What is new about idiopathic intracranial hypertension? An updated review of mechanism and treatment

Primary Cough Headache

PURPOSE OF REVIEW

In this review article, we summarize the most recent findings and observations in patients experiencing primary cough headache.

RECENT FINDINGS

Recent studies draw attention to further characterization of patients with primary cough headache in a pulmonology clinic. There have also been recent case studies describing new therapy considerations, including noninvasive vagus nerve stimulation and lumbar punctures. Primary cough headache has been a recognized entity since as early as 1932. Patients generally report a sudden onset, sharp headache lasting a few hours that is precipitated by Valsalva maneuver or coughing. It remains an uncommon diagnosis, and secondary causes are crucial to rule out with imaging studies. Additionally, there can be an overlap with other primary headache disorders such as primary exercise headache and headache associated with sexual activity, thus requiring a detailed history. Many hypotheses exist regarding the pathophysiology including relative pressure gradients and a crowded posterior fossa. Generally, patients are responsive to indomethacin, but more recent case reports have suggested benefits of other medications and procedures that may offer patients an alternative option, including vagus nerve stimulation, lumbar punctures, and beta blockers. Future case series and studies should focus on management of these patients, with a specific focus on individuals who do not tolerate indomethacin.

Intracranial venous stenting for idiopathic intracranial hypertension

INTRODUCTION

There is increasing evidence in the literature to support venous sinus stenting in patients with idiopathic intracranial hypertension who fail first-line therapy. Venous sinus stenting is a safe and successful technique compared with cerebrospinal fluid diversion procedures. This study examines the clinical outcomes of patients post intracranial venous stenting for intracranial hypertension across three tertiary hospitals in Western Australia.

METHODS

A retrospective analysis was performed on 83 consecutive patients treated with intracranial venous stenting for IIH at three tertiary hospitals from October 2013 to March 2020. Data were collected from outpatient clinic letters, electronic discharge letters, electronic radiological imaging and procedural reports.

RESULTS

89.2% patients were able to cease Acetazolomide post stenting. 78.3% patients reported resolution of headaches. 84.3% patients demonstrated resolution of their papilloedema. 91.6% patients demonstrated improvement of their visual acuity. Compared with a recent meta-analysis by Satti and Chaudry in 2015, our results demonstrated a higher technical success rate and lower complication rates.

CONCLUSION

Our study findings support the paradigm shift from CSF diversion procedures to venous sinus stenting in patients with IIH who fail first-line therapy. Venous sinus stenting has a high technical success rate and significantly lower complication rates than other invasive treatments.

CT Cisternogram Findings in Idiopathic Cerebrospinal Fluid Leaks with Emphasis on Long Term Management

To study the various computed tomography (CT) cisternogram findings in idiopathic cerebrospinal fluid (CSF) leaks and the long term treatment modalities after surgical repair of idiopathic CSF leaks. This was a descriptive study conducted among 25 patients in MCV memorial ENT trust hospital, Pollachi between May 2014 and May 2020 amongst patients who underwent CT cisternogram for unilateral or bilateral spontaneous rhinorrhea with or without associated headache, visual disturbances and papilloedema diagnosed to be idiopathic CSF leak by investigations. These patients then underwent CSF leak repair and postoperatively were managed with weight reduction, low salt diet and diuretic therapy. Post surgery these patients were followed up for a period of 12 months and were evaluated on the basis of presence or absence of headache, rhinorrhea and papilloedema at the end of 1st month, 3rd month, 6th month and 1 year and data was collected. CT cisternogram findings were evaluated by proportion method and evaluation of long term management was done using proportion and repeated measures ANOVA for all patients. Evidence of the presence of previously mentioned CT cisternogram or contrast MRI findings at the end of 1 year of post-surgical treatment was recorded where patients were willing for the same. CT Cisternography was done for all patients and 72% patients had empty sella appearance while 28% had partially empty sella. Other findings included perioptic filling, optic blunting and arachnoid pits which were found in 11(44%), 8(32%) and 12(48%) of patients respectively. Only 3(12%) out of 25 patients had an encephalocoele. The commonest site of leak in CT cisternography was the cribriform plate (52%) followed by lateral recess of sphenoid (48%). None of the patients had multiple sites of leak in CT cisternography. On follow up post surgery maximum resolution of symptoms was found at the end of 12 months where 23 out of 25 patients improved. In our study, out of 25 only 5 patients agreed to undergo post diuretic therapy MRI scan out of which 2 patients had partially empty sella and 3 had normal sella indicating resolution of BIH. CT cisternography is an important investigation which aids in the diagnosis of CSF rhinorrhea due to idiopathic intracranial hypertension (IIH). The medical management of IIH post surgery such as weight reduction, salt restriction and diuretic therapy is also crucial to prevent recurrence of symptoms.

Safety and efficacy comparison between OACs plus single antiplatelet and dual antiplatelet therapy in patients with cerebral venous sinus stenosis poststenting

Background and purpose

The present strategies regarding poststent management for cerebral venous sinus stenosis (CVSS) are inconsistent. Herein, we compared the safety and efficacy of oral anticoagulants (OACs) plus single antiplatelet therapy and dual antiplatelet therapy for CVSS poststenting.

Methods

A real-world observational study conducted from January 2009 through October 2019 enrolled patients who were diagnosed with CVSS and received stenting. Patients were divided into two groups according to the management they received poststenting. Group 1: OACs plus a single antiplatelet agent (clopidogrel 75 mg or aspirin 100 mg) and Group 2: dual antiplatelet therapy (clopidogrel 75 mg plus aspirin 100 mg). The safety (such as major or minor bleeding or venous thrombosis) and efficacy (the incidences of cerebral venous sinus restenosis, intrastent thrombosis, or stent displacement) of the two groups were compared.

Results

There were a total of 110 eligible patients in the final analysis, including 79 females and 31 males with a mean age of 43.42 ± 13.23 years. No major bleeding or venous thrombosis occurred in either of the two groups. Two minor bleeding events occurred in group 2 (one with subcutaneous bleeding points in both lower limbs, another with submucosal bleeding in the mouth), whereas no bleeding events occurred in Group 1. In addition, at the 1-year follow-up, one case of intraluminal restenosis and two cases of in-stent thrombi occurred in Group 2, while none occurred in Group 1. Neither stenosis at stent-adjacent segments nor stent migration was detected in either group during the 1-year following stent placement.

Conclusion

OACs plus single antiplatelet therapy and dual antiplatelet therapy alone are both safe and efficacious management strategies after CVSS stent placement. The former may have more advantages than the latter for inhibiting intrastent thrombosis. However, further research by larger, multicenter clinical trials is needed.

Clinical features and the role of magnetic resonance imaging in pediatric patients with intracranial hypertension

Increased intracranial hypertension (IIH) is a defined clinical condition; however, an unsolved pathophysiologic background usually creates problems in its diagnosis and proper approach. The aim of this study was to emphasize the clinical conditions and brain magnetic resonce imaging (MRI) clues of pediatric patients, especially this clinical entity with high morbidity. Here, we review the etiology, clinical presentation, brain MRI findings, and prognosis of IIH in children. The symptoms' onset age ranged from 9 months to 16 years. Headache (81%), vomiting (37%), and diplopia (33.3%) were the most frequent symptoms. The most common etiologic factors were found to be obesity and dural venous sinus thrombosis. Cerebrospinal fluid (CSF) opening pressure had mean a mean value of 615.2 ± 248 mm H₂O. A significant relationship was found between visual field impairment and height of CSF pressure (p < 0.001). Optic nerve sheath enlargement (88.8%) and optic nerve tortuosity (85.1%) were found as the most common brain MRI findings. Slit-like ventricle (37%), venous sinus thrombosis (29.6%), posterior globe sclera flattening (29.6%), empty sella (25.9%), and intraocular protrusion of the optic nerve (14.8%) were the other findings. A significant relationship was found between CSF opening pressure and the presence of optic nerve tortuosity (p = 0.002), and distension of the optic nerve sheath (p = 0.006). All patients received acetazolamide, only one patient underwent lumboperitoneal shunt, and only one received steroids. In children, IIH can present with different etiologies and symptoms. Brain MRI provides crucial clues in diagnosis. Urgent diagnosis and treatment planning are required to protect vision functions.

Diagnostic value of brain MR imaging and its correlation with clinical presentation and cognitive functions in idiopathic intracranial hypertension patients

Background

Idiopathic intracranial hypertension (IIH) is a neurological disorder of unknown etiology and ambiguous pathophysiology due to cerebrospinal fluid dysregulation. This study is designed to evaluate the role of brain magnetic resonance imaging (MRI) and magnetic resonance venography (MRV) in diagnosis of IIH, to clarify the nature and extent of cognitive deficits, and to detect if there is a correlation between radiology, clinical findings, and cognitive dysfunctions in those patients.

Results

The study included 34 patients and 34 age-, sex-, body mass index (BMI)-, and education-matched healthy control subjects. MR brain imaging and Montreal cognitive assessment (MoCA) test were used for both groups. MRI and MRV sensitivity for IIH diagnosis were 85.2% and 85.3% with 100% and 94.1% specificity respectively. 44.1% had cognitive impairment, memory was the most affected domain, followed by attention, abstraction, and orientation with statistically significantly lower total MoCA score (p < 0.005). Domain comparisons reveal a statistically significantly lower memory/delayed recall (p < 0.001) and abstract scores (p < 0.007) in IIH cases versus control subjects. In comparing patients with cognitive impairment (CI) versus those without CI, there were statistically significantly higher CI in low education level, presence of diplopia, hormonal contraceptive use, abnormal MRI brain, papilledema grades, BMI, and opening pressure.

Conclusions

Presence of more than or equal 3 MR imaging findings, bilateral transverse sinus stenosis, and less than or equal 4 combined conduit score increase the specificity and sensitivity of MRI and MRV for IIH diagnosis. IIH had detrimental effect on different cognitive domains especially when patient have low education level, diplopia, papilledema ≥ grade III, high OP ≥ 61.5 cm H2O, and BMI ≥ 34 Kg/m2 with abnormal MRI and MRV findings.

Management of Idiopathic Intracranial Hypertension During the COVID-19 Pandemic

BACKGROUND

In the current coronavirus disease 2019 (COVID-19) pandemic, health systems are struggling to prioritize care for affected patients; however, physicians globally are also attempting to maintain care for other less-threatening medical conditions that may lead to permanent disabilities if untreated. Idiopathic intracranial hypertension (IIH) is a relatively common condition affecting young females that could lead to permanent blindness if not properly treated. In this article, we provide some insight and recommendations regarding the management of IIH during the pandemic.

METHODS

The diagnosis, follow-up, and treatment methods of IIH during the COVID-19 pandemic period are reviewed. COVID-19, as a mimic of IIH, is also discussed.

RESULTS

Diagnosis and follow-up of papilledema due to IIH during the COVID-19 pandemic can be facilitated by nonmydriatic fundus photography and optical coherence tomography. COVID-19 may mimic IIH by presenting as cerebral venous sinus thrombosis, papillophlebitis, or meningoencephalitis, so a high index of suspicion is required in these cases. When surgical treatment is indicated, optic nerve sheath fenestration may be the primary procedure of choice during the pandemic period.

CONCLUSION

IIH is a serious vision-threatening condition that could lead to permanent blindness and disability at a relatively young age if left untreated. It could be the first presentation of a COVID-19 infection. Certain precautions during the diagnosis and management of this condition could be taken that may allow appropriate care to be delivered to these patients while minimizing the risk of coronavirus infection.

MRI-findings in idiopathic intracranial hypertension (Pseudotumor cerebri)

BACKGROUND

 Pseudotumor cerebri, also known as idiopathic intracranial hypertension, is a disorder of increased intracranial pressure of unknown etiology. Main symptom is headache which has a characteristic similar to other headache diseases, therefore the idiopathic intracranial hypertension often remains undetected. The incidence is 1/100 000 with the number of unreported cases being much higher. This article highlights the essential role of MRI in the differential diagnosis.

METHODS

 A literature search was carried out on idiopathic intracranial hypertension and Pseudotumor cerebri in English and German. Original and Review articles as well as case reports were taken into account. Since the main focus of the article is MRI diagnostics, some images were selected to illustrate the characteristic MRI morphological features.

RESULTS AND CONCLUSION

 The diagnosis of idiopathic intracranial hypertension is based on an exclusion procedure. Most common syndromes are headache, transient visual obscurations, pulsatile tinnitus and nausea. In the presence of an underlying cause for the increased intracranial pressure one speaks of a secondary intracranial hypertension. The diagnostics include a detailed medical history, neurological and ophthalmic examination, lumbar puncture, and neuroradiological imaging procedures. MRI, in particular, has become increasingly important in recent years, since signs for changes in cerebrospinal fluid pressure are now detectable and well-defined. The therapeutic approaches are symptom-oriented and aim to lower the pressure. With a precise diagnosis and timely start of therapy, idiopathic intracranial hypertension has a good prognosis, especially with regard to the preservation of eyesight.

KEY POINTS

  · The idiopathic intracranial hypertension is an important differential diagnosis for unspecific headache and impaired vision. · Overweight women in childbearing age are particularly affected. · The most important component in diagnostics is MRI.

CITATION FORMAT

· Juhász J, Hensler J, Jansen O. MRT-Befunde bei der idiopathischen intrakraniellen Hypertension (Pseudotumor cerebri). Fortschr Röntgenstr 2021; DOI: 10.1055/a-1447-0264.

Numerical Investigation on the Role of Mechanical Factors Contributing to Globe Flattening in States of Elevated Intracranial Pressure

Flattening of the posterior eye globe in the magnetic resonance (MR) images is a sign associated with elevated intracranial pressure (ICP), often seen in people with idiopathic intracranial hypertension (IIH). The exact underlying mechanisms of globe flattening (GF) are not fully known but mechanical factors are believed to play a role. In the present study, we investigated the effects of material properties and pressure loads on GF. For this purpose, we used a generic finite element model to investigate the deformation of the posterior eyeball. The degree of GF in numerical models and the significance of different mechanical factors on GF were characterized using an automated angle-slope technique and a statistical measure. From the numerical models, we found that ICP had the most important role in GF. We also showed that the angle-slope graphs pertaining to MR images from five people with high ICP can be represented numerically by manipulating the parameters of the finite element model. This numerical study suggests that GF observed in IIH patients can be accounted for by the forces caused by elevation of ICP from its normal level, while material properties of ocular tissues, such as sclera (SC), peripapillary sclera (PSC), and optic nerve (ON), would impact its severity.

Cerebrospinal fluid hydrodynamics in arachnoid cyst patients with persistent idiopathic intracranial hypertension: A case series and review

Background:

A clear connection has been established between arachnoid cysts (ACs) and the evolution of idiopathic intracranial hypertension (IIH), a connection, which is presently not well understood. Cerebrospinal fluid (CSF) is an integral element of this condition. Little is known about either the influence of AC on CSF hydrodynamics or the specific nature of CSF, which contributes to the complex pathology of IIH.

Case Description:

This study aimed to chronicle in detail four patients with previously treated intracranial ACs, who developed persistent IIH. This series and review aims to identify and qualitatively analyze the multiple constituents, which could possibly elucidate the intrinsic relationship between arachnoid cyst-induced IIH and CSF hydrodynamics. A retrospective analysis of the medical records of four patients admitted to the institution’s neurosurgery department during the period of 1994–2013 was completed. This study investigated discernible aspects linking CSF pathophysiology with the development of IIH in AC patients. Four male patients, ranging from 3 to 44 years of age at presentation, had a left-sided arachnoid cyst treated surgically. All four patients subsequently developed IIH. Three patients remain persistently symptomatic.

Conclusion:

IIH associated with AC is a hydrodynamic disorder. The full discovery of its fluctuant pathophysiology is the only way to identify an effective standard for the management and treatment of this condition.

Management of Idiopathic Intracranial Hypertension: Experience of a North African Center

Background The idiopathic intracranial hypertension (IIH) is characterized by elevation of intracranial pressure (ICP) in the absence of intracerebral space occupation or venous sinus thrombosis. It usually occurs in obese young women but is very rare in childhood.

Materials and Methods We conducted a retrospective study in the neurosurgical department of Bab El Oued teaching hospital of Algiers over a period of 8 years from January 2008 to December 2015. We analyzed clinical data of 10 patients with IIH diagnosis, and the surgical technique consisted of an insertion of a lumbo-peritoneal shunt.

Results In our study, 80% were women with sex ratio M/F of 0.25; the mean age was 32 years and 60% of our patients were obese. For most of our patients, the postoperative outcome was marked by the disappearance of the headache immediately, disappearance of strabismus and diplopia in the following week, followed by improvement of visual function.

Conclusion The IIH is predominantly a disease of women in the childbearing age; surgical treatment is a good option for patients who resisted medication or did not tolerate it as well as for ICH fulminous in emergency cases.

Clinical availability of SNOOP4 in acute non-traumatic headache patients admitted to the emergency department

Objectives:

Non-traumatic headache accounts for up to 4.5% of all patients presenting to the emergency department. Non-traumatic headache is generally classified into two categories: primary and secondary headache disorders. Differentiating secondary from primary headache disorders is essential. SNOOP4 is known as a mnemonic for suggesting clinicians send neuroimaging to rule out serious conditions. Yet, the benefit of using this mnemonic in the emergency department is not well established. This study aimed to assess the significance of SNOOP4 in detecting serious causes of non-traumatic headache in adults presenting to the emergency department.

Methods:

We conducted a prospective observational study of adult patients presenting to the emergency department of the single tertiary hospital over a period of 12 months. Patients with acute non-traumatic headache presented at the emergency department were included. A standard record form was used. Patients were investigated and treated following the pre-existing protocols. Results were interpreted by attending radiologists. Each factor, according to SNOOP4, was then evaluated for the ability to predict serious causes of non-traumatic headache.

Results:

A total of 90 patients were included in this study with complete details obtained on 83 (92.2%) patients. Of these, 63 (75.9%) were female. The mean age was 44.5 years (inter-quartile range: 27–58.5). The duration of the headache ranged from 10 min to 7 days. Out of 83, 27 (32.5%) had at least one SNOOP4 criterion. In all, 25 patients (30.1%) underwent neuroimaging. The sensitivity, specificity, positive predictive value, and negative predictive value of SNOOP4 were 77.8%, 73.0%, 25.9%, and 96.4% respectively.

Conclusion:

SNOOP4 criteria show very high negative predictive value for excluding serious causes of acute non-traumatic headache in adult patients presenting to the emergency department.

The role of opening CSF pressure in response to treatment for idiopathic intracranial hypertension (IIH)

The aim of the current study was to assess the risk factors, clinical symptoms and Cerebrospinal fluid (CSF) pressure of idiopathic intracranial hypertension (IIH) with emphasis on determining the risk factors which involved in poor response to treatment. We retrospectively included 202 patients who were diagnosed with IIH. Disease severity was classified according to prescribed therapeutic option into 4 groups: acetazolamide (group 1), Acetazolamide plus topiramate or Lasix (group 2), repeated LP (group 3) and surgical intervention (group 4). Being in the higher group was considered as a higher severity of disease and poor response to treatment. Among the evaluated features of IIH, the strongest association were observed between opening CSF pressure and disease severity. So that, the highest CSF pressure was observed in patients who underwent surgery, which represent the highest severity of disease (group 4) and poor response to therapy (mean ± SD: 43.9 ± 21.1 cm H₂O). Headache was the most prevalent symptom of IIH in our series which was significantly higher among acetazolamide group. Blurred vision was the second most common symptoms which, unlike the headache was more reported in surgery group. Our results suggested that higher CSF pressure could be the risk factors of poor response to therapy, which may raise need for more intensive treatment. Furthermore, suffering of headache without blurred vision can consider as a prognostic factor for mild severity and good response to treatment.

ROS-Mediated Mitochondrial Dysfunction and ER Stress Contribute to Compression-Induced Neuronal Injury

Intracranial hypertension (IH) is a medical or surgical emergency that can be the common ending of various neurological disorders, such as traumatic brain injury, cerebral vascular diseases and brain tumors. However, the molecular mechanisms underlying IH-induced neuronal apoptosis have not been fully determined, and the treatments are symptomatic, insufficient and complicated by side-effects. In this study, a cellular model induced by compressed gas treatment in primary cultured rat cortical neurons was performed to mimic IH-induced neuronal injury in vitro. We found that compression induced cytotoxicity and apoptosis in cortical neurons in a dose- and time-dependent manner. Compression resulted in oxidative stress, which could be prevented by the ROS scavenger N-acetylcysteine (NAC). Compression produced mitochondrial oxidative stress, ATP loss and mitochondrial fragmentation. The results of western blot showed that compression differently regulated the expression of mitochondrial dynamic proteins, and the Drp1 inhibitor mdivi-1 partially reversed the compression-induced cytotoxicity. Compression significantly increased the expression of ER stress-associated factors in a time-dependent manner. The results of calcium imaging showed that compression induced intracellular calcium overload via promoting ER calcium release. Furthermore, the results using inhibitors of each signaling pathway demonstrated that ROS mediated the compression-induced ER stress and mitochondrial dysfunction in cortical neurons. In conclusion, our results demonstrated that compression induced apoptosis in primary cultured cortical neurons, which was associated with ROS mediated ER stress and mitochondrial dysfunction. Pharmacological compounds or agents targeting mitochondrial dysfunction and ER stress associated oxidative stress might be ideal candidates for the treatment of IH-related neurological diseases.

Assessment of the Olfactory Function in Patients With Idiopathic Intracranial Hypertension Using the Sniffin' Sticks Test: A Case-Control Study

OBJECTIVE

Despite the lack of recognition in clinical practice, there is increasing evidence that patients with idiopathic intracranial hypertension may suffer from hyposmia. The current case-control study aims to evaluate olfactory dysfunction in a large series of patients with idiopathic intracranial hypertension.

METHODS

All subjects, 44 idiopathic intracranial hypertension patients and 57 healthy controls, underwent olfactory function assessment using standardized "Sniffin' Sticks" test at a tertiary referral center of a university hospital. Threshold, discrimination, identification, and total threshold-discrimination-identification scores have been determined and analyzed statistically.

RESULTS

Idiopathic intracranial hypertension patients had significantly lower threshold (6.5 [3.69] vs 8 [1.88], P < .001, 95% CI [-2.250, -0.750]) and threshold-discrimination-identification scores (29.75 [5.56] vs 32.5 [5.25], P = .003, 95% CI [-4.250, -0.750]). Twenty-five patients (57%) were diagnosed with hyposmia. Test scores of patients with active idiopathic intracranial hypertension (n = 18) were not statistically different from patients with inactive disease (n = 26), except for discrimination score (14 [2.50] vs 11 [2.25], P = .005, 95% CI [-3.000, -1.000]). Although idiopathic intracranial hypertension patients with a cerebrospinal fluid opening pressure of ≥330 mmH₂ O had lower test scores, the difference was significant only for total threshold-discrimination-identification scores (28.5 [5.50] vs 30.5 [4.38], P = .044, 95% CI [0.750, 5.500]). Multiple regression analysis revealed that test scores were related to disease activity, cerebrospinal fluid opening pressure, papilledema, headache, and medication.

CONCLUSION

Our clinical study revealed significant olfactory dysfunction in patients with idiopathic intracranial hypertension compared with healthy controls. Future research should employ larger samples to search for usability of olfactory testing in clinical management of patients with idiopathic intracranial hypertension.

Nonmigraine Headache and Facial Pain

The vast majority of headache patients encountered in the outpatient general medicine setting will be diagnosed with a primary headache disorder, mostly migraine or tension-type headache. Other less common primary headaches and secondary headaches, related to or caused by another condition, are the topic of this article. Nonmigraine primary headaches include trigeminal autonomic cephalalgias, primarily cluster headache; facial pain, primarily trigeminal neuralgia; and miscellaneous headache syndromes, such as hemicrania continua and new daily persistent headache. Selected secondary headaches related to vascular disease, cerebrospinal fluid dynamics, and inflammatory conditions are also reviewed.

Isolated spontaneous cerebrospinal fluid rhinorrhoea as a rare presentation of idiopathic intracranial hypertension: Case reports with comprehensive review of literature

Isolated cerebrospinal fluid (CSF) rhinorrhoea as a sole presenting symptom of idiopathic intracranial hypertension (IIH) is extremely rare. IIH typically presents with headache, pulsatile tinnitus, dizziness, nausea, vomiting, and visual disturbance. We report two cases which presented with acute onset spontaneous CSF rhinorrhoea without any other symptom. In addition, we discuss in detail imaging features of IIH with review of its literature.

Trigeminal Hyperexcitability in Idiopathic Intracranial Hypertension: A Blink Reflex Study

PURPOSE

To compare blink reflex examination findings in patients with idiopathic intracranial hypertension (IIH) with migraineurs and controls and to investigate the role of blink reflex data in the follow-up by evaluating their relationship with clinical symptoms.

METHODS

We included 23 patients with IIH, 15 migraineurs, and 16 controls. Blink reflex was studied with bilateral paired stimulations, and the 2R2/1R2 and 2R2c/1R2c area ratios, 1R2, 2R2, 1R2c, and 2R2c latencies were compared (R2:ipsilateral R2 response, R2c:contralateral R2 response).

RESULTS

2R2/1R2 area ratios at 200, 300, and 500 ms interstimulus intervals were significantly higher in the IIH group compared with the controls, and significantly higher 2R2/1R2 area ratio at 200 ms interstimulus interval was also detected in the IIH group compared with the migraine group. Significantly shorter 2R2 latencies were found at 500 and 800 ms interstimulus intervals in IIH group compared with the migraine group and controls. Significantly higher 2R2/1R2 area ratios at 500, 800 ms, and 2R2c/1R2c area ratios at 300, 500, and 800 ms were detected in patients with IIH in remission compared with patients with attacks.

CONCLUSIONS

The significant increase in R2 recovery rates in patients with IIH in remission suggests that there is an increased excitability in the trigeminal pathways. Our findings may provide a new perspective for IIH mechanism related to trigeminal hyperexcitability and evaluating new management strategies.

Brainstem herniation into the internal acoustic canal secondary to hydrocephalus in context of spontaneous cerebrospinal fluid otorrhea: report of a novel entity

INTRODUCTION AND CLINICAL PRESENTATION

The authors report a case of a 5-year-old boy presenting with vision loss, right-sided hearing loss, and facial paralysis secondary to hydrocephalus causing brainstem herniation into the internal auditory canal (IAC) following cerebrospinal fluid (CSF) otorrhea.

MANAGEMENT AND OUTCOME

After placement of a ventriculo-peritoneal shunt (VP shunt), the vision and facial palsy improved whilst hearing loss persisted. Imaging demonstrated partial reduction of the herniated brainstem and resolution of hydrocephalus. To our knowledge, this is the first case reported of brainstem herniation into the internal auditory canal.

Neuron-specific enolase levels as a marker for possible neuronal damage in idiopathic intracranial hypertension

Although formerly considered as a "benign" disease, the presence of some important problems such as vision loss, resistance to appropriate medical treatment and relapses suggests that neuronal damage might play a role in the pathophysiology of IIH. In order to demonstrate possible neuronal damage/dysfunction participating in IIH pathophysiology, we aimed to investigate the relationship between serum neuron-specific enolase (NSE) levels and clinical features in patients with idiopathic intracranial hypertension (IIH). Thirty-six patients with IIH, diagnosed according to the revised criteria, and 40 age, gender and body mass index-matched healthy controls were enrolled in this study after their consent. Serum samples were evaluated for NSE via enzyme-linked immunosorbent assay method. NSE levels were higher in the IIH group (23.7 ± 14.53 ng/ml) compared to the control group (22.7 ± 13.11 ng/ml), but the difference was not statistically significant (p = 0.824). There were also no statistically significant differences in NSE levels in IIH patients regarding the presence of visual loss, relapse, oligoclonal bands and papilledema. We could not demonstrate any correlations between NSE levels and age, body mass index, cerebrospinal fluid opening pressure and disease duration. The present study is the first to analyze NSE levels in IIH patients and showed no significant difference between patients and controls, and also between different clinical subgroups of IIH patients.

Uncommon Presentation of Idiopathic Intracranial Hypertension in a Patient with Polycystic Ovary Syndrome: A Case Report

INTRODUCTION

Idiopathic intracranial hypertension is a rare condition characterized by increased intracranial pressure without clinical, laboratory, or radiological evidence of intracranial pathology. Early management could prevent irreversible outcomes.

CASE PRESENTATION

A 17-year-old single Arabian female of Arab origin presented with a 2-day complaint of horizontal diplopia and transient visual obscurations. She denied any history of headache or decreased vision. The patient was diagnosed with polycystic ovary syndrome a year prior to presentation. Examination revealed bilateral moderate papilledema and limited left eye abduction. However, visual acuity and fields were normal. Increased intracranial pressure was confirmed by lumbar puncture opening pressure (550 mm H<Sub>2</Sub>O). The cerebrospinal fluid composition and imaging of brain and cerebral venous system were normal. The diagnosis of idiopathic intracranial hypertension was confirmed and the patient was treated with acetazolamide 500 mg twice per day. The symptoms totally resolved within 3 days and the papilledema disappeared after 2 months.

CONCLUSION

Awareness of such uncommon presentation of idiopathic intracranial hypertension emphasizes the critical importance of detailed ophthalmic examination and shows the good prognosis of early management.

Transverse Sinus Stenosis Is the Most Sensitive MR Imaging Correlate of Idiopathic Intracranial Hypertension

BACKGROUND AND PURPOSE

Patients with idiopathic intracranial hypertension have transverse sinus stenosis on gadolinium-bolused MRV, but other MR imaging signs are less consistently seen. Our aim was to demonstrate that transverse sinus stenosis could be identified on conventional MR imaging, and this identification would allow improved diagnostic sensitivity to this condition.

MATERIALS AND METHODS

MR imaging and MRV images from 63 patients with idiopathic intracranial hypertension and 96 controls were reviewed by using 3 independent procedures. MRV images were graded for the presence and degree of stenosis of the transverse sinus. Postgadolinium coronal T1-weighted sequences were evaluated independent of MRV. The dimensions of the proximal and distal transverse sinus were measured from the MRV examinations, and the cross-sectional area of the transverse sinus was calculated. Correlation among the 3 modes of evaluation of the transverse sinus was conducted by using Wilcoxon/Kruskal-Wallis, Pearson, and Spearman ρ nonparametric statistical techniques.

RESULTS

Transverse sinus stenosis was identified bilaterally on MRV in 94% of patients with idiopathic intracranial hypertension and in 3% of controls. On coronal T1 postgadolinium MR images, transverse sinus stenosis was identified in 83% of patients with idiopathic intracranial hypertension and 7% of controls. Previously described MR imaging signs of intracranial hypertension were identified in 8%-61% of patients with idiopathic intracranial hypertension. Correlation among the 3 modes of evaluation was highly significant (P < .0001).

CONCLUSIONS

Even without the assistance of an MRV sequence, neuroradiologists can validly identify bilateral transverse sinus stenosis in patients with intracranial hypertension more reliably than other previously described MR imaging findings in this condition. We conclude that transverse sinus stenosis is the most useful and sensitive imaging indicator of this disease state.

Idiopathic Intracranial Hypertension – Pathophysiology Based on Case Series

According to the definition, idiopathic intracranial hypertension (IIH) is a pathological state characterized by an increase in intracranial pressure; however, there are no obvious intracranial pathological processes. The pathophysiology of this disorder is not clear, although there are many reports related to it.

We present an overview of possible etiopathogenetic mechanisms, clinical presentations and therapeutic interventions from a series of patients hospitalized with the clinical picture and final diagnosis of idiopathic intracranial hypertension (IIH). All data were collected from the moment of IIH diagnosis as well as three months later.

The obtained data showed that IIH is a disease that primarily affects obese women in early and midlife. The positive correlation between values of cerebrospinal fluid pressure and body mass index was observed. The disorders of sexual hormones were identified as a possible etiology for IIH female patients. Headache, papilloedema, decreased visual acuity, vertigo and cranial nerve palsy were identified as the most prevalent IIH clinical presentations. The existence of stenosis and hypoplasia of the sigmoid and transverse sinus were confirmed only in one third of IIH patients. Pharmacotherapy combined with weight loss was efficacious in a large number of patients. In this series, there were no short-term consequences of IIH.

The results suggest the importance of early and accurate looking for IIH in obese early and midlife women with any hormonal imbalances having a variety of neurological expression, mostly presented as headaches and visual disturbances. Early detection of IIH might influence the timely treatment and prevent far-reaching and severe clinical consequences.

Idiopathic intracranial hypertension occurred after spinal surgery: report of two rare cases and systematic review of the literature

BACKGROUND

Idiopathic intracranial hypertension (IIH) is a relatively rare syndrome of increased intracranial pressure of unknown etiology. It is characterized by cerebrospinal fluid (CSF) opening pressure more than 250 mmH₂O, with normal cranial imaging and CSF content. IIH occurred after spinal surgery is extremely rare.

METHODS

We present two IIH cases occurred after spinal surgery and conduct a systematic review of articles reporting IIH occurred after spinal surgery.

RESULTS

The first patient underwent a posterior decompression and fixation for cervical fractures. IIH symptoms appeared 3 days postoperatively and gradually resolved with appropriate medication. The second patient underwent posterior spinal fusion with segmental instrumentation for congenital scoliosis. IIH symptoms appeared 5 days postoperatively and the patient died due to the irreversible intracranial hypertension although underwent intensive care and treatment. The literature review revealed that there were only five cases of IIH occurred after spinal surgery reported till date.

CONCLUSIONS

IIH occurred after spinal surgery is relatively rare; the diagnosis is based upon exclusion of other diseases. IIH should be kept in mind in patients underwent spinal surgery as it could develop into irreversible intracranial hypertension.

Evidence for potential involvement of pro-inflammatory adipokines in the pathogenesis of idiopathic intracranial hypertension

Background Although specific role players are currently unknown, contribution of inflammatory mediators has been suggested in the pathophysiology of idiopathic intracranial hypertension (IIH), which is a disease more prevalent in obese female individuals of childbearing age. We aimed to investigate the levels of adipokines and cytokines to demonstrate possible markers for inflammation that participate in IIH pathophysiology and their association with clinical features of IIH. Methods IIH patients, diagnosed according to the revised criteria, and age-, gender- and body mass index (BMI)-matched healthy controls were enrolled in this study. Serum samples were evaluated for insulin-like growth factor 1, insulin, nesfatin, adiponectin, interleukin (IL)-1β, IL-6, IL-8, leptin, plasminogen activator inhibitor type-1, resistin, tumour necrosis factor-alpha (TNF-α) and monocyte chemotactic protein 1 via enzyme-linked immunosorbent assay or multiplex immunoassays. Results IL-1β level was significantly higher ( p = 0.012), and IL-8 and TNF-α levels were significantly lower in the IIH group ( p < 0.001 and p = 0.008, respectively) compared to the control group. There were no correlations between the cytokine/adipokine levels and age, BMI, disease duration, and cerebrospinal fluid oligoclonal bands. There were also no significant differences in cytokine and adipokine levels between IIH patients regarding visual impairment. However, statistically significant differences were found between IIH patients with relapse versus healthy controls regarding IL-1β ( p = 0.007), IL-8 ( p = 0.001) and TNF-α ( p = 0.017) levels. Other investigated cytokines and adipokines showed no significant alterations in IIH patients investigated in the remission period. Conclusion Altered serum levels of IL-1β, IL-8 and TNF-α seem to be associated with IIH pathogenesis, and these cytokines may be used as prognostic markers in IIH to predict relapse.

Cortical astrogliosis and increased perivascular aquaporin-4 in idiopathic intracranial hypertension

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.

Quantitative Magnetic Resonance Venography is Correlated With Intravenous Pressures Before and After Venous Sinus Stenting: Implications for Treatment and Monitoring

BACKGROUND

Endovascular stenting is an effective treatment for patients with clinically significant cerebral venous sinus stenosis. Traditionally, stenting is indicated in elevated intravenous pressures on conventional venography; however, noninvasive monitoring is more desirable. Quantitative magnetic resonance angiography is an imaging modality that measures blood flow noninvasively. Established in the arterial system, applications to the venous sinuses have been limited.

OBJECTIVE

To examine quantitative magnetic resonance venography (qMRV) in the measurement of venous sinus flow in patients undergoing endovascular stenting and to identify a relationship with intravenous pressures.

METHODS

Five patients with intracranial hypertension secondary to venous sinus stenosis underwent cerebral venous stenting between 2009 and 2013 at a single institution. Preoperatively, venous sinus flow was determined by using qMRV, and intravenous pressure was measured during venography. After stenting, intravenous pressure, qMRV flow, and clinical outcomes were assessed and compared.

RESULTS

A mean prestenotic intravenous pressure of 45.2 mm Hg was recorded before stenting, which decreased to 27.4 mm Hg afterward (Wilcoxon signed rank test P = .04). Total jugular outflow on qMRV increased by 260.2 mL/min. Analysis of the change in intravenous pressure and qMRV flow identified a linear relationship (Pearson correlation r = 0.926). All patients displayed visual improvement at 6 weeks.

CONCLUSION

Venous outflow by qMRV increases after endovascular stenting and correlates with significantly improved intravenous pressures. These findings introduce qMRV as a potential adjunct to measure venous flow after stenting, and as a plausible tool in the selection and postoperative surveillance of the patient who has cerebral venous sinus stenosis.

Intracranial Hypertension in Children: Etiologies, Clinical Features, and Outcome

This retrospective study aimed to describe the clinical presentations, possible causes, and outcomes of children with idiopathic intracranial hypertension who presented to the authors' clinic. The mean age at onset of symptoms in the authors' cohort of 19 children was 6 years (range: 7 months to 12 years). Most patients (90%) were under 11 years old and (84.2%) symptomatic. The probable cause was identified in 7/19 (37.0%) patients. The most common cause was vitamin D deficiency (26.3%). Other associated probably coincidental comorbidities included sinusitis (5/19, 26.3%), hypophosphatasia (1/19), Pyle disease (1/19), and measles vaccine (1/19). Apart from 2 patients who required lumboperitoneal shunt, the cerebrospinal fluid pressure returned to normal in all patients within a period of 6 weeks to 1 year (average, 5 months). Of those who followed up with the authors' ophthalmologist, 30.7% developed optic atrophy or pallor; 75% of these patients had previous ocular comorbidities.

Resolution of idiopathic intracranial hypertension after sustained lowering of cerebrospinal fluid pressure

Idiopathic intracranial hypertension (IIH) is a syndrome of headache due to raised intracranial pressure (ICP) where the cerebrospinal fluid (CSF) is normal and there is no alternative pathology on imaging. The aetiology is unknown. This review questions many of the prevailing views regarding aetiology and treatment of IIH. It explores the concept that there is a vicious cycle of fluctuating raised ICP leading to secondary compression of the transverse sinuses and further elevation of ICP. It also raises the question as to whether this vicious cycle could be relieved by prolonged drainage of CSF as seen in Lumbar puncture induced low-pressure headache or alternatively a lumbar drain.

Oligoclonal bands and increased cytokine levels in idiopathic intracranial hypertension

OBJECTIVES

The pathogenesis of idiopathic intracranial hypertension (IIH) is currently unknown and there are speculations about the contribution of some immunologic factors. The aim of this study is to investigate the presence of oligoclonal bands (OCBs) and cerebrospinal fluid (CSF) and/or serum cytokine levels in patients with IIH.

METHODS

Patients fulfilling revised diagnostic criteria for IIH were included. Their demographic, clinical, ophthalmologic and laboratory features were examined. Serum and CSF samples were detected by isoelectric focusing and immunoblotting for OCBs. The samples of IIH patients and control groups were investigated by ELISA for cytokine levels.

RESULTS

We detected OCBs in eight (30.77%) patients diagnosed with IIH. There were no other obvious clinical and laboratory differences of IIH profiles between the patients with and without OCBs, but frequency of vision loss was significantly higher in the group with OCBs in comparison to OCB negatives (p = 0.038). Patients with IIH had highly elevated TNF-α, IFN-γ, IL-4, IL-10, IL-12, IL-17 in their sera compared to patients with multiple sclerosis (MS) and healthy controls. Furthermore, all cytokines except TNF-α in the CSF were found significantly higher in IIH patients compared to MS controls.

CONCLUSION

The presence of OCBs and elevated cytokine levels in IIH patients may support an immunologic background in the pathophysiological pathway of this disorder.

Pseudotumor cerebri/idiopathic intracranial hypertension in children: an experience of a tertiary care hospital

OBJECTIVE

Pseudotumor cerebri (PTC) is diagnosed at increasing rates probably due to the increase in obesity prevalence all over the world and awareness about the disease. Our aim in this study was to evaluate the PTC clinical picture and etiological factors in children at the present time.

METHOD

The records of 53 patients with 32 females, who were diagnosed with PTC in a child neurology department between the years of 2005 and 2012 were retrospectively analyzed.

RESULTS

The mean age at presentation was 10.9 years (3-17 years) and approximately half of patients were aged of 11 years or less. While more than half of prepubertal patients were male, girls rate reaches 74% at puberty. An etiological factor such as venous sinus thrombosis, infections, anemia, steroid discontinuation, drugs, slit ventricle syndrome and minor head injury causing the PTC was identified in 43% of the patients. The mean duration of treatment was 6.4 months (3-24 months) and the mean follow-up duration 16.5 months (3-52 months). Visual field constriction was moderate in only two pubertal and obese female patients and mild in four patients.

CONCLUSIONS

PTC is seen in prepubertal children as often as in puberty. An etiological factor causing PTC is present in about half the patients in childhood. The main etiological factors of the disease currently consist of cranial venous thrombosis, infections, anemia and drugs. Malnutrition, renutrition and related vitamin deficiencies or excesses commonly seen previously have become less important in PTC etiology. PTC is a disease that requires long-term treatment and follow-up but the prognosis is good in patients who are diagnosed early, receive appropriate treatment and show good compliance with the treatment.

[Idiopathic intracranial hypertension and factor V Leiden mutation]

Activated proteinC resistance is a frequent prothrombotic abnormality. In most cases it is due to factorV Leiden mutation by nucleotide G1691A substitution. This recently described thrombophilic defect of activated proteinC resistance has been postulated to be implicated in the pathogenesis of idiopathic intracranial hypertension (IIH). We report a case of factorV Leiden mutation in association with IIH and their likely link and implication in the management of IIH.

Low-dose acetazolamide reverses periventricular white matter hyperintensities in iNPH

OBJECTIVE

To assess the effects of low-dose acetazolamide treatment on volumetric MRI markers and clinical outcome in idiopathic normal-pressure hydrocephalus (iNPH).

METHODS

We analyzed MRI and gait measures from 8 patients with iNPH with serial MRIs from an institutional review board-approved imaging protocol who had been treated off-label with low-dose acetazolamide (125-375 mg/day). MRI studies included fluid-attenuated inversion recovery and 3D T1-weighted high-resolution imaging. Automated analyses were employed to quantify each patient's ventricular, global white matter hyperintensities (WMH), and periventricular WMH (PVH) volumes prior to and throughout treatment. Clinical outcome was based on gait changes assessed quantitatively using the Boon scale.

RESULTS

Five of 8 patients responded positively to treatment, with median gait improvement of 4 points on the Boon scale. A significant decrease in PVH volume (-6.1 ± 1.9 mL, p = 0.002) was seen in these patients following treatment. One patient's gait was unchanged and 2 patients demonstrated worsened gait and were referred for shunt surgery. No reduction in PVH volume was detected in the latter 2 patients. Nonperiventricular WMH and lateral ventricle volumes remained largely unchanged in all patients.

CONCLUSIONS

These preliminary findings provide new evidence that low-dose acetazolamide can reduce PVH and may improve gait in iNPH. PVH volume, reflecting transependymal CSF, is shown to be a potential MRI indicator of pharmacologic intervention effectiveness. Further studies of pharmacologic treatment of iNPH are needed and may be enhanced by incorporating quantitative MRI outcomes.

CLASSIFICATION OF EVIDENCE

This study provides Class IV evidence that low-dose acetazolamide reverses PVH volume and, in some cases, improves gait in iNPH.

The incidence and prevalance of idiopathic intracranial hypertension in south Sharaqiah region, Oman

BACKGROUND

To determine the incidence and demographic features of idiopathic intracranial hypertension (IIH) in south Sharqiyah, Sultanate of Oman.

MATERIALS AND METHODS

A retrospective review of Omani patients diagnosed as IIH in Sur Regional Hospital from January 2001 to December 2011 was carried out. All patients fulfilled the modified Dandy criteria for IIH. Data collected included age and sex of patients, age of onset of the disease, body mass index (BMI), presence of comorbid conditions, and medication use. Findings of ophthalmic examination, neuroimaging, and neurological assessment were recorded. Total number of new outpatients in the study period and the 2010 south Sharqiyah mid-population statistics were also collected.

RESULTS

Forty patients were diagnosed as IIH during a period of 11 years from January 2001 to December 2011 in Sur Regional Hospital. The female to male ratio was 3:1; of the 40 patients; 30 (75%) females and 10 (25%) males. Thirteen patients (32.5%) were children below 15 years. Of females in the child bearing age (15-44 years), 60% were obese. As per 2010 census, the Omani population in south Sharqiyah region was 166,318. The calculated annual incidence per 100,000 persons of general population was 2.18. Annual incidence in women of all ages per 100,000 persons was 3.25 and in women of child bearing age was 4.14. In children below 15 years, the incidence was 1.9 per 100,000 children; it was 2.96 per 100,000 for female children.

CONCLUSION

This study shows that the incidence in south Sharqiyah is comparable to that of other countries. Females and obese patients are at a higher risk of developing IIH. Obesity is not a risk factor in males and children. Nearly 60% of the females in the child bearing age were obese.

Idiopathic intracranial hypertension from the perspective of headache center

Idiopathic intracranial hypertension (IIH) is a pathological state defined as an increase of intracranial pressure in the absence of a causative pathological process. The aim of this study was to evaluate the clinical features of the patients with IIH diagnosed in our Headache Center according to the current knowledge of this disorder. In the retrospective and cross-sectional analysis of 3395 patients we present 12 newly diagnosed IIH patients, ten women and two men, aged from 19 to 51, with obtained values of cerebrospinal fluid pressure between 250 and 680 mm of water. The symptoms of IIH clinical presentation have been headache, reported by 92% of patients; papilledema, noted in 67%; and cranial nerve impairment (25%). The results obtained from presented patients confirmed the presence of headache features that are included in criteria for headache attributed with IIH in majority of them: progressive, daily, diffuse, non-pulsatile headache with aggravation by coughing or straining. Decrease of pain intensity after lumbar puncture was noted in all patients. We notice the relatively small proportion of patients with headache attributed to IIH among the patients treated in our Headache Center. The prevalence of IIH is not low and headache is the most frequent presenting symptom; therefore, we could only conclude that some chronic headache patients refractory for treatment are patients with IIH.

Bibrachial amyotrophy and ventral spinal cyst associated with myelomalacia and intracranial hypertension

It has been recently recognised that patients with ventral intraspinal fluid collections secondary to cerebrospinal fluid leaks can present with bibrachial amyotrophy or mimic Hirayama disease. Here we present two further patients that expand the clinical spectrum of this disorder to include association with myelomalacia and intracranial hypertension.

Volumetric assessment of optic nerve sheath and hypophysis in idiopathic intracranial hypertension

BACKGROUND AND PURPOSE

Idiopathic intracranial hypertension is a headache syndrome characterized by increased CSF pressure. Compression of the hypophysis and distension of the optic nerve sheath are reliable imaging signs. The purpose of the study was to validate, in patients with idiopathic intracranial hypertension, MR imaging-based volumetric measurements of the optic nerve sheath and hypophysis as an objective observation method for more accurate diagnosis and posttreatment follow-up.

MATERIALS AND METHODS

Twenty-three patients with idiopathic intracranial hypertension as well as age-, sex-, and body mass index-matched controls underwent volumetric measurements of the optic nerve, optic nerve sheath, and hypophysis on high-resolution T2-weighted MR images by using a 7-cm surface coil, followed by correlation with CSF opening pressures and clinical symptom scores of visual disturbances and headache.

RESULTS

Mean values of optic nerve sheath (341.86 ± 163.69 mm(3) versus 127.56 ± 53.17 mm(3), P < .001) and hypophysis volumes (554.59 ± 142.82 mm(3) versus 686.60 ± 137.84 mm(3), P < .05) differed significantly between healthy and diseased subjects. No significant differences between mean optic nerve volumes were observed. Receiver operating characteristic analysis showed optic nerve sheath volumes of >201.30 mm(3) (sensitivity, 86.96%; specificity, 91.30%) and hypophysis volumes of <611.21 mm(3) (sensitivity, 78.26%; specificity, 69.57%) to be indicative of idiopathic intracranial hypertension diagnosis. In patients with idiopathic intracranial hypertension, no correlations were found between optic nerve sheath and hypophysis volumes and CSF opening pressures or clinical scores of visual disturbances and headache.

CONCLUSIONS

Semiautomated volumetric measurement of optic nerve sheath and hypophysis has the potential to more accurately diagnose and follow patients with idiopathic intracranial hypertension.

Idiopathic Intracranial Hypertension. A Systematic Analysis of Transverse Sinus Stenting

BACKGROUND

Idiopathic intracranial hypertension (IIH) is a disorder characterized by signs and symptoms of increased intracranial pressure without structural cause seen on conventional imaging. Hallmark treatment after failed medical management, has been CSF shunting or optic nerve fenestration with the goal of treatment being preservation of vision. Recently, there have been multiple case reports and case series on dural sinus stenting for this disorder.

OBJECTIVE

We aim to review all published cases and case series of dural sinus stenting for IIH, with analysis of patient presenting symptoms, objective findings (CSF pressures, papilledema, pressure gradients across dural sinuses), follow-up of objective findings, and complications.

METHODS

A Medline search was performed to identify studies meeting pre-specified criteria of a case report or case series of patients treated with dural sinus stent placement for IIH. The manuscripts were reviewed and data was extracted.

RESULTS

A total of 22 studies were identified, of which 19 studies representing 207 patients met criteria and were included in the analysis. Only 3 major complications related to procedure were identified. Headaches resolved or improved in 81% of patients. Papilledema improved the (172/189) 90%. Sinus pressure decreased from an average of 30.3 to 15 mm Hg. Sinus pressure gradient decreased from 18.5 (n=185) to 3.2 mm Hg (n=172). Stenting had an overall symptom improvement rate of 87%.

CONCLUSION

Although all published case reports and case series are nonrandomized, the low complication and high symptom improvement rate make dural sinus stenting for IIH a potential alternative surgical treatment. Standardized patient selection and randomization trials or registry are warranted.

Is higher choroid plexus ‘load’ an aetiologic factor in idiopathic intracranial hypertension? A clinico-imaging morphometric correlative study

Background

Idiopathic intracranial hypertension (IIH) is a condition of raised cerebrospinal fluid (CSF) pressure with normal ventricular size. Although the pathogenesis of IIH remains controversial, increased CSF formation may be important. We hypothesised that if increased CSF formation was an aetiologic factor, it might result in a macroscopic increase in size of the choroid plexus (CP).

Method

We retrospectively studied 50 patients with IIH. Total size of the CP was estimated on computed tomography (CT) venograms from the sum of axial areas measured at three locations. Results were compared with the CP load of 50 matched controls on post-contrast head CTs. Evans Index was measured to exclude ventriculomegaly. Results were analysed using a Student’s t test for independent samples ( p < 0.05), and the effect of ICP was tested on the dependent variable (area of CP) using regression analysis.

Results

There was no significant difference in the size of the CP glomus, total axial areas of the CP between IIH patients (183 mm2) and controls (178 mm2) and no correlation between the ‘load’ of CP and the degree of intracranial pressure (ICP) ( R2 < 0.02).

Conclusion

If increased CSF formation is an aetiologic factor in IIH, this is not reflected in a corresponding raised ‘load’ of CP.

Reference programme: diagnosis and treatment of headache disorders and facial pain. Danish Headache Society, 2nd Edition, 2012

Headache and facial pain are among the most common, disabling and costly disorders in Europe. Correct diagnosis and treatment is important for achieving a high quality of care. As a national organisation whose role is to educate and advocate for the needs of patients with primary headaches, the Danish Headache Society has set up a task force to develop a set of guidelines for the diagnosis, organisation and treatment of the most common types of headaches and for trigeminal neuralgia in Denmark. The guideline was published in Danish in 2010 and has been a great success. The Danish Headache Society decided to translate and publish our guideline in English to stimulate the discussion on optimal organisation and treatment of headache disorders and to encourage other national headache authorities to produce their own guidelines. The recommendations regarding the most common primary headaches and trigeminal neuralgia are largely in accordance with the European guidelines produced by the European Federation of Neurological Societies. The guideline provides a practical tool for use in daily clinical practice for primary care physicians, neurologists with a common interest in headache, as well as other health-care professionals treating headache patients. The guideline first describes how to examine and diagnose the headache patient and how headache treatment is organised in Denmark. This description is followed by individual sections on the characteristics, diagnosis, differential diagnosis and treatment of each of the major headache disorders and trigeminal neuralgia. The guideline includes many tables to facilitate a quick overview. Finally, the particular problems regarding headache in children and headache in relation to female hormones and pregnancy are described.

The analysis of allodynia in patients with idiopathic intracranial hypertension

OBJECTIVES

Allodynia is frequently associated with migraine and other primary headaches. Our aim was to investigate the presence of allodynia and related features in idiopathic intracranial hypertension (IIH), which is a disabling secondary headache disorder.

METHODS

We included 46 IIH patients and analyzed their clinical and laboratory findings retrospectively. Allodynia was assessed using the validated 12-item allodynia symptom checklist (ASC-12), in addition to examining pressure (with von Frey filaments) and brush allodynia.

RESULTS

Allodynia was detected in 23 (50%) of IIH patients with ASC-12 and/or instrumental testing. The most commonly reported location was unilateral V1 distribution. The allodynic symptom profile was similar but milder when compared to 143 migraineurs with ASC-12. Only the aggravation of headache with physical activity emerged as a significant variable associated with allodynia in IIH. Among allodynic patients, only eight had previous migraine diagnosis. After onset of IIH, 20 patients reported migraine-like headache, while only three reported non-migrainous headache. In contrast, 13 of 23 non-allodynic IIH patients had non-migrainous headache features (p = 0.0045).

CONCLUSION

Half of the IIH patients reported allodynia, and these allodynic patients had mostly migraine-like headache profiles. Our study suggested that IIH may trigger some common mechanisms with migraine in pain pathways causing allodynia.

Neuroimaging and other investigations in patients presenting with headache

Headache is very common. In the United Kingdom, it accounts for 4.4% of primary care consultations, 30% of referrals to neurology services and 0.5-0.8% of alert patients presenting to emergency departments. Primary headache disorders account for the majority of patients and most patients do not require investigation. Warning features (red flags) in the history and on examination help target those who need investigation and what investigations are required. This article summarizes the typical presentations of the common secondary headaches and what neuroimaging and other investigations are appropriate for each headache type.