (54.6%), reduced activity (37.7%), reduced stairs/jumping ability (35.4%), touch aversion (30.0%), altered emotional state (28.5%), and sleep disturbance (22%). Head scratching/rubbing (28.5%) was inversely associated with syrinx size (P = .005), less common in group 4 (P = .003), and not associated with OME (P = .977). Phantom scratching, scoliosis, weakness, and postural deficits were only seen in group 4 (SM ≥4 mm; P = .004). Conclusions and Clinical Importance Signs of pain are common in CM/SM but are not SM‐dependent, suggesting (not proving) CM‐P causality. Wide (≥4 mm) SM is associated with signs of myelopathy and, if the dorsal horn is involved, phantom scratching (ipsilateral) and torticollis (shoulder deviated ipsilateral; head tilt contralateral).
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Affiliation(s)
- Clare Rusbridge
- Fitzpatrick Referrals, Surrey, United Kingdom.,School of Veterinary Medicine, Faculty of Health & Medical Sciences, University of Surrey, Surrey, United Kingdom
| | | | - Susan P Knower
- School of Veterinary Medicine, Faculty of Health & Medical Sciences, University of Surrey, Surrey, United Kingdom
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12
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Isolated cerebrospinal fluid hypertension in chronic headache: diagnostic innovations and clinical implications. Neurol Sci 2019; 40:71-74. [PMID: 30900097 DOI: 10.1007/s10072-019-03836-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
Isolated cerebrospinal fluid hypertension (ICH) is a condition of increased cerebrospinal fluid (CSF) pressure in the cranial-spinal compartment without an identifiable cause. Isolated headache is the most common symptom of ICH, while missing may be signs such as papilledema or sixth nerve palsy. This fact makes difficult the clinical diagnosis of headache attributable to ICH in headache sufferers. Another source of confusion stems from the CSF pressure measurement. It has been observed that a single-spot CSF opening pressure measurement may be insufficient to identify elevated CSF pressure in headache sufferers. A new method of CSF pressure measurement has been able to identify pressure-related features of isolated CSF hypertension (ICH). In fact, nocturnal or postural headache and abnormal pressure pulsations are the more common pressure-related features of ICH in patients with chronic headache. The compressive action of these abnormal pressure pulsations causes the periventricular white matter microstructure alterations leading to the focal diffusion tensor imaging findings in patients with ICH. Abnormal pressure pulsations are a marker of ICH in chronic headache. The identification of the CSF pressure-related features may be useful for differentiating headache sufferers with ICH from those with primary headache disorder in clinical practice. The therapeutic strategy in these headache sufferers with ICH includes the CSF removal and a medical treatment.
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Bono F, Curcio M, Rapisarda L, Vescio B, Bombardieri C, Mangialavori D, Aguglia U, Quattrone A. Cerebrospinal Fluid Pressure-Related Features in Chronic Headache: A Prospective Study and Potential Diagnostic Implications. Front Neurol 2018; 9:1090. [PMID: 30619049 PMCID: PMC6305580 DOI: 10.3389/fneur.2018.01090] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2018] [Accepted: 11/28/2018] [Indexed: 11/13/2022] Open
Abstract
Objective: To identify the pressure-related features of isolated cerebrospinal fluid hypertension (ICH) in order to differentiate headache sufferers with ICH from those with primary headache disorder. Methods: In this prospective study, patients with refractory chronic headaches and suspected of having cerebrospinal fluid-pressure elevation without papilledema or sixth nerve palsy, together with controls, underwent 1-h lumbar cerebrospinal fluid pressure monitoring via a spinal puncture needle. Results: We recruited 148 consecutive headache patients and 16 controls. Lumbar cerebrospinal fluid pressure monitoring showed high pressure and abnormal pressure pulsations in 93 (63 %) patients with headache: 37 of these patients with the most abnormal pressure parameters (opening pressure above 250 mm H2O, mean pressure 301 mm H2O, mean peak pressure 398 mm H2O, and severe abnormal pressure pulsations) had the most severe headaches and associated symptoms (nocturnal headache, postural headache, transient visual obscuration); 56 patients with the less abnormal pressure parameters (opening pressure between 200 and 250 mm H2O, mean pressure 228 mm H2O, mean peak pressure 316 mm H2O, and abnormal pressure pulsations) had less severe headaches and associated symptoms. Conclusions: Nocturnal and postural headache, and abnormal pressure pulsations are the more common pressure-related features of ICH in patients with chronic headache. Abnormal pressure pulsations may be considered a marker of ICH in chronic headache.
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Affiliation(s)
- Francesco Bono
- Center for Headache and Intracranial Pressure Disorders, Magna Græcia University, Catanzaro, Italy.,Institute of Neurology, Department of Medical and Surgical Sciences, Magna Græcia University, Catanzaro, Italy
| | - Maria Curcio
- Center for Headache and Intracranial Pressure Disorders, Magna Græcia University, Catanzaro, Italy
| | - Laura Rapisarda
- Center for Headache and Intracranial Pressure Disorders, Magna Græcia University, Catanzaro, Italy
| | - Basilio Vescio
- Neurosciences Research Center, Magna Græcia University, Catanzaro, Italy
| | - Caterina Bombardieri
- Institute of Neuroradiology, Department of Medical and Surgical Sciences, Magna Græcia University, Catanzaro, Italy
| | - Domenica Mangialavori
- Institute of Ophthalmology, Department of Medical and Surgical Sciences, Magna Græcia University, Catanzaro, Italy
| | - Umberto Aguglia
- Institute of Neurology, Department of Medical and Surgical Sciences, Magna Græcia University, Catanzaro, Italy
| | - Aldo Quattrone
- Neurosciences Research Center, Magna Græcia University, Catanzaro, Italy
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Hoffmann J, Mollan SP, Paemeleire K, Lampl C, Jensen RH, Sinclair AJ. European headache federation guideline on idiopathic intracranial hypertension. J Headache Pain 2018; 19:93. [PMID: 30298346 PMCID: PMC6755569 DOI: 10.1186/s10194-018-0919-2] [Citation(s) in RCA: 108] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2018] [Accepted: 09/14/2018] [Indexed: 02/08/2023] Open
Abstract
Background Idiopathic Intracranial Hypertension (IIH) is characterized by an elevation of intracranial pressure (ICP no identifiable cause. The aetiology remains largely unknown, however observations made in a number of recent clinical studies are increasing the understanding of the disease and now provide the basis for evidence-based treatment strategies. Methods The Embase, CDSR, CENTRAL, DARE and MEDLINE databases were searched up to 1st June 2018. We analyzed randomized controlled trials and systematic reviews that investigate IIH. Results Diagnostic uncertainty, headache morbidity and visual loss are among the highest concerns of clinicians and patients in this disease area. Research in this field is infrequent due to the rarity of the disease and the lack of understanding of the underlying pathology. Conclusions This European Headache Federation consensus paper provides evidence-based recommendations and practical advice on the investigation and management of IIH. Electronic supplementary material The online version of this article (10.1186/s10194-018-0919-2) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Jan Hoffmann
- Basic and Clinical Neuroscience, Institute of Psychiatry, Psychology and Neuroscience, Wellcome Foundation Building, Denmark Hill Campus, King's College London, London, SE5 9PJ, UK.
| | - Susan P Mollan
- Birmingham Neuro-Ophthalmology, University Hospitals Birmingham NHS Foundation Trust, Queen Elizabeth Hospital, Birmingham, UK
| | - Koen Paemeleire
- Department of Neurology, Ghent University Hospital, Ghent, Belgium
| | - Christian Lampl
- Headache Medical Centre, Seilerstaette Linz, Ordensklinikum Linz, Barmherzige Schwestern, Linz, Austria
| | - Rigmor H Jensen
- Danish Headache Center, Department of Neurology, Rigshospitalet-Glostrup, University of Copenhagen, Glostrup, Denmark
| | - Alexandra J Sinclair
- Metabolic Neurology, Institute of Metabolism and Systems Research, University of Birmingham, Edgbaston, UK
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15
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Hamedani AG, Witonsky KFR, Cosico M, Rennie R, Xiao R, Sheldon CA, Paley GL, McCormack SE, Liu GW, Friedman DI, Liu GT, Szperka CL. Headache Characteristics in Children With Pseudotumor Cerebri Syndrome, Elevated Opening Pressure Without Papilledema, and Normal Opening Pressure: A Retrospective Cohort Study. Headache 2018; 58:1339-1346. [PMID: 30137653 DOI: 10.1111/head.13362] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2016] [Revised: 08/22/2016] [Accepted: 05/18/2018] [Indexed: 11/27/2022]
Abstract
BACKGROUND Certain headache characteristics and associated symptoms are commonly attributed to increased intracranial pressure, but they have not been systematically studied among children in the context of revised diagnostic criteria for pseudotumor cerebri syndrome (PTCS). METHODS We performed a retrospective cohort study of patients treated for suspected or confirmed PTCS. Charts were reviewed for PTCS and headache diagnostic criteria and associated characteristics. Chi-squared or Fisher's exact tests were used to compare the frequency of headache characteristics between groups. RESULTS One hundred and twenty-seven individuals were identified: 61 had definite PTCS, 10 had probable PTCS, 31 had elevated opening pressure (OP) without papilledema, and 25 had normal OP without papilledema. Eleven children had no headache (6 with definite PTCS, 5 with probable PTCS). Headache pattern was episodic in 49% (95% CI: 34-64%) of those with definite PTCS, 18% (95% CI 6-37%) of those with elevated OP without papilledema, and 16% (5-36%) of those with normal OP without papilledema. Headache location was more likely to involve the head along with neck or shoulders in those with definite PTCS compared with elevated OP without papilledema (OR = 7.2, 95% CI: 1.9-27.6) and normal OP (OR = 4.5, 95% CI: 1.3-15.6) groups. DISCUSSION While missing data and small cohort size are limitations, this study suggests that headache in PTCS is more likely to involve the head along with neck/shoulders, and that headache in PTCS may be episodic or constant. Headache is occasionally absent in PTCS.
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Affiliation(s)
- Ali G Hamedani
- Department of Neurology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Kailyn F R Witonsky
- Division of Neurology, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Mahgenn Cosico
- Division of Neurology, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Robert Rennie
- Division of Neurology, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Riu Xiao
- Department of Biostatistics and Epidemiology, University of Pennsylvania, Philadelphia, PA, USA
| | - Claire A Sheldon
- Neuro-Ophthalmology Service, Division of Ophthalmology, Children's Hospital of Philadelphia, Philadelphia, PA, USA.,Department of Ophthalmology & Visual Sciences, University of British Columbia, Vancouver, CA, Canada
| | - Grace L Paley
- Neuro-Ophthalmology Service, Division of Ophthalmology, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Shana E McCormack
- Division of Endocrinology & Diabetes, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Geraldine W Liu
- Division of Neurology, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Deborah I Friedman
- Department of Neurology & Neurotherapeutics, University of Texas Southwestern Medical Center, Dallas, TX, USA.,Department of Ophthalmology, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Grant T Liu
- Department of Neurology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA.,Neuro-Ophthalmology Service, Division of Ophthalmology, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Christina L Szperka
- Department of Neurology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA.,Division of Neurology, Children's Hospital of Philadelphia, Philadelphia, PA, USA
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16
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Favoni V, Pierangeli G, Toni F, Cirillo L, La Morgia C, Abu-Rumeileh S, Messia M, Agati R, Cortelli P, Cevoli S. Idiopathic Intracranial Hypertension Without Papilledema (IIHWOP) in Chronic Refractory Headache. Front Neurol 2018; 9:503. [PMID: 29997572 PMCID: PMC6029151 DOI: 10.3389/fneur.2018.00503] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2018] [Accepted: 06/08/2018] [Indexed: 01/03/2023] Open
Abstract
Background: To determine the prevalence of Idiopathic intracranial hypertension without papilledema (IIHWOP) testing revised diagnostic criteria by Friedman in refractory chronic headache (CH) patients. Methods: This is a prospective observational study. Each patient underwent ophthalmologic evaluation and Optical Coherence Tomography; brain magnetic resonance venography (MRV) and a lumbar puncture (LP) with opening pressure (OP) measurement. CSF withdrawal was performed in patients with CSF OP > 200 mmH20. IIHWOP was defined according Friedman's diagnostic criteria. Effect of CSF withdrawal was evaluated clinically in a 6-month follow-up and with a MRV study at 1 month. Results: Forty-five consecutive patients were enrolled. Five were excluded due to protocol violations. Analyses were conducted in 40 patients (32 F, 8 M; mean age 49.4 ± 10.8). None had papilledema. Nine patients (22.5%) had OP greater than 200 mmH2O, two of them above 250 mmH2O. Two (5%) had neuroimaging findings suggestive of elevated intracranial pressure. One of them (2.5%) met the newly proposed diagnostic criteria by Friedman for IIHWOP. After CSF withdrawal seven (77.8%) of the nine patients improved. No changes in neuroimaging findings were found. Conclusions: We found a low prevalence (2.5%) of IIHWOP in refractory CH patients according to current diagnostic criteria. In agreement with Friedman's criteria, our results confirm that a diagnosis of IIHWOP should be based on CSF OP and the combination of neuroradiological findings. However, where to set the CSF OP upper limit in IIHWOP needs further field testing. Although IIHWOP is a rare clinical condition, it should be considered and treated in refractory CH patients.
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Affiliation(s)
- Valentina Favoni
- Unità Operativa Complessa Clinica Neurologica, IRCCS Institute of Neurological Sciences of Bologna, Bologna, Italy
- Department of Biomedical and NeuroMotor Sciences, Alma Mater Studiorum–University of Bologna, Bologna, Italy
| | - Giulia Pierangeli
- Unità Operativa Complessa Clinica Neurologica, IRCCS Institute of Neurological Sciences of Bologna, Bologna, Italy
- Department of Biomedical and NeuroMotor Sciences, Alma Mater Studiorum–University of Bologna, Bologna, Italy
| | - Francesco Toni
- Neuroradiology Department, IRCCS Institute of Neurological Sciences of Bologna, Bologna, Italy
| | - Luigi Cirillo
- Neuroradiology Department, IRCCS Institute of Neurological Sciences of Bologna, Bologna, Italy
| | - Chiara La Morgia
- Unità Operativa Complessa Clinica Neurologica, IRCCS Institute of Neurological Sciences of Bologna, Bologna, Italy
- Department of Biomedical and NeuroMotor Sciences, Alma Mater Studiorum–University of Bologna, Bologna, Italy
| | - Samir Abu-Rumeileh
- Unità Operativa Complessa Clinica Neurologica, IRCCS Institute of Neurological Sciences of Bologna, Bologna, Italy
- Department of Biomedical and NeuroMotor Sciences, Alma Mater Studiorum–University of Bologna, Bologna, Italy
| | - Monica Messia
- Neuroradiology Department, IRCCS Institute of Neurological Sciences of Bologna, Bologna, Italy
| | - Raffaele Agati
- Neuroradiology Department, IRCCS Institute of Neurological Sciences of Bologna, Bologna, Italy
| | - Pietro Cortelli
- Unità Operativa Complessa Clinica Neurologica, IRCCS Institute of Neurological Sciences of Bologna, Bologna, Italy
- Department of Biomedical and NeuroMotor Sciences, Alma Mater Studiorum–University of Bologna, Bologna, Italy
| | - Sabina Cevoli
- Unità Operativa Complessa Clinica Neurologica, IRCCS Institute of Neurological Sciences of Bologna, Bologna, Italy
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17
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Eidsvaag VA, Hansson HA, Heuser K, Nagelhus EA, Eide PK. Cerebral microvascular abnormalities in patients with idiopathic intracranial hypertension. Brain Res 2018; 1686:72-82. [PMID: 29477544 DOI: 10.1016/j.brainres.2018.02.017] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2017] [Revised: 01/16/2018] [Accepted: 02/13/2018] [Indexed: 01/01/2023]
Abstract
AIM Idiopathic intracranial hypertension (IIH) is characterized by symptoms indicative of increased intracranial pressure (ICP), such as headache and visual impairment. We have previously reported that brain biopsies from IIH patients show patchy astrogliosis and increased expression of the water channel aquaporin-4 (AQP4) at perivascular astrocytic endfeet. METHODS The present study was undertaken to investigate for ultrastructural changes of the cerebral capillaries in individuals with IIH. We examined by electron microscopy (EM) biopsies from the cortical parenchyma of 10 IIH patients and 8 reference subjects (patients, not healthy individuals), in whom tissue was retrieved from other elective and necessary brain surgeries (epilepsy, tumors or vascular diseases). IIH patients were diagnosed on the basis of typical clinical symptoms and abnormal intracranial pressure wave amplitudes during overnight ICP monitoring. RESULTS All 10 IIH patients underwent shunt surgery followed by favorable clinical outcome. EM revealed abnormal pericyte processes in IIH. The basement membrane (BM) showed more frequently evidence of degeneration in IIH, but neither the BM dimensions nor the pericyte coverage differed between IIH and reference tissue. The BM thickness increased significantly with increasing age. Reference individuals were older than IIH cases; observations may to some extent be age-related. CONCLUSION The present study disclosed marked changes of the cerebral cortical capillaries in IIH patients, suggesting that microvascular alterations are involved in the evolvement of IIH.
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Affiliation(s)
- Vigdis Andersen Eidsvaag
- Department of Neurosurgery, Oslo University Hospital - Rikshospitalet, Oslo, Norway; Institute of Clinical Medicine, Faculty of Medicine, University of Oslo, Oslo, Norway,; Institute of Basic Medical Sciences, University of Oslo, Norway
| | - Hans-Arne Hansson
- Institute of Biomedicine, University of Gothenburg, Göteborg, Sweden
| | - Kjell Heuser
- Department of Neurology, Oslo University Hospital - Rikshospitalet, Oslo, Norway
| | - Erlend A Nagelhus
- Institute of Clinical Medicine, Faculty of Medicine, University of Oslo, Oslo, Norway,; Institute of Basic Medical Sciences, University of Oslo, Norway
| | - Per Kristian Eide
- Department of Neurosurgery, Oslo University Hospital - Rikshospitalet, Oslo, Norway; Institute of Clinical Medicine, Faculty of Medicine, University of Oslo, Oslo, Norway,.
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18
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Hvedstrup J, Radojicic A, Moudrous W, Herklots MW, Wert A, Holzgraefe M, Obermann M, Schoonman GG, Jensen RH, Schytz HW. Intracranial Pressure: A Comparison of the Noninvasive HeadSense Monitor versus Lumbar Pressure Measurement. World Neurosurg 2018; 112:e576-e580. [PMID: 29409948 DOI: 10.1016/j.wneu.2018.01.089] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2017] [Revised: 01/11/2018] [Accepted: 01/12/2018] [Indexed: 01/03/2023]
Abstract
OBJECTIVE To compare a new method of noninvasive intracranial pressure (nICP) measurement with conventional lumbar puncture (LP) opening pressure. METHODS In a prospective multicenter study, patients undergoing LP for diagnostic purposes underwent intracranial pressure measurements with HeadSense, a noninvasive transcranial acoustic device, and indirectly with LP. Noninvasive measurements were conducted with the head in a 30° tilt and in supine position before and after LP. The primary endpoint was the correlation between nICP measurement in supine position before LP and the LP opening pressure. RESULTS There was no correlation between supine nICPs before LP and the LP opening pressures (r = -0.211, P = 0.358). The 30° head-tilt nICPs correlated with the supine nICPs before LP (r = 0.830, P < 0.01). There was no correlation between supine nICPs before and after LP (r = 0.056, P = 0.831) or between 30° head-tilt nICPs and LP opening pressures (r = -0.038, P = 0.861). CONCLUSIONS There was no correlation between nICPs and LP opening pressures. Further development is warranted before transcranial acoustic HeadSense can become a clinical tool for investigating patients with neurologic conditions.
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Affiliation(s)
- Jeppe Hvedstrup
- Headache Diagnostic Laboratory, Danish Headache Center and Department of Neurology, Rigshospitalet-Glostrup, Faculty of Health Sciences, University of Copenhagen, Glostrup, Denmark
| | - Aleksandra Radojicic
- Danish Headache Center and Department of Neurology, Rigshospitalet-Glostrup, Faculty of Health Sciences, University of Copenhagen, Glostrup, Denmark; Neurology Clinic, Clinical Center of Serbia, Belgrade, Serbia
| | - Walid Moudrous
- Department of Neurology, Maasstad Hospital, Rotterdam, The Netherlands
| | | | - Anton Wert
- Center for Neurology, Asklepios Hospitals Schildautal, Seesen, Germany
| | | | - Mark Obermann
- Center for Neurology, Asklepios Hospitals Schildautal, Seesen, Germany; Department of Neurology, University Hospital Essen, University of Duisburg-Essen, Essen, Germany
| | - Guus G Schoonman
- Department of Neurology, Elisabeth-TweeSteden Hospital, Tilburg, The Netherlands
| | - Rigmor Højland Jensen
- Danish Headache Center and Department of Neurology, Rigshospitalet-Glostrup, Faculty of Health Sciences, University of Copenhagen, Glostrup, Denmark
| | - Henrik Winther Schytz
- Headache Diagnostic Laboratory, Danish Headache Center and Department of Neurology, Rigshospitalet-Glostrup, Faculty of Health Sciences, University of Copenhagen, Glostrup, Denmark.
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19
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Haider AS, Graffeo CS, Perry A, Carlstrom LP, Burns TC. Spontaneous Resolution of a Confounding Insular Lesion. Cureus 2018. [PMID: 29541573 PMCID: PMC5844597 DOI: 10.7759/cureus.2053] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Insular gliomas were previously considered inoperable lesions and were typically treated via biopsy, chemotherapy and/or radiation, if not observation alone. Stereotactic biopsies of low grade insular gliomas can underestimate tumor grade or fail to establish malignancy. Moreover, the survival advantages of maximal safe resection for insular lesions are increasingly being recognized. As such, early surgical resection is increasingly being performed. As with most lesions, a differential diagnosis exists for apparent insular gliomas, with definitive diagnosis generally obtained upon resection. We report an illuminating case that presented similarly to an insular glioma undergoing malignant transformation, but resolved spontaneously following a nondiagnostic biopsy. A 53-year-old female patient presented with aphasia and dizziness, followed by syncope and a 30-minute loss-of-consciousness. Imaging findings included a 12 mm region of contrast enhancement and central necrosis within a larger 3.5 cm expansile, T2-hyperintense lesion involving most of the left insula and extending into the anterior left temporal lobe. Imaging was felt most consistent with high-grade glioma. Stereotactic biopsy demonstrated nonspecific gliosis without definitive neoplastic tissue. A systemic workup was unrevealing, and thus an open procedure was subsequently planned in the intraoperative magnetic resonance imaging (MRI) suite. Preoperative MRI demonstrated interval resolution of the original lesion, despite profound T2 hyperintensity along the needle tract; thus, the planned resection was aborted. Subsequent imaging and systemic studies failed to establish a definitive infectious, neoplastic, autoimmune, or other diagnosis. However, poor dentition, history of a recent dental procedure, and the tiny central focus of diffusion restriction on the index MRI rendered abscess the most parsimonious explanation. On follow-up imaging, the lesion was noted to have further resolved without intervention. Our case illustrates the complexity of managing insular lesions and highlights the potential for alternate pathologies that can mimic insular glioma. Additionally, it provides a humbling reminder that, even in the presence of seemingly pathognomonic imaging findings, a differential diagnosis of insular lesions must be thoughtfully considered in patient counseling and presurgical planning.
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20
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Tumani H, Huss A, Bachhuber F. The cerebrospinal fluid and barriers - anatomic and physiologic considerations. HANDBOOK OF CLINICAL NEUROLOGY 2018; 146:21-32. [PMID: 29110772 DOI: 10.1016/b978-0-12-804279-3.00002-2] [Citation(s) in RCA: 110] [Impact Index Per Article: 18.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
The cerebrospinal fluid (CSF) space consists of the intracerebral ventricles, subarachnoid spaces of the spine and brain (e.g., cisterns and sulci), and the central spinal cord canal. The CSF protects the central nervous system (CNS) in different ways involving metabolic homeostasis, supply of nutrients, functioning as lymphatic system, and regulation of intracranial pressure. CSF is produced by the choroid plexus, brain interstitium, and meninges, and it circulates in a craniocaudal direction from ventricles to spinal subarachnoid space from where it is removed via craniocaudal lymphatic routes and the venous system. The CSF is renewed 3-5 times daily and its molecular constituents are mainly blood-derived (80%), while the remainder consists of brain-derived and intrathecally produced molecules (20%). The CSF space is separated from the vascular system by the blood-CSF barrier (BCB), whereas the blood-brain barrier (BBB), responsible for maintaining the homeostasis of the brain, is located between brain parenchyma and vascular system. Although both barriers have similar functions, they differ with regard to their morphologic and functional properties. Both barrier systems are permeable not only for small molecules, but also for macromolecules and circulating cells. The transport of molecules across the BBB and BCB is regulated by passive diffusion (e.g., albumin, immunoglobulins) and facilitated or active transport (e.g., glucose). The extracellular space volume, potassium buffering, CSF circulation, and interstitial fluid absorption are mainly regulated by aquaporin-4 channels, which are abundantly located at the blood-brain and brain-CSF interfaces. The composition of CSF shows a high dynamic range, and the levels of distinct proteins vary due to several influencing factors, such as site of production (brain or blood-derived), site of sampling (ventricular or lumbar), CSF flow rate (BCB function), diurnal fluctuations of CSF production rate, and finally, molecular size of blood-derived proteins (IgM vs. albumin) and circadian rhythm (glucose, prostaglandin D synthase). Alterations of lumbar CSF are mainly influenced by processes of the CNS located adjacent to the ventricular and spinal CSF space and less by pathologies in cortical areas remote from the ventricles.
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Affiliation(s)
- Hayrettin Tumani
- Department of Neurology, University Hospital Ulm, Ulm, Germany; Specialty Hospital of Neurology, Dietenbronn, Schwendi, Germany.
| | - André Huss
- Department of Neurology, University Hospital Ulm, Ulm, Germany
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21
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Hoffmann J. Impaired cerebrospinal fluid pressure. HANDBOOK OF CLINICAL NEUROLOGY 2017; 146:171-185. [PMID: 29110769 DOI: 10.1016/b978-0-12-804279-3.00011-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/24/2023]
Abstract
Abnormalities of cerebrospinal fluid (CSF) pressure are relatively common and may lead to a variety of symptoms, with headache usually being the most prominent one. The clinical presentation of alterations in CSF pressure may vary significantly and show a striking similitude to several primary headache syndromes. While an increase in CSF pressure may be of primary or secondary origin, a pathologic decrease of CSF pressure is usually the result of a meningeal rupture with a resulting leakage of CSF. The pathophysiologic mechanisms of idiopathic intracranial hypertension (IIH) remain largely unknown. However recent evidence indicates that an abnormality in CSF outflow and absorption is likely to play a significant role. Treatment usually consists of a combination of weight loss and a pharmacologic approach using carbonic anhydrase inhibitors. Recent results of the first randomized, double-blind, placebo-controlled trial (RCT) with acetazolamide proved its efficacy in reducing headache and visual disturbances. Clinical evidence suggests efficacy for topiramate and furosemide but no RCT has been conducted to date to confirm these results. In contrast to IIH, spontaneous intracranial hypotension frequently remits spontaneously without specific treatment. If necessary, treatment options range from conservative methods to epidural blood or fibrin sealant patches and surgical interventions.
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Affiliation(s)
- Jan Hoffmann
- Department of Systems Neuroscience, University Medical Center Hamburg-Eppendorf, Hamburg, Germany.
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22
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Lawley JS, Petersen LG, Howden EJ, Sarma S, Cornwell WK, Zhang R, Whitworth LA, Williams MA, Levine BD. Effect of gravity and microgravity on intracranial pressure. J Physiol 2017; 595:2115-2127. [PMID: 28092926 DOI: 10.1113/jp273557] [Citation(s) in RCA: 177] [Impact Index Per Article: 25.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2016] [Accepted: 12/19/2016] [Indexed: 11/08/2022] Open
Abstract
KEY POINTS Astronauts have recently been discovered to have impaired vision, with a presentation that resembles syndromes of elevated intracranial pressure on Earth. Gravity has a profound effect on fluid distribution and pressure within the human circulation. In contrast to prevailing theory, we observed that microgravity reduces central venous and intracranial pressure. This being said, intracranial pressure is not reduced to the levels observed in the 90 deg seated upright posture on Earth. Thus, over 24 h in zero gravity, pressure in the brain is slightly above that observed on Earth, which may explain remodelling of the eye in astronauts. ABSTRACT Astronauts have recently been discovered to have impaired vision, with a presentation that resembles syndromes of elevated intracranial pressure (ICP). This syndrome is considered the most mission-critical medical problem identified in the past decade of manned spaceflight. We recruited five men and three women who had an Ommaya reservoir inserted for the delivery of prophylactic CNS chemotherapy, but were free of their malignant disease for at least 1 year. ICP was assessed by placing a fluid-filled 25 gauge butterfly needle into the Ommaya reservoir. Subjects were studied in the upright and supine position, during acute zero gravity (parabolic flight) and prolonged simulated microgravity (6 deg head-down tilt bedrest). ICP was lower when seated in the 90 deg upright posture compared to lying supine (seated, 4 ± 1 vs. supine, 15 ± 2 mmHg). Whilst lying in the supine posture, central venous pressure (supine, 7 ± 3 vs. microgravity, 4 ± 2 mmHg) and ICP (supine, 17 ± 2 vs. microgravity, 13 ± 2 mmHg) were reduced in acute zero gravity, although not to the levels observed in the 90 deg seated upright posture on Earth. Prolonged periods of simulated microgravity did not cause progressive elevations in ICP (supine, 15 ± 2 vs. 24 h head-down tilt, 15 ± 4 mmHg). Complete removal of gravity does not pathologically elevate ICP but does prevent the normal lowering of ICP when upright. These findings suggest the human brain is protected by the daily circadian cycles in regional ICPs, without which pathology may occur.
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Affiliation(s)
- Justin S Lawley
- Institute for Exercise and Environmental Medicine, Texas Health Presbyterian Dallas, Dallas, TX, USA.,University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Lonnie G Petersen
- Department of Biomedical Sciences, Faculty of Health Sciences, University of Copenhagen, Denmark
| | - Erin J Howden
- Institute for Exercise and Environmental Medicine, Texas Health Presbyterian Dallas, Dallas, TX, USA.,University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Satyam Sarma
- Institute for Exercise and Environmental Medicine, Texas Health Presbyterian Dallas, Dallas, TX, USA.,University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - William K Cornwell
- Institute for Exercise and Environmental Medicine, Texas Health Presbyterian Dallas, Dallas, TX, USA.,University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Rong Zhang
- Institute for Exercise and Environmental Medicine, Texas Health Presbyterian Dallas, Dallas, TX, USA.,University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Louis A Whitworth
- Institute for Exercise and Environmental Medicine, Texas Health Presbyterian Dallas, Dallas, TX, USA
| | - Michael A Williams
- Departments of Neurology and Neurological Surgery, University of Washington School of Medicine, Seattle, WA, USA
| | - Benjamin D Levine
- Institute for Exercise and Environmental Medicine, Texas Health Presbyterian Dallas, Dallas, TX, USA.,University of Texas Southwestern Medical Center, Dallas, TX, USA
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Abstract
AbstractChronic daily headache (CDH) is a multi-faceted, often complex pain syndrome in children and adolescents. Chronic daily headache may be primary or secondary. Chronic migraine and chronic tension-type are the most frequent subtypes. Chronic daily headache is co-morbid with adverse life events, anxiety and depressive disorders, possibly with other psychiatric disorders, other pain syndromes and sleep disorders; these conditions contribute to initiating and maintaining CDH. Hence, early management of episodic headache and treatment of associated conditions are crucial to prevention. There is evidence for the benefit of psychological therapies, principally relaxation and cognitive behavioral, and promising information on acupuncture for CDH. Data on drug treatment are based primarily on open label studies. The controversies surrounding CDH are discussed and proposals for improvement presented. The multifaceted nature of CDH makes it a good candidate for a multi-axial classification system. Such an approach should facilitate biopsychosocial management and enhance consistency in clinical research.
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24
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Mollan SP, Ali F, Hassan-Smith G, Botfield H, Friedman DI, Sinclair AJ. Evolving evidence in adult idiopathic intracranial hypertension: pathophysiology and management. J Neurol Neurosurg Psychiatry 2016; 87:982-92. [PMID: 26888960 PMCID: PMC5013119 DOI: 10.1136/jnnp-2015-311302] [Citation(s) in RCA: 146] [Impact Index Per Article: 18.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/01/2015] [Accepted: 01/19/2016] [Indexed: 01/12/2023]
Abstract
Idiopathic intracranial hypertension (IIH) is a rare but important disease associated with significant morbidity. There is an expected rise in prevalence in line with the escalating global burden of obesity. Modern revisions in the terminology and diagnostic criteria for IIH help guide clinicians in investigations and researchers in standardising recruitment criteria for clinical trials. The pathophysiology of IIH is incompletely characterised; suggested underpinning mechanisms include the role of cerebrospinal fluid regulation as well as metabolic and endocrinological perspectives. Recent treatment trials are providing insights into the management but debate still surrounds key areas in treatment. This review will provide an up-to-date discussion on the potential pathogenic mechanisms and management of IIH.
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Affiliation(s)
- Susan P Mollan
- Birmingham Neuro-Ophthalmology Unit, Ophthalmology Department, University Hospitals Birmingham NHS Trust, Queen Elizabeth Hospital Birmingham, Birmingham, UK
| | - Fizzah Ali
- Neurometabolism, Institute of Metabolism and Systems Research, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
| | - Ghaniah Hassan-Smith
- Neurometabolism, Institute of Metabolism and Systems Research, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK Neurology Department, University Hospitals Birmingham NHS Trust, Queen Elizabeth Hospital Birmingham, Birmingham, UK
| | - Hannah Botfield
- Neurometabolism, Institute of Metabolism and Systems Research, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
| | - Deborah I Friedman
- Department of Neurology and Neurotherapeutics, University of Texas Southwestern Medical Center, Dallas, Texas, USA Department of Ophthalmology, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Alexandra J Sinclair
- Neurometabolism, Institute of Metabolism and Systems Research, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK Neurology Department, University Hospitals Birmingham NHS Trust, Queen Elizabeth Hospital Birmingham, Birmingham, UK
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Horcajadas Almansa A, Román Cutillas A, Jorques Infante A, Ruiz Gómez J, Busquier H. [Idiopathic intracranial hypertension and spontaneous cerebrospinal fluid fistula. Usefulness of intracranial pressure monitoring]. Neurocirugia (Astur) 2016; 28:93-96. [PMID: 27445081 DOI: 10.1016/j.neucir.2016.06.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2016] [Revised: 06/08/2016] [Accepted: 06/19/2016] [Indexed: 10/21/2022]
Abstract
Spontaneous cerebrospinal fluid (CSF) fistulas are rather common in daily practice. The aim of the surgical treatment is closure of the leak, but recurrences are quite frequent. The association between spontaneous CSF fistulas and idiopathic intracranial hypertension (IIH) is not uncommon, and this is probably the cause of the low rate of success of the surgical treatment. Symptoms of IIH associated with spontaneous CSF fistula are atypical, and diagnosis is often missed. Continuous intracranial pressure monitoring is very useful in the diagnosis of chronic IIH and in patients with spontaneous CSF fistula, as it helps in making decisions on the treatment of these patients.
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Affiliation(s)
| | | | | | - José Ruiz Gómez
- Servicio de Otorrinolaringología, Hospital Vithas La Salud, Granada, España
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Abstract
Context The classification of headache disorders has improved over the years, but further work is needed to develop and improve headache diagnosis within headache subtypes. The present review is a call for action to implement laboratory tests in the classification and management of primary and some secondary headaches. Background In this narrative review we present and discuss published tests that might be useful in phenotyping and/or diagnosis of long-lasting headache disorders such as migraine, tension-type headache, trigeminal autonomic cephalalgias, trigeminal neuralgia and persisting secondary headaches. Aim The palpometer test, quantitative sensory testing, nociceptive blink reflex and autonomic tests may be valuable to phenotype and/or diagnose subforms of migraine, tension-type headache, cluster headache, trigeminal neuralgia and medication-overuse headache. Provocation tests with glyceryl trinitrate (GTN) and calcitonin gene-related peptide (CGRP) may be valuable in subclassification of migraine and cluster headache. Lumbar pressure monitoring and optical coherence tomography may valuable tools to diagnose and follow patients with chronic headache and raised intracranial pressure. Finding A number of laboratory tests in headache research are presently available, but have primarily been performed in single research studies or a few studies that differ in methods and patient groups. At present, there is no evidence-based strategy for implementing diagnostic tests, but this could be achieved if well-reputed tertiary headache centers commence developing and implementing laboratory tests in order to improve the classification and treatment of headache patients.
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Affiliation(s)
- Henrik Winther Schytz
- University of Copenhagen, Danish Headache Centre, Department of Neurology at Glostrup Hospital, Denmark
| | - Jes Olesen
- University of Copenhagen, Danish Headache Centre, Department of Neurology at Glostrup Hospital, Denmark
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Eide PK, Ringstad G. Increased pulsatile intracranial pressure in patients with symptomatic pineal cysts and magnetic resonance imaging biomarkers indicative of central venous hypertension. J Neurol Sci 2016; 367:247-55. [PMID: 27423599 DOI: 10.1016/j.jns.2016.06.028] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2016] [Revised: 05/11/2016] [Accepted: 06/10/2016] [Indexed: 11/28/2022]
Abstract
BACKGROUND In symptomatic individuals with non-hydrocephalic pineal cysts (PCs), it remains controversial what causes the symptoms. Based on magnetic resonance imaging (MRI) biomarkers, we proposed that PC-associated crowding of the pineal recess may cause central venous hypertension. The aim of this study was to compare pulsatile and static ICP in patients with PCs and chronic daily headache (CDH), and compare ICP data in PC patients with the previously identified MRI biomarkers. METHODS All patients assessed with over-night ICP monitoring for PCs or CDH who had been ruled out for idiopathic intracranial hypertension without papilledema (IIHWOP) were retrieved from the database. The symptoms as well as the pulsatile and static ICP scores were compared between the PC and CDH patients, and ICP scores were compared with the MRI biomarkers indicative of central venous hypertension. RESULTS The pulsatile ICP was significantly increased in the symptomatic patients with non-hydrocephalic PCs as compared to the CDH patients. Pulsatile ICP was significantly increased in the individuals with PC-grades 3-4, who had MRI biomarkers indicative of central venous hypertension. The tectum-splenium-cyst ratio correlated positively with pulsatile ICP and an index of thalamic edema. CONCLUSIONS Pulsatile ICP is increased in symptomatic patients with PCs and imaging evidence of central venous hypertension, supporting the hypothesis that PC-induced crowding of the pineal recess and venous obstruction may cause a central venous hypertension syndrome.
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Affiliation(s)
- Per Kristian Eide
- Dept. of Neurosurgery, Oslo University Hospital-Rikshospitalet, Oslo, Norway; Faculty of Medicine, University of Oslo, Oslo, Norway.
| | - Geir Ringstad
- Dept. of Radiology and Nuclear Medicine, Oslo University Hospital- Rikshospitalet, Oslo, Norway
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Eide PK, Eidsvaag VA, Nagelhus EA, Hansson HA. Cortical astrogliosis and increased perivascular aquaporin-4 in idiopathic intracranial hypertension. Brain Res 2016; 1644:161-75. [PMID: 27188961 DOI: 10.1016/j.brainres.2016.05.024] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2016] [Revised: 04/07/2016] [Accepted: 05/12/2016] [Indexed: 01/15/2023]
Abstract
The syndrome idiopathic intracranial hypertension (IIH) includes symptoms and signs of raised intracranial pressure (ICP) and impaired vision, usually in overweight persons. The pathogenesis is unknown. In the present prospective observational study, we characterized the histopathological changes in biopsies from the frontal brain cortical parenchyma obtained from 18 IIH patients. Reference specimens were sampled from 13 patients who underwent brain surgery for epilepsy, tumors or acute vascular diseases. Overnight ICP monitoring revealed abnormal intracranial pressure wave amplitudes in 14/18 IIH patients, who underwent shunt surgery and all responded favorably. A remarkable histopathological observation in IIH patients was patchy astrogliosis defined as clusters of hypertrophic astrocytes enclosing a nest of nerve cells. Distinct astrocyte domains (i.e. no overlap between astrocyte processes) were lacking in most IIH biopsy specimens, in contrast to their prevalence in reference specimens. Evidence of astrogliosis in IIH was accompanied with significantly increased aquaporin-4 (AQP4) immunoreactivity over perivascular astrocytic endfeet, compared to the reference specimens, measured with densitometry. Scattered CD68 immunoreactive cells (activated microglia and macrophages) were recognized, indicative of some inflammation. No apoptotic cells were demonstrable. We conclude that the patchy astrogliosis is a major finding in patients with IIH. We propose that the astrogliosis impairs intracranial pressure-volume reserve capacity, i.e. intracranial compliance, and contributes to the IIH by restricting the outflow of fluid from the cranium. The increased perivascular AQP4 in IIH may represent a compensatory mechanism to enhance brain fluid drainage.
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Affiliation(s)
- Per Kristian Eide
- Department of Neurosurgery, Oslo University Hospital - Rikshospitalet, Oslo, Norway; Faculty of Medicine, University of Oslo, Oslo, Norway.
| | - Vigdis Andersen Eidsvaag
- Department of Neurosurgery, Oslo University Hospital - Rikshospitalet, Oslo, Norway; Institute of Basic Medical Sciences, University of Oslo, Norway
| | - Erlend A Nagelhus
- Faculty of Medicine, University of Oslo, Oslo, Norway; Institute of Basic Medical Sciences, University of Oslo, Norway
| | - Hans-Arne Hansson
- Institute of Biomedicine, University of Gothenburg, Göteborg, Sweden
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Lang EW, Kasprowicz M, Smielewski P, Pickard J, Czosnyka M. Changes in Cerebral Partial Oxygen Pressure and Cerebrovascular Reactivity During Intracranial Pressure Plateau Waves. Neurocrit Care 2016; 23:85-91. [PMID: 25501688 DOI: 10.1007/s12028-014-0074-9] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
BACKGROUND Plateau waves in intracranial pressure (ICP) are frequently recorded in neuro intensive care and are not yet fully understood. To further investigate this phenomenon, we analyzed partial pressure of cerebral oxygen (pbtO2) and a moving correlation coefficient between ICP and mean arterial blood pressure (ABP), called PRx, along with the cerebral oxygen reactivity index (ORx), which is a moving correlation coefficient between cerebral perfusion pressure (CPP) and pbtO2 in an observational study. METHODS We analyzed 55 plateau waves in 20 patients after severe traumatic brain injury. We calculated ABP, ABP pulse amplitude (ampABP), ICP, CPP, pbtO2, heart rate (HR), ICP pulse amplitude (ampICP), PRx, and ORx, before, during, and after each plateau wave. The analysis of variance with Bonferroni post hoc test was used to compare the differences in the variables before, during, and after the plateau wave. We considered all plateau waves, even in the same patient, independent because they are separated by long intervals. RESULTS We found increases for ICP and ampICP according to our operational definitions for plateau waves. PRx increased significantly (p = 0.00026), CPP (p < 0.00001) and pbtO2 (p = 0.00007) decreased significantly during the plateau waves. ABP, ampABP, and HR remained unchanged. PRx during the plateau was higher than before the onset of wave in 40 cases (73 %) with no differences in baseline parameters for those with negative and positive ΔPRx (difference during and after). ORx showed an increase during and a decrease after the plateau waves, however, not statistically significant. PbtO2 overshoot after the wave occurred in 35 times (64 %), the mean difference was 4.9 ± 4.6 Hg (mean ± SD), and we found no difference in baseline parameters between those who overshoot and those who did not overshoot. CONCLUSIONS Arterial blood pressure remains stable in ICP plateau waves, while cerebral autoregulatory indices show distinct changes, which indicate cerebrovascular reactivity impairment at the top of the wave. PbtO2 decreases during the waves and may show a slight overshoot after normalization. We assume that this might be due to different latencies of the cerebral blood flow and oxygen level control mechanisms. Other factors may include baseline conditions, such as pre-plateau wave cerebrovascular reactivity or pbtO2 levels, which differ between studies.
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Affiliation(s)
- Erhard W Lang
- Neurosurgical Associates, Red Cross Hospital, Bergmannstrasse 30, 34121, Kassel, Germany,
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Lawley JS, Levine BD, Williams MA, Malm J, Eklund A, Polaner DM, Subudhi AW, Hackett PH, Roach RC. Cerebral spinal fluid dynamics: effect of hypoxia and implications for high-altitude illness. J Appl Physiol (1985) 2016; 120:251-62. [DOI: 10.1152/japplphysiol.00370.2015] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2015] [Accepted: 08/17/2015] [Indexed: 12/24/2022] Open
Abstract
The pathophysiology of acute mountain sickness and high-altitude cerebral edema, the cerebral forms of high-altitude illness, remain uncertain and controversial. Persistently elevated or pathological fluctuations in intracranial pressure are thought to cause symptoms similar to those reported by individuals suffering cerebral forms of high-altitude illness. This review first focuses on the basic physiology of the craniospinal system, including a detailed discussion of the long-term and dynamic regulation of intracranial pressure. Thereafter, we critically examine the available literature, based primarily on invasive pressure monitoring, that suggests intracranial pressure is acutely elevated at altitude due to brain swelling and/or elevated sagittal sinus pressure, but normalizes over time. We hypothesize that fluctuations in intracranial pressure occur around a slightly elevated or normal mean intracranial pressure, in conjunction with oscillations in arterial Po2 and arterial blood pressure. Then these modest fluctuations in intracranial pressure, in concert with direct vascular stretch due to dilatation and/or increased blood pressure transmission, activate the trigeminal vascular system and cause symptoms of acute mountain sickness. Elevated brain water (vasogenic edema) may be due to breakdown of the blood-brain barrier. However, new information suggests cerebral spinal fluid flux into the brain may be an important factor. Regardless of the source (or mechanisms responsible) for the excess brain water, brain swelling occurs, and a “tight fit” brain would be a major risk factor to produce symptoms; activities that produce large changes in brain volume and cause fluctuations in blood pressure are likely contributing factors.
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Affiliation(s)
- Justin S. Lawley
- Institute for Exercise and Environmental Medicine, Presbyterian Hospital of Dallas, Dallas, Texas
- UT Southwestern Medical Center, Dallas, Texas
| | - Benjamin D. Levine
- Institute for Exercise and Environmental Medicine, Presbyterian Hospital of Dallas, Dallas, Texas
- UT Southwestern Medical Center, Dallas, Texas
| | - Michael A. Williams
- Sandra and Malcolm Berman Brain & Spine Institute, Dept. of Neurology, Sinai Hospital, Baltimore, Maryland
| | - Jon Malm
- Department of Clinical Neuroscience, Umeå University, Umeå, Sweden
| | - Anders Eklund
- Department of Radiation Sciences, Umeå University, Umeå, Sweden
| | - David M. Polaner
- Departments of Anesthesiology and Pediatrics, University of Colorado School of Medicine and Children's Hospital Colorado, Aurora, Colorado
| | - Andrew W. Subudhi
- Department of Biology, University of Colorado, Colorado Springs, Colorado
- Altitude Research Center, Department of Emergency Medicine, University of Colorado Anschutz Medical Campus, Aurora, Colorado; and
| | | | - Robert C. Roach
- Altitude Research Center, Department of Emergency Medicine, University of Colorado Anschutz Medical Campus, Aurora, Colorado; and
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The Role of the Craniocervical Junction in Craniospinal Hydrodynamics and Neurodegenerative Conditions. Neurol Res Int 2015; 2015:794829. [PMID: 26770824 PMCID: PMC4681798 DOI: 10.1155/2015/794829] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2015] [Revised: 09/07/2015] [Accepted: 09/17/2015] [Indexed: 02/07/2023] Open
Abstract
The craniocervical junction (CCJ) is a potential choke point for craniospinal hydrodynamics and may play a causative or contributory role in the pathogenesis and progression of neurodegenerative diseases such as Alzheimer's disease, Parkinson's disease, MS, and ALS, as well as many other neurological conditions including hydrocephalus, idiopathic intracranial hypertension, migraines, seizures, silent-strokes, affective disorders, schizophrenia, and psychosis. The purpose of this paper is to provide an overview of the critical role of the CCJ in craniospinal hydrodynamics and to stimulate further research that may lead to new approaches for the prevention and treatment of the above neurodegenerative and neurological conditions.
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Horcajadas Almansa A, Cordero Tous N, Román Cutillas A, Saura Rojas E, Jorques Infante A, Iáñez Velasco B, Sánchez Corral C. Utilidad de la monitorización de la presión intracraneal en pacientes con sospecha de hipertensión intracraneal benigna. Neurocirugia (Astur) 2015; 26:157-66. [DOI: 10.1016/j.neucir.2014.11.010] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2013] [Revised: 06/10/2014] [Accepted: 11/08/2014] [Indexed: 11/25/2022]
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Ranieri A, Topa A, Cavaliere M, De Simone R. Recurrent epistaxis following stabbing headache responsive to acetazolamide. Neurol Sci 2015; 35 Suppl 1:181-3. [PMID: 24867862 DOI: 10.1007/s10072-014-1766-9] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
The co-occurrence of epistaxis and headache is not uncommon in migraine patients, although only few case reports have been published. A trigeminovascular activation may be causally involved although the exact mechanisms linking epistaxis and migraine remain unclear. Significant dural sinus stenosis may sustain or worsen an increased cerebral venous pressure and is considered a radiological predictor of idiopathic intracranial hypertension. We report a 49-year-old female patient with chronic migraine associated to stabbing headache-like attacks followed by epistaxis and by the resolution or the significant improvement of pain. As she also reported adjunctive symptoms suggestive of raised intracranial pressure and showed a bilateral narrowing of transverse sinuses at MR-venography, a possible intracranial hypertension was hypothesized despite the lack of papilledema. Acetazolamide 250 mg twice/day was added to therapy and the patient reported sudden reduction of headache severity and frequency and complete resolution of both the stabbing pain and the recurrent epistaxis, maintained for 5 months. At treatment discontinuation she complained the worsening of migraine headache and the reoccurrence of the superimposed stabbing pain followed by epistaxis. The mechanism linking the sequential occurrence of painful stabs, epistaxis and relief from pain with raised intracranial pressure in our patients remains unclear. We speculate that the sudden reopening of collapsed collateral veins of the anterior venous circle, possibly prompted by periodic waves of central venous hypertension coupled with intracranial hypertensive peaks, could explain the unusual strict time succession of painful stabs, epistaxis, and subsequent resolution of pain.
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Affiliation(s)
- A Ranieri
- Department of Neurosciences, Reproductive Sciences and Odontostomatology, University "Federico II" of Naples, Naples, Italy
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Lawley JS, Alperin N, Bagci AM, Lee SH, Mullins PG, Oliver SJ, Macdonald JH. Normobaric hypoxia and symptoms of acute mountain sickness: Elevated brain volume and intracranial hypertension. Ann Neurol 2014; 75:890-8. [PMID: 24788400 DOI: 10.1002/ana.24171] [Citation(s) in RCA: 42] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2014] [Revised: 04/24/2014] [Accepted: 04/27/2014] [Indexed: 01/31/2023]
Abstract
OBJECTIVE The study was undertaken to determine whether normobaric hypoxia causes elevated brain volume and intracranial pressure in individuals with symptoms consistent with acute mountain sickness (AMS). METHODS Thirteen males age = (26 (sd 6)) years were exposed to normobaric hypoxia (12% O2 ) and normoxia (21% O2 ). After 2 and 10 hours, AMS symptoms were assessed alongside ventricular and venous vessel volumes, cerebral blood flow, regional brain volumes, and intracranial pressure, using high-resolution magnetic resonance imaging. RESULTS In normoxia, neither lateral ventricular volume (R(2) = 0.07, p = 0.40) nor predominance of unilateral transverse venous sinus drainage (R(2) = 0.07, p = 0.45) was related to AMS symptoms. Furthermore, despite an increase in cerebral blood flow after 2 hours of hypoxia (hypoxia vs normoxia: Δ148ml/min(-1) , 95% confidence interval [CI] = 58 to 238), by 10 hours, when AMS symptoms had developed, cerebral blood flow was normal (Δ-51ml/min(-1) , 95% CI = -141 to 39). Conversely, at 10 hours brain volume was increased (Δ59ml, 95% CI = 8 to 110), predominantly due to an increase in gray matter volume (Δ73ml, 95% CI = 25 to 120). Therefore, cerebral spinal fluid volume was decreased (Δ-40ml, 95% CI = -67 to -14). The intracranial pressure response to hypoxia varied between individuals, and as hypothesized, the most AMS-symptomatic participants had the largest increases in intracranial pressure (AMS present, Δ7mmHg, 95% CI = -2.5 to 17.3; AMS not present, Δ-1mmHg, 95% CI = -3.3 to 0.5). Consequently, there was a significant relationship between the change in intracranial pressure and AMS symptom severity (R(2) = 0.71, p = 0.002). INTERPRETATION The data provide the strongest evidence to date to support the hypothesis that the "random" nature of AMS symptomology is explained by a variable intracranial pressure response to hypoxia.
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Affiliation(s)
- Justin S Lawley
- Extremes Research Group, School of Sport, Health, and Exercise Sciences, Bangor University, Gwynedd, United Kingdom; Institute for Exercise and Environmental Medicine, Presbyterian Hospital of Dallas, Dallas, TX
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Intracranial pressure in unresponsive chronic migraine. J Neurol 2014; 261:1365-73. [PMID: 24781838 PMCID: PMC4097326 DOI: 10.1007/s00415-014-7355-2] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2013] [Revised: 03/01/2014] [Accepted: 04/13/2014] [Indexed: 11/17/2022]
Abstract
To assess the prevalence and possible pathogenetic involvement of raised intracranial pressure in patients presenting with unresponsive chronic migraine (CM), we evaluated the intracranial opening pressure (OP) and clinical outcome of a single cerebrospinal fluid withdrawal by lumbar puncture in 44 consecutive patients diagnosed with unresponsive chronic/transformed migraine and evidence of sinus stenosis at magnetic resonance venography. The large majority of patients complained of daily or near-daily headache. Thirty-eight (86.4 %) had an OP >200 mmH2O. Lumbar puncture-induced normalization of intracranial pressure resulted in prompt remission of chronic pain in 34/44 patients (77.3 %); and an episodic pattern of headache was maintained for 2, 3 and 4 months in 24 (54.6 %), 20 (45.4 %) and 17 (38.6 %) patients, respectively. The medians of overall headache days/month and of disabling headache days/month significantly decreased (p < 0.0001) at each follow-up versus baseline. Despite the absence of papilledema, 31/44 (70.5 %) patients fulfilled the ICHD-II criteria for “Headache attributed to Intracranial Hypertension”. Our findings indicate that most patients diagnosed with unresponsive CM in specialized headache clinics may present an increased intracranial pressure involved in the progression and refractoriness of pain. Moreover, a single lumbar puncture with cerebrospinal fluid withdrawal results in sustained remission of chronic pain in many cases. Prospective controlled studies are needed before this procedure can be translated into clinical practice. Nonetheless, we suggest that intracranial hypertension without papilledema should be considered in all patients with almost daily migraine pain, with evidence of sinus stenosis, and unresponsive to medical treatment referred to specialized headache clinics.
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Larimer P, McDermott MW, Scott BJ, Shih TT, Poisson SN. Recurrent syncope due to refractory cerebral venous sinus thrombosis and transient elevations of intracranial pressure. Neurohospitalist 2014; 4:18-21. [PMID: 24381706 DOI: 10.1177/1941874413493183] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Chronic paroxysmal intracranial hypertension leading to syncope is a phenomenon not reported previously in patients with refractory cerebral venous sinus thrombosis. We report a case of paroxysmal intracranial hypertension leading to syncopal episodes in a patient with idiopathic autoimmune hemolytic anemia and venous sinus thrombosis. This case demonstrates that intermittent elevations in intracranial pressure can lead to syncope in patients with venous sinus thrombosis and emphasizes the importance of considering this potentially treatable etiology of syncopal episodes.
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Affiliation(s)
- P Larimer
- Department of Neurology, University of California San Francisco, San Francisco, CA, USA
| | - M W McDermott
- Department of Neurological Surgery, University of California San Francisco, San Francisco, CA, USA
| | - B J Scott
- Department of Neurology, University of California San Francisco, San Francisco, CA, USA
| | - T T Shih
- Department of Neurology, University of California San Francisco, San Francisco, CA, USA
| | - S N Poisson
- Department of Neurology, University of California San Francisco, San Francisco, CA, USA ; Department of Neurology, University of Colorado, Denver, CO, USA
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Abstract
PURPOSE OF REVIEW The aim of this article is to review recent findings on the pathophysiology of idiopathic changes in intracranial pressure. The review will focus on idiopathic intracranial hypertension (IIH) and spontaneous intracranial hypotension (SIH). RECENT FINDINGS Substantial evidence indicates that IIH is associated with delayed absorption of cerebrospinal fluid (CSF). Stenoses of the transverse sinus are common in IIH, but their clinical significance has not been entirely clarified. Despite the observed efficacy of endovascular treatment in some IIH patients, a correlation between the extent of observed stenoses and the clinical course of the disease could not be demonstrated. The underlying cause of SIH is a spontaneous CSF leakage into the epidural space. Conservative treatment and the epidural blood patch remain the treatment of choice for this rare syndrome. SUMMARY Recent clinical evidence indicates that IIH is probably a result of CSF outflow abnormality rather than of CSF production. Further research is needed to elucidate the causes of elevated intracranial pressure and the mechanism leading to visual loss. Prospective randomized clinical trials are needed to clarify a possible therapeutic potential of endovascular treatment. Research efforts on SIH should focus further on associated connective tissue disorders predisposing to CSF leaks.
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Batra R, Sinclair A. Idiopathic intracranial hypertension; research progress and emerging themes. J Neurol 2013; 261:451-60. [PMID: 24085346 DOI: 10.1007/s00415-013-7019-7] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2013] [Revised: 06/19/2013] [Accepted: 06/20/2013] [Indexed: 12/29/2022]
Abstract
Idiopathic intracranial hypertension (IIH) is a condition characterised by increased intracranial pressure of unknown cause predominantly seen in obese women of childbearing age and associated with a history of recent weight gain. The aetiology is poorly understood and there are no evidence-based guidelines on the management of the disease. We aim to provide a review of the recent literature outlining the latest advances in this field over the past few years. Areas of emerging interest related to the pathophysiology of IIH will be discussed, such as the role of obesity, adipose tissue and 11β-hydroxysteroid dehydrogenase type 1. We consider the latest research on the role of venous sinus stenosis in IIH and ex vivo advances into cerebrospinal fluid drainage via the arachnoid granulation tissue. The latest techniques for optic nerve head evaluation and the role of optical coherence tomography will be summarised. Finally, we will discuss recent advances in the management of IIH, including weight loss, and medical and surgical treatment strategies.
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Affiliation(s)
- Ruchika Batra
- Birmingham Neuro-ophthalmology Unit, University Hospital Birmingham, Mindelsohn Way, Edgbaston, Birmingham, B15 2WB, UK,
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Stevens SA, Thakore NJ, Lakin WD, Penar PL, Tranmer BI. A modeling study of idiopathic intracranial hypertension: etiology and diagnosis. Neurol Res 2013; 29:777-86. [PMID: 17553215 DOI: 10.1179/016164107x208112] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022]
Abstract
OBJECTIVE To investigate the relationship between idiopathic intracranial hypertension (IIH) and transverse sinus stenosis through experiments performed on a validated mathematical model. METHODS A mathematical model of intracranial pressure (ICP) dynamics has been extended to accommodate venous sinus compression through the introduction of a Starling-like resistor between the sagittal and transverse sinuses. RESULTS In the absence of this type of resistor, the sinuses are rigid, and the model has only a unique, stable steady state with normal pressures. With resistance a function of the external pressure on the sinus, a second stable steady state may exist. This state is characterized by elevated ICP concurrent with a compressed transverse sinus. Simulations predict that a temporary perturbation that causes a transient elevation of ICP can induce a permanent transition from the normal to the higher steady state. Comparisons to clinical data from IIH patients provide supporting evidence for the validity of the model's predictions. Simulations suggest a possible clinical diagnostic technique to determine if an individual has a compressible transverse sinus and is at risk for developing IIH. CONCLUSIONS Results of the model experiments suggest that the primary cause of IIH may be a compressible, as opposed to rigid, transverse sinus, and that the observed stenosis is a necessary characteristic of the elevated pressure state.
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Affiliation(s)
- Scott A Stevens
- Division of Information Technology and Sciences, Champlain College, Burlington, VT 05402-0670, USA
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Allen KP, Perez CL, Kutz JW, Gerecci D, Roland PS, Isaacson B. Elevated intracranial pressure in patients with spontaneous cerebrospinal fluid otorrhea. Laryngoscope 2013; 124:251-4. [PMID: 23775147 DOI: 10.1002/lary.24251] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2013] [Revised: 05/22/2013] [Accepted: 05/22/2013] [Indexed: 11/11/2022]
Abstract
OBJECTIVES/HYPOTHESIS To determine the prevalence of elevated intracranial hypertension in patients with spontaneous cerebrospinal fluid otorrhea (SCSFO). STUDY DESIGN Case series with chart review at a tertiary care academic medical center following institutional review board approval. METHODS A retrospective review was performed of patients undergoing operative repair of SCSFO between January 2007 and May 2012. RESULTS Thirty-eight patients underwent operative repair of SCSFO. Of these, 22 underwent postoperative lumbar puncture with measurement of opening pressure. The opening pressure was elevated (> 20 cm/H2 0) in eight patients (36.4%). Preoperative magnetic resonance imaging was available for review by a neuroradiologist in 27 patients. Radiographic evidence of elevated intracranial pressure (ICP) was present in 48.1% of patients. CONCLUSION Elevated ICP is common in patients with SCSFO. However, as only a minority of patients have elevated ICP, it is not the sole factor in the development of SCSFO.
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Affiliation(s)
- Kyle P Allen
- Department of Otolaryngology-Head and Neck Surgery, University of Texas Southwestern Medical Center, Dallas, Texas, U.S.A
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Peng KP, Fuh JL, Wang SJ. High-pressure headaches: idiopathic intracranial hypertension and its mimics. Nat Rev Neurol 2012; 8:700-10. [DOI: 10.1038/nrneurol.2012.223] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
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De Simone R, Ranieri A, Montella S, Marchese M, Bonavita V. Sinus venous stenosis-associated idiopathic intracranial hypertension without papilledema as a powerful risk factor for progression and refractoriness of headache. Curr Pain Headache Rep 2012; 16:261-9. [PMID: 22382759 DOI: 10.1007/s11916-012-0254-2] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Data from two recent studies strongly support the hypothesis that idiopathic intracranial hypertension without papilledema (IIHWOP) could represent a powerful risk factor for the progression of pain in primary headache individuals. The first study highlights that an asymptomatic IIHWOP is much more prevalent than believed in the general population and occurs only in central venous stenosis carriers. In the second study, about one half of a large consecutive series of unresponsive primary chronic headache patients shows significant sinus venous stenosis. A continuous or intermittent IIHWOP was detectable in 91% of this subgroup and in no patient with normal venography. Moreover, after the lumbar puncture, a 2- to 4-week improvement in headache frequency was observed in most of the intracranial hypertensive patients. These findings strongly suggest that patients prone to primary headache who carry central venous outflow abnormalities are at high risk of developing a comorbid IIHWOP, which in turn is responsible for the progression and the unresponsiveness of the pain. Based on the available literature data, we propose that central sinus stenosis-related IIHWOP, although highly prevalent among otherwise healthy people, represents an important modifiable risk factor for the progression and refractoriness of pain in patients predisposed to primary headache. The mechanism could refer to up to one half of the primary chronic headache patients with minimal response to treatments referring to specialized headache clinics. Due to the clinical and taxonomic relevance of this hypothesis further studies are urgently needed.
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Affiliation(s)
- Roberto De Simone
- Department of Neurological Sciences, University Federico II of Naples, Via Sergio Pansini 5, Naples, Italy.
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[Headache from increased cerebrospinal fluid pressure]. Schmerz 2012; 26:331-40; quiz 341. [PMID: 22760466 DOI: 10.1007/s00482-012-1187-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
Increased cerebrospinal fluid (CSF) pressure is often accompanied by headache. The term idiopathic intracranial hypertension (pseudotumor cerebri) describes an increase in CSF pressure without a space-occupying intracranial lesion or hydrocephalus. After headaches, visual field defects are the second most common feature. Therapeutic measures include both drugs and surgical procedures. In high-pressure hydrocephalus, the volume of the CSF is increased, resulting either from increased production or reduced absorption. If an acquired or congenital obstruction of the ventricular system can be demonstrated, the term non-communicating hydrocephalus is used. In contrast, the CSF passage is blocked outside the ventricles in communicating hydrocephalus. Symptoms include diffuse headache worsening in the morning and with the Valsalva-like maneuver. Treatment is guided by etiology whenever possible; otherwise, drainage of CSF by ventriculostomy or shunt is necessary.
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Diagnostic value of optical coherence tomography for intracranial pressure in idiopathic intracranial hypertension. Graefes Arch Clin Exp Ophthalmol 2012; 251:567-74. [DOI: 10.1007/s00417-012-2039-z] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2012] [Revised: 04/02/2012] [Accepted: 04/10/2012] [Indexed: 10/28/2022] Open
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Simone RD, Ranieri A, Cardillo G, Bonavita V. High prevalence of bilateral transverse sinus stenosis-associated IIHWOP in unresponsive chronic headache sufferers: Pathogenetic implications in primary headache progression. Cephalalgia 2011; 31:763-5. [DOI: 10.1177/0333102411399350] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
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Eide PK, Kerty E. Static and pulsatile intracranial pressure in idiopathic intracranial hypertension. Clin Neurol Neurosurg 2010; 113:123-8. [PMID: 21075509 DOI: 10.1016/j.clineuro.2010.10.008] [Citation(s) in RCA: 44] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2009] [Revised: 08/09/2010] [Accepted: 10/17/2010] [Indexed: 11/16/2022]
Abstract
OBJECTIVE The aim of this observational study was to characterize the static and pulsatile intracranial pressure (ICP) in conservatively (medically) treated idiopathic intracranial hypertension (IIH) patients in need of shunt surgery, and also in patients with chronic daily headache (CDH) without visual disturbances. METHODS The material includes 14 IIH patients and 7 CDH patients in whom ICP was monitored continuously over-night. Static ICP was characterized by mean ICP, pulsatile ICP was characterized by the wave amplitude, rise time, and rise time coefficient. RESULTS In the IIH group all 14 had headache and visual disturbances. Mean ICP was high (> 15 mmHg) in only 7 patients (50%), while mean ICP wave amplitude was high (≥ 4 mmHg) in all 14 (100%). All IIH patients were shunted and improved clinically thereafter (i.e., relief from visual disturbances and/or headache). None in the CDH group had high mean ICP or mean ICP wave amplitude, and none were shunted. CONCLUSIONS In this cohort of 14 conservatively treated IIH patients with lasting and shunt-responsive headache and visual disturbances, the mean ICP wave amplitude was elevated (≥ 4 mmHg) in all patients despite normal mean ICP (< 15 mmHg) in 7 patients (all but one on medication). Therefore, the pulsatile ICP may be more relevant than the static ICP in the diagnostic setting for patients with IIH. Further prospective standardized approaches are warranted.
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Affiliation(s)
- Per Kristian Eide
- Department of Neurosurgery, Oslo University Hospital - Rikshospitalet, Oslo, Norway; University of Oslo, Oslo, Norway.
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