A comparison of idiopathic intracranial hypertension with and without papilledema

The additive value of complementing diagnostic idiopathic intracranial hypertension criteria by MRI - an external validation study

BACKGROUND

Recently, diagnostic criteria including a standardized MRI criterion were presented to identify patients suffering from idiopathic intracranial hypertension (IIH) proposing that IIH might be defined by two out of three objective findings (papilledema, ≥ 25 cm cerebrospinal fluid opening pressure (CSF-OP) and ≥ 3/4 neuroimaging signs).

METHODS

To provide independent external validation, we retrospectively applied the proposed diagnostic criteria to our cohort of patients with clinical suspicion of IIH from the Vienna IIH database. Neuroimaging was reevaluated for IIH signs according to standardized definitions by a blinded expert neuroradiologist. We determined isolated diagnostic accuracy of the neuroimaging criterion (≥ 3/4 signs) as well as overall accuracy of the new proposed criteria.

RESULTS

We included patients with IIH (n = 102) and patients without IIH (no-IIH, n = 23). Baseline characteristics were balanced between IIH and no-IIH groups, but papilledema and CSF-OP were significantly higher in IIH. For the presence of ≥ 3/4 MRI signs, sensitivity was 39.2% and specificity was 91.3% with positive predictive value (PPV) of 95.2% and negative predictive value (NPV) 25.3%. Reclassifying our cohort according to the 2/3 IIH definition correctly identified 100% of patients without IIH, with definite IIH and suggested to have IIH without papilledema by Friedman criteria, respectively.

CONCLUSION

The standardized neuroimaging criteria are easily applicable in clinical routine and provide moderate sensitivity and excellent specificity to identify patients with IIH. Defining IIH by 2/3 criteria significantly simplifies diagnosis without compromising accuracy.

The Pseudotumor Cerebri Syndrome

Pseudotumor cerebri syndrome is a syndrome of increased cerebrospinal fluid pressure without ventriculomegaly, mass lesion, or meningeal abnormality. It is either primary (idiopathic intracranial hypertension, IIH) or secondary. A secondary cause is unlikely when adhering to the diagnostic criteria. Permanent visual loss occurs if undetected or untreated, and the associated headaches may be debilitating. Fulminant disease may result in blindness despite aggressive treatment. This study addresses the diagnosis and management of IIH including new insights into the pathobiology of IIH, updates in therapeutics and causes of overdiagnosis.

A novel case of Horner syndrome as the presenting sign of craniosynostosis

Craniosynostosis, the premature fusion of cranial sutures, can lead to distortion of skull shape and neurological dysfunction. We present a novel case of Horner syndrome as the presenting sign of craniosynostosis associated with elevated intracranial pressure. A 10-year-old boy presenting for strabismus follow-up was noted to have new-onset anisocoria, greater in the dark, and mild right upper eyelid ptosis. Apraclonidine testing was concerning for Horner syndrome. Neuroimaging demonstrated previously undiagnosed sagittal craniosynostosis with tortuous optic nerves and large cerebrospinal fluid spaces around both optic nerves. The patient was referred to neurosurgery and underwent a lumbar puncture with an opening pressure of 44 cm H2O. He underwent surgical cranial expansion. By six months postoperatively, his anisocoria had resolved.

Surgical management of pseudotumor cerebri syndrome: A single center experience with endoscopic optic nerve decompression and CSF diversion procedures

OBJECTIVES

Pseudotumor cerebri syndrome (PTC) is a chronic disorder, which is initially treated by conservative measures, yet surgery is inevitable in case of progressive worsening of vision or headache despite medical treatment. The surgical management is controversial including CSF diversion procedures and optic decompression. The purpose of this study was to evaluate the efficacy of different surgeries in PTC and to present surgical outcomes in a single center.

METHODS

This retrospective study included the patients with PTC who were operated by endoscopic optic nerve decompression (EOND), ventriculoperitoneal (VP) and lumboperitoneal (LP) shunting. Surgical outcomes, i.e. visual acuity, visual field, papilledema and headache were compared according to type of surgery. Surgical complications were noted.

RESULTS

Seventeen of 36 patients were treated with shunting, 14 with EOND and 5 patients with both EOND and shunting. No statistical significance was observed between CSF diversion procedures and EOND concerning clinical outcomes. The improvement rate of papilledema was higher with VPS (p = 0574) while more patients benefitted from LPS regarding visual field and acuity (p = 0471 and p = 0718, respectively). The best treatment response for headache was in shunt implemented patients (VPS and LPS) with a rate of 88.2% followed by EOND (78.6%) and both surgeries (60%)(p = 0.294). Gender and BMI were significant predictors of improved papilledema (p = 0.034).

CONCLUSIONS

Our study demonstrated comparable results between shunting and EOND, regarding the efficacy on surgical outcomes. EOND is quite effective for headache besides its advantage on treatment-refractory visual loss. Shunting may offer sustained relief of symptoms when compared with EOND.

The Vienna idiopathic intracranial hypertension database-An Austrian registry

BACKGROUND

Idiopathic intracranial hypertension (IIH) is becoming increasingly more prevalent bearing the risk of visual impairment and affecting the quality of life. Clinical presentation and outcome are heterogeneous. Large, well-characterized cohorts are scarce.

OBJECTIVE

To characterize the clinical spectrum, diagnostic findings, therapeutic management, and outcome of IIH.

METHODS

We identified patients with IIH according to modified Friedman criteria treated at our center between 2014 and 2021. The Vienna IIH database is described in detail.

RESULTS

Of 113 patients 89% were female (mean age 32.3 years). Median body mass index (BMI) was 31.8, with 85% overweight (BMI > 25) and 5% were classified as IIH without papilledema. Headache was present in 84% and showed migraine features in 43%. Median opening pressure in lumbar puncture was 31 cmH2O. Pharmacotherapy (predominantly acetazolamide) was established in 99%, 56% required at least 1 therapeutic lumbar puncture and 13% a surgical intervention. After a median 3.7 years follow-up, 57% had achieved significant weight loss, papilledema was present in 59% and headache in 76% (58% improved). Comparing initial presentation to follow-up, perimetry was abnormal in 67% vs. 50% (8% worsened, 24% improved) and transorbital sonography in 87% vs. 65% with a median optic nerve sheath diameter of 5.4 mm vs. 4.9 mm. Median peripapillary retinal nerve fiber layer thickness decreased from 199 µm to 99 µm and ganglion cell layer volume from 1.13 mm3 to 1.05 mm3.

CONCLUSION

The large representative Vienna IIH cohort characterizes IIH-related symptoms, diagnostic findings, treatment, and outcome emphasizing substantial long-term sequelae of IIH. Future analyses will aim to refine phenotyping and identify factors predicting outcome.

Idiopathic intracranial hypertension in Omani adults: A tertiary center experience

BACKGROUND

To evaluate the clinical profile, risk factors, and ophthalmic diagnostic and monitoring tools in Omani patients with idiopathic intracranial hypertension (IIH) using optical coherence tomography (OCT).

METHODS

A retrospective single institutional cohort study on Omani patients with a fulfilled diagnosis of IIH from January 1, 2014, to January 1, 2020, was conducted. The data obtained from the neuro-ophthalmic clinic contained age of onset of the disease, gender of patients, body mass index (BMI), presence of other associated conditions, and medication use.

RESULTS

Our study group comprised 21 patients with IIH with an annual incidence rate of 2.8 per 100,000 population. Female-to-male ratio was 9.5:1 with a mean age of 27.24 ± 7.1. Headaches appeared to be the most prevalent symptom in 21 (100%) patients, followed by transient obscuration of vision in 9 (42.9%) patients and diplopia in 3 (14.3%) patients, and the least common symptom was pulsatile tinnitus in 2 (9.5%) patients. Increased BMI was seen in 19 (90.5%) patients and noted to be the most prevalent predisposing factor among our study group. The use of oral contraceptive pills was documented in 4 (19%) patients and 1 (4.8%) patient was noted to have polycystic ovary syndrome. All patients (100%) had a best-corrected visual acuity of 1.0 in both eyes pre- and postrecovery and 7 (33.3%) patients had an enlarged blind spot on visual field testing. All patients had papilledema on presentation and an average of 14.1 months to resolve to normal clinically and on OCT monitoring. All patients were treated with medications and only 1 (4.8%) continued to have intractable headaches that did not respond to maximum medical therapy and required surgery.

CONCLUSION

The incidence of IIH in the Omani population was found to be less than neighboring countries but comparable worldwide. OCT is considered a useful tool to confirm and document papilledema and more importantly monitor recovery.

Idiopathic intracranial hypertension: a step change in understanding the disease mechanisms

The understanding of idiopathic intracranial hypertension (IIH) has evolved over the past few years. Previously, IIH was considered a disease exclusively affecting the neuro-ophthalmic axis, characterized by raised intracranial pressure, headache and papilloedema, and resulting in the risk of severe and permanent visual loss and life-changing disabling headaches. Recent advances have begun to redefine IIH as a probable metabolic disease involving a range of systemic manifestations. More than 95% of individuals affected by the disease are women of reproductive age with obesity. The incidence is rapidly rising and parallels the escalating worldwide obesity rates. Contemporary insights identify associations with insulin resistance, type 2 diabetes and a twofold increased risk of cardiovascular disease in excess of that driven by obesity alone. Adipose distribution in people with IIH, like that in other metabolic diseases, is preferentially centripetal and is associated with changes in intracranial pressure. Evidence now demonstrates adipose tissue dysfunction in people with IIH, involving transcriptional and metabolic priming for lipogenesis and weight gain. Hormonal perturbations are also observed, including a unique phenotype of androgen excess that promotes cerebrospinal fluid secretion. Knowledge of these additional disease features is driving research into novel therapeutic targets and altering the approach to multidisciplinary care.

Overlap and Differences in Migraine and Idiopathic Intracranial Hypertension

PURPOSE OF REVIEW

Migraine and idiopathic intracranial hypertension (IIH) are increasingly encountered but remain enigmatic. This review compares the similarities and differences of the diagnostic criteria, pathophysiology, and risk factors for chronic migraine and IIH.

RECENT FINDINGS

While migraine and IIH are distinct diseases, both conditions are frequently found concurrently and may share a link. Increased intracranial pressure (ICP) in those with or without pre-existing migraine may present with migraine-like headaches and contribute to migraine chronification. Increased intracranial pressure may be a coincidental occurrence in patients with migraine and normalization of pressure does not always translate to headache improvement. Limited information is available regarding the standard of treatment for patients with chronic migraine and IIH without papilledema. There continues to be controversy over the normal range of cerebral spinal fluid (CSF) values. Recognizing the concurrence of both conditions advances our understanding of headache pathology and demonstrates a striking need for more research.

Secondary headaches - red and green flags and their significance for diagnostics

A small percentage of patients suffer from a secondary headache syndrome. It is imperative that clinicians are able to differentiate primary headache syndromes from secondary headache syndromes, as failure to do so significantly worsens morbidity and mortality. Recent advances in our understanding of pathobiological mechanisms offer useful information on these enigmatic disorders. We now understand that the causes of secondary headache syndromes can vary significantly - these may be infectious, inflammatory, vascular, traumatic or structural in origin. A well-taken history and targeted physical examination coupled with appropriate investigations can enable these syndromes to be recognized consistently and thus allow their timely and appropriate treatment. Along with their epidemiology, some of their key characteristics shall thus be discussed in this review so as to aid the busy clinician at the bedside. Red flags including sudden onset, high pain intensity, pattern of change of a preexisting headache, focal neurological signs or seizure, systemic signs and precipitation by physical activity can guide the clinician to suspect a secondary headache. Importantly a preexisting headache is not an exclusion of a secondary headache - it might even be a predisposition in certain cases.

Presumptive Idiopathic Intracranial Hypertension Based on Neuroimaging Findings: A Referral Pattern Study

BACKGROUND

Radiologic findings of intracranial hypertension (RAD-IH) are common in idiopathic intracranial hypertension (IIH) patients. Paralleling the increasing rates of obesity, the burden of IIH is growing. Urgent neuro-ophthalmology consultations for possible IIH in patients with incidentally detected RAD-IH are increasing, with many patients receiving unnecessary lumbar punctures (LPs) and treatments. This retrospective observational study aimed to determine the prevalence of neuro-ophthalmology consultations for RAD-IH, rate of funduscopic examination by referring providers, prevalence of papilledema, outcomes after neuro-ophthalmic evaluation, and rates of misdiagnosis.

METHODS

Records of 1,262 consecutive new patients seen in one neuro-ophthalmology clinic from January 2019 to January 2020 were reviewed. We identified patients who were: 1) referred with concern for IIH because of findings of RAD-IH; 2) referred for "papilledema"; 3) referred with a diagnosis of IIH; and 4) referred for spontaneous cranial cerebrospinal fluid (CSF) leaks. In addition to basic demographic profiles for all groups, detailed information was collected for patients referred solely for RAD-IH, including referral patterns, prior history of IIH, previous LPs, prior medical or surgical treatment(s), risk factors for increased intracranial pressure (ICP), presenting symptoms, radiologic features observed on neuroimaging, and final disposition. When available, the neuroimaging was reviewed by an expert neuroradiologist.

RESULTS

Of 1,262 consecutive new patients, 66 (5%) were referred specifically for RAD-IH; most referrals came from neurologists (58%); 8/66 (12%) patients had papilledema; 16/66 (24%) patients had prior LP and 13/66 (20%) were already treated based on MRI findings; and 22/66 (33%) patients had ≤2 RAD-IH. Only 34/66 (52%) of patients referred for RAD-IH had prior funduscopic examinations. We confirmed papilledema in 26/82 (32%) patients referred for "papilledema." Only 29/83 (35%) patients referred with a diagnosis of IIH had active papilledema, and 3/16 (19%) patients with spontaneous CSF leaks had papilledema. In total, 247/1,262 (20%) new patients were referred to our clinic over 1 year with concern for IIH, among whom only 66 (27%) were confirmed to have active IIH with papilledema.

CONCLUSIONS

One in 5 new patient referrals seen in our neuro-ophthalmology clinic were referred because of concern for increased ICP, but only 1/4 had active papilledema. Most patients referred for isolated RAD-IH do not have papilledema, many having undergone unnecessary LPs and treatments. The burden of these "rule-out IIH" consultations is overwhelming and will only continue to increase with the concurrent rise of obesity and IIH, straining the already limited neuro-ophthalmologic resources available in the US.

Ultrasound measurement of optic nerve sheath diameter in a healthy adult Colombian population

BACKGROUND

Measurement of the optic nerve sheath diameter (ONSD) provides a rapid, safe, and easy method for detecting increased intracranial pressure (ICP). However, the normal mean and upper limit values may vary according to sex, age, ethnicity, and ultrasound technique.

AIM

We aimed to obtain the mean ONSD in a healthy Colombian adult population and to correlate it with demographic and anthropometric measures.

METHODS

In a prospective study using a 10-13 MHz linear ultrasound probe, eye transverse diameter (ETD) and ONSD in the transverse (ONSD-TP) and sagittal planes (ONSD-SP) were measured in healthy adult volunteers in Bogota, Colombia.

RESULTS

A total of 100 healthy subjects were included, with a mean age of 26,7 ± 8,3 years and 62 women. The mean ETD, ONSD-TP and ONSD-SP was 23.11 mm (95% confidence interval (CI): 22.90 mm-23.32 mm), 3.96 mm (95% CI: 3.85 mm-4.07 mm) and 4.0 mm (95% CI: 3.90 mm-4.11 mm), respectively. The ONSD in both planes ranged from 2.35 mm to 5.20 mm. There was a significant correlation between ONSD-SP and ONSD-TP (p < 0.0001) but no correlation between the ocular measures and demographic or anthropometric variables (p > 0.05). The intraclass correlation between the eyes was statistically significant.

CONCLUSION

Our study shows that ultrasound-measured ONSD in healthy adults in Colombia is similar to that found worldwide. An ONSD of 5.5 mm may be considered the upper limit for healthy adults in Colombia. ONSD can be measured in either plane; there is a good correlation between the two eyes; and ONSD is not modified by demographic or anthropometric characteristics.

Visual outcomes of idiopathic intracranial hypertension in a neuro-ophthalmology clinic in Jeddah, Saudi Arabia

PURPOSE

Idiopathic intracranial hypertension (IIH) is a disorder with elevated intracranial pressure more than 250 mm H2O, without evidence of meningeal inflammation, space-occupying lesion, or venous thrombosis. In this study, we aim to study the clinical profile, evaluation, management, and visual outcome in a hospital-based population of IIH cases in Jeddah.

METHODS

This is a retrospective observational cohort study that included the medical records of all patients referred to neuro-ophthalmology service for evaluation of papilledema. The medical records have been reviewed from October 2018 to February 2020 at Jeddah Eye Hospital, Saudi Arabia. A total of 51 patients presented with papilledema in the studied period. Forty-seven patients met our inclusion criteria and were included in the study.

RESULTS

The study found that the incidence rate of IIH is 16:100 of the referred cases to the neuro-ophthalmology clinic. Most of the patients were females (41, 91.2%), with a mean age of presentation of 32 ± 11 years. The most common presenting symptom was headache (40 patients, 88.8%), followed by transient visual obscuration (TVO) (20 patients, 44.4%), and reduced visual acuity (15 patients, 33.3%). All 45 patients were started on medical treatment with oral acetazolamide with four patients (8.8%) shifted to topiramate because of the lack of response or intolerance to acetazolamide while four patients (8.8%) underwent lumbar-peritoneal shunt because of inadequate control of the disease despite the treatment with medical therapy. For both eyes, the change in visual acuity across all assessment points was statistically significant. Nevertheless, there were no significant changes in the visual field findings among all of the compared assessment points.

CONCLUSION

The present study has shown that IIH-related papilledema is common in young female patients with headaches, TVOs, and reduced visual acuity. Those are the most common symptoms in our IIH population. Medical treatment and monitoring of IIH is efficient and should be considered to enhance the prognosis of IIH-related complications. In addition, the visual acuity and the visual field should be frequently monitored for these patients.

Chiari Malformation Type 1 in Adults

The term Chiari malformation refers to a heterogeneous group of anatomical abnormalities at the craniovertebral junction. Chiari malformation type 1 (CM1) refers to the abnormal protrusion of cerebellar tonsils through the foramen magnum and is by far the commonest type. Its prevalence is estimated approximately 1%; it is more common in women and is associated with syringomyelia in 25-70% of cases. The prevalent pathophysiological theory proposes a morphological mismatch between a small posterior cranial fossa and a normally developed hindbrain that results in ectopia of the tonsils.In most people, CM1 is asymptomatic and diagnosed incidentally. In symptomatic cases, headache is the cardinal symptom. The typical headache is induced by Valsalva-like maneuvers. Many of the other symptoms are nonspecific, and in the absence of syringomyelia, the natural history is benign. Syringomyelia manifests with spinal cord dysfunction of varying severity. The approach to patients with CM1 should be multidisciplinary, and the first step in the management is phenotyping the symptoms, because they may be due to other pathologies, like a primary headache syndrome. Magnetic resonance imaging, which shows cerebellar tonsillar decent 5 mm or more below the foramen magnum, is the gold standard investigative modality. The diagnostic workup may include dynamic imaging of the craniocervical junction and intracranial pressure monitoring.The management of CM1 is variable and sometimes controversial. Surgery is usually reserved for patients with disabling headaches or neurological deficits from the syrinx. Surgical decompression of the craniocervical junction is the most widely used procedure. Several surgical techniques have been proposed, but there is no consensus on the best treatment strategy, mainly due to lack of high-quality evidence. The management of the condition during pregnancy, restriction to lifestyle related to athletic activities, and the coexistence of hypermobility require special considerations.

An Unusual Case of Headache in a Child: Idiopathic Intracranial Hypertension with Diagnostic Challenge

Introduction

In children, idiopathic intracranial hypertension (IIH) is relatively uncommon. It is characterized by an increase in intracranial pressure, in the absence of evidence of underlying brain disease, structural abnormalities, hydrocephalus, or abnormal meningeal improvement. However, very rarely it can occur without papilledema, even though it is the most recognizable clinical sign. Due to this, a delay in diagnosis can lead to severe visual impairments.

Case presentation

We describe a patient with a chronic headache but no papilledema. His neurological and systemic examinations were otherwise unremarkable. A lumbar puncture revealed a high opening pressure of 450 mmH₂O and normal cerebrospinal fluid (CSF) parameters. Magnetic resonance imaging of the brain revealed only tortuous optic nerves, no parenchymal lesions, and no evidence of venous sinus thrombosis. He required acetazolamide treatment. Our patient's symptoms improved significantly in 2 months with medical treatment, weight loss, and exercise, with no development of papilledema.

Conclusion

There is a wide range of clinical manifestations of IIH, making it difficult to decide when to begin treatment.

Idiopathic Intracranial Hypertension from Benign to Fulminant: Diagnostic and Management Issues

Idiopathic intracranial hypertension (IIH) primarrily affects obese women of childbearing years and is commonly associated with headaches, pulsatile tinnitus, and vision changes. Though most patients have a "benign" course, it can lead to significant morbidity, including blindness. The treatment approach is based on severity of visual impact and includes weight loss, intracranial pressure lowering medications, and sometimes surgery, such as spinal fluid diversion, optic nerve sheath fenestration, or venous sinus stenting. More studies are needed to determine when surgery is most appropriate and which surgical procedure provides maximal benefit with the least risk.

Update on Idiopathic Intracranial Hypertension Management

BACKGROUND

Idiopathic Intracranial Hypertension (IIH) is a secondary headache with a steadily growing incidence. Currently, there is little evidence to guide the treatment of IIH.

OBJECTIVE

To review the pathophysiology of IIH, with focus on the role of obesity as a risk factor, and the implications for new therapeutic perspectives.

METHODS

in this narrative review, we summarized the current knowledge on treatment options highlighting available evidence for managing intracranial hypertension, obesity, and headache.

RESULTS

Clinical Presentation: headache is the most common symptom and a significant cause of quality-of-life impairment. Visual loss is common in the diagnosis. Pathophysiology: there is no unified theory able to explain all symptoms and the evolution of the disease. There is growing data pointing to metabolic changes and obesity with a central role in IIH pathophysiology. Treatment: most published data on IIH treatment is related to pressure control and protection from visual loss. Acetazolamide and cerebrospinal fluid diversion are the best options available. Optic nerve sheath fenestration might be useful to temporally control the pressure over the optic nerve and thus protect from visual deterioration. Recently, venous sinus stenting has proven to be a safe option in selected cases. Finally, bariatric surgery has proven to effectively control elevated intracranial pressure.

CONCLUSION

IIH is a potential cause of high disability. Early recognition is important, and treatment should be tailored to the needs of each case. There is a lack of research on headache management, which might persist after ICP control.

Advances in the Understanding of the Complex Role of Venous Sinus Stenosis in Idiopathic Intracranial Hypertension

Idiopathic intracranial hypertension (IIH) is a disorder characterized by elevated intracranial pressure (ICP) that predominantly affects young obese women. IIH is a diagnosis of exclusion. That is, if increased ICP is suspected, magnetic resonance imaging and magnetic resonance venography of the brain are recommended to exclude secondary causes. Imaging findings, such as empty sella, orbital findings, meningocele, and encephalocele, are not diagnostic of ICP, nor does their absence exclude ICP either. Therefore, venous manometry is recommended as the gold standard for evaluation, regardless of previous anatomic imaging results. Venous manometry is an invasive examination that is frequently applied to derive physiologic information concerning the nature of the pressure gradient. However, the pathogenesis of IIH has not been fully elucidated. The presence of venous sinus stenosis in a subset of patients has provided some support for the potential mechanisms underlying this condition. Hence, this review provides an up‐to‐date discussion on the potential pathogenic mechanisms of IIH with a special focus on venous sinus stenosis.

Idiopathic Intracranial Hypertension - Challenges and Pearls

Idiopathic intracranial hypertension (IIH) is defined as a syndrome of raised intracranial pressure with normal imaging of the brain and cerebrospinal fluid (CSF) composition. There is a rising incidence and prevalence of this disease related to the increased prevalence of obesity. It typically affects women of working age, and headache is the predominant morbidity in over 90%. The disease is also more prevalent in young males. There are many controversies and myths that surround IIH. There are currently few treatment options for IIH, management is typically medical with those experiencing progressive visual loss undergoing surgical procedures. Weight loss and venous sinus stenting are a few therapies directed at the etiology.

Pediatric Headache in Primary Care and Emergency Departments: Consensus with RAND/UCLA Method

Headache is the most frequent neurological symptom in childhood and the main reason for admission to pediatric emergency departments. The aim of this consensus document is to define a shared clinical pathway between primary care pediatricians (PCP) and hospitals for the management of children presenting with headache. For the purposes of the study, a group of hospital pediatricians and a group of PCP from the Emilia Romagna’s health districts were selected to achieve consensus using the RAND/UCLA appropriateness method. Thirty-nine clinical scenarios were developed: for each scenario, participants were asked to rank the appropriateness of each option from 1 to 9. Agreement was reached if ≥75% of participants ranked within the same range of appropriateness. The answers, results, and discussion helped to define the appropriateness of procedures with a low level of evidence regarding different steps of the diagnostic-therapeutic process: primary care evaluation, emergency department evaluation, hospital admission, acute therapy, prophylaxis, and follow-up. The RAND proved to be a valid method to value appropriateness of procedures and define a diagnostic-therapeutic pathway suitable to the local reality in the management of pediatric headache. From our results, some useful recommendations were developed for optimizing the healthcare professionals’ network among primary care services and hospitals.

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

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.

Neuroimaging of Dizziness and Vertigo

Dizziness and vertigo are common symptoms in the primary care and emergency settings, resulting in a significant decrease in quality of life and a high cost burden to the US health care system. The etiology of these symptoms is difficult to elucidate owing to a wide range of diseases with overlapping manifestations. The broad differential diagnosis based on whether the disease process is central or peripheral is showcased. Each differential will be categorized into neoplastic, infectious or inflammatory, structural, traumatic, and iatrogenic causes. Computed tomography scans, MRI, and vascular imaging are frequently complimentary in providing diagnoses and guidance in management.

A paradigm for chronic fatigue syndrome: caught between idiopathic intracranial hypertension and spontaneous intracranial hypotension; caused by cranial venous outflow obstruction

Background

Clinical similarities between chronic fatigue syndrome and idiopathic intracranial hypertension, supported by measurements of intracranial pressure, invite suggestions that they may be connected, the first representing a mild version of the second. Yet, if this is to be the basis for a structural explanation for chronic fatigue syndrome, it already seems incomplete, failing to explain cases where disability seems disproportionate. Is there some other confounding variable?

Purpose

To refine, in this theoretical paper, an earlier model connecting chronic fatigue syndrome with idiopathic intracranial hypertension to allow for a cerebrospinal fluid (CSF) leak.

Model

In this model, the primary structural problem is acquired obstruction to cranial venous outflow. This obstruction can take different forms, may be intermittent and subtle, and even be mistaken for normal venous anatomy, yet would be the driving force behind a tendency towards increased intracranial pressure. This chronic elevation of intracranial pressure stresses the dural membrane maintaining the integrity of the subarachnoid space, which can rupture at a weak point, allowing CSF to leak away and intracranial pressure to fall. The clinical manifestation of this disorder is the product of the severity of cranial venous outflow compromise and of the competing forces on intracranial pressure. In some instances, a CSF leak will mitigate the effects of venous compromise, in others it will compound it, producing a disease spectrum ranging through idiopathic intracranial hypertension, chronic fatigue syndrome, fibromyalgia, and spontaneous intracranial hypotension.

Conclusion

In chronic fatigue syndrome a normal intracranial pressure does not exclude significant physiological disturbance.

Incidence of idiopathic intracranial hypertension in Southern Tasmania, Australia

Introduction

Anecdotally, the incidence of idiopathic intracranial hypertension (IIH) is increasing, linked to an increase in the obesity rate in Australian society. However, formal incidence and prevalence studies are rare. We therefore sought to determine the incidence and clinical features of IIH in Southern Tasmania, Australia.

Method

Neurology discharge summaries and lumbar puncture referrals from the single tertiary referral centre in this region were screened for an IIH diagnosis. All regional neurologists were surveyed to capture patients diagnosed through private neurology clinics. A retrospective review of medical records was conducted to confirm the diagnosis and determine whether patients met the Modified Dandy Criteria (MDC). Patients were included if they were above the age of 18 years and received a new diagnosis of IIH between June 2016 and June 2018. Population statistics were obtained from the Australian Bureau of Statistics.

Results

IIH incidence was 5.4/100 000. All patients were females, aged between 18 and 45 years. Headache was the most commonly reported symptom, with high rates of pre-existing or concurrent migraine diagnoses. Weight loss and commencement of oral acetazolamide were the most common treatment approaches. Four patients were medically refractory and required surgical intervention.

Conclusion

The incidence of IIH in Southern Tasmania is comparable with the incidence reported in subgroups of females of childbearing age in recent prior studies. The demographic, diagnostic and therapeutic data presented can inform future local health service provision and serve as a baseline for ongoing assessment of change in incidence and treatment of IIH at a community level.

Current Perspectives on Idiopathic Intracranial Hypertension without Papilloedema

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.

Bilateral optic disc swelling resulting from lymphocytic meningitis and posterior uveitis secondary to syphilis

Idiopathic intracranial hypertension (IIH) is being diagnosed more often in the UK due to the rise in obesity. In fact, patients who present with bilateral optic disc swelling are habitually put on the papilloedema pathway, often without consideration of other diagnoses. We report the case of a middle-aged woman diagnosed with papilloedema and managed as IIH, until, cerebrospinal fluid (CSF) analysis revealed evidence of lymphocytic meningitis secondary to syphilis. The patient was treated successfully with intravenous antibiotics. Syphilis is the great masquerader and should be a diagnosis to consider in patients who have CSF findings incongruent with their clinical presentation.

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.

Assessment of Pediatric Pseudotumor Cerebri Clinical Characteristics and Outcomes

Pseudotumor cerebri also known as idiopathic intracranial hypertension is a relatively uncommon disorder of unknown pathophysiology. Although pseudotumor cerebri occurs in both children and adults, the pseudotumor cerebri literature is heavily dominated by adult studies. The aim of this study is to retrospectively describe the clinical presentation, imaging, treatment, and outcomes of a large pediatric pseudotumor cerebri population over a 23-year period. We also discuss secondary pseudotumor cerebri (44%) as well as the increasingly recognized patient subgroups without headache (13.3%) and without papilledema (7.3%). Female sex, obesity, and initial symptoms were consistent with the literature; however radiographic findings were surprisingly low in this cohort. Headache outcomes at 1 week, 1 month, and 3 months following initial lumbar puncture/treatment and visual function outcomes are reported.

Evaluating the optic nerve stiffness and optic nerve sheath diameter in idiopathic intracranial hypertension patients after the resolution of papilledema

PURPOSE

The objective of this study was to investigate the optic nerve's elastic properties and optic nerve sheath diameter (ONSD) using shear-wave elastography (SWE) in patients with idiopathic intracranial hypertension (IIH) compared to healthy individuals.

METHODS

The study included 22 IIH patients and 15 healthy subjects. SWEs were performed on the optic nerve and ONSD, and optic nerve stiffness were measured.

RESULTS

The patients with IIH demonstrated higher stiffness of the optic nerve compared with that of healthy volunteers (P < 0.001). The optic nerve sheath diameter of the optic nerve in the IIH group was significantly larger than that in the control group (P < 0.001). There was no correlation between the disease duration and SWE values in the Spearman correlation test.

CONCLUSION

These findings suggest that ONSD can be used as a follow-up method in the treatment of IIH. However, there was not any correlation between the disease duration and SWE-based stiffness measurement of the optic nerve.

Idiopathic intracranial hypertension and visual function in North Indian population

BACKGROUND

Idiopathic Intracranial Hypertension (IIH) is a neurological disorder with varied presentation, visual morbidity being the most important one. Literature is sparse as regards the effects of IIH on the visual system in Asians.

OBJECTIVE

Assessment of visual morbidity and change with treatment in IIH patients in North India through a prospective interventional study.

MATERIALS AND METHODS

Sixty eyes of newly diagnosed IIH patients were evaluated for functional and structural tests of visual system. Lumbar puncture was performed to establish IIH diagnosis and received oral Carbonic anhydrase inhibitor thereafter. Change in visual function was studied from baseline to 6-month follow-up visit.

RESULTS

Mean age of participants at presentation was 33.27 ± 10.68 years and majority were females (73.3%). Seventy percent eyes (n = 42) had visual acuity 20/20 at presentation. Average Pelli Robson contrast sensitivity (CS) improved from 1.86 ± 0.34 to 2.11 ± 0.24 (Friedman Test: X2 = 59.2, p ⩽ 0.001) while number of eyes with detectable visual field deficits reduced from 70% to 43.7%. Retinal nerve fibre layer (RNFL) thickness reduced from 176.27 to 114.97 µ (Friedman Test: X2 = 69.3, p ⩽ 0.001).

CONCLUSIONS

The socio-demographic profile in our study showed higher male incidence than noted in previous studies. Visual function deficits were present in patients, even in those with 20/20 visual acuity. Significant improvement was seen after lumbar puncture and initiation of medical treatment. CS and RNFL thickness showed significant improvement even after 1 month of treatment and can be used for monitoring IIH patients.

Primary non-continuous new daily persistent headache: Seven cases and proposed diagnostic criteria

Primary new daily persistent headache (NDPH) is a rare disorder defined by the third edition of the International Headache Society (ICHD-3) as a continuous and unremitting headache. Non-continuous cases have been reported which do not fit any ICHD-3 criteria. Seven patients are presented who meet all ICHD-3 criteria except for being non-continuous from onset without treatment with a duration of 4 or more hours per day with only one headache per day. The average age of onset was 35.3 years, 57.1% female, and 71.4% had migraine-like features. No cases were unilateral and all cases were persistent without remission. These seven cases constitute a primary NDPH variant. Criteria are proposed for diagnosis similar to ICHD-3 for NDPH with the following change: “pain becoming daily within 24 hours of onset with a duration of 4 to 24 hours without acute or preventive medication or other treatment.”

Diagnosis and treatment of idiopathic intracranial hypertension

Objective

To review and discuss the clinical presentation and treatment of idiopathic intracranial hypertension.

Discussion

Visual alterations and headache are the two main symptoms of idiopathic intracranial hypertension, although additional features including cranial nerve palsies, cognitive deficits, olfactory deficits and tinnitus are not uncommon. The headache associated with idiopathic intracranial hypertension frequently has a migrainous phenotype. The underlying cause of the disorder has not yet been elucidated. Several hypotheses have been postulated but none of them can explain the full clinical picture. Therapeutic options remain limited, focusing mainly on reduction in body weight and the reduction of CSF production with carbonic anhydrase inhibitors.

Conclusion

The accurate diagnosis of idiopathic intracranial hypertension is essential as visual deterioration due to papilledema may be irreversible. Given its phenotypic similarity and frequent overlap with chronic migraine it is essential to consider idiopathic intracranial hypertension in the diagnostic workup of chronic headache; in particular, when considering its increasing prevalence. Understanding in detail the pathophysiological mechanisms behind the associated headache would also allow study of current and future therapeutic options in a structured way.

Atypical presentations of idiopathic intracranial hypertension

Idiopathic intracranial hypertension (IIH) is a disorder of unknown etiology that results in isolated raised intracranial pressure. Classic symptoms and signs of IIH include headache, papilledema, diplopia from sixth nerve palsy and divergence insufficiency, and pulsatile tinnitus. Atypical presentations include: (1) highly asymmetric or even unilateral papilledema, and IIH without papilledema; (2) ocular motor disturbances from third nerve palsy, fourth nerve palsy, internuclear ophthalmoplegia, diffuse ophthalmoplegia, and skew deviation; (3) olfactory dysfunction; (4) trigeminal nerve dysfunction; (5) facial nerve dysfunction; (6) hearing loss and vestibular dysfunction; (7) lower cranial nerve dysfunction including deviated uvula, torticollis, and tongue weakness; (8) spontaneous skull base cerebrospinal fluid leak; and (9) seizures. Although atypical findings should raise a red flag and prompt further investigation for an alternative etiology, clinicians should be familiar with these unusual presentations.

Demographics, Clinical Characteristics, and Management of Idiopathic Intracranial Hypertension in Kuwait: A Single-Center Experience

Background: Idiopathic intracranial hypertension (IIH) affects predominantly obese females during their reproductive age period. The demographics of this condition has not been studied in Kuwait before. Objectives: To determine the demographics, clinical features, risk factors, and treatment modalities of IIH in the main neurology tertiary referral hospital in Kuwait and to compare our data with literature. Methods: A retrospective study was conducted to identify cases of IIH seen between January 1, 2018, and December 31, 2018. Patients were diagnosed in and referred from the neurology and neuro-ophthalmology clinics. Results: Our cohort consisted of 139 patients. We estimated a crude annual incidence rate of IIH of 3.28 per 100,000 population. Female-to-male ratio was 9.6:1. Mean age was 32.1 ± 10.8 years. Mean age of males was 31.46 ± 12.63 and that of females was 32.11 ± 10.67. The median of the duration from the first symptoms till diagnosis was 6 weeks (2-10 weeks). Headache was the most common symptom in 134 (96.4%) patients, followed by visual disturbances in 85 (61.2%) patients, transient visual obscurations (TVOs) in 84 (60.4%) patients, pulsatile tinnitus in 72 (51.8%) patients, diplopia in 22 (15.8%) patients, other symptoms (e.g., nausea, vomiting, radicular neck, and back pain) in 19 (13.7%) patients, and 1 (0.7%) patient had facial weakness. High body mass index (BMI) was seen in 89.9% of patients, either overweight or obese, and it was the most common risk factors in both males (46.2%) and females (61.1%). Anemia was found in 38.1%; 21.6% of patients used OCPs and 7.9% used vitamin A. Bilateral transverse sinus stenosis (BTSS) was detected in 47 (33.8%) patients. Only 2 (1.4%) patients developed "fulminant IIH" characterized by rapidly progressive disease. All the patients received medical treatment and only 12 (8.6%) needed surgical management. Conclusion: Incidence of IIH in Kuwait is similar to other regional studies but higher than Western studies. Demographics and clinical features of IIH in our study are comparable to international and regional figures. Most of our patients had a benign course. IIH is more prevalent in females and strongly associated with obesity.

Neurofilament light chain as biomarker in idiopathic intracranial hypertension

BACKGROUND

Damage of the optic nerve is the major complication of idiopathic intracranial hypertension. A biomarker indicative for optic nerve damage would help identifying high-risk patients requiring surgical procedures. Here, we studied the potential of cerebrospinal fluid neurofilament to predict idiopathic intracranial hypertension-induced optic nerve damage.

METHODS

In two centers, serum and cerebrospinal fluid of 61 patients with clinically suspected idiopathic intracranial hypertension were prospectively collected. Neurofilament concentrations were measured and related to ophthalmological assessment.

RESULTS

The average cerebrospinal fluid neurofilament concentration in patients with moderate and severe papilledema was increased compared to patients with minor and no papilledema (1755 ± 3507 pg/ml vs. 244 ± 102 pg/ml; p < 0.001). Cerebrospinal fluid neurofilament concentrations correlated with the maximal lumbar puncture opening pressure (r = 0.67, p < 0.001). In patients fulfilling the Friedman criteria for idiopathic intracranial hypertension with or without papilledema (n = 35), development of bilateral visual field defects and bilateral atrophy of the optic nerve were associated with increased average age-adjusted cerebrospinal fluid neurofilament concentrations. At last follow-up (n = 30), 8/13 of patients with increased, but only 3/17 with normal, cerebrospinal fluid neurofilament had developed bilateral visual field defects and/or bilateral optic nerve atrophy resulting in a sensitivity of 72.7% and a specificity of 73.7% of cerebrospinal fluid neurofilament to detect permanent optic nerve damage.

CONCLUSIONS

Cerebrospinal fluid neurofilament is a putative biomarker for optical nerve damage in idiopathic intracranial hypertension.

Emerging themes in idiopathic intracranial hypertension

Purpose

Idiopathic intracranial hypertension (IIH) is a rare disorder characterised by raised intracranial pressure. The underlying pathophysiology is mostly unknown and effective treatment is an unmet clinical need in this disease. This review evaluates key emerging themes regarding disease characteristics, mechanisms contributing to raised intracranial pressure and advances in potential therapeutic targets.

Findings

IIH is becoming more common, with the incidence rising in parallel with the global obesity epidemic. Current medical management remains centred around weight management, which is challenging. Metabolic investigations of patients have identified specific androgen profiles in cerebrospinal fluid (CSF), which suggest an endocrine dysfunction impacting CSF secretion in IIH. Glucagon-like peptide-1 (GLP-1) and 11β-hydroxysteroid dehydrogenase type 1 (11β-HSD1) have been found to play a role in CSF dynamics in IIH and have formed the basis of the first clinical trials looking at new treatments.

Conclusions

Identification of novel molecular targets thought to underlie IIH pathology is now being translated to clinical trials.

A clinical and radiological study in patients with idiopathic intracranial hypertension

Abstract

Idiopathic intracranial hypertension (IIH) is one of the chronic causes of elevated intracranial pressure with no evident cause in neuroimaging and normal CSF analysis. It primarily affects overweight women of childbearing age.

Aim of work

To describe the clinical picture of IIH, neuroimaging and response to treatment after 3 months follow up in a sample of Egyptian patients.

Patients and methods

This was a prospective study carried out on 25 patients presented at Alexandria University Hospital with symptomatology of IIH. All the patients were subjected to complete history taking, neurological examination, fundus examination, lumbar puncture, and MRI brain and MR cerebral venography. The patients were followed-up for 3 months for assessment of treatment response.

Results

Patients’ ages ranged from 1 0to 50 years, with a mean BMI 32.32 ± 5.28 kg m2. Headache was the presenting manifestation in 100% of the patients. About 60% of the sample were either misdiagnosed or had a delayed diagnosis. There was a significant positive correlation between CSF opening pressure (r = 0.504, p = 0.010), severity of headache (r = 0.472, p = 0.017) and grade of papilledema. Optic hydropes and empty sellaturcica were the most common MRI abnormalities occurring in 95.8% and 70.8%, respectively. Only 30% of the cases had normal MRV. Stenosis at genu junction and focal stenosis at transverse sinus occurred in 24% and 20% of the cases, respectively. Combined medical and serial lumbar puncture were the most effective line of therapy in the recruited patients.

Conclusion

Headache is the most common presentation of IIH, and its severity is positively correlated with papilledema grade. CSF pressure is also positively correlated with papilledema grade.

Utility of Magnetic Resonance Imaging Features for Improving the Diagnosis of Idiopathic Intracranial Hypertension Without Papilledema

OBJECTIVE

Revised diagnostic criteria for idiopathic intracranial hypertension (IIH) were proposed in part to reduce misdiagnosis of intracranial hypertension without papilledema (WOP) by using 3 or 4 MRI features of intracranial hypertension when a sixth nerve palsy is absent. This study was undertaken to evaluate the sensitivity and specificity of the MRI criteria and to validate their utility for diagnosing IIH in patients with chronic headaches and elevated opening pressure (CH + EOP), but WOP.

METHODS

Brain MRIs from 80 patients with IIH with papilledema (WP), 33 patients with CH + EOP, and 70 control patients with infrequent episodic migraine were assessed in a masked fashion for MRI features of intracranial hypertension.

RESULTS

Reduced pituitary gland height was moderately sensitive for IIH WP (80%) but had low specificity (64%). Increased optic nerve sheath diameter was less sensitive (51%) and only moderately specific (83%). Flattening of the posterior globe was highly specific (97%) but had low sensitivity (57%). Transverse venous sinus stenosis was moderately sensitive for IIH WP (78%) but of undetermined specificity. A combination of any 3 of 4 MRI features was nearly 100% specific, while maintaining a sensitivity of 64%. Of patients with CH + EOP, 30% had 3 or more MRI features, suggesting IIH WOP in those patients.

CONCLUSION

A combination of any 3 of 4 MRI features is highly specific for intracranial hypertension and suggests IIH WOP when present in patients with chronic headache and no papilledema.

Lumbo-peritoneal shunt as treatment modality for visual symptoms in idiopathic intracranial hypertension: A single institution experience

OBJECTIVES

To evaluate the efficacy of lumbo-peritoneal shunt (LPS) in patients of idiopathic intracranial hypertension presenting with visual symptoms.

METHODS

Between Apr. 2014 and Mar. 2018, 70 patients of Idiopathic Intracranial Hypertension (IIH) underwent treatment at our institution. Patients were evaluated for neurological and ophthalmological status and were subjected to LPS depending on their symptoms.

RESULTS

Mean opening pressure was 29.97±5.33cm of water and mean Body-Mass Index (BMI) was 26.51±3 and the two were significantly correlated (p-value 0.006). All patients with visual symptoms (23) underwent LPS and others (47) were managed medically. All patients with LPS and 25 of medically managed patients improved, while 22 medically-managed patients required LPS due to deterioration in visual symptomatology. The proportion of patients showing complete resolution of features of IIH was significantly different between the three groups. Of the 7 patients with shunt extrusion/migration, only 2 required revision.

CONCLUSION

LPS is an equally effective and more technically familiar modality for treatment of IIH for neurosurgeons and should be offered to asymptomatic patients with objective visual signs. Shunt extrusion/migration may not always warrant revision due to "mini-shunt" that drains Cerebro-Spinal Fluid (CSF) through shunt tract even after extrusion.

An update on idiopathic intracranial hypertension in adults: a look at pathophysiology, diagnostic approach and management

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.

Idiopathic Intracranial Hypertension

PURPOSE OF REVIEW

Idiopathic intracranial hypertension is a syndrome of increased intracranial pressure of unclear etiology that most often occurs in obese women of childbearing age but can also occur in men, children, and older adults. This article reviews the diagnostic criteria, clinical features, neuroimaging findings, differential diagnosis, and management options for this condition.

RECENT FINDINGS

Recent population studies have found that the annual incidence of idiopathic intracranial hypertension is increasing in association with obesity rates, whereas recent scientific studies indicate a possible role for androgen sex hormones and adipose tissue in the pathogenesis of the disease. Prospective clinical trials have demonstrated a role for weight loss, acetazolamide, and topiramate in the management of mild disease. A recently begun randomized multicenter trial of surgical interventions will provide insight into the indications for surgical intervention, optimal timing and choice of intervention, and long-term outcomes.

SUMMARY

Idiopathic intracranial hypertension is a disorder producing symptoms and signs of increased intracranial pressure in the absence of an alternative cause. The main goals of treatment are to preserve visual function and alleviate symptoms, which can usually be achieved with a combination of weight loss, medical therapies, and surgical interventions depending on the severity of symptoms and vision loss, response to treatment, and subsequent clinical course.

Idiopathic Intracranial Hypertension: The Monster Within

Idiopathic intracranial hypertension (IIH) is defined as a syndrome of raised intracranial pressure with normal imaging of the brain and cerebrospinal fluid (CSF) composition. There are many controversies and myths that surround IIH. Although patients of IIH may present “typical” symptoms and signs of raised intracranial pressure, clinical scenarios often vary. A typical clinical and radiological finding poses significant problems in diagnosis and management of patients with IIH. We have tried to resolve these controversies and provide a comprehensive update on different aspects of IIH. In this article, we review the common problems encountered while dealing with patients of IIH.

The role of intracranial pressure in glaucoma and therapeutic implications

Despite glaucoma being the second leading cause of blindness globally, its pathogenesis remains incompletely understood. Although intraocular pressure (IOP) contributes to glaucoma, and reducing IOP slows progress of the disease, some patients progress despite normal IOP (NTG). Glaucomatous damage causes characteristic cupping of the optic nerve where it passes through the lamina cribrosa. There is evidence that cerebrospinal fluid (CSF) within the optic nerve sheath has a different composition from CSF surrounding the brain. Furthermore, fluctuations in CSF flow into the optic nerve sheath may be reduced by trabeculae within the sheath, and on standing intracranial pressure (ICP) within the sheath is stabilised at around 3 mmHg due to orbital pressure. Blood pressure has been linked both to glaucoma and ICP. These facts have led some to conclude that ICP does not play a role in glaucoma. However, according to stress formulae and Laplace's Law, stress within the lamina cribrosa is dependent on the forces on either side of it, (IOP and ICP), and its thickness. On lying flat at night, ICP between the brain and optic nerve sheath should equalise. Most evidence suggests ICP is lower in glaucoma than in control groups, and that the lamina cribrosa is thinner and more posteriorly displaced in glaucoma. Subjects who have had ICP reduced have developed signs of glaucoma. This review finds most evidence supports a role for low ICP in the pathogenesis of glaucoma. Caffeine, theophylline and vitamin A may increase ICP, and could be new candidates for an oral treatment.

Update on the Diagnosis and Treatment of Idiopathic Intracranial Hypertension

Advances in ophthalmic diagnostics and results of interventional clinical trials are shifting diagnosis and management of idiopathic intracranial hypertension (IIH) to be more technology- and evidence-based. In this article, the evidence supporting current diagnostic criteria, evaluation, and medical and surgical management of IIH are reviewed.