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Bonelli L, Menon V, Arnold AC, Mollan SP. Managing idiopathic intracranial hypertension in the eye clinic. Eye (Lond) 2024; 38:2472-2481. [PMID: 38789788 PMCID: PMC11306398 DOI: 10.1038/s41433-024-03140-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2024] [Revised: 04/30/2024] [Accepted: 05/07/2024] [Indexed: 05/26/2024] Open
Abstract
Idiopathic intracranial hypertension (IIH) is a neuro-ophthalmological condition characterised by a raised intracranial pressure and papilloedema that causes disabling headaches. The main risk factors of female sex and living with obesity have been known for some time, however the knowledge of the underlying pathophysiology is evolving. Papilloedema can impact the visual function, and the majority of people are offered acetazolamide. Those with sight threatening disease need urgent management, though there is little high quality evidence to recommend any particular surgical intervention. Headache treatment is an unmet clinical need and simple medication overuse advice has the potential to reduce the chronification of migraine-like headaches. IIH is emerging as a systemic metabolic disease distinct from people living with obesity alone. While weight loss is the main stay of disease modifying therapy this is challenging to access and many healthcare professionals that manage the condition have no formal training or accessible pathways for weight management. The aim of this "how to do it" article is to present the latest advances in knowledge of IIH that we pragmatically included in routine clinical care for people living with the condition.
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Affiliation(s)
- Laura Bonelli
- Department of Ophthalmology, University of California, Los Angeles, Stein Eye Institute, Los Angeles, CA, USA
| | - Vaishnavi Menon
- Birmingham Neuro-Ophthalmology, University Hospitals Birmingham NHS Foundation Trust, Birmingham, B15 2GW, UK
| | - Anthony C Arnold
- Department of Ophthalmology, University of California, Los Angeles, Stein Eye Institute, Los Angeles, CA, USA
| | - Susan P Mollan
- Translational Brain Science, Institute of Metabolism and Systems Research, University of Birmingham, Edgbaston, B15 2TT, UK.
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Potter O, Menon V, Mollan SP. Risk factors and disease associations in people living with idiopathic intracranial hypertension. Expert Rev Neurother 2024; 24:681-689. [PMID: 38803205 DOI: 10.1080/14737175.2024.2359420] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2024] [Accepted: 05/21/2024] [Indexed: 05/29/2024]
Abstract
INTRODUCTION Idiopathic intracranial hypertension is a neurological condition characterized by a raised intracranial pressure and papilledema, leading to chronic headaches and visual disturbances. By recognizing modifiable risk factors and deploying evidence-based interventions, healthcare providers have the potential to mitigate the burden of the disease and improve patient outcomes. AREAS COVERED It is well known that the condition occurs in predominantly pre-menopausal females who live with obesity particularly in the context of recent weight gain. This review discusses what risk factors may contribute to the metabolic underpinnings of cerebrospinal fluid dysregulation. There are a number of disease associations that are important to screen for as they can alter management. EXPERT OPINION There is emerging evidence to suggest that idiopathic intracranial hypertension is a systemic metabolic disease and it is unknown what are all the risk factors are that precipitate the condition. Targeting certain hardwired risk factors is unachievable. However, as recent weight gain has been identified as a predominant risk factor for the development of the disease and relapse, modification of body weight should be the primary aim of management. Insightful research into the involvement of the neuroendocrine axis driving cerebrospinal fluid dysregulation now has the potential for the development of therapeutic targets.
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Affiliation(s)
- Olivia Potter
- Birmingham Neuro-Ophthalmology, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Vaishnavi Menon
- Birmingham Neuro-Ophthalmology, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Susan P Mollan
- Birmingham Neuro-Ophthalmology, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
- Translational Brain Science, Institute of Metabolism and Systems Research, University of Birmingham, Edgbaston, UK
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Svart K, Korsbæk JJ, Jensen RH, Parkner T, Knudsen CS, Hasselbalch SG, Hagen SM, Wibroe EA, Molander LD, Beier D. Neurofilament light chain is elevated in patients with newly diagnosed idiopathic intracranial hypertension: A prospective study. Cephalalgia 2024; 44:3331024241248203. [PMID: 38690635 DOI: 10.1177/03331024241248203] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/02/2024]
Abstract
BACKGROUND Idiopathic intracranial hypertension is a secondary headache disorder potentially causing visual loss. Neurofilament light chain is a candidate, prognostic biomarker, but further studies of neuronal biomarkers are needed. Our objective was to investigate neurofilament light chain in cerebrospinal fluid (cNfL) and plasma (pNfL), amyloid-beta 42 (Aβ-42), total-tau and phosphorylated-tau in cerebrospinal fluid in new-onset idiopathic intracranial hypertension. METHODS Prospective case-control study including new-onset idiopathic intracranial hypertension and age, sex and BMI matched controls. Biomarkers were compared between patients and controls and related to papilledema, visual fields and opening pressure. RESULTS We included 37 patients and 35 controls. Patients had higher age-adjusted cNfL (1.4 vs. 0.6 pg/mL, p-adjusted < 0.001), pNfL (0.5 vs. 0.3 pg/mL, p-adjusted < 0.001) and total-tau/Aβ-42 (0.12 vs. 0.11, p-adjusted = 0.039). Significant, positive linear correlations were found between cNfL, pNfL, total-tau/Aβ-42 and opening pressure. Patients with severe papilledema had elevated cNfL compared to mild-moderate papilledema (median cNfL: 4.3 pg/mL (3.7) versus 1.0 pg/mL (1.4), p-adjusted = 0.009). cNFL was inversely associated with perimetric mean deviation (r = -0.47, p-adjusted < 0.001). CONCLUSIONS cNfL, pNfL and total-tau/Aβ-42 were elevated in new-onset idiopathic intracranial hypertension. cNfL was associated with severity of papilledema and visual field defects at diagnosis. This indicates early axonal damage. Neurofilament light chain is a candidate biomarker for disease severity.
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Affiliation(s)
- Katrine Svart
- Danish Headache Center, Department of Neurology, Rigshospitalet-Glostrup, Copenhagen, Denmark
| | - Johanne Juhl Korsbæk
- Danish Headache Center, Department of Neurology, Rigshospitalet-Glostrup, Copenhagen, Denmark
- University of Copenhagen, Copenhagen, Denmark
| | - Rigmor Højland Jensen
- Danish Headache Center, Department of Neurology, Rigshospitalet-Glostrup, Copenhagen, Denmark
| | - Tina Parkner
- Department of Clinical Biochemistry, Aarhus University Hospital, Aarhus, Denmark
- Department of Clinical Medicine, University of Aarhus, Århus, Denmark
| | - Cindy Søndersø Knudsen
- Department of Clinical Biochemistry, Aarhus University Hospital, Aarhus, Denmark
- Department of Clinical Medicine, University of Aarhus, Århus, Denmark
| | - Steen Gregers Hasselbalch
- University of Copenhagen, Copenhagen, Denmark
- Danish Dementia Research Center, Department of Neurology, Neuroscience Centre, Rigshospitalet, Copenhagen, Denmark
| | - Snorre Malm Hagen
- University of Copenhagen, Copenhagen, Denmark
- Department of Ophthalmology, Rigshospitalet-Glostrup, Copenhagen, Denmark
| | - Elisabeth Arnberg Wibroe
- University of Copenhagen, Copenhagen, Denmark
- Department of Ophthalmology, Rigshospitalet-Glostrup, Copenhagen, Denmark
| | | | - Dagmar Beier
- Department of Neurology, Odense University Hospital, Odense, Denmark
- Department of Clinical Research, University of Southern Denmark, Odense, Denmark
- OPEN, Odense Patient data Explorative Network, Odense University Hospital, Odense, Denmark
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Grech O, Mitchell JL, Lyons HS, Yiangou A, Thaller M, Tsermoulas G, Brock K, Mollan SP, Sinclair AJ. Effect of glucagon like peptide-1 receptor agonist exenatide, used as an intracranial pressure lowering agent, on cognition in Idiopathic Intracranial Hypertension. Eye (Lond) 2024; 38:1374-1379. [PMID: 38212401 PMCID: PMC11076535 DOI: 10.1038/s41433-023-02908-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2023] [Revised: 12/14/2023] [Accepted: 12/14/2023] [Indexed: 01/13/2024] Open
Abstract
BACKGROUND Cognitive function can be affected in conditions with raised intracranial pressure (ICP) such as idiopathic intracranial hypertension (IIH). Drugs used off label to treat raised ICP also have cognitive side effects, underscoring the unmet need for effective therapeutics which reduce ICP without worsening cognition. The Glucagon Like Peptide-1 (GLP-1) receptor agonist, exenatide, has been shown to significantly reduce ICP in IIH, therefore this study aimed to determine the effects of exenatide on cognition in IIH. METHODS This was an exploratory study of the IIH:Pressure trial (ISTCRN 12678718). Women with IIH and telemetric ICP monitors (n = 15) were treated with exenatide (n = 7) or placebo (n = 8) for 12 weeks. Cognitive function was tested using the National Institute of Health Toolbox Cognitive Battery at baseline and 12 weeks. RESULTS Cognitive performance was impaired in fluid intelligence ((T-score of 50 = population mean), mean (SD) 37.20 (9.87)), attention (33.93 (7.15)) and executive function (38.07 (14.61)). After 12-weeks there was no evidence that exenatide compromised cognition (no differences between exenatide and placebo). Cognition improved in exenatide treated patients in fluid intelligence (baseline 38.4 (8.2), 12 weeks 52.9 (6.6), p = 0.0005), processing speed (baseline 43.7 (9.4), 12 weeks 58.4 (10.4), p = 0.0058) and episodic memory (baseline 49.4 (5.3), 12 weeks 62.1 (13.2), p = 0.0315). CONCLUSIONS In patients with raised ICP due to IIH, exenatide, a drug emerging as an ICP lowering agent, does not adversely impact cognition. This is encouraging and has potential to be relevant when considering prescribing choices to lower ICP.
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Affiliation(s)
- Olivia Grech
- Institute of Metabolism and Systems Research, College of Medical and Dental Sciences, University of Birmingham, Birmingham, B15 2TT, UK
- Centre for Endocrinology, Diabetes and Metabolism, Birmingham Health Partners, Birmingham, B15 2TH, UK
| | - James L Mitchell
- Institute of Metabolism and Systems Research, College of Medical and Dental Sciences, University of Birmingham, Birmingham, B15 2TT, UK
- Centre for Endocrinology, Diabetes and Metabolism, Birmingham Health Partners, Birmingham, B15 2TH, UK
- Department of Neurology, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham, B15 2WB, UK
| | - Hannah S Lyons
- Institute of Metabolism and Systems Research, College of Medical and Dental Sciences, University of Birmingham, Birmingham, B15 2TT, UK
- Centre for Endocrinology, Diabetes and Metabolism, Birmingham Health Partners, Birmingham, B15 2TH, UK
- Department of Neurology, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham, B15 2WB, UK
| | - Andreas Yiangou
- Institute of Metabolism and Systems Research, College of Medical and Dental Sciences, University of Birmingham, Birmingham, B15 2TT, UK
- Centre for Endocrinology, Diabetes and Metabolism, Birmingham Health Partners, Birmingham, B15 2TH, UK
- Department of Neurology, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham, B15 2WB, UK
| | - Mark Thaller
- Institute of Metabolism and Systems Research, College of Medical and Dental Sciences, University of Birmingham, Birmingham, B15 2TT, UK
- Centre for Endocrinology, Diabetes and Metabolism, Birmingham Health Partners, Birmingham, B15 2TH, UK
- Department of Neurology, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham, B15 2WB, UK
| | - Georgios Tsermoulas
- Institute of Metabolism and Systems Research, College of Medical and Dental Sciences, University of Birmingham, Birmingham, B15 2TT, UK
- Centre for Endocrinology, Diabetes and Metabolism, Birmingham Health Partners, Birmingham, B15 2TH, UK
- Department of Neurosurgery, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham, B15 2WB, UK
| | - Kristian Brock
- Cancer Research UK Clinical Trials Unit, University of Birmingham, Birmingham, B15 2TT, UK
| | - Susan P Mollan
- Institute of Metabolism and Systems Research, College of Medical and Dental Sciences, University of Birmingham, Birmingham, B15 2TT, UK
- Centre for Endocrinology, Diabetes and Metabolism, Birmingham Health Partners, Birmingham, B15 2TH, UK
- Birmingham Neuro-Ophthalmology, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham, B15 2WB, UK
| | - Alexandra J Sinclair
- Institute of Metabolism and Systems Research, College of Medical and Dental Sciences, University of Birmingham, Birmingham, B15 2TT, UK.
- Centre for Endocrinology, Diabetes and Metabolism, Birmingham Health Partners, Birmingham, B15 2TH, UK.
- Department of Neurology, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham, B15 2WB, UK.
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Toshniwal SS, Kinkar J, Chadha Y, Khurana K, Reddy H, Kadam A, Acharya S. Navigating the Enigma: A Comprehensive Review of Idiopathic Intracranial Hypertension. Cureus 2024; 16:e56256. [PMID: 38623134 PMCID: PMC11016992 DOI: 10.7759/cureus.56256] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2024] [Accepted: 03/16/2024] [Indexed: 04/17/2024] Open
Abstract
An unidentified source of increased intracranial pressure is a hallmark of idiopathic intracranial hypertension (IIH), also referred to as pseudotumor cerebri. It mainly affects young, obese women, yet it can happen to anyone, regardless of age, gender, or weight. IIH presents with symptoms such as headaches, visual disturbances, and pulsatile tinnitus and can lead to severe complications, including vision loss, if left untreated. Diagnosis involves clinical evaluation, neuroimaging, and lumbar puncture, while management options include medical interventions and surgical procedures. This review provides a comprehensive overview of IIH, including its etiology, clinical presentation, epidemiology, complications, management approaches, and challenges. Increased awareness among healthcare professionals, standardized diagnostic criteria, and further research efforts are essential for improving outcomes and quality of life for individuals with IIH.
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Affiliation(s)
- Saket S Toshniwal
- Medicine, Jawaharlal Nehru Medical College, Datta Meghe Institute of Higher Education & Research, Wardha, IND
| | - Jiwan Kinkar
- Neurology, Jawaharlal Nehru Medical College, Datta Meghe Institute of Higher Education & Research, Nagpur, IND
| | - Yatika Chadha
- Psychiatry, Jawaharlal Nehru Medical College, Datta Meghe Institute of Higher Education & Research, Wardha, IND
| | - Kashish Khurana
- Medicine, Jawaharlal Nehru Medical College, Datta Meghe Institute of Higher Education & Research, Wardha, IND
| | - Harshitha Reddy
- Medicine, Jawaharlal Nehru Medical College, Datta Meghe Institute of Higher Education & Research, Wardha, IND
| | - Abhinav Kadam
- Medicine, Jawaharlal Nehru Medical College, Datta Meghe Institute of Higher Education & Research, Wardha, IND
| | - Sourya Acharya
- Medicine, Jawaharlal Nehru Medical College, Datta Meghe Institute of Higher Education & Research, Wardha, IND
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Abbott S, Denton A, Wong SH, Mollan SP, Bul KCM. Weight management communications in idiopathic intracranial hypertension: challenges and recommendations from the patients' perspective. BMJ Neurol Open 2023; 5:e000527. [PMID: 38116470 PMCID: PMC10729070 DOI: 10.1136/bmjno-2023-000527] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2023] [Accepted: 11/05/2023] [Indexed: 12/21/2023] Open
Abstract
Background Idiopathic intracranial hypertension (IIH) is a neurometabolic condition severely impacting the quality of life of people living with IIH (PwIIH). Most PwIIH are overweight or live with obesity, and weight loss is recommended by healthcare professionals (HCPs) as it is central to disease management. There is currently no research evaluating patient-clinician interactions when discussing weight management in IIH. The aim of this study was to evaluate the patient experience of communication with HCPs regarding weight management from the perspective of PwIIH. Methods A cross-sectional online survey was developed and distributed by the IIH UK charity via their mailing list and social media network. Eligible participants were adults with IIH who have been recommended to lose weight by their HCP. Descriptive statistics were used to summarise quantitative responses and content analysis was used to inductively draw out themes from open-ended free-text responses. Results There were 625 respondents. One-fifth of PwIIH (n=127/603, 21%) felt that HCPs were supportive and empathetic about weight management. Five themes were identified on how experiences regarding weight management for IIH can be improved, with PwIIH recommending for HCPs to: (1) detail the relationship between IIH and weight, (2) individualise care, (3) give advice, (4) provide support and (5) adapt communication. Conclusion The majority of PwIIH recalled a poor experience and negative emotions when engaged in discussions regarding weight management with their HCPs. Further research should explore the HCPs perspective and evaluate interventions aiming to improve the quality of patient-HCPs communication in IIH.
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Affiliation(s)
- Sally Abbott
- Institute for Health and Wellbeing, Centre for Healthcare and Communities, Coventry University, Coventry, UK
- Department of Dietetics, University Hospitals Coventry and Warwickshire NHS Trust, Coventry, UK
| | | | - Sui H Wong
- Department of Neuro-Ophthalmology, Moorfields Eye Hospital NHS Foundation Trust, London, UK
- Medical Eye Unit, Guy's and St Thomas' Hospitals NHS Trust, London, UK
- Faculty of Life Sciences and Medicine, King’s College London, London, UK
- Institute of Neurology, Department of Clinical and Movement Neuroscience, University College London, London, UK
| | - Susan P Mollan
- Birmingham Neuro-Ophthalmology, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
- Institute of Metabolism and Systems Research, Translational Brain Science, University of Birmingham, Birmingham, UK
| | - Kim CM Bul
- Institute for Health and Wellbeing, Centre for Intelligent Healthcare, Coventry University, Coventry, UK
- Renal Services, University Hospitals Coventry and Warwickshire NHS Trust, Coventry, UK
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7
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Yiangou A, Mollan SP, Sinclair AJ. Idiopathic intracranial hypertension: a step change in understanding the disease mechanisms. Nat Rev Neurol 2023; 19:769-785. [PMID: 37957260 DOI: 10.1038/s41582-023-00893-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/11/2023] [Indexed: 11/15/2023]
Abstract
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.
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Affiliation(s)
- Andreas Yiangou
- Institute of Metabolism and Systems Research, University of Birmingham, Birmingham, UK
- Department of Neurology, Queen Elizabeth Hospital Birmingham, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Susan P Mollan
- Institute of Metabolism and Systems Research, University of Birmingham, Birmingham, UK
- Birmingham Neuro-Ophthalmology, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Alexandra J Sinclair
- Institute of Metabolism and Systems Research, University of Birmingham, Birmingham, UK.
- Department of Neurology, Queen Elizabeth Hospital Birmingham, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK.
- Centre for Endocrinology, Diabetes and Metabolism, Birmingham Health Partners, Birmingham, UK.
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Abbott S, Chan F, Tahrani AA, Wong SH, Campbell FEJ, Parmar C, Pournaras DJ, Denton A, Sinclair AJ, Mollan SP. Weight Management Interventions for Adults With Idiopathic Intracranial Hypertension: A Systematic Review and Practice Recommendations. Neurology 2023; 101:e2138-e2150. [PMID: 37813577 PMCID: PMC10663033 DOI: 10.1212/wnl.0000000000207866] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2023] [Accepted: 08/15/2023] [Indexed: 10/14/2023] Open
Abstract
BACKGROUND AND OBJECTIVES Idiopathic intracranial hypertension (IIH) is associated with obesity; however, there is a lack of clinical consensus on how to manage weight in IIH. The aim of this systematic review was to evaluate weight loss interventions in people with IIH to determine which intervention is superior in terms of weight loss, reduction in intracranial pressure (ICP), benefit to visual and headache outcomes, quality of life, and mental health. METHODS A systematic review was conducted in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines and registered with PROSPERO (CRD42023339569). MEDLINE and CINAHL were searched for relevant literature published from inception until December 15, 2022. Screening and quality appraisal was conducted by 2 independent reviewers. Recommendations were graded using Scottish Intercollegiate Guidelines Network methodology. RESULTS A total of 17 studies were included. Bariatric surgery resulted in 27.2-27.8 kg weight loss at 24 months (Level 1- to 1++). Lifestyle weight management interventions resulted in between 1.4 and 15.7 kg weight loss (Level 2+ to 1++). Bariatric surgery resulted in the greatest mean reduction in ICP (-11.9 cm H2O) at 24 months (Level 1++), followed by multicomponent lifestyle intervention + acetazolamide (-11.2 cm H2O) at 6 months (Level 1+) and then a very low-energy diet intervention (-8.0 cm H2O) at 3 months (Level 2++). The least ICP reduction was shown at 24 months after completing a 12-month multicomponent lifestyle intervention (-3.5 cm H2O) (Level 1++). Reduction in body weight was shown to be highly correlated with reduction in ICP (Level 2++ to 1++). DISCUSSION Bariatric surgery should be considered for women with IIH and a body mass index (BMI) ≥35 kg/m2 since this had the most robust evidence for sustained weight management (grade A). A multicomponent lifestyle intervention (diet + physical activity + behavior) had the most robust evidence for modest weight loss with a BMI <35 kg/m2 (grade B). Longer-term outcomes for weight management interventions in people with IIH are required to determine whether there is a superior weight loss intervention for IIH.
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Affiliation(s)
- Sally Abbott
- From the Research Centre for Healthcare and Communities (S.A.), Coventry University; Birmingham Neuro-Ophthalmology (F.C.), University Hospitals Birmingham; Institute of Metabolism and Systems Research (A.A.T.), University of Birmingham, United Kingdom; Novo Nordisk (A.A.T.), Bagsvaerd, Denmark; Department of Neuro-Ophthalmology (S.H.W.), Moorfields Eye Hospital; Medical Eye Unit (S.H.W.), Guy's and St Thomas' NHSFT, London; School of Life Course & Population Sciences (S.H.W.), Kings College London; Department of Clinical and Movement Neurosciences (S.H.W.), University College London; Adult Weight Management (Bariatric Surgery) (F.E.J.C.), NHS Grampian; Department of Surgery (C.P.), University College London Hospitals; Department of Surgery (C.P.), Barts Health NHS Trust, London; Upper Gastrointestinal (D.J.P.), Bariatric and Metabolic Surgery, North Bristol NHS Trust; IIH UK (A.D.), London; Translational Brain Science (A.J.S., S.P.M.), Institute of Metabolism and Systems Research, College of Medical and Dental Sciences, University of Birmingham; and Birmingham Neuro-Ophthalmology (S.P.M.), University Hospitals Birmingham NHS Trust, United Kingdom
| | - Fiona Chan
- From the Research Centre for Healthcare and Communities (S.A.), Coventry University; Birmingham Neuro-Ophthalmology (F.C.), University Hospitals Birmingham; Institute of Metabolism and Systems Research (A.A.T.), University of Birmingham, United Kingdom; Novo Nordisk (A.A.T.), Bagsvaerd, Denmark; Department of Neuro-Ophthalmology (S.H.W.), Moorfields Eye Hospital; Medical Eye Unit (S.H.W.), Guy's and St Thomas' NHSFT, London; School of Life Course & Population Sciences (S.H.W.), Kings College London; Department of Clinical and Movement Neurosciences (S.H.W.), University College London; Adult Weight Management (Bariatric Surgery) (F.E.J.C.), NHS Grampian; Department of Surgery (C.P.), University College London Hospitals; Department of Surgery (C.P.), Barts Health NHS Trust, London; Upper Gastrointestinal (D.J.P.), Bariatric and Metabolic Surgery, North Bristol NHS Trust; IIH UK (A.D.), London; Translational Brain Science (A.J.S., S.P.M.), Institute of Metabolism and Systems Research, College of Medical and Dental Sciences, University of Birmingham; and Birmingham Neuro-Ophthalmology (S.P.M.), University Hospitals Birmingham NHS Trust, United Kingdom
| | - Abd A Tahrani
- From the Research Centre for Healthcare and Communities (S.A.), Coventry University; Birmingham Neuro-Ophthalmology (F.C.), University Hospitals Birmingham; Institute of Metabolism and Systems Research (A.A.T.), University of Birmingham, United Kingdom; Novo Nordisk (A.A.T.), Bagsvaerd, Denmark; Department of Neuro-Ophthalmology (S.H.W.), Moorfields Eye Hospital; Medical Eye Unit (S.H.W.), Guy's and St Thomas' NHSFT, London; School of Life Course & Population Sciences (S.H.W.), Kings College London; Department of Clinical and Movement Neurosciences (S.H.W.), University College London; Adult Weight Management (Bariatric Surgery) (F.E.J.C.), NHS Grampian; Department of Surgery (C.P.), University College London Hospitals; Department of Surgery (C.P.), Barts Health NHS Trust, London; Upper Gastrointestinal (D.J.P.), Bariatric and Metabolic Surgery, North Bristol NHS Trust; IIH UK (A.D.), London; Translational Brain Science (A.J.S., S.P.M.), Institute of Metabolism and Systems Research, College of Medical and Dental Sciences, University of Birmingham; and Birmingham Neuro-Ophthalmology (S.P.M.), University Hospitals Birmingham NHS Trust, United Kingdom
| | - Sui Hsien Wong
- From the Research Centre for Healthcare and Communities (S.A.), Coventry University; Birmingham Neuro-Ophthalmology (F.C.), University Hospitals Birmingham; Institute of Metabolism and Systems Research (A.A.T.), University of Birmingham, United Kingdom; Novo Nordisk (A.A.T.), Bagsvaerd, Denmark; Department of Neuro-Ophthalmology (S.H.W.), Moorfields Eye Hospital; Medical Eye Unit (S.H.W.), Guy's and St Thomas' NHSFT, London; School of Life Course & Population Sciences (S.H.W.), Kings College London; Department of Clinical and Movement Neurosciences (S.H.W.), University College London; Adult Weight Management (Bariatric Surgery) (F.E.J.C.), NHS Grampian; Department of Surgery (C.P.), University College London Hospitals; Department of Surgery (C.P.), Barts Health NHS Trust, London; Upper Gastrointestinal (D.J.P.), Bariatric and Metabolic Surgery, North Bristol NHS Trust; IIH UK (A.D.), London; Translational Brain Science (A.J.S., S.P.M.), Institute of Metabolism and Systems Research, College of Medical and Dental Sciences, University of Birmingham; and Birmingham Neuro-Ophthalmology (S.P.M.), University Hospitals Birmingham NHS Trust, United Kingdom
| | - Fiona E J Campbell
- From the Research Centre for Healthcare and Communities (S.A.), Coventry University; Birmingham Neuro-Ophthalmology (F.C.), University Hospitals Birmingham; Institute of Metabolism and Systems Research (A.A.T.), University of Birmingham, United Kingdom; Novo Nordisk (A.A.T.), Bagsvaerd, Denmark; Department of Neuro-Ophthalmology (S.H.W.), Moorfields Eye Hospital; Medical Eye Unit (S.H.W.), Guy's and St Thomas' NHSFT, London; School of Life Course & Population Sciences (S.H.W.), Kings College London; Department of Clinical and Movement Neurosciences (S.H.W.), University College London; Adult Weight Management (Bariatric Surgery) (F.E.J.C.), NHS Grampian; Department of Surgery (C.P.), University College London Hospitals; Department of Surgery (C.P.), Barts Health NHS Trust, London; Upper Gastrointestinal (D.J.P.), Bariatric and Metabolic Surgery, North Bristol NHS Trust; IIH UK (A.D.), London; Translational Brain Science (A.J.S., S.P.M.), Institute of Metabolism and Systems Research, College of Medical and Dental Sciences, University of Birmingham; and Birmingham Neuro-Ophthalmology (S.P.M.), University Hospitals Birmingham NHS Trust, United Kingdom
| | - Chetan Parmar
- From the Research Centre for Healthcare and Communities (S.A.), Coventry University; Birmingham Neuro-Ophthalmology (F.C.), University Hospitals Birmingham; Institute of Metabolism and Systems Research (A.A.T.), University of Birmingham, United Kingdom; Novo Nordisk (A.A.T.), Bagsvaerd, Denmark; Department of Neuro-Ophthalmology (S.H.W.), Moorfields Eye Hospital; Medical Eye Unit (S.H.W.), Guy's and St Thomas' NHSFT, London; School of Life Course & Population Sciences (S.H.W.), Kings College London; Department of Clinical and Movement Neurosciences (S.H.W.), University College London; Adult Weight Management (Bariatric Surgery) (F.E.J.C.), NHS Grampian; Department of Surgery (C.P.), University College London Hospitals; Department of Surgery (C.P.), Barts Health NHS Trust, London; Upper Gastrointestinal (D.J.P.), Bariatric and Metabolic Surgery, North Bristol NHS Trust; IIH UK (A.D.), London; Translational Brain Science (A.J.S., S.P.M.), Institute of Metabolism and Systems Research, College of Medical and Dental Sciences, University of Birmingham; and Birmingham Neuro-Ophthalmology (S.P.M.), University Hospitals Birmingham NHS Trust, United Kingdom
| | - Dimitri J Pournaras
- From the Research Centre for Healthcare and Communities (S.A.), Coventry University; Birmingham Neuro-Ophthalmology (F.C.), University Hospitals Birmingham; Institute of Metabolism and Systems Research (A.A.T.), University of Birmingham, United Kingdom; Novo Nordisk (A.A.T.), Bagsvaerd, Denmark; Department of Neuro-Ophthalmology (S.H.W.), Moorfields Eye Hospital; Medical Eye Unit (S.H.W.), Guy's and St Thomas' NHSFT, London; School of Life Course & Population Sciences (S.H.W.), Kings College London; Department of Clinical and Movement Neurosciences (S.H.W.), University College London; Adult Weight Management (Bariatric Surgery) (F.E.J.C.), NHS Grampian; Department of Surgery (C.P.), University College London Hospitals; Department of Surgery (C.P.), Barts Health NHS Trust, London; Upper Gastrointestinal (D.J.P.), Bariatric and Metabolic Surgery, North Bristol NHS Trust; IIH UK (A.D.), London; Translational Brain Science (A.J.S., S.P.M.), Institute of Metabolism and Systems Research, College of Medical and Dental Sciences, University of Birmingham; and Birmingham Neuro-Ophthalmology (S.P.M.), University Hospitals Birmingham NHS Trust, United Kingdom
| | - Amanda Denton
- From the Research Centre for Healthcare and Communities (S.A.), Coventry University; Birmingham Neuro-Ophthalmology (F.C.), University Hospitals Birmingham; Institute of Metabolism and Systems Research (A.A.T.), University of Birmingham, United Kingdom; Novo Nordisk (A.A.T.), Bagsvaerd, Denmark; Department of Neuro-Ophthalmology (S.H.W.), Moorfields Eye Hospital; Medical Eye Unit (S.H.W.), Guy's and St Thomas' NHSFT, London; School of Life Course & Population Sciences (S.H.W.), Kings College London; Department of Clinical and Movement Neurosciences (S.H.W.), University College London; Adult Weight Management (Bariatric Surgery) (F.E.J.C.), NHS Grampian; Department of Surgery (C.P.), University College London Hospitals; Department of Surgery (C.P.), Barts Health NHS Trust, London; Upper Gastrointestinal (D.J.P.), Bariatric and Metabolic Surgery, North Bristol NHS Trust; IIH UK (A.D.), London; Translational Brain Science (A.J.S., S.P.M.), Institute of Metabolism and Systems Research, College of Medical and Dental Sciences, University of Birmingham; and Birmingham Neuro-Ophthalmology (S.P.M.), University Hospitals Birmingham NHS Trust, United Kingdom
| | - Alexandra Jean Sinclair
- From the Research Centre for Healthcare and Communities (S.A.), Coventry University; Birmingham Neuro-Ophthalmology (F.C.), University Hospitals Birmingham; Institute of Metabolism and Systems Research (A.A.T.), University of Birmingham, United Kingdom; Novo Nordisk (A.A.T.), Bagsvaerd, Denmark; Department of Neuro-Ophthalmology (S.H.W.), Moorfields Eye Hospital; Medical Eye Unit (S.H.W.), Guy's and St Thomas' NHSFT, London; School of Life Course & Population Sciences (S.H.W.), Kings College London; Department of Clinical and Movement Neurosciences (S.H.W.), University College London; Adult Weight Management (Bariatric Surgery) (F.E.J.C.), NHS Grampian; Department of Surgery (C.P.), University College London Hospitals; Department of Surgery (C.P.), Barts Health NHS Trust, London; Upper Gastrointestinal (D.J.P.), Bariatric and Metabolic Surgery, North Bristol NHS Trust; IIH UK (A.D.), London; Translational Brain Science (A.J.S., S.P.M.), Institute of Metabolism and Systems Research, College of Medical and Dental Sciences, University of Birmingham; and Birmingham Neuro-Ophthalmology (S.P.M.), University Hospitals Birmingham NHS Trust, United Kingdom
| | - Susan P Mollan
- From the Research Centre for Healthcare and Communities (S.A.), Coventry University; Birmingham Neuro-Ophthalmology (F.C.), University Hospitals Birmingham; Institute of Metabolism and Systems Research (A.A.T.), University of Birmingham, United Kingdom; Novo Nordisk (A.A.T.), Bagsvaerd, Denmark; Department of Neuro-Ophthalmology (S.H.W.), Moorfields Eye Hospital; Medical Eye Unit (S.H.W.), Guy's and St Thomas' NHSFT, London; School of Life Course & Population Sciences (S.H.W.), Kings College London; Department of Clinical and Movement Neurosciences (S.H.W.), University College London; Adult Weight Management (Bariatric Surgery) (F.E.J.C.), NHS Grampian; Department of Surgery (C.P.), University College London Hospitals; Department of Surgery (C.P.), Barts Health NHS Trust, London; Upper Gastrointestinal (D.J.P.), Bariatric and Metabolic Surgery, North Bristol NHS Trust; IIH UK (A.D.), London; Translational Brain Science (A.J.S., S.P.M.), Institute of Metabolism and Systems Research, College of Medical and Dental Sciences, University of Birmingham; and Birmingham Neuro-Ophthalmology (S.P.M.), University Hospitals Birmingham NHS Trust, United Kingdom.
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9
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Ehrstedt C, Lehtonen M, Liminga G. Patient Delay, Lead Times, and Adherence to Diagnostic Guidelines in Children and Adolescents With Idiopathic Intracranial Hypertension. Pediatr Neurol 2023; 148:65-72. [PMID: 37672964 DOI: 10.1016/j.pediatrneurol.2023.07.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/22/2022] [Revised: 07/03/2023] [Accepted: 07/06/2023] [Indexed: 09/08/2023]
Abstract
AIMS In a cohort of 45 children and adolescents diagnosed with idiopathic intracranial hypertension (IIH), our main aims were to investigate patient delay, lead time to final diagnosis, and adherence to current diagnostic guidelines. METHODS This population-based, retrospective, single-center cohort study was performed at Uppsala University Children's Hospital, Sweden, a tertiary referral center for children and adolescents with rare and/or complicated neurologic disease. Patient data were retrieved from the local registries for patients filling the following criteria: age (0-17.99 yr), study period (2000-2020), and International Classification of Diseases code G93.2 (IIH). Medical records from pediatric, neuropediatric, ophthalmology, and neurosurgery departments were scrutinized. All included patients met the Friedman criteria. RESULTS Fifty-one percent of the patients sought medical advice within 1 month of symptom debut, 23% were seen within 1 to three months, and 26% after three months. A final diagnosis of IIH was reached within 48 hours in 60%, within two weeks in 80%, and within four weeks in 89% of patients. Visual fields, color vision, and complete ancillary laboratory investigations to exclude secondary etiologies were performed in 62%, 47%, and 59% of patients, respectively. CONCLUSION The clinical presentation of IIH in children and adolescents may range from acute fulminant symptoms, to a more insidious or even chronic presentation with long-term headache. Although a majority of patients received a correct and prompt diagnosis, lead time to final diagnosis and adherence to diagnostic care guidelines might be improved. A higher awareness and knowledge of the condition may achieve this.
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Affiliation(s)
- Christoffer Ehrstedt
- Department of Women's and Children's Health, Uppsala University, and Uppsala University Children's Hospital, Uppsala, Sweden.
| | - Mira Lehtonen
- Department of Women's and Children's Health, Uppsala University, and Uppsala University Children's Hospital, Uppsala, Sweden
| | - Gunnar Liminga
- Department of Women's and Children's Health, Uppsala University, and Uppsala University Children's Hospital, Uppsala, Sweden
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10
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Mollan SP, Fraser CL, Digre KB, Diener HC, Lipton RB, Juhler M, Miller NR, Pozo-Rosich P, Togha M, Brock K, Dinkin MJ, Chan CKM, Tassorelli C, Sinclair AJ, Terwindt GM, Jensen RH. Guidelines of the International Headache Society for Controlled Clinical Trials in Idiopathic Intracranial Hypertension. Cephalalgia 2023; 43:3331024231197118. [PMID: 37661711 DOI: 10.1177/03331024231197118] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/05/2023]
Abstract
The quality of clinical trials is essential to advance treatment, inform regulatory decisions and meta-analysis. With the increased incidence of idiopathic intracranial hypertension and the emergence of clinical trials for novel therapies in this condition, the International Headache Society Guidelines for Controlled Clinical Trials in Idiopathic Intracranial Hypertension aims to establish guidelines for designing state-of-the-art controlled clinical trials for idiopathic intracranial hypertension.
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Affiliation(s)
- Susan P Mollan
- Neuro-ophthalmology, Queen Elizabeth Hospital, University Hospital Birmingham NHS Foundation Trust, Birmingham, Birmingham, UK
- Translational Brain Science, Institute of Metabolism and Systems Research, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
| | - Clare L Fraser
- Save Sight Institute, University of Sydney, Sydney, NSW, Australia
| | - Kathleen B Digre
- Neuro-ophthalmology Division, John A. Moran Eye Center, University of Utah, Salt Lake City, USA
| | - Hans-Christoph Diener
- Institut für Medizinische Informatik, Biometrie undEpidemiologie (IMIBE), Medizinische Fakultät der Universität Duisburg-Essen, Essen, Germany
| | - Richard B Lipton
- The Saul R. Korey Department of Neurology, and the Montefiore Headache Center, Albert Einstein College of Medicine, Bronx, New York, USA
| | - Marianne Juhler
- Department of Neurosurgery, Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark
- Institute of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Neil R Miller
- Wilmer Eye Institute and Departments of Ophthalmology, Neurology, and Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Patricia Pozo-Rosich
- Headache Unit, Neurology Department, Hospital Universitari Vall d'Hebron, Barcelona, Spain
- Headache and Neurological Pain Research Group, Vall d'Hebron Research Institute, Department of Medicine, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Mansoureh Togha
- Headache Department, Iranian Centre of Neurological Research, Neuroscience Institute, Tehran University of Medical Sciences, Tehran, Iran
- Headache Department, Neurology Ward, Sina Hospital, School of Medicine, Tehran University of Medical Sciences, Tehran, Iran
| | - Kristian Brock
- Cancer Research Clinical Trials Unit, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
| | - Marc J Dinkin
- Department of Ophthalmology, Weill Cornell Medical College, NY Presbyterian Hospital, New York, New York, USA
- Department of Neurology, Weill Cornell Medical College, NY Presbyterian Hospital, New York, New York, USA
| | - Carmen K M Chan
- Department of Ophthalmology and Visual Sciences, The Chinese University of Hong Kong, Hong Kong SAR, China
- Hong Kong Eye Hospital, Hong Kong SAR, China
| | - Cristina Tassorelli
- Unit of Translational Neurovascular Research, IRCCS Mondino Foundation, 27100, Pavia, Italy
- Department of Brain and Behavioural Sciences, University of Pavia, 27100, Pavia, Italy
| | - Alex J Sinclair
- Translational Brain Science, Institute of Metabolism and Systems Research, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
- Department of Neurology, University Hospitals Birmingham, Queen Elizabeth Hospital, Birmingham, UK
| | - Gisela M Terwindt
- Department of Neurology, Leiden University Medical Center, Leiden, the Netherlands
| | - Rigmor H Jensen
- Department of Neurology, Danish Headache Center, Rigshospitalet-Glostrup, University of Copenhagen, Copenhagen, Denmark
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11
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Khatkar P, Hubbard JC, Hill L, Sinclair AJ, Mollan SP. Experimental drugs for the treatment of idiopathic intracranial hypertension (IIH): shedding light on phase I and II trials. Expert Opin Investig Drugs 2023; 32:1123-1131. [PMID: 38006580 DOI: 10.1080/13543784.2023.2288073] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2023] [Accepted: 11/22/2023] [Indexed: 11/27/2023]
Abstract
INTRODUCTION Idiopathic intracranial hypertension is a neurological condition characterized by a raised intracranial pressure and papilledema that causes debilitating headaches. While the extent of the pathophysiology is being discovered, the condition is emerging as a systemic metabolic disease distinct to people living with obesity alone. Idiopathic intracranial hypertension is becoming more common and therefore establishing licensed therapeutics is a key priority. AREA COVERED The translation of preclinical work in idiopathic intracranial hypertension is evident by the two early phase trials evaluating 11-β-hydroxysteroid dehydrogenase inhibitor, AZD4017, and a glucagon like peptide-1 receptor agonist, Exenatide. This review summarizes these two early phase trials evaluating targeted medicines for the treatment of intracranial pressure. The modulation of these two distinct mechanisms have potential for therapeutic intervention in people living with idiopathic intracranial hypertension. EXPERT OPINION The clinical trial landscape in idiopathic intracranial hypertension is a challenge due to the rarity of the disease and the lack of agreed meaningful trial outcomes. Further preclinical work to fully understand the pathogenesis is required to enable personalized targeted drug treatment.
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Affiliation(s)
- Pavan Khatkar
- Medical school Imperial College London, UK
- Birmingham Neuro-Ophthalmology, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Jess C Hubbard
- School of Biomedical Sciences, Institute of Clinical Sciences, University of Birmingham, Birmingham, UK
- Translational Brain Science, Institute of Metabolism and Systems Research, University of Birmingham, Edgbaston, UK
| | - Lisa Hill
- School of Biomedical Sciences, Institute of Clinical Sciences, University of Birmingham, Birmingham, UK
- Translational Brain Science, Institute of Metabolism and Systems Research, University of Birmingham, Edgbaston, UK
| | - Alexandra J Sinclair
- Translational Brain Science, Institute of Metabolism and Systems Research, University of Birmingham, Edgbaston, UK
- Centre for Endocrinology, Diabetes and Metabolism, Birmingham Health Partners, Birmingham, UK
- Department of Neurology, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Susan P Mollan
- Birmingham Neuro-Ophthalmology, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
- Translational Brain Science, Institute of Metabolism and Systems Research, University of Birmingham, Edgbaston, UK
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12
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Hyder YF, Homer V, Thaller M, Byrne M, Tsermoulas G, Piccus R, Mollan SP, Sinclair AJ. Defining the Phenotype and Prognosis of People With Idiopathic Intracranial Hypertension After Cerebrospinal Fluid Diversion Surgery. Am J Ophthalmol 2023; 250:70-81. [PMID: 36682516 DOI: 10.1016/j.ajo.2023.01.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2022] [Revised: 01/11/2023] [Accepted: 01/12/2023] [Indexed: 01/22/2023]
Abstract
PURPOSE To characterize the phenotype of patients with idiopathic intracranial hypertension (IIH) who received cerebrospinal (CSF) diversion surgery and to detail the trajectory of recovery. DESIGN Prospective cohort registry study. METHODS Patients with IIH with sight-threatening papilledema presenting to a single United Kingdom neuroscience center between 2019 and 2021 were included. Outcomes consisted of perimetric mean deviation (PMD) and optical coherence tomography measures of papilledema (retinal nerve fiber layer [RNFL]) and macular ganglion cell layer (GCL) in both eyes. Headache outcomes included monthly headache days (MHD). Logistic regression methods were used to model long-term outcomes. RESULTS Fifty-one patients without previous surgical interventions were included (92% female, mean age 28.1 years [SD 8.4], body mass index 37.4 kg/m2 [SD 9.7], mean days of follow-up 330 [SD 209]). Measurements before surgery showed mean PMD -11.4 dB (SD 9.7), RNFL 364 µm (SD 128), Frisén grade papilledema 4.3 (SD 0.9). and MHD 23 (SD 10.6). At 1 month postoperatively, RNFL and PMD had improved by 38% and 4%, respectively. At 4 months postoperatively, papilledema had resolved. GCL declined by 13% over 12 months. MHD reduced by 75% 3 months postoperatively before returning to baseline levels by 12 months. Five patients (9.8%) required revision surgeries. CONCLUSIONS Detailed characteristics of patients with sight-threatening IIH who received CSF diversion surgery and their typical postoperative recovery are presented. These parameters should guide physicians as to when patients with IIH may require surgery and enable the early identification of outliers who fail to respond. Papilledema and PMD recovered but GCL atrophy continued for 12 months. The implication of this delayed atrophy is unknown.
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Affiliation(s)
- Yousef F Hyder
- From the Translational Brain Science (Y.F.H., M.T., S.P.M., A.J.S.), Institute of Metabolism and Systems Research, University of Birmingham, Birmingham, United Kingdom; Department of Neurology (Y.F.H., M.T., A.J.S.), University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK; Centre for Endocrinology, Diabetes and Metabolism (Y.F.H., M.T., A.J.S.), Birmingham Health Partners, Birmingham, UK
| | - Victoria Homer
- Cancer Research (UK) Clinical Trials Unit (V.H.), University of Birmingham, Birmingham, Birmingham, UK
| | - Mark Thaller
- From the Translational Brain Science (Y.F.H., M.T., S.P.M., A.J.S.), Institute of Metabolism and Systems Research, University of Birmingham, Birmingham, United Kingdom; Department of Neurology (Y.F.H., M.T., A.J.S.), University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK; Centre for Endocrinology, Diabetes and Metabolism (Y.F.H., M.T., A.J.S.), Birmingham Health Partners, Birmingham, UK
| | - Marian Byrne
- Department of Neurosurgery (M.B., G.T.), Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Georgios Tsermoulas
- Department of Neurosurgery (M.B., G.T.), Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Rachel Piccus
- and Birmingham Neuro-Ophthalmology (R.P., S.P.M.), Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Susan P Mollan
- From the Translational Brain Science (Y.F.H., M.T., S.P.M., A.J.S.), Institute of Metabolism and Systems Research, University of Birmingham, Birmingham, United Kingdom; and Birmingham Neuro-Ophthalmology (R.P., S.P.M.), Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Alexandra J Sinclair
- From the Translational Brain Science (Y.F.H., M.T., S.P.M., A.J.S.), Institute of Metabolism and Systems Research, University of Birmingham, Birmingham, United Kingdom; Department of Neurology (Y.F.H., M.T., A.J.S.), University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK; Centre for Endocrinology, Diabetes and Metabolism (Y.F.H., M.T., A.J.S.), Birmingham Health Partners, Birmingham, UK.
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13
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Mitchell JL, Lyons HS, Walker JK, Yiangou A, Grech O, Alimajstorovic Z, Greig NH, Li Y, Tsermoulas G, Brock K, Mollan SP, Sinclair AJ. The effect of GLP-1RA exenatide on idiopathic intracranial hypertension: a randomized clinical trial. Brain 2023; 146:1821-1830. [PMID: 36907221 PMCID: PMC10151178 DOI: 10.1093/brain/awad003] [Citation(s) in RCA: 31] [Impact Index Per Article: 31.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2022] [Revised: 11/08/2022] [Accepted: 11/19/2022] [Indexed: 03/14/2023] Open
Abstract
Therapeutics to reduce intracranial pressure are an unmet need. Preclinical data have demonstrated a novel strategy to lower intracranial pressure using glucagon-like peptide-1 (GLP-1) receptor signalling. Here, we translate these findings into patients by conducting a randomized, placebo-controlled, double-blind trial to assess the effect of exenatide, a GLP-1 receptor agonist, on intracranial pressure in idiopathic intracranial hypertension. Telemetric intracranial pressure catheters enabled long-term intracranial pressure monitoring. The trial enrolled adult women with active idiopathic intracranial hypertension (intracranial pressure >25 cmCSF and papilloedema) who receive subcutaneous exenatide or placebo. The three primary outcome measures were intracranial pressure at 2.5 h, 24 h and 12 weeks and alpha set a priori at less than 0.1. Among the 16 women recruited, 15 completed the study (mean age 28 ± 9, body mass index 38.1 ± 6.2 kg/m2, intracranial pressure 30.6 ± 5.1 cmCSF). Exenatide significantly and meaningfully lowered intracranial pressure at 2.5 h -5.7 ± 2.9 cmCSF (P = 0.048); 24 h -6.4 ± 2.9 cmCSF (P = 0.030); and 12 weeks -5.6 ± 3.0 cmCSF (P = 0.058). No serious safety signals were noted. These data provide confidence to proceed to a phase 3 trial in idiopathic intracranial hypertension and highlight the potential to utilize GLP-1 receptor agonist in other conditions characterized by raised intracranial pressure.
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Affiliation(s)
- James L Mitchell
- University of Birmingham, Institute of Metabolism and Systems Research, Birmingham, B15 2TT, UK
- Department of Neurology, University Hospitals Birmingham NHS Foundation Trust, Birmingham, B15 2GW, UK
- Academic Department of Military Rehabilitation, Defence Medical Rehabilitation Centre, Stanford Hall, LE12 5QD, UK
| | - Hannah S Lyons
- University of Birmingham, Institute of Metabolism and Systems Research, Birmingham, B15 2TT, UK
- Department of Neurology, University Hospitals Birmingham NHS Foundation Trust, Birmingham, B15 2GW, UK
| | - Jessica K Walker
- University of Birmingham, Institute of Metabolism and Systems Research, Birmingham, B15 2TT, UK
| | - Andreas Yiangou
- University of Birmingham, Institute of Metabolism and Systems Research, Birmingham, B15 2TT, UK
- Department of Neurology, University Hospitals Birmingham NHS Foundation Trust, Birmingham, B15 2GW, UK
| | - Olivia Grech
- University of Birmingham, Institute of Metabolism and Systems Research, Birmingham, B15 2TT, UK
| | - Zerin Alimajstorovic
- University of Birmingham, Institute of Metabolism and Systems Research, Birmingham, B15 2TT, UK
| | - Nigel H Greig
- Drug Design & Development Section, Translational Gerontology Branch, National Institute on Aging, National Institutes of Health, Baltimore, MD 21224, USA
| | - Yazhou Li
- Drug Design & Development Section, Translational Gerontology Branch, National Institute on Aging, National Institutes of Health, Baltimore, MD 21224, USA
| | - Georgios Tsermoulas
- University of Birmingham, Institute of Metabolism and Systems Research, Birmingham, B15 2TT, UK
- Department of Neurosurgery, University Hospitals Birmingham, Birmingham, B15 2GW, UK
| | - Kristian Brock
- Cancer Research UK Clinical Trials Unit, University of Birmingham, Birmingham, B15 2TT, UK
| | - Susan P Mollan
- University of Birmingham, Institute of Metabolism and Systems Research, Birmingham, B15 2TT, UK
- Department of Neuro-ophthalmology, University Hospitals Birmingham NHS Foundation Trust, Birmingham, B15 2GW, UK
| | - Alexandra J Sinclair
- University of Birmingham, Institute of Metabolism and Systems Research, Birmingham, B15 2TT, UK
- Department of Neurology, University Hospitals Birmingham NHS Foundation Trust, Birmingham, B15 2GW, UK
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14
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Piccus R, Thaller M, Sinclair AJ, Mollan SP. Current and emerging diagnostic and management approaches for idiopathic intracranial hypertension. Expert Rev Neurother 2023; 23:457-466. [PMID: 37114519 DOI: 10.1080/14737175.2023.2206567] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/29/2023]
Abstract
INTRODUCTION Idiopathic intracranial hypertension is characterized by raised intracranial pressure that triggers disabling headaches and can cause permanent visual loss. There is an increased incidence and prevalence of the condition linked to location-specific obesity rates. There are no licensed treatments for the condition. The majority of approaches to managing the disease prioritize resolution of papilledema. However, evidence is emerging that idiopathic intracranial hypertension is a systemic metabolic disease. AREAS COVERED The aim of this review is to present the emerging pathophysiology evidence which is leading to novel targeted therapeutics. The diagnostic pathway is outlined. The current and potential management approaches for idiopathic intracranial hypertension are also discussed. EXPERT OPINION Idiopathic intracranial hypertension is a condition with metabolic dysregulation with systemic manifestations that are present over and above what can be expl.ained by obesity alone. While most of the current management of this condition focuses on the eyes, future management needs to address the disabling headaches and the systemic risks of preeclampsia, gestational diabetes, and major cardiovascular events.
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Affiliation(s)
- Ravi Piccus
- Medical school, University of Birmingham, Birmingham, UK
| | - Mark Thaller
- Translational Brain Science, Institute of Metabolism and Systems Research, University of Birmingham, Birmingham, UK
- Department of Neurology, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
- Centre for Endocrinology, Diabetes and Metabolism, Birmingham Health Partners, Birmingham, UK
| | - Alexandra J Sinclair
- Translational Brain Science, Institute of Metabolism and Systems Research, University of Birmingham, Birmingham, UK
- Department of Neurology, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
- Centre for Endocrinology, Diabetes and Metabolism, Birmingham Health Partners, Birmingham, UK
| | - Susan P Mollan
- Translational Brain Science, Institute of Metabolism and Systems Research, University of Birmingham, Birmingham, UK
- Birmingham Neuro-Ophthalmology, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
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15
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Thaller M, Homer V, Mollan SP, Sinclair AJ. Disease Course and Long-term Outcomes in Pregnant Women With Idiopathic Intracranial Hypertension: The IIH Prospective Maternal Health Study. Neurology 2023; 100:e1598-e1610. [PMID: 36750388 PMCID: PMC10103118 DOI: 10.1212/wnl.0000000000206854] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2022] [Accepted: 12/07/2022] [Indexed: 02/09/2023] Open
Abstract
BACKGROUND AND OBJECTIVES Idiopathic intracranial hypertension (IIH) most typically occurs in women of childbearing age with increased weight as a key risk factor for development or exacerbation of the disease. Pregnancy is common in this group of patients. The longer-term effect of pregnancy on IIH has not been established and was the aim of this study. METHODS A prospective cohort study (IIH Life) recruited consecutive patients with IIH between 2012 and 2021 and evaluated outcomes including vision (logarithm of the minimum angle of resolution visual acuity, Humphrey visual field perimetric mean deviation, and optical coherence tomography [OCT] imaging) and headache. Four cohorts were evaluated: those with IIH diagnosed for the first time while pregnant, those with established IIH who became pregnant, those with a pregnancy prior to their diagnosis of IIH, and those with IIH who never became pregnant. RESULTS Three hundred seventy-seven people with IIH agreed to participate in the IIH Life maternal health study. Mean follow-up was 17.5 months (SD 20.5). IIH diagnosed in pregnancy was rare. Patients diagnosed with IIH while pregnant had greater papilledema (mean OCT total retinal thickness +11.59 µm/mo [95% CI 1.25-21.93]), although they had comparable visual field and acuity measures compared with those with established IIH who became pregnant during their disease course (-1.2 µm/mo [95% CI -2.6 to 0.21]). In those with established IIH, pregnancy did not adversely affect visual or headache outcomes over time, and the trajectory was akin to those with IIH who never had a pregnancy. Headache outcomes showed variability reflecting the IIH cohort as a whole. DISCUSSION A diagnosis of IIH while pregnant was rare but associated with more severe papilledema. Long-term visual outcomes in IIH were analogous irrespective of the timing of the pregnancy. These data are reassuring; however, close vigilance of IIH clinical features during pregnancy is recommended.
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Affiliation(s)
- Mark Thaller
- From the Translational Brain Science (M.T., S.P.M., A.J.S.), Institute of Metabolism and Systems Research, and Cancer Research (UK) Clinical Trials Unit (V.H.), University of Birmingham; Department of Neurology (M.T., A.J.S.) and Birmingham Neuro-Ophthalmology (S.P.M.), University Hospitals Birmingham NHS Foundation Trust; Centre for Endocrinology (M.T., A.J.S.), Diabetes and Metabolism, Birmingham Health Partners, UK
| | - Victoria Homer
- From the Translational Brain Science (M.T., S.P.M., A.J.S.), Institute of Metabolism and Systems Research, and Cancer Research (UK) Clinical Trials Unit (V.H.), University of Birmingham; Department of Neurology (M.T., A.J.S.) and Birmingham Neuro-Ophthalmology (S.P.M.), University Hospitals Birmingham NHS Foundation Trust; Centre for Endocrinology (M.T., A.J.S.), Diabetes and Metabolism, Birmingham Health Partners, UK
| | - Susan P Mollan
- From the Translational Brain Science (M.T., S.P.M., A.J.S.), Institute of Metabolism and Systems Research, and Cancer Research (UK) Clinical Trials Unit (V.H.), University of Birmingham; Department of Neurology (M.T., A.J.S.) and Birmingham Neuro-Ophthalmology (S.P.M.), University Hospitals Birmingham NHS Foundation Trust; Centre for Endocrinology (M.T., A.J.S.), Diabetes and Metabolism, Birmingham Health Partners, UK
| | - Alexandra Jean Sinclair
- From the Translational Brain Science (M.T., S.P.M., A.J.S.), Institute of Metabolism and Systems Research, and Cancer Research (UK) Clinical Trials Unit (V.H.), University of Birmingham; Department of Neurology (M.T., A.J.S.) and Birmingham Neuro-Ophthalmology (S.P.M.), University Hospitals Birmingham NHS Foundation Trust; Centre for Endocrinology (M.T., A.J.S.), Diabetes and Metabolism, Birmingham Health Partners, UK.
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16
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Mollan SP, Sinclair AJ. Author Response: Association of Amount of Weight Lost After Bariatric Surgery With Intracranial Pressure in Women With Idiopathic Intracranial Hypertension. Neurology 2023; 100:543. [PMID: 36914270 PMCID: PMC10074456 DOI: 10.1212/wnl.0000000000207120] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/16/2023] Open
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17
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Thaller M, Homer V, Hyder Y, Yiangou A, Liczkowski A, Fong AW, Virdee J, Piccus R, Roque M, Mollan SP, Sinclair AJ. The idiopathic intracranial hypertension prospective cohort study: evaluation of prognostic factors and outcomes. J Neurol 2023; 270:851-863. [PMID: 36242625 PMCID: PMC9886634 DOI: 10.1007/s00415-022-11402-6] [Citation(s) in RCA: 25] [Impact Index Per Article: 25.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2022] [Revised: 09/22/2022] [Accepted: 09/23/2022] [Indexed: 02/03/2023]
Abstract
BACKGROUND There are limited longitudinal data evaluating outcomes in idiopathic intracranial hypertension (IIH). We aimed to evaluate the long-term outcomes in a real-world cohort of patients with IIH and sought to establish the prognostic factors. METHODS A longitudinal prospective cohort study was conducted over 9 years (2012-2021). Data included demographics and disease status. All consenting patients with IIH were recruited. Visual outcomes included visual acuity, Humphrey visual field and optical coherence tomography (OCT) imaging measurements. Headache frequency, severity, and impact were noted. We analysed the key variables impacting visual and headache outcomes. RESULTS The cohort contained 490 patients with a confirmed IIH diagnosis. 98% were female with a mean body mass index (BMI) of 38 kg/m2. Those with the highest OCT retinal nerve fibre layer had the worst visual outcomes. We noted a delayed decline, in the visual field and OCT ganglion cell layer after 12 months. In the medically managed cohort (n = 426), we found that disease duration and change in BMI had the greatest influence on visual outcomes. There was a high burden of headache, with a daily headache at presentation and prior migraine history influencing long-term headache prognosis. CONCLUSIONS There is a delayed decline in visual outcomes in those with the most severe papilloedema. Disease duration and change in BMI were the key visual prognostic factors, therefore those with the more acute disease may require closer monitoring. Improving prognosis in IIH should focus on the potentially modifiable factor of weight management.
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Affiliation(s)
- Mark Thaller
- Translational Brain Science, Institute of Metabolism and Systems Research, University of Birmingham, Birmingham, B15 2TT, UK.,Department of Neurology, University Hospitals Birmingham NHS Foundation Trust, Birmingham, B15 2TH, UK.,Centre for Endocrinology, Diabetes and Metabolism, Birmingham Health Partners, Birmingham, B15 2TH, UK
| | - Victoria Homer
- Cancer Research (UK) Clinical Trials Unit, University of Birmingham, Birmingham, B15 2TT, UK
| | - Yousef Hyder
- Translational Brain Science, Institute of Metabolism and Systems Research, University of Birmingham, Birmingham, B15 2TT, UK.,Department of Neurology, University Hospitals Birmingham NHS Foundation Trust, Birmingham, B15 2TH, UK.,Centre for Endocrinology, Diabetes and Metabolism, Birmingham Health Partners, Birmingham, B15 2TH, UK
| | - Andreas Yiangou
- Translational Brain Science, Institute of Metabolism and Systems Research, University of Birmingham, Birmingham, B15 2TT, UK.,Department of Neurology, University Hospitals Birmingham NHS Foundation Trust, Birmingham, B15 2TH, UK.,Centre for Endocrinology, Diabetes and Metabolism, Birmingham Health Partners, Birmingham, B15 2TH, UK
| | - Anthony Liczkowski
- Translational Brain Science, Institute of Metabolism and Systems Research, University of Birmingham, Birmingham, B15 2TT, UK.,Emergency Medicine, Hull University Teaching Hospitals NHS Trust, Anlaby Rd, Hull, HU3 2JZ, UK
| | - Anthony W Fong
- Birmingham Neuro-Ophthalmology, University Hospitals Birmingham NHS Foundation Trust, Birmingham, B15 2TH, UK.,Ophthalmology, School of Medicine, University of Queensland, Queensland, 4006, Australia
| | - Jasvir Virdee
- Birmingham Neuro-Ophthalmology, University Hospitals Birmingham NHS Foundation Trust, Birmingham, B15 2TH, UK
| | - Rachel Piccus
- Birmingham Neuro-Ophthalmology, University Hospitals Birmingham NHS Foundation Trust, Birmingham, B15 2TH, UK
| | - Marianne Roque
- Birmingham Neuro-Ophthalmology, University Hospitals Birmingham NHS Foundation Trust, Birmingham, B15 2TH, UK
| | - Susan P Mollan
- Translational Brain Science, Institute of Metabolism and Systems Research, University of Birmingham, Birmingham, B15 2TT, UK.,Birmingham Neuro-Ophthalmology, University Hospitals Birmingham NHS Foundation Trust, Birmingham, B15 2TH, UK
| | - Alexandra J Sinclair
- Translational Brain Science, Institute of Metabolism and Systems Research, University of Birmingham, Birmingham, B15 2TT, UK. .,Department of Neurology, University Hospitals Birmingham NHS Foundation Trust, Birmingham, B15 2TH, UK. .,Centre for Endocrinology, Diabetes and Metabolism, Birmingham Health Partners, Birmingham, B15 2TH, UK.
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18
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Mollan SP, Subramanian A, Perrins M, Nirantharakumar K, Adderley NJ, Sinclair AJ. Depression and anxiety in women with idiopathic intracranial hypertension compared to migraine: A matched controlled cohort study. Headache 2023; 63:290-298. [PMID: 36748660 PMCID: PMC10952318 DOI: 10.1111/head.14465] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2022] [Revised: 12/02/2022] [Accepted: 12/04/2022] [Indexed: 02/08/2023]
Abstract
OBJECTIVE To evaluate mental health burden in women with idiopathic intracranial hypertension (IIH) compared to matched women with migraine and population controls. BACKGROUND Depression and anxiety are recognized comorbid conditions in those with IIH and lead to worse predicted medical outcomes. The mental health burden in IIH has not been previously evaluated in a large, matched cohort study. METHODS We performed a population-based matched, retrospective cohort study to explore mental health outcomes (depression and anxiety). We used data from IQVIA Medical Research Data, an anonymized, nationally representative primary care electronic medical records database in the United Kingdom, from January 1, 1995, to September 25, 2019. Women aged ≥16 years were eligible for inclusion. Women with IIH (exposure) were matched by age and body mass index with up to 10 control women without IIH but with migraine (migraine controls), and without IIH or migraine (population controls). RESULTS A total of 3411 women with IIH, 30,879 migraine controls and 33,495 population controls were included. Of these, 237, 2372 and 1695 women with IIH, migraine controls and population controls, respectively, developed depression during follow-up, and 179, 1826 and 1197, respectively, developed anxiety. There was a greater hazard of depression and anxiety in IIH compared to population controls (adjusted hazard ratio [aHR] 1.38, 95% confidence interval [CI] 1.20-1.58; and aHR 1.40, 95% CI 1.19-1.64, respectively), while hazards were similar to migraine controls (aHR 0.98, 95% CI 0.86-1.13; and aHR 0.98, 95% CI 0.83-1.14, respectively). CONCLUSION Depression and anxiety burden in women with IIH is higher than in the general population, and comparable to that in matched women with migraine. This may indicate that presence of headache is a potential driver for comorbid depression and anxiety in IIH.
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Affiliation(s)
- Susan P. Mollan
- Translational Brain Science, Institute of Metabolism and Systems ResearchUniversity of BirminghamBirminghamUK
- Health Data Research UKBirminghamUK
- Birmingham Neuro‐OphthalmologyQueen Elizabeth HospitalBirminghamUK
| | | | - Mary Perrins
- Institute of Applied Health ResearchUniversity of BirminghamBirminghamUK
| | | | - Nicola J. Adderley
- Institute of Applied Health ResearchUniversity of BirminghamBirminghamUK
| | - Alexandra J. Sinclair
- Translational Brain Science, Institute of Metabolism and Systems ResearchUniversity of BirminghamBirminghamUK
- Birmingham Neuro‐OphthalmologyQueen Elizabeth HospitalBirminghamUK
- Department of NeurologyUniversity Hospitals Birmingham, Queen Elizabeth HospitalBirminghamUK
- Centre for Endocrinology, Diabetes, and MetabolismBirmingham Health PartnersBirminghamUK
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19
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Alimajstorovic Z, Mollan SP, Grech O, Mitchell JL, Yiangou A, Thaller M, Lyons H, Sassani M, Seneviratne S, Hancox T, Jankevics A, Najdekr L, Dunn W, Sinclair AJ. Dysregulation of Amino Acid, Lipid, and Acylpyruvate Metabolism in Idiopathic Intracranial Hypertension: A Non-targeted Case Control and Longitudinal Metabolomic Study. J Proteome Res 2022; 22:1127-1137. [PMID: 36534069 PMCID: PMC10088035 DOI: 10.1021/acs.jproteome.2c00449] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Background: Idiopathic intracranial hypertension (IIH) is characterized by increased intracranial pressure occurring predominantly in women with obesity. The pathogenesis is not understood. We have applied untargeted metabolomic analysis using ultrahigh-performance liquid chromatography-mass spectrometry to characterize the cerebrospinal fluid (CSF) and serum in IIH compared to control subjects. Methods and findings: Samples were collected from IIH patients (n = 66) with active disease at baseline and again at 12 months following therapeutic weight loss. Control samples were collected from gender- and weight-matched healthy controls (n = 20). We identified annotated metabolites in CSF, formylpyruvate and maleylpyruvate/fumarylpyruvate, which were present at lower concentrations in IIH compared to control subjects and returned to values observed in controls following weight loss. These metabolites showed the opposite trend in serum at baseline. Multiple amino acid metabolic pathways and lipid classes were perturbed in serum and CSF in IIH alone. Serum lipid metabolite pathways were significantly increased in IIH. Conclusions: We observed a number of differential metabolic pathways related to amino acid, lipid, and acylpyruvate metabolism, in IIH compared to controls. These pathways were associated with clinical measures and normalized with disease remission. Perturbation of these metabolic pathways provides initial understanding of disease dysregulation in IIH.
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Affiliation(s)
- Zerin Alimajstorovic
- Institute of Metabolism and Systems Research, College of Medical and Dental Sciences, University of Birmingham, Birmingham B15 2TT, U.K
| | - Susan P. Mollan
- Birmingham Neuro-Ophthalmology, Queen Elizabeth Hospital, University Hospitals Birmingham, Birmingham B15 2WB, U.K
| | - Olivia Grech
- Institute of Metabolism and Systems Research, College of Medical and Dental Sciences, University of Birmingham, Birmingham B15 2TT, U.K
| | - James L. Mitchell
- Institute of Metabolism and Systems Research, College of Medical and Dental Sciences, University of Birmingham, Birmingham B15 2TT, U.K
- Department of Neurology, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham B15 2WB, U.K
| | - Andreas Yiangou
- Institute of Metabolism and Systems Research, College of Medical and Dental Sciences, University of Birmingham, Birmingham B15 2TT, U.K
- Department of Neurology, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham B15 2WB, U.K
| | - Mark Thaller
- Institute of Metabolism and Systems Research, College of Medical and Dental Sciences, University of Birmingham, Birmingham B15 2TT, U.K
- Department of Neurology, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham B15 2WB, U.K
| | - Hannah Lyons
- Institute of Metabolism and Systems Research, College of Medical and Dental Sciences, University of Birmingham, Birmingham B15 2TT, U.K
- Department of Neurology, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham B15 2WB, U.K
| | - Matilde Sassani
- Institute of Metabolism and Systems Research, College of Medical and Dental Sciences, University of Birmingham, Birmingham B15 2TT, U.K
- Department of Neurology, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham B15 2WB, U.K
| | - Senali Seneviratne
- Institute of Metabolism and Systems Research, College of Medical and Dental Sciences, University of Birmingham, Birmingham B15 2TT, U.K
| | - Thomas Hancox
- School of Biosciences, University of Birmingham, Birmingham B15 2TT, U.K
| | - Andris Jankevics
- School of Biosciences, University of Birmingham, Birmingham B15 2TT, U.K
- Phenome Centre Birmingham, University of Birmingham, Birmingham B15 2TT, U.K
| | - Lukáš Najdekr
- School of Biosciences, University of Birmingham, Birmingham B15 2TT, U.K
- Phenome Centre Birmingham, University of Birmingham, Birmingham B15 2TT, U.K
- Institute of Molecular and Translational Medicine, Palacký University Olomouc, Hněvotínská 5, Olomouc 77900, Czech Republic
| | - Warwick Dunn
- Institute of Metabolism and Systems Research, College of Medical and Dental Sciences, University of Birmingham, Birmingham B15 2TT, U.K
- School of Biosciences, University of Birmingham, Birmingham B15 2TT, U.K
- Phenome Centre Birmingham, University of Birmingham, Birmingham B15 2TT, U.K
- Department of Biochemistry and Systems Biology, Institute of Systems, Molecular, and Integrative Biology, University of Liverpool, Liverpool L69 7ZB, U.K
| | - Alexandra J. Sinclair
- Institute of Metabolism and Systems Research, College of Medical and Dental Sciences, University of Birmingham, Birmingham B15 2TT, U.K
- Department of Neurology, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham B15 2WB, U.K
- Centre for Endocrinology, Diabetes and Metabolism, Birmingham Health Partners, Birmingham B15 2TT, U.K
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20
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Lyons HS, Mollan SLP, Liu GT, Bowman R, Thaller M, Sinclair AJ, Mollan SP. Different Characteristics of Pre-Pubertal and Post-Pubertal Idiopathic Intracranial Hypertension: A Narrative Review. Neuroophthalmology 2022; 47:63-74. [PMID: 36891406 PMCID: PMC9988343 DOI: 10.1080/01658107.2022.2153874] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2022] [Revised: 11/10/2022] [Accepted: 11/20/2022] [Indexed: 12/23/2022] Open
Abstract
Idiopathic intracranial hypertension (IIH) affects both children and adults. There are currently no clinical trials in IIH for those who are adolescents or children. The aims of this narrative review were to characterise the differences between pre- and post-pubertal IIH and to highlight the need to be more inclusive in clinical trial planning and recruitment. A detailed search of the scientific literature was performed using the PubMed database, from inception until 30 May 2022 using keywords. This included English language papers only. The abstracts and full texts were reviewed by two independent assessors. The literature revealed that the pre-pubertal group had a more variable presentation. The presenting features in the post-pubertal paediatric group were more akin to adults with headache as the dominant feature. They were also more likely to be female and have an increased body mass index. A clear limitation of the literature was that a number of paediatric studies had variable inclusion criteria, including secondary causes of raised intracranial pressure. Pre-pubertal children do not display the same predilection towards the female sex and obesity as post-pubertal children, who have a similar phenotype to the adult cohort. Inclusion of adolescents in clinical trials should be considered given the similar phenotype to adults. There is a lack of consistency in the definition of puberty, making the IIH literature difficult to compare. Inclusion of secondary causes of raised intracranial pressure has the potential to confound the accuracy of analysis and interpretation of the results.
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Affiliation(s)
- Hannah S. Lyons
- Translational Brain Science, Institute of Metabolism and Systems Research, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
- Department of Neurology, University Hospitals Birmingham NHS Foundation Trust, Queen Elizabeth Hospital, Birmingham, UK
- Centre for Endocrinology, Diabetes and Metabolism, Birmingham Health Partners, Birmingham, UK
| | | | - Grant T. Liu
- Children's Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Richard Bowman
- Ophthalmology Department, Great Ormond Street Children’s Hospital, London, UK
| | - Mark Thaller
- Translational Brain Science, Institute of Metabolism and Systems Research, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
- Department of Neurology, University Hospitals Birmingham NHS Foundation Trust, Queen Elizabeth Hospital, Birmingham, UK
- Centre for Endocrinology, Diabetes and Metabolism, Birmingham Health Partners, Birmingham, UK
| | - Alexandra J. Sinclair
- Translational Brain Science, Institute of Metabolism and Systems Research, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
- Department of Neurology, University Hospitals Birmingham NHS Foundation Trust, Queen Elizabeth Hospital, Birmingham, UK
- Centre for Endocrinology, Diabetes and Metabolism, Birmingham Health Partners, Birmingham, UK
| | - Susan P. Mollan
- Translational Brain Science, Institute of Metabolism and Systems Research, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
- Birmingham Neuro-Ophthalmology, University Hospitals Birmingham NHS Foundation Trust, Queen Elizabeth Hospital, Birmingham, UK
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21
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Thaller M, Mytton J, Wakerley BR, Mollan SP, Sinclair AJ. Idiopathic intracranial hypertension: Evaluation of births and fertility through the Hospital Episode Statistics dataset. BJOG 2022; 129:2019-2027. [PMID: 35620863 PMCID: PMC9796176 DOI: 10.1111/1471-0528.17241] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2021] [Revised: 05/05/2022] [Accepted: 05/19/2022] [Indexed: 01/01/2023]
Abstract
OBJECTIVE Idiopathic intracranial hypertension (IIH) predominantly affects women of reproductive age with obesity, and these women have a distinct profile of hyperandrogenism and insulin resistance. Polycystic ovary syndrome (PCOS) has an established adverse fertility phenotype that typically affects obese women. As IIH may impact reproductive health, we sought to evaluate fertility, gestational complications and pregnancy outcome in IIH. DESIGN Prospective cohort study from English Hospital Episode Statistics dataset. SETTING English hospitals, UK. POPULATION Women aged 18-45 years seen in English hospitals between 1 April 2002 and 31 March 2019. Patients were required to have an IIH diagnosis and were compared with those with PCOS and general population female controls. MAIN OUTCOME MEASURES Pregnancies resulting in live births, complications of gestational diabetes and pre-eclampsia, and method of delivery. RESULTS Data was collected from 17 587 IIH, 199633 PCOS and 10 947 012 women in the general population. The live birth rate, adjusted for age, was significantly lower among women with IIH (54.1%) than PCOS (67.9%), p < 0.0001 and the general population (57.7%), p < 0.0001. Pre-eclampsia and gestational diabetes risks were higher following a diagnosis of IIH (5.3-fold and 2.7-fold, respectively, p < 0.0001) compared with the general population controls. Following a diagnosis of IIH, elective caesarean section rates were more than twice that of general population (odds ratio [OR] 2.4) and prior to a diagnosis of IIH (OR 2.2). CONCLUSIONS These data indicate there are lower age-adjusted total pregnancy rates, increased risk of pre-eclampsia and gestational diabetes, and a doubling of elective caesarean section rates in those with a diagnosis of IIH.
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Affiliation(s)
- Mark Thaller
- Metabolic NeurologyInstitute of Metabolism and Systems ResearchUniversity of BirminghamBirminghamUK,Department of NeurologyUniversity Hospitals Birmingham NHS Foundation TrustBirminghamUK
| | - Jemma Mytton
- InformaticsUniversity Hospitals Birmingham NHS Foundation TrustBirminghamUK
| | - Benjamin R. Wakerley
- Metabolic NeurologyInstitute of Metabolism and Systems ResearchUniversity of BirminghamBirminghamUK,Department of NeurologyUniversity Hospitals Birmingham NHS Foundation TrustBirminghamUK
| | - Susan P. Mollan
- Birmingham Neuro‐OphthalmologyUniversity Hospitals Birmingham NHS Foundation TrustBirminghamUK
| | - Alexandra J. Sinclair
- Metabolic NeurologyInstitute of Metabolism and Systems ResearchUniversity of BirminghamBirminghamUK,Department of NeurologyUniversity Hospitals Birmingham NHS Foundation TrustBirminghamUK,Centre for Endocrinology, Diabetes and Metabolism, Birmingham Health PartnersBirminghamUK
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22
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Adderley NJ, Subramanian A, Perrins M, Nirantharakumar K, Mollan SP, Sinclair AJ. Headache, Opiate Use, and Prescribing Trends in Women With Idiopathic Intracranial Hypertension: A Population-Based Matched Cohort Study. Neurology 2022; 99:e1968-e1978. [PMID: 35985824 PMCID: PMC9651462 DOI: 10.1212/wnl.0000000000201064] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2022] [Accepted: 06/21/2022] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND AND OBJECTIVES Physician prescribing habits for opiates and headache therapies have not been previously evaluated in a large, matched cohort study in idiopathic intracranial hypertension (IIH). Our objective was to evaluate opiate and headache medication prescribing habits in women with IIH compared with matched women with migraine and population controls. We also investigated the occurrence of new onset headache in IIH compared with population controls. METHODS We performed a population-based matched, retrospective cohort study to explore headache outcomes. Cross-sectional analyses were used to describe medication prescribing patterns. We used data from IQVIA Medical Research Data, an anonymized, nationally representative primary care electronic medical record database in the United Kingdom, from January 1, 1995, to September 25, 2019. Women aged 16 years and older were eligible for inclusion. Women with IIH (exposure) were matched by age and body mass index with up to 10 control women without IIH but with migraine (migraine controls), and without IIH or migraine (population controls). RESULTS A total of 3,411 women with IIH, 13,966 migraine controls, and 33,495 population controls were included. The adjusted hazard ratio for new onset headache in IIH compared with population controls was 3.09 (95% CI 2.78-3.43). In the first year after diagnosis, 58% of women with IIH were prescribed acetazolamide and 20% topiramate. In total, 20% of women with IIH were prescribed opiates within the first year of their diagnosis, reducing to 17% after 6 years, compared with 8% and 11% among those with migraine, respectively. Twice as many women with IIH were prescribed opiates compared with migraine controls, and 3 times as many women with IIH were prescribed opiates compared with population controls. Women with IIH were also prescribed more headache preventative medications compared with migraine controls. DISCUSSION Women with IIH were more likely to be prescribed opiate and simple analgesics compared with both migraine and population controls. Women with IIH trialed more preventative medications over their disease course suggesting that headaches in IIH may be more refractory to treatment.
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Affiliation(s)
- Nicola Jaime Adderley
- From the Institute of Applied Health Research (N.J.A., A.S., M.P., K.N.), University of Birmingham; Centre for Endocrinology, Diabetes, and Metabolism (K.N.), Birmingham Health Partners; Health Data Research UK (K.N.), Birmingham; Birmingham Neuro-Ophthalmology (S.P.M.), Queen Elizabeth Hospital; Metabolic Neurology (A.J.S.), Institute of Metabolism and Systems Research, University of Birmingham; and Department of Neurology (A.J.S.), University Hospitals Birmingham, Queen Elizabeth Hospital, United Kingdom
| | - Anuradhaa Subramanian
- From the Institute of Applied Health Research (N.J.A., A.S., M.P., K.N.), University of Birmingham; Centre for Endocrinology, Diabetes, and Metabolism (K.N.), Birmingham Health Partners; Health Data Research UK (K.N.), Birmingham; Birmingham Neuro-Ophthalmology (S.P.M.), Queen Elizabeth Hospital; Metabolic Neurology (A.J.S.), Institute of Metabolism and Systems Research, University of Birmingham; and Department of Neurology (A.J.S.), University Hospitals Birmingham, Queen Elizabeth Hospital, United Kingdom
| | - Mary Perrins
- From the Institute of Applied Health Research (N.J.A., A.S., M.P., K.N.), University of Birmingham; Centre for Endocrinology, Diabetes, and Metabolism (K.N.), Birmingham Health Partners; Health Data Research UK (K.N.), Birmingham; Birmingham Neuro-Ophthalmology (S.P.M.), Queen Elizabeth Hospital; Metabolic Neurology (A.J.S.), Institute of Metabolism and Systems Research, University of Birmingham; and Department of Neurology (A.J.S.), University Hospitals Birmingham, Queen Elizabeth Hospital, United Kingdom
| | - Krishnarajah Nirantharakumar
- From the Institute of Applied Health Research (N.J.A., A.S., M.P., K.N.), University of Birmingham; Centre for Endocrinology, Diabetes, and Metabolism (K.N.), Birmingham Health Partners; Health Data Research UK (K.N.), Birmingham; Birmingham Neuro-Ophthalmology (S.P.M.), Queen Elizabeth Hospital; Metabolic Neurology (A.J.S.), Institute of Metabolism and Systems Research, University of Birmingham; and Department of Neurology (A.J.S.), University Hospitals Birmingham, Queen Elizabeth Hospital, United Kingdom
| | - Susan P Mollan
- From the Institute of Applied Health Research (N.J.A., A.S., M.P., K.N.), University of Birmingham; Centre for Endocrinology, Diabetes, and Metabolism (K.N.), Birmingham Health Partners; Health Data Research UK (K.N.), Birmingham; Birmingham Neuro-Ophthalmology (S.P.M.), Queen Elizabeth Hospital; Metabolic Neurology (A.J.S.), Institute of Metabolism and Systems Research, University of Birmingham; and Department of Neurology (A.J.S.), University Hospitals Birmingham, Queen Elizabeth Hospital, United Kingdom
| | - Alexandra Jean Sinclair
- From the Institute of Applied Health Research (N.J.A., A.S., M.P., K.N.), University of Birmingham; Centre for Endocrinology, Diabetes, and Metabolism (K.N.), Birmingham Health Partners; Health Data Research UK (K.N.), Birmingham; Birmingham Neuro-Ophthalmology (S.P.M.), Queen Elizabeth Hospital; Metabolic Neurology (A.J.S.), Institute of Metabolism and Systems Research, University of Birmingham; and Department of Neurology (A.J.S.), University Hospitals Birmingham, Queen Elizabeth Hospital, United Kingdom.
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23
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Grech O, Seneviratne SY, Alimajstorovic Z, Yiangou A, Mitchell JL, Smith TB, Mollan SP, Lavery GG, Ludwig C, Sinclair AJ. Nuclear Magnetic Resonance Spectroscopy Metabolomics in Idiopathic Intracranial Hypertension to Identify Markers of Disease and Headache. Neurology 2022; 99:e1702-e1714. [PMID: 36240084 PMCID: PMC9620805 DOI: 10.1212/wnl.0000000000201007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2022] [Accepted: 06/09/2022] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND AND OBJECTIVE We evaluated the metabolomic profile in the CSF, serum, and urine of participants with idiopathic intracranial hypertension (IIH) compared with that in controls and measured changes in metabolism associated with clinical markers of disease activity and treatment. METHODS A case-control study compared women aged 18-55 years with active IIH (Friedman diagnostic criteria) with a sex-matched, age-matched, and body mass index-matched control group. IIH participants were identified from neurology and ophthalmology clinics from National Health Service hospitals and underwent a prospective intervention to induce disease remission through weight loss with reevaluation at 12 months. Clinical assessments included lumbar puncture, headache, papilledema, and visual measurements. Spectra of the CSF, serum, and urine metabolites were acquired using proton nuclear magnetic resonance spectroscopy. RESULTS Urea was lower in IIH participants (CSF, controls median ± IQR 0.196 ± 0.008, IIH 0.058 ± 0.059, p < 0.001; urine, controls 5971.370 ± 3021.831, IIH 4691.363 ± 1955.774, p = 0.009), correlated with ICP (urine p = 0.019) and headache severity (CSF p = 0.031), and increased by 12 months (CSF 12 months; 0.175 ± 0.043, p = 0.004, urine; 5210.874 ± 1825.302, p = 0.043). The lactate:pyruvate ratio was increased in IIH participants compared with that in controls (CSF, controls 49.739 ± 19.523, IIH 113.114 ± 117.298, p = 0.023; serum, controls 38.187 ± 13.392, IIH 54.547 ± 18.471, p = 0.004) and decreased at 12 months (CSF, 113.114 ± 117.298, p < 0.001). Baseline acetate was higher in IIH participants (CSF, controls 0.128 ± 0.041, IIH 0.192 ± 0.151, p = 0.008), correlated with headache severity (p = 0.030) and headache disability (p = 0.003), and was reduced at 12 months (0.160 ± 0.060, p = 0.007). Ketones, 3-hydroxybutyrate and acetoacetate, were altered in the CSF at baseline in IIH participants (3-hydroxybutyrate, controls 0.074 ± 0.063, IIH 0.049 ± 0.055, p = 0.019; acetoacetate, controls 0.013 ± 0.007, IIH 0.017 ± 0.010, p = 0.013) and normalized at 12 months (0.112 ± 0.114, p = 0.019, 0.029 ± 0.017, p = 0.015, respectively). DISCUSSION We observed metabolic disturbances that are evident in the CSF, serum, and urine of IIH participants, suggesting global metabolic dysregulation. Altered ketone body metabolites normalized after therapeutic weight loss. CSF:serum urea ratio was altered, which may influence ICP dynamics and headache. Elevated CSF acetate, known to stimulate trigeminal sensitization, was associated with headache morbidity. These alterations of metabolic pathways specific to IIH provide biological insight and warrant mechanistic evaluation. TRIAL REGISTRATION INFORMATION Registered on ClinicalTrials.gov, NCT02124486 (submitted April 22, 2014) and NCT02017444 (submitted December 16, 2013).
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Affiliation(s)
- Olivia Grech
- Metabolic Neurology (O.G., S.Y.S., Z.A., A.Y., J.L.M., A.J.S.), Institute of Metabolism and Systems Research, College of Medical and Dental Sciences, University of Birmingham; Department of Neurology (A.Y., J.L.M., A.J.S.), University Hospitals Birmingham NHS Foundation Trust; Department of Surgery (T.B.S.), Addenbrooke's Hospital, The University of Cambridge; Birmingham Neuro-Ophthalmology (S.P.M), Queen Elizabeth Hospital, University Hospitals Birmingham; Institute of Metabolism and Systems Research (G.G.L., C.L.), College of Medical and Dental Sciences, University of Birmingham; and Department of Biosciences (G.G.L.), School of Science and Technology, Nottingham Trent University, Clifton Campus, UK
| | - Senali Y Seneviratne
- Metabolic Neurology (O.G., S.Y.S., Z.A., A.Y., J.L.M., A.J.S.), Institute of Metabolism and Systems Research, College of Medical and Dental Sciences, University of Birmingham; Department of Neurology (A.Y., J.L.M., A.J.S.), University Hospitals Birmingham NHS Foundation Trust; Department of Surgery (T.B.S.), Addenbrooke's Hospital, The University of Cambridge; Birmingham Neuro-Ophthalmology (S.P.M), Queen Elizabeth Hospital, University Hospitals Birmingham; Institute of Metabolism and Systems Research (G.G.L., C.L.), College of Medical and Dental Sciences, University of Birmingham; and Department of Biosciences (G.G.L.), School of Science and Technology, Nottingham Trent University, Clifton Campus, UK
| | - Zerin Alimajstorovic
- Metabolic Neurology (O.G., S.Y.S., Z.A., A.Y., J.L.M., A.J.S.), Institute of Metabolism and Systems Research, College of Medical and Dental Sciences, University of Birmingham; Department of Neurology (A.Y., J.L.M., A.J.S.), University Hospitals Birmingham NHS Foundation Trust; Department of Surgery (T.B.S.), Addenbrooke's Hospital, The University of Cambridge; Birmingham Neuro-Ophthalmology (S.P.M), Queen Elizabeth Hospital, University Hospitals Birmingham; Institute of Metabolism and Systems Research (G.G.L., C.L.), College of Medical and Dental Sciences, University of Birmingham; and Department of Biosciences (G.G.L.), School of Science and Technology, Nottingham Trent University, Clifton Campus, UK
| | - Andreas Yiangou
- Metabolic Neurology (O.G., S.Y.S., Z.A., A.Y., J.L.M., A.J.S.), Institute of Metabolism and Systems Research, College of Medical and Dental Sciences, University of Birmingham; Department of Neurology (A.Y., J.L.M., A.J.S.), University Hospitals Birmingham NHS Foundation Trust; Department of Surgery (T.B.S.), Addenbrooke's Hospital, The University of Cambridge; Birmingham Neuro-Ophthalmology (S.P.M), Queen Elizabeth Hospital, University Hospitals Birmingham; Institute of Metabolism and Systems Research (G.G.L., C.L.), College of Medical and Dental Sciences, University of Birmingham; and Department of Biosciences (G.G.L.), School of Science and Technology, Nottingham Trent University, Clifton Campus, UK
| | - James L Mitchell
- Metabolic Neurology (O.G., S.Y.S., Z.A., A.Y., J.L.M., A.J.S.), Institute of Metabolism and Systems Research, College of Medical and Dental Sciences, University of Birmingham; Department of Neurology (A.Y., J.L.M., A.J.S.), University Hospitals Birmingham NHS Foundation Trust; Department of Surgery (T.B.S.), Addenbrooke's Hospital, The University of Cambridge; Birmingham Neuro-Ophthalmology (S.P.M), Queen Elizabeth Hospital, University Hospitals Birmingham; Institute of Metabolism and Systems Research (G.G.L., C.L.), College of Medical and Dental Sciences, University of Birmingham; and Department of Biosciences (G.G.L.), School of Science and Technology, Nottingham Trent University, Clifton Campus, UK
| | - Thomas B Smith
- Metabolic Neurology (O.G., S.Y.S., Z.A., A.Y., J.L.M., A.J.S.), Institute of Metabolism and Systems Research, College of Medical and Dental Sciences, University of Birmingham; Department of Neurology (A.Y., J.L.M., A.J.S.), University Hospitals Birmingham NHS Foundation Trust; Department of Surgery (T.B.S.), Addenbrooke's Hospital, The University of Cambridge; Birmingham Neuro-Ophthalmology (S.P.M), Queen Elizabeth Hospital, University Hospitals Birmingham; Institute of Metabolism and Systems Research (G.G.L., C.L.), College of Medical and Dental Sciences, University of Birmingham; and Department of Biosciences (G.G.L.), School of Science and Technology, Nottingham Trent University, Clifton Campus, UK
| | - Susan P Mollan
- Metabolic Neurology (O.G., S.Y.S., Z.A., A.Y., J.L.M., A.J.S.), Institute of Metabolism and Systems Research, College of Medical and Dental Sciences, University of Birmingham; Department of Neurology (A.Y., J.L.M., A.J.S.), University Hospitals Birmingham NHS Foundation Trust; Department of Surgery (T.B.S.), Addenbrooke's Hospital, The University of Cambridge; Birmingham Neuro-Ophthalmology (S.P.M), Queen Elizabeth Hospital, University Hospitals Birmingham; Institute of Metabolism and Systems Research (G.G.L., C.L.), College of Medical and Dental Sciences, University of Birmingham; and Department of Biosciences (G.G.L.), School of Science and Technology, Nottingham Trent University, Clifton Campus, UK
| | - Gareth G Lavery
- Metabolic Neurology (O.G., S.Y.S., Z.A., A.Y., J.L.M., A.J.S.), Institute of Metabolism and Systems Research, College of Medical and Dental Sciences, University of Birmingham; Department of Neurology (A.Y., J.L.M., A.J.S.), University Hospitals Birmingham NHS Foundation Trust; Department of Surgery (T.B.S.), Addenbrooke's Hospital, The University of Cambridge; Birmingham Neuro-Ophthalmology (S.P.M), Queen Elizabeth Hospital, University Hospitals Birmingham; Institute of Metabolism and Systems Research (G.G.L., C.L.), College of Medical and Dental Sciences, University of Birmingham; and Department of Biosciences (G.G.L.), School of Science and Technology, Nottingham Trent University, Clifton Campus, UK
| | - Christian Ludwig
- Metabolic Neurology (O.G., S.Y.S., Z.A., A.Y., J.L.M., A.J.S.), Institute of Metabolism and Systems Research, College of Medical and Dental Sciences, University of Birmingham; Department of Neurology (A.Y., J.L.M., A.J.S.), University Hospitals Birmingham NHS Foundation Trust; Department of Surgery (T.B.S.), Addenbrooke's Hospital, The University of Cambridge; Birmingham Neuro-Ophthalmology (S.P.M), Queen Elizabeth Hospital, University Hospitals Birmingham; Institute of Metabolism and Systems Research (G.G.L., C.L.), College of Medical and Dental Sciences, University of Birmingham; and Department of Biosciences (G.G.L.), School of Science and Technology, Nottingham Trent University, Clifton Campus, UK
| | - Alexandra J Sinclair
- Metabolic Neurology (O.G., S.Y.S., Z.A., A.Y., J.L.M., A.J.S.), Institute of Metabolism and Systems Research, College of Medical and Dental Sciences, University of Birmingham; Department of Neurology (A.Y., J.L.M., A.J.S.), University Hospitals Birmingham NHS Foundation Trust; Department of Surgery (T.B.S.), Addenbrooke's Hospital, The University of Cambridge; Birmingham Neuro-Ophthalmology (S.P.M), Queen Elizabeth Hospital, University Hospitals Birmingham; Institute of Metabolism and Systems Research (G.G.L., C.L.), College of Medical and Dental Sciences, University of Birmingham; and Department of Biosciences (G.G.L.), School of Science and Technology, Nottingham Trent University, Clifton Campus, UK.
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Mollan SP, Mitchell JL, Yiangou A, Ottridge RS, Alimajstorovic Z, Cartwright DM, Hickman SJ, Markey KA, Singhal R, Tahrani AA, Frew E, Brock K, Sinclair AJ. Association of Amount of Weight Lost After Bariatric Surgery With Intracranial Pressure in Women With Idiopathic Intracranial Hypertension. Neurology 2022; 99:e1090-e1099. [PMID: 35790425 PMCID: PMC9536743 DOI: 10.1212/wnl.0000000000200839] [Citation(s) in RCA: 18] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2021] [Accepted: 04/22/2022] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND AND OBJECTIVES The idiopathic intracranial hypertension randomized controlled weight trial (IIH:WT) established that weight loss through bariatric surgery significantly reduced intracranial pressure when compared with a community weight management intervention. This substudy aimed to evaluate the amount of weight loss required to reduce intracranial pressure and to explore the effect of different bariatric surgical approaches. METHODS IIH:WT was a multicenter randomized controlled trial. Adult women with active idiopathic intracranial hypertension and a body mass index ≥35 kg/m2 were randomized to bariatric surgery or a community weight management intervention (1:1). This per-protocol analysis evaluated the relationship between intracranial pressure, weight loss, and the weight loss methods. A linear hierarchical regression model was used to fit the trial outcomes, adjusted for time, treatment arm, and weight. RESULTS Sixty-six women were included, of whom 23 had received bariatric surgery by 12 months; the mean age was 31 (SD 8.7) years in the bariatric surgery group and 33.2 (SD 7.4) years in the dietary group. Baseline weight and intracranial pressure were similar in both groups with a mean weight of 119.5 (SD 24.1) and 117.9 (SD 19.5) kg and mean lumbar puncture opening pressure of 34.4 (SD 6.3) and 34.9 (SD 5.3) cmCSF in the bariatric surgery and dietary groups, respectively. Weight loss was significantly associated with reduction in intracranial pressure (R2 = 0.4734, p ≤ 0.0001). Twenty-four percentage of weight loss (weight loss of 13.3 kg [SD 1.76]) was associated with disease remission (intracranial pressure [ICP] ≤ 25 cmCSF). Roux-en-Y gastric bypass achieved greater, more rapid, and sustained ICP reduction compared with other methods. DISCUSSION The greater the weight loss, the greater the reduction in ICP was documented. Twenty four percentage of weight loss was associated with disease remission. Such magnitude of weight loss was unlikely to be achieved without bariatric surgery, and hence, consideration of referral to a bariatric surgery program early for those with active idiopathic intracranial hypertension may be appropriate. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT02124486; ISRCTN registry number ISRCTN40152829; doi.org/10.1186/ISRCTN40152829. CLASSIFICATION OF EVIDENCE This study provides Class II evidence that weight loss after bariatric surgery results in reduction in intracranial pressure in adult women with idiopathic intracranial hypertension. This study is Class II because of the use of a per-protocol analysis.
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Affiliation(s)
- Susan P Mollan
- From the Birmingham Neuro-Ophthalmology (S.P.M.), University Hospitals Birmingham NHS Foundation Trust, Queen Elizabeth Hospital; Metabolic Neurology (J.L.M., A.Y., Z.A., K.A.M., A.J.S.), Institute of Metabolism and Systems Research, College of Medical and Dental Sciences, University of Birmingham; Department of Neurology (J.L.M., A.Y., A.J.S.), University Hospitals Birmingham NHS Foundation Trust, Queen Elizabeth Hospital; Centre for Endocrinology (J.L.M., A.Y., A.A.T., A.J.S.), Diabetes and Metabolism, Birmingham Health Partners; Birmingham Clinical Trials Unit (R.S.O.); Institute of Metabolism and Systems Research (Z.A., D.M.C., A.A.T., A.J.S.), College of Medical and Dental Sciences, University of Birmingham, Birmingham, United Kingdom; Department of Neurology (S.J.H.), Royal Hallamshire Hospital, Sheffield, United Kingdom; Upper GI Unit and Minimally Invasive Unit (R.S.), Birmingham Heartlands Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham; Institute of Cancer and Genomic Sciences (R.S.), University of Birmingham; Department of Endocrinology (A.A.T.), University Hospitals Birmingham NHS Foundation Trust, Queen Elizabeth Hospital; Health Economics Unit (E.F.), Institute of Applied Health Research, University of Birmingham; and Cancer Research UK Clinical Trials Unit (K.B.), University of Birmingham, Birmingham, United Kingdom.
| | - James L Mitchell
- From the Birmingham Neuro-Ophthalmology (S.P.M.), University Hospitals Birmingham NHS Foundation Trust, Queen Elizabeth Hospital; Metabolic Neurology (J.L.M., A.Y., Z.A., K.A.M., A.J.S.), Institute of Metabolism and Systems Research, College of Medical and Dental Sciences, University of Birmingham; Department of Neurology (J.L.M., A.Y., A.J.S.), University Hospitals Birmingham NHS Foundation Trust, Queen Elizabeth Hospital; Centre for Endocrinology (J.L.M., A.Y., A.A.T., A.J.S.), Diabetes and Metabolism, Birmingham Health Partners; Birmingham Clinical Trials Unit (R.S.O.); Institute of Metabolism and Systems Research (Z.A., D.M.C., A.A.T., A.J.S.), College of Medical and Dental Sciences, University of Birmingham, Birmingham, United Kingdom; Department of Neurology (S.J.H.), Royal Hallamshire Hospital, Sheffield, United Kingdom; Upper GI Unit and Minimally Invasive Unit (R.S.), Birmingham Heartlands Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham; Institute of Cancer and Genomic Sciences (R.S.), University of Birmingham; Department of Endocrinology (A.A.T.), University Hospitals Birmingham NHS Foundation Trust, Queen Elizabeth Hospital; Health Economics Unit (E.F.), Institute of Applied Health Research, University of Birmingham; and Cancer Research UK Clinical Trials Unit (K.B.), University of Birmingham, Birmingham, United Kingdom
| | - Andreas Yiangou
- From the Birmingham Neuro-Ophthalmology (S.P.M.), University Hospitals Birmingham NHS Foundation Trust, Queen Elizabeth Hospital; Metabolic Neurology (J.L.M., A.Y., Z.A., K.A.M., A.J.S.), Institute of Metabolism and Systems Research, College of Medical and Dental Sciences, University of Birmingham; Department of Neurology (J.L.M., A.Y., A.J.S.), University Hospitals Birmingham NHS Foundation Trust, Queen Elizabeth Hospital; Centre for Endocrinology (J.L.M., A.Y., A.A.T., A.J.S.), Diabetes and Metabolism, Birmingham Health Partners; Birmingham Clinical Trials Unit (R.S.O.); Institute of Metabolism and Systems Research (Z.A., D.M.C., A.A.T., A.J.S.), College of Medical and Dental Sciences, University of Birmingham, Birmingham, United Kingdom; Department of Neurology (S.J.H.), Royal Hallamshire Hospital, Sheffield, United Kingdom; Upper GI Unit and Minimally Invasive Unit (R.S.), Birmingham Heartlands Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham; Institute of Cancer and Genomic Sciences (R.S.), University of Birmingham; Department of Endocrinology (A.A.T.), University Hospitals Birmingham NHS Foundation Trust, Queen Elizabeth Hospital; Health Economics Unit (E.F.), Institute of Applied Health Research, University of Birmingham; and Cancer Research UK Clinical Trials Unit (K.B.), University of Birmingham, Birmingham, United Kingdom
| | - Ryan S Ottridge
- From the Birmingham Neuro-Ophthalmology (S.P.M.), University Hospitals Birmingham NHS Foundation Trust, Queen Elizabeth Hospital; Metabolic Neurology (J.L.M., A.Y., Z.A., K.A.M., A.J.S.), Institute of Metabolism and Systems Research, College of Medical and Dental Sciences, University of Birmingham; Department of Neurology (J.L.M., A.Y., A.J.S.), University Hospitals Birmingham NHS Foundation Trust, Queen Elizabeth Hospital; Centre for Endocrinology (J.L.M., A.Y., A.A.T., A.J.S.), Diabetes and Metabolism, Birmingham Health Partners; Birmingham Clinical Trials Unit (R.S.O.); Institute of Metabolism and Systems Research (Z.A., D.M.C., A.A.T., A.J.S.), College of Medical and Dental Sciences, University of Birmingham, Birmingham, United Kingdom; Department of Neurology (S.J.H.), Royal Hallamshire Hospital, Sheffield, United Kingdom; Upper GI Unit and Minimally Invasive Unit (R.S.), Birmingham Heartlands Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham; Institute of Cancer and Genomic Sciences (R.S.), University of Birmingham; Department of Endocrinology (A.A.T.), University Hospitals Birmingham NHS Foundation Trust, Queen Elizabeth Hospital; Health Economics Unit (E.F.), Institute of Applied Health Research, University of Birmingham; and Cancer Research UK Clinical Trials Unit (K.B.), University of Birmingham, Birmingham, United Kingdom
| | - Zerin Alimajstorovic
- From the Birmingham Neuro-Ophthalmology (S.P.M.), University Hospitals Birmingham NHS Foundation Trust, Queen Elizabeth Hospital; Metabolic Neurology (J.L.M., A.Y., Z.A., K.A.M., A.J.S.), Institute of Metabolism and Systems Research, College of Medical and Dental Sciences, University of Birmingham; Department of Neurology (J.L.M., A.Y., A.J.S.), University Hospitals Birmingham NHS Foundation Trust, Queen Elizabeth Hospital; Centre for Endocrinology (J.L.M., A.Y., A.A.T., A.J.S.), Diabetes and Metabolism, Birmingham Health Partners; Birmingham Clinical Trials Unit (R.S.O.); Institute of Metabolism and Systems Research (Z.A., D.M.C., A.A.T., A.J.S.), College of Medical and Dental Sciences, University of Birmingham, Birmingham, United Kingdom; Department of Neurology (S.J.H.), Royal Hallamshire Hospital, Sheffield, United Kingdom; Upper GI Unit and Minimally Invasive Unit (R.S.), Birmingham Heartlands Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham; Institute of Cancer and Genomic Sciences (R.S.), University of Birmingham; Department of Endocrinology (A.A.T.), University Hospitals Birmingham NHS Foundation Trust, Queen Elizabeth Hospital; Health Economics Unit (E.F.), Institute of Applied Health Research, University of Birmingham; and Cancer Research UK Clinical Trials Unit (K.B.), University of Birmingham, Birmingham, United Kingdom
| | - David M Cartwright
- From the Birmingham Neuro-Ophthalmology (S.P.M.), University Hospitals Birmingham NHS Foundation Trust, Queen Elizabeth Hospital; Metabolic Neurology (J.L.M., A.Y., Z.A., K.A.M., A.J.S.), Institute of Metabolism and Systems Research, College of Medical and Dental Sciences, University of Birmingham; Department of Neurology (J.L.M., A.Y., A.J.S.), University Hospitals Birmingham NHS Foundation Trust, Queen Elizabeth Hospital; Centre for Endocrinology (J.L.M., A.Y., A.A.T., A.J.S.), Diabetes and Metabolism, Birmingham Health Partners; Birmingham Clinical Trials Unit (R.S.O.); Institute of Metabolism and Systems Research (Z.A., D.M.C., A.A.T., A.J.S.), College of Medical and Dental Sciences, University of Birmingham, Birmingham, United Kingdom; Department of Neurology (S.J.H.), Royal Hallamshire Hospital, Sheffield, United Kingdom; Upper GI Unit and Minimally Invasive Unit (R.S.), Birmingham Heartlands Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham; Institute of Cancer and Genomic Sciences (R.S.), University of Birmingham; Department of Endocrinology (A.A.T.), University Hospitals Birmingham NHS Foundation Trust, Queen Elizabeth Hospital; Health Economics Unit (E.F.), Institute of Applied Health Research, University of Birmingham; and Cancer Research UK Clinical Trials Unit (K.B.), University of Birmingham, Birmingham, United Kingdom
| | - Simon J Hickman
- From the Birmingham Neuro-Ophthalmology (S.P.M.), University Hospitals Birmingham NHS Foundation Trust, Queen Elizabeth Hospital; Metabolic Neurology (J.L.M., A.Y., Z.A., K.A.M., A.J.S.), Institute of Metabolism and Systems Research, College of Medical and Dental Sciences, University of Birmingham; Department of Neurology (J.L.M., A.Y., A.J.S.), University Hospitals Birmingham NHS Foundation Trust, Queen Elizabeth Hospital; Centre for Endocrinology (J.L.M., A.Y., A.A.T., A.J.S.), Diabetes and Metabolism, Birmingham Health Partners; Birmingham Clinical Trials Unit (R.S.O.); Institute of Metabolism and Systems Research (Z.A., D.M.C., A.A.T., A.J.S.), College of Medical and Dental Sciences, University of Birmingham, Birmingham, United Kingdom; Department of Neurology (S.J.H.), Royal Hallamshire Hospital, Sheffield, United Kingdom; Upper GI Unit and Minimally Invasive Unit (R.S.), Birmingham Heartlands Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham; Institute of Cancer and Genomic Sciences (R.S.), University of Birmingham; Department of Endocrinology (A.A.T.), University Hospitals Birmingham NHS Foundation Trust, Queen Elizabeth Hospital; Health Economics Unit (E.F.), Institute of Applied Health Research, University of Birmingham; and Cancer Research UK Clinical Trials Unit (K.B.), University of Birmingham, Birmingham, United Kingdom
| | - Keira A Markey
- From the Birmingham Neuro-Ophthalmology (S.P.M.), University Hospitals Birmingham NHS Foundation Trust, Queen Elizabeth Hospital; Metabolic Neurology (J.L.M., A.Y., Z.A., K.A.M., A.J.S.), Institute of Metabolism and Systems Research, College of Medical and Dental Sciences, University of Birmingham; Department of Neurology (J.L.M., A.Y., A.J.S.), University Hospitals Birmingham NHS Foundation Trust, Queen Elizabeth Hospital; Centre for Endocrinology (J.L.M., A.Y., A.A.T., A.J.S.), Diabetes and Metabolism, Birmingham Health Partners; Birmingham Clinical Trials Unit (R.S.O.); Institute of Metabolism and Systems Research (Z.A., D.M.C., A.A.T., A.J.S.), College of Medical and Dental Sciences, University of Birmingham, Birmingham, United Kingdom; Department of Neurology (S.J.H.), Royal Hallamshire Hospital, Sheffield, United Kingdom; Upper GI Unit and Minimally Invasive Unit (R.S.), Birmingham Heartlands Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham; Institute of Cancer and Genomic Sciences (R.S.), University of Birmingham; Department of Endocrinology (A.A.T.), University Hospitals Birmingham NHS Foundation Trust, Queen Elizabeth Hospital; Health Economics Unit (E.F.), Institute of Applied Health Research, University of Birmingham; and Cancer Research UK Clinical Trials Unit (K.B.), University of Birmingham, Birmingham, United Kingdom
| | - Rishi Singhal
- From the Birmingham Neuro-Ophthalmology (S.P.M.), University Hospitals Birmingham NHS Foundation Trust, Queen Elizabeth Hospital; Metabolic Neurology (J.L.M., A.Y., Z.A., K.A.M., A.J.S.), Institute of Metabolism and Systems Research, College of Medical and Dental Sciences, University of Birmingham; Department of Neurology (J.L.M., A.Y., A.J.S.), University Hospitals Birmingham NHS Foundation Trust, Queen Elizabeth Hospital; Centre for Endocrinology (J.L.M., A.Y., A.A.T., A.J.S.), Diabetes and Metabolism, Birmingham Health Partners; Birmingham Clinical Trials Unit (R.S.O.); Institute of Metabolism and Systems Research (Z.A., D.M.C., A.A.T., A.J.S.), College of Medical and Dental Sciences, University of Birmingham, Birmingham, United Kingdom; Department of Neurology (S.J.H.), Royal Hallamshire Hospital, Sheffield, United Kingdom; Upper GI Unit and Minimally Invasive Unit (R.S.), Birmingham Heartlands Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham; Institute of Cancer and Genomic Sciences (R.S.), University of Birmingham; Department of Endocrinology (A.A.T.), University Hospitals Birmingham NHS Foundation Trust, Queen Elizabeth Hospital; Health Economics Unit (E.F.), Institute of Applied Health Research, University of Birmingham; and Cancer Research UK Clinical Trials Unit (K.B.), University of Birmingham, Birmingham, United Kingdom
| | - Abd A Tahrani
- From the Birmingham Neuro-Ophthalmology (S.P.M.), University Hospitals Birmingham NHS Foundation Trust, Queen Elizabeth Hospital; Metabolic Neurology (J.L.M., A.Y., Z.A., K.A.M., A.J.S.), Institute of Metabolism and Systems Research, College of Medical and Dental Sciences, University of Birmingham; Department of Neurology (J.L.M., A.Y., A.J.S.), University Hospitals Birmingham NHS Foundation Trust, Queen Elizabeth Hospital; Centre for Endocrinology (J.L.M., A.Y., A.A.T., A.J.S.), Diabetes and Metabolism, Birmingham Health Partners; Birmingham Clinical Trials Unit (R.S.O.); Institute of Metabolism and Systems Research (Z.A., D.M.C., A.A.T., A.J.S.), College of Medical and Dental Sciences, University of Birmingham, Birmingham, United Kingdom; Department of Neurology (S.J.H.), Royal Hallamshire Hospital, Sheffield, United Kingdom; Upper GI Unit and Minimally Invasive Unit (R.S.), Birmingham Heartlands Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham; Institute of Cancer and Genomic Sciences (R.S.), University of Birmingham; Department of Endocrinology (A.A.T.), University Hospitals Birmingham NHS Foundation Trust, Queen Elizabeth Hospital; Health Economics Unit (E.F.), Institute of Applied Health Research, University of Birmingham; and Cancer Research UK Clinical Trials Unit (K.B.), University of Birmingham, Birmingham, United Kingdom
| | - Emma Frew
- From the Birmingham Neuro-Ophthalmology (S.P.M.), University Hospitals Birmingham NHS Foundation Trust, Queen Elizabeth Hospital; Metabolic Neurology (J.L.M., A.Y., Z.A., K.A.M., A.J.S.), Institute of Metabolism and Systems Research, College of Medical and Dental Sciences, University of Birmingham; Department of Neurology (J.L.M., A.Y., A.J.S.), University Hospitals Birmingham NHS Foundation Trust, Queen Elizabeth Hospital; Centre for Endocrinology (J.L.M., A.Y., A.A.T., A.J.S.), Diabetes and Metabolism, Birmingham Health Partners; Birmingham Clinical Trials Unit (R.S.O.); Institute of Metabolism and Systems Research (Z.A., D.M.C., A.A.T., A.J.S.), College of Medical and Dental Sciences, University of Birmingham, Birmingham, United Kingdom; Department of Neurology (S.J.H.), Royal Hallamshire Hospital, Sheffield, United Kingdom; Upper GI Unit and Minimally Invasive Unit (R.S.), Birmingham Heartlands Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham; Institute of Cancer and Genomic Sciences (R.S.), University of Birmingham; Department of Endocrinology (A.A.T.), University Hospitals Birmingham NHS Foundation Trust, Queen Elizabeth Hospital; Health Economics Unit (E.F.), Institute of Applied Health Research, University of Birmingham; and Cancer Research UK Clinical Trials Unit (K.B.), University of Birmingham, Birmingham, United Kingdom
| | - Kristian Brock
- From the Birmingham Neuro-Ophthalmology (S.P.M.), University Hospitals Birmingham NHS Foundation Trust, Queen Elizabeth Hospital; Metabolic Neurology (J.L.M., A.Y., Z.A., K.A.M., A.J.S.), Institute of Metabolism and Systems Research, College of Medical and Dental Sciences, University of Birmingham; Department of Neurology (J.L.M., A.Y., A.J.S.), University Hospitals Birmingham NHS Foundation Trust, Queen Elizabeth Hospital; Centre for Endocrinology (J.L.M., A.Y., A.A.T., A.J.S.), Diabetes and Metabolism, Birmingham Health Partners; Birmingham Clinical Trials Unit (R.S.O.); Institute of Metabolism and Systems Research (Z.A., D.M.C., A.A.T., A.J.S.), College of Medical and Dental Sciences, University of Birmingham, Birmingham, United Kingdom; Department of Neurology (S.J.H.), Royal Hallamshire Hospital, Sheffield, United Kingdom; Upper GI Unit and Minimally Invasive Unit (R.S.), Birmingham Heartlands Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham; Institute of Cancer and Genomic Sciences (R.S.), University of Birmingham; Department of Endocrinology (A.A.T.), University Hospitals Birmingham NHS Foundation Trust, Queen Elizabeth Hospital; Health Economics Unit (E.F.), Institute of Applied Health Research, University of Birmingham; and Cancer Research UK Clinical Trials Unit (K.B.), University of Birmingham, Birmingham, United Kingdom
| | - Alexandra Jean Sinclair
- From the Birmingham Neuro-Ophthalmology (S.P.M.), University Hospitals Birmingham NHS Foundation Trust, Queen Elizabeth Hospital; Metabolic Neurology (J.L.M., A.Y., Z.A., K.A.M., A.J.S.), Institute of Metabolism and Systems Research, College of Medical and Dental Sciences, University of Birmingham; Department of Neurology (J.L.M., A.Y., A.J.S.), University Hospitals Birmingham NHS Foundation Trust, Queen Elizabeth Hospital; Centre for Endocrinology (J.L.M., A.Y., A.A.T., A.J.S.), Diabetes and Metabolism, Birmingham Health Partners; Birmingham Clinical Trials Unit (R.S.O.); Institute of Metabolism and Systems Research (Z.A., D.M.C., A.A.T., A.J.S.), College of Medical and Dental Sciences, University of Birmingham, Birmingham, United Kingdom; Department of Neurology (S.J.H.), Royal Hallamshire Hospital, Sheffield, United Kingdom; Upper GI Unit and Minimally Invasive Unit (R.S.), Birmingham Heartlands Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham; Institute of Cancer and Genomic Sciences (R.S.), University of Birmingham; Department of Endocrinology (A.A.T.), University Hospitals Birmingham NHS Foundation Trust, Queen Elizabeth Hospital; Health Economics Unit (E.F.), Institute of Applied Health Research, University of Birmingham; and Cancer Research UK Clinical Trials Unit (K.B.), University of Birmingham, Birmingham, United Kingdom
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25
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Young AE, Staruch RMT, Dziewulski P. Why is priority setting important for global burn care research? Burns 2022; 48:1035-1039. [PMID: 35525771 DOI: 10.1016/j.burns.2022.04.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2022] [Accepted: 04/12/2022] [Indexed: 12/15/2022]
Abstract
The use of robust evidence is a key component of providing high quality care to patients. Synthesised evidence to support clinical decision-making is lacking for many aspects of clinical burn care. Identifying the most important areas of care that lack high quality evidence and requires research is necessary, as funding for primary research is limited. Priority setting research studies are a joint endeavour between patients, carers and clinicians to identify and rank topics for research in a healthcare area in order to reduce research waste. Such an exercise has yet to be undertaken in burns. The aim of this paper is to outline the importance of research prioritisation in burn care, to discuss how it facilitates the maximum benefit from limited research funding and to explain the methodologies used.
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Affiliation(s)
- A E Young
- Population Health Sciences, Bristol Medical School, University of Bristol, UK.
| | - R M T Staruch
- Department of Engineering Science, University of Oxford, Oxford, UK
| | - P Dziewulski
- St Andrews Centre for Burns & Plastic Surgery, Chelmsford, UK
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26
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Katirai A, Kogetsu A, Kato K, Yamamoto B. Patient involvement in priority-setting for medical research: A mini review of initiatives in the rare disease field. Front Public Health 2022; 10:915438. [PMID: 35928485 PMCID: PMC9343727 DOI: 10.3389/fpubh.2022.915438] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2022] [Accepted: 06/30/2022] [Indexed: 11/19/2022] Open
Abstract
Patient involvement (PI) in determining medical research priorities is an important way to ensure that limited research funds are allocated to best serve patients. As a disease area for which research funds are limited, we see a particular utility for PI in priority-setting for medical research on rare diseases. In this review, we argue that PI initiatives are an important form of evidence for policymaking. We conducted a study to identify the extent to which PI initiatives are being conducted in the rare disease field, the features of such initiatives, the trends in the priorities elicited, and the extent to which translation into policy is reported in the academic literature. Here, we report the results of this exploratory review of the English-language literature gathered through online databases and search engines, with the aim of identifying journal articles published prior to December 2020, describing PI initiatives focused on determining priorities for medical research funding in the rare disease field. We identified seven recently-published articles and found that the majority made use of structured methodologies to ensure the robustness of the evidence produced, but found little reported practical implementation or concrete plans for implementation of the results of the initiatives. We conclude that priority-setting initiatives are meaningful mechanisms for involving patients in determining research directions. However, we highlight the importance of translation into policy as a necessary next step to fully utilize the results and move beyond well-intentioned exercises. Finally, we draw attention to the benefits of involving patients throughout this process.
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Affiliation(s)
- Amelia Katirai
- Department of Kyosei Studies (Critical Studies in Coexistence, Symbiosis and Conviviality), Graduate School of Human Sciences, Osaka University, Suita, Japan
| | - Atsushi Kogetsu
- Department of Biomedical Ethics and Public Policy, Graduate School of Medicine, Osaka University, Suita, Japan
| | - Kazuto Kato
- Department of Biomedical Ethics and Public Policy, Graduate School of Medicine, Osaka University, Suita, Japan
| | - Beverley Yamamoto
- Department of Kyosei Studies (Critical Studies in Coexistence, Symbiosis and Conviviality), Graduate School of Human Sciences, Osaka University, Suita, Japan
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27
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Westgate CSJ, Israelsen IME, Jensen RH, Eftekhari S. Understanding the link between obesity and headache- with focus on migraine and idiopathic intracranial hypertension. J Headache Pain 2021; 22:123. [PMID: 34629054 PMCID: PMC8504002 DOI: 10.1186/s10194-021-01337-0] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2021] [Accepted: 09/26/2021] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Obesity confers adverse effects to every system in the body including the central nervous system. Obesity is associated with both migraine and idiopathic intracranial hypertension (IIH). The mechanisms underlying the association between obesity and these headache diseases remain unclear. METHODS We conducted a narrative review of the evidence in both humans and rodents, for the putative mechanisms underlying the link between obesity, migraine and IIH. RESULTS Truncal adiposity, a key feature of obesity, is associated with increased migraine morbidity and disability through increased headache severity, frequency and more severe cutaneous allodynia. Obesity may also increase intracranial pressure and could contribute to headache morbidity in migraine and be causative in IIH headache. Weight loss can improve both migraine and IIH headache. Preclinical research highlights that obesity increases the sensitivity of the trigeminovascular system to noxious stimuli including inflammatory stimuli, but the underlying molecular mechanisms remain unelucidated. CONCLUSIONS This review highlights that at the epidemiological and clinical level, obesity increases morbidity in migraine and IIH headache, where weight loss can improve headache morbidity. However, further research is required to understand the molecular underpinnings of obesity related headache in order to generate novel treatments.
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Affiliation(s)
- Connar Stanley James Westgate
- Danish Headache Center, Department of Neurology, Rigshospitalet- Glostrup, Glostrup Research Institute, University of Copenhagen, Nordstjernevej 42, 2600, Glostrup, Denmark
| | - Ida Marchen Egerod Israelsen
- Danish Headache Center, Department of Neurology, Rigshospitalet- Glostrup, Glostrup Research Institute, University of Copenhagen, Nordstjernevej 42, 2600, Glostrup, Denmark
| | - Rigmor Højland Jensen
- Danish Headache Center, Department of Neurology, Rigshospitalet- Glostrup, Glostrup Research Institute, University of Copenhagen, Nordstjernevej 42, 2600, Glostrup, Denmark
| | - Sajedeh Eftekhari
- Danish Headache Center, Department of Neurology, Rigshospitalet- Glostrup, Glostrup Research Institute, University of Copenhagen, Nordstjernevej 42, 2600, Glostrup, Denmark.
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28
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Mollan SP, Wakerley BR, Alimajstorovic Z, Mitchell J, Ottridge R, Yiangou A, Thaller M, Gupta A, Grech O, Lavery G, Brock K, Sinclair AJ. Intracranial pressure directly predicts headache morbidity in idiopathic intracranial hypertension. J Headache Pain 2021; 22:118. [PMID: 34620087 PMCID: PMC8499560 DOI: 10.1186/s10194-021-01321-8] [Citation(s) in RCA: 28] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2021] [Accepted: 09/01/2021] [Indexed: 01/03/2023] Open
Abstract
Objective Headache is the predominant disabler in idiopathic intracranial hypertension (IIH). The aim was to characterise headache and investigate the association with intracranial pressure. Methods IIH:WT was a randomised controlled parallel group multicentre trial in the United Kingdom investigating weight management methods in IIH. Participants with active IIH (evidenced by papilloedema) and a body mass index (BMI) ≥35 kg/m2 were recruited. At baseline, 12 months and 24 months headache characteristics and quality of life outcome measures were collected and lumbar puncture measurements were performed. Results Sixty-six women with active IIH were included with a mean age of 32.0 years (SD ± 7.8), and mean body mass index of 43.9 ± 7.0 kg/m2. The headache phenotype was migraine-like in 90%. Headache severity correlated with ICP at baseline (r = 0.285; p = 0.024); change in headache severity and monthly headache days correlated with change in ICP at 12 months (r = 0.454, p = 0.001 and r = 0.419, p = 0.002 respectively). Cutaneous allodynia was significantly correlated with ICP at 12 months. (r = 0.479, p < 0.001). Boot strap analysis noted a positive association between ICP at 12 and 24 months and enabled prediction of both change in headache severity and monthly headache days. ICP was associated with significant improvements in quality of life (SF-36). Conclusions We demonstrate a positive relationship between ICP and headache and cutaneous allodynia, which has not been previously reported in IIH. Those with the greatest reduction in ICP over 12 months had the greatest reduction in headache frequency and severity; this was associated with improvement of quality of life measures. Trial registration This work provides Class IIa evidence of the association of raised intracranial pressure and headache. ClinicalTrials.gov number, NCT02124486. Supplementary Information The online version contains supplementary material available at 10.1186/s10194-021-01321-8.
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Affiliation(s)
- S P Mollan
- Birmingham Neuro-Ophthalmology Unit, University Hospitals Birmingham, Birmingham, UK
| | - B R Wakerley
- University of Birmingham, Metabolic Neurology, Institute of Metabolism and Systems Research, Birmingham, UK.,Department of Neurology, University Hospitals Birmingham, Birmingham, UK
| | - Z Alimajstorovic
- University of Birmingham, Metabolic Neurology, Institute of Metabolism and Systems Research, Birmingham, UK
| | - J Mitchell
- University of Birmingham, Metabolic Neurology, Institute of Metabolism and Systems Research, Birmingham, UK.,Department of Neurology, University Hospitals Birmingham, Birmingham, UK
| | - R Ottridge
- University of Birmingham College of Medical and Dental Sciences, Birmingham, UK
| | - A Yiangou
- University of Birmingham, Metabolic Neurology, Institute of Metabolism and Systems Research, Birmingham, UK.,Department of Neurology, University Hospitals Birmingham, Birmingham, UK
| | - M Thaller
- University of Birmingham, Metabolic Neurology, Institute of Metabolism and Systems Research, Birmingham, UK.,Department of Neurology, University Hospitals Birmingham, Birmingham, UK
| | - A Gupta
- University of Birmingham College of Medical and Dental Sciences, Birmingham, UK
| | - O Grech
- University of Birmingham, Metabolic Neurology, Institute of Metabolism and Systems Research, Birmingham, UK
| | - G Lavery
- University of Birmingham, Metabolic Neurology, Institute of Metabolism and Systems Research, Birmingham, UK
| | - K Brock
- Birmingham Clinical Trials Unit, University of Birmingham, Birmingham, UK
| | - A J Sinclair
- University of Birmingham, Metabolic Neurology, Institute of Metabolism and Systems Research, Birmingham, UK. .,Department of Neurology, University Hospitals Birmingham, Birmingham, UK.
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29
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Jensen RH, Vukovic-Cvetkovic V, Korsbaek JJ, Wegener M, Hamann S, Beier D. Awareness, Diagnosis and Management of Idiopathic Intracranial Hypertension. Life (Basel) 2021; 11:718. [PMID: 34357090 PMCID: PMC8303648 DOI: 10.3390/life11070718] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2021] [Revised: 07/06/2021] [Accepted: 07/14/2021] [Indexed: 11/16/2022] Open
Abstract
The diagnosis and management of idiopathic intracranial hypertension (IIH) can be difficult and multiple medical subspecialities are often involved. Several national and international guidelines regarding the investigations and management of IIH have been published in recent years but still there is no consensus about the optimal organization of IIH-care. The objective of this review was to propose and describe a referral pathway and an organization scheme for diagnosis and management of IIH. An extensive search of existing literature was conducted and summarized. In total, 237 IIH-articles were identified and hereof 43 included. The clinical practice in our specialized IIH-clinic is characterized and described. We conclude that an educational campaign involving medical care providers and patients with chronic headaches is necessary. A detailed organizational proposal for a referral pathway and management of IIH patients based on the literature search and our clinical experience from a highly specialized IIH outpatient clinic is suggested and discussed.
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Affiliation(s)
- Rigmor Højland Jensen
- Danish Headache Center, Department of Neurology, Rigshospitalet, University of Copenhagen, 1165 København, Denmark; (V.V.-C.); (J.J.K.)
| | - Vlasta Vukovic-Cvetkovic
- Danish Headache Center, Department of Neurology, Rigshospitalet, University of Copenhagen, 1165 København, Denmark; (V.V.-C.); (J.J.K.)
| | - Johanne Juhl Korsbaek
- Danish Headache Center, Department of Neurology, Rigshospitalet, University of Copenhagen, 1165 København, Denmark; (V.V.-C.); (J.J.K.)
| | - Marianne Wegener
- Department of Ophthalmology, Rigshospitalet, University of Copenhagen, 1165 København, Denmark; (M.W.); (S.H.)
| | - Steffen Hamann
- Department of Ophthalmology, Rigshospitalet, University of Copenhagen, 1165 København, Denmark; (M.W.); (S.H.)
| | - Dagmar Beier
- Department of Neurology, Odense University Hospital, 5000 Odense, Denmark;
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Patient engagement in preclinical laboratory research: A scoping review. EBioMedicine 2021; 70:103484. [PMID: 34280783 PMCID: PMC8318845 DOI: 10.1016/j.ebiom.2021.103484] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2021] [Revised: 06/24/2021] [Accepted: 06/25/2021] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND 'Patient engagement' involves meaningful collaboration between researchers and 'patient partners' to co-create research. It helps ensure that research being conducted is relevant to its ultimate end-users. Although patient engagement within clinical research has been well documented, the prevalence and effects of patient engagement in translational preclinical laboratory research remain unclear. The aim of this scoping review is to present current patient engagement activities reported in preclinical laboratory research. METHODS MEDLINE, Embase, and grey literature were systematically searched from inception to April 2021. Studies that described or investigated patient engagement in preclinical laboratory research were included. Patient engagement activities where patients (i.e. patients, family members, caregivers or community members) provided input, or consultation on at least one element of the research process were eligible for inclusion. Study characteristics and outcomes were extracted and organized thematically. FINDINGS 32 reports were included (30 primary studies, 1 narrative review, and 1 researcher guide). Most studies engaged patients at the education or priority setting stages (n=26). The most frequently reported benefit of patient engagement was 'providing a mutual learning opportunity'. Reported barriers to patient engagement reflected concerns around 'differences in knowledge and research experience' and how this may challenge communication and limit meaningful collaboration. INTERPRETATION Patient engagement is feasible and beneficial for preclinical laboratory research. Future work should focus on assessing the impacts of patient engagement in this area of research.
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31
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Mollan SP, Grech O, Sinclair AJ. Headache attributed to idiopathic intracranial hypertension and persistent post-idiopathic intracranial hypertension headache: A narrative review. Headache 2021; 61:808-816. [PMID: 34106464 DOI: 10.1111/head.14125] [Citation(s) in RCA: 34] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2021] [Accepted: 04/12/2021] [Indexed: 01/01/2023]
Abstract
OBJECTIVE Headache is a near-universal sequela of idiopathic intracranial hypertension (IIH). The aim of this paper is to report current knowledge of headache in IIH and to identify therapeutic options. BACKGROUND Disability in IIH is predominantly driven by headache; thus, headache management is an urgent and unmet clinical need. At present, there is currently no scientific evidence for the directed use of abortive or preventative headache therapy. METHODS A detailed search of the scientific literature and narrative review was performed. RESULTS Headache in IIH is driven by raised intracranial pressure (ICP) and reduction of ICP has been reported in some studies to reduce headache. Despite resolution of papilledema and normalization of raised ICP, a majority suffer persistent post-IIH headache. The lack of evidence-based management approaches leaves many untreated. Where clinicians attempt to manage IIH headache, they use off-label therapies to target the prevailing headache phenotype. A recent prospective open-label study demonstrated the effective use of a calcitonin gene-related peptide monoclonal antibody therapy in IIH for persistent post-IIH headache. CONCLUSIONS There is overwhelming evidence of the headache burden in IIH. Studies are required to investigate the biological foundations of headache related to ICP and to develop treatments specifically directed to manage headache in IIH.
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Affiliation(s)
- Susan P Mollan
- Birmingham Neuro-Ophthalmology, Queen Elizabeth Hospital, Birmingham, UK
| | - Olivia Grech
- Metabolic Neurology, Institute of Metabolism and Systems Research, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK.,Centre for Endocrinology, Diabetes and Metabolism, Birmingham Health Partners, Birmingham, UK
| | - Alexandra J Sinclair
- Birmingham Neuro-Ophthalmology, Queen Elizabeth Hospital, Birmingham, UK.,Metabolic Neurology, Institute of Metabolism and Systems Research, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK.,Centre for Endocrinology, Diabetes and Metabolism, Birmingham Health Partners, Birmingham, UK.,Department of Neurology, University Hospitals Birmingham NHS Foundation Trust, Queen Elizabeth Hospital, Birmingham, UK
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32
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Mollan SP, Sinclair AJ. Outcomes measures in idiopathic intracranial hypertension. Expert Rev Neurother 2021; 21:687-700. [PMID: 34047224 DOI: 10.1080/14737175.2021.1931127] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Introduction: Idiopathic intracranial hypertension is a condition characterized by raised intracranial pressure, papilledema, and normal neuroimaging (aside from radiological signs of raised intracranial pressure). Symptoms of idiopathic intracranial hypertension include chronic headaches and for some, visual loss. New treatments are unmet clinical needs.Areas covered: The aim of this review is to present the evidence base and considered opinion on outcome measures to determine successful management of idiopathic intracranial hypertension.Expert opinion: Less invasive measures of disease activity such as optical coherence tomography will continue to grow in this field, both as a measure of papilledema, and potentially as a surrogate for intracranial pressure and visual function. As a highly disabling aspect of the disease is headache, treatment outcomes for headache morbidity need to be appropriately chosen and standardized to allow comparison between trials.
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Affiliation(s)
- Susan P Mollan
- Birmingham Neuro-Ophthalmology, Queen Elizabeth Hospital, Birmingham, United Kingdom (UK)
| | - Alexandra J Sinclair
- Birmingham Neuro-Ophthalmology, Queen Elizabeth Hospital, Birmingham, United Kingdom (UK).,Metabolic Neurology, Institute of Metabolism and Systems Research, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK.,Centre for Endocrinology, Diabetes and Metabolism, Birmingham Health Partners, Birmingham, UK.,Department of Neurology, University Hospitals Birmingham NHS Foundation Trust, Queen Elizabeth Hospital, Birmingham, UK
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33
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Mollan SP, Mitchell JL, Ottridge RS, Aguiar M, Yiangou A, Alimajstorovic Z, Cartwright DM, Grech O, Lavery GG, Westgate CSJ, Vijay V, Scotton W, Wakerley BR, Matthews TD, Ansons A, Hickman SJ, Benzimra J, Rick C, Singhal R, Tahrani AA, Brock K, Frew E, Sinclair AJ. Effectiveness of Bariatric Surgery vs Community Weight Management Intervention for the Treatment of Idiopathic Intracranial Hypertension: A Randomized Clinical Trial. JAMA Neurol 2021; 78:678-686. [PMID: 33900360 PMCID: PMC8077040 DOI: 10.1001/jamaneurol.2021.0659] [Citation(s) in RCA: 71] [Impact Index Per Article: 23.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Question Is bariatric surgery superior to a community weight management intervention in sustaining the weight loss necessary to achieve sustained remission among patients with idiopathic intracranial hypertension? Findings In this randomized clinical trial of 66 women with idiopathic intracranial hypertension and a body mass index of 35 or higher, bariatric surgery was superior to a community weight management intervention in decreasing intracranial pressure, with continued improvement at 2 years. Meaning The study’s findings indicate that, among women with idiopathic intracranial hypertension and a body mass index of 35 or higher, bariatric surgery is an effective treatment to reduce intracranial pressure and for sustained disease remission. Importance Idiopathic intracranial hypertension (IIH) causes headaches, vision loss, and reduced quality of life. Sustained weight loss among patients with IIH is necessary to modify the disease and prevent relapse. Objective To compare the effectiveness of bariatric surgery with that of a community weight management (CWM) intervention for the treatment of patients with active IIH. Design, Setting, and Participants This 5-year randomized clinical trial (Idiopathic Intracranial Hypertension Weight Trial) enrolled women with active IIH and a body mass index (calculated as weight in kilograms divided by height in meters squared) of 35 or higher at 5 National Health Service hospitals in the UK between March 1, 2014, and May 25, 2017. Of 74 women assessed for eligibility, 6 did not meet study criteria and 2 declined to participate; 66 women were randomized. Data were analyzed from November 1, 2018, to May 14, 2020. Interventions Bariatric surgery (n = 33) or CWM intervention (Weight Watchers) (n = 33). Main Outcomes and Measures The primary outcome was change in intracranial pressure measured by lumbar puncture opening pressure at 12 months, as assessed in an intention-to-treat analysis. Secondary outcomes included lumbar puncture opening pressure at 24 months as well as visual acuity, contrast sensitivity, perimetric mean deviation, and quality of life (measured by the 36-item Short Form Health Survey) at 12 and 24 months. Because the difference in continuous outcomes between groups is presented, the null effect was at 0. Results Of the 66 female participants (mean [SD] age, 32.0 [7.8] years), 64 (97.0%) remained in the clinical trial at 12 months and 54 women (81.8%) were included in the primary outcome analysis. Intracranial pressure was significantly lower in the bariatric surgery arm at 12 months (adjusted mean [SE] difference, −6.0 [1.8] cm cerebrospinal fluid [CSF]; 95% CI, −9.5 to −2.4 cm CSF; P = .001) and at 24 months (adjusted mean [SE] difference, −8.2 [2.0] cm CSF; 95% CI, −12.2 to −4.2 cm CSF; P < .001) compared with the CWM arm. In the per protocol analysis, intracranial pressure was significantly lower in the bariatric surgery arm at 12 months (adjusted mean [SE] difference, −7.2 [1.8] cm CSF; 95% CI, −10.6 to −3.7 cm CSF; P < .001) and at 24 months (adjusted mean [SE] difference, −8.7 [2.0] cm CSF; 95% CI, −12.7 to −4.8 cm CSF; P < .001). Weight was significantly lower in the bariatric surgery arm at 12 months (adjusted mean [SE] difference, −21.4 [5.4] kg; 95% CI, −32.1 to −10.7 kg; P < .001) and at 24 months (adjusted mean [SE] difference, −26.6 [5.6] kg; 95% CI, −37.5 to −15.7 kg; P < .001). Quality of life was significantly improved at 12 months (adjusted mean [SE] difference, 7.3 [3.6]; 95% CI, 0.2-14.4; P = .04) and 24 months (adjusted mean [SE] difference, 10.4 [3.8]; 95% CI, 3.0-17.9; P = .006) in the bariatric surgery arm. Conclusions and Relevance In this randomized clinical trial, bariatric surgery was superior to a CWM intervention in lowering intracranial pressure. The continued improvement over the course of 2 years shows the impact of this intervention with regard to sustained disease remission. Trial Registration ClinicalTrials.gov Identifier: NCT02124486
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Affiliation(s)
- Susan P Mollan
- Birmingham Neuro-Ophthalmology, University Hospitals Birmingham NHS Foundation Trust, Queen Elizabeth Hospital, Birmingham, United Kingdom
| | - James L Mitchell
- Department of Metabolic Neurology, Institute of Metabolism and Systems Research, College of Medical and Dental Sciences, University of Birmingham, Birmingham, United Kingdom.,Department of Neurology, University Hospitals Birmingham NHS Foundation Trust, Queen Elizabeth Hospital, Birmingham, United Kingdom
| | - Ryan S Ottridge
- Birmingham Clinical Trials Unit, College of Medical and Dental Sciences, University of Birmingham, Birmingham, United Kingdom
| | - Magda Aguiar
- Health Economics Unit, Institute of Applied Health Research, University of Birmingham, Birmingham, United Kingdom
| | - Andreas Yiangou
- Department of Metabolic Neurology, Institute of Metabolism and Systems Research, College of Medical and Dental Sciences, University of Birmingham, Birmingham, United Kingdom.,Department of Neurology, University Hospitals Birmingham NHS Foundation Trust, Queen Elizabeth Hospital, Birmingham, United Kingdom.,Centre for Endocrinology, Diabetes and Metabolism, Birmingham Health Partners, Birmingham, United Kingdom
| | - Zerin Alimajstorovic
- Department of Metabolic Neurology, Institute of Metabolism and Systems Research, College of Medical and Dental Sciences, University of Birmingham, Birmingham, United Kingdom.,Centre for Endocrinology, Diabetes and Metabolism, Birmingham Health Partners, Birmingham, United Kingdom.,Institute of Metabolism and Systems Research, College of Medical and Dental Sciences, University of Birmingham, Birmingham, United Kingdom
| | - David M Cartwright
- Centre for Endocrinology, Diabetes and Metabolism, Birmingham Health Partners, Birmingham, United Kingdom.,Institute of Metabolism and Systems Research, College of Medical and Dental Sciences, University of Birmingham, Birmingham, United Kingdom
| | - Olivia Grech
- Department of Metabolic Neurology, Institute of Metabolism and Systems Research, College of Medical and Dental Sciences, University of Birmingham, Birmingham, United Kingdom.,Centre for Endocrinology, Diabetes and Metabolism, Birmingham Health Partners, Birmingham, United Kingdom.,Institute of Metabolism and Systems Research, College of Medical and Dental Sciences, University of Birmingham, Birmingham, United Kingdom
| | - Gareth G Lavery
- Centre for Endocrinology, Diabetes and Metabolism, Birmingham Health Partners, Birmingham, United Kingdom.,Institute of Metabolism and Systems Research, College of Medical and Dental Sciences, University of Birmingham, Birmingham, United Kingdom
| | - Connar S J Westgate
- Department of Metabolic Neurology, Institute of Metabolism and Systems Research, College of Medical and Dental Sciences, University of Birmingham, Birmingham, United Kingdom
| | - Vivek Vijay
- Department of Metabolic Neurology, Institute of Metabolism and Systems Research, College of Medical and Dental Sciences, University of Birmingham, Birmingham, United Kingdom.,Department of Neurology, University Hospitals Birmingham NHS Foundation Trust, Queen Elizabeth Hospital, Birmingham, United Kingdom
| | - William Scotton
- Department of Neurology, University Hospitals Birmingham NHS Foundation Trust, Queen Elizabeth Hospital, Birmingham, United Kingdom
| | - Ben R Wakerley
- Department of Neurology, Gloucestershire Hospitals NHS Foundation Trust, Gloucester, United Kingdom
| | - Tim D Matthews
- Birmingham Neuro-Ophthalmology, University Hospitals Birmingham NHS Foundation Trust, Queen Elizabeth Hospital, Birmingham, United Kingdom
| | - Alec Ansons
- Manchester University NHS Foundation Trust, Manchester Royal Eye Hospital, Manchester, United Kingdom
| | - Simon J Hickman
- Department of Neurology, Royal Hallamshire Hospital, Sheffield, United Kingdom
| | - James Benzimra
- Department of Ophthalmology, Royal Devon and Exeter NHS Foundation Trust, Exeter, United Kingdom
| | - Caroline Rick
- Nottingham Clinical Trials Unit, University of Nottingham, University Park, Nottingham, United Kingdom
| | - Rishi Singhal
- Upper GI Unit and Minimally Invasive Unit, Birmingham Heartlands Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham, United Kingdom.,Institute of Cancer and Genomic Sciences, University of Birmingham, Birmingham, United Kingdom
| | - Abd A Tahrani
- Centre for Endocrinology, Diabetes and Metabolism, Birmingham Health Partners, Birmingham, United Kingdom.,Institute of Metabolism and Systems Research, College of Medical and Dental Sciences, University of Birmingham, Birmingham, United Kingdom.,Department of Endocrinology, University Hospitals Birmingham NHS Foundation Trust, Queen Elizabeth Hospital, Birmingham, United Kingdom
| | - Kristian Brock
- Cancer Research UK Clinical Trials Unit, University of Birmingham, Birmingham, United Kingdom
| | - Emma Frew
- Health Economics Unit, Institute of Applied Health Research, University of Birmingham, Birmingham, United Kingdom
| | - Alexandra J Sinclair
- Department of Metabolic Neurology, Institute of Metabolism and Systems Research, College of Medical and Dental Sciences, University of Birmingham, Birmingham, United Kingdom.,Department of Neurology, University Hospitals Birmingham NHS Foundation Trust, Queen Elizabeth Hospital, Birmingham, United Kingdom.,Centre for Endocrinology, Diabetes and Metabolism, Birmingham Health Partners, Birmingham, United Kingdom
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34
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Westgate CS, Botfield HF, Alimajstorovic Z, Yiangou A, Walsh M, Smith G, Singhal R, Mitchell JL, Grech O, Markey KA, Hebenstreit D, Tennant DA, Tomlinson JW, Mollan SP, Ludwig C, Akerman I, Lavery GG, Sinclair AJ. Systemic and adipocyte transcriptional and metabolic dysregulation in idiopathic intracranial hypertension. JCI Insight 2021; 6:145346. [PMID: 33848268 PMCID: PMC8262372 DOI: 10.1172/jci.insight.145346] [Citation(s) in RCA: 34] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2020] [Accepted: 04/07/2021] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Idiopathic intracranial hypertension (IIH) is a condition predominantly affecting obese women of reproductive age. Recent evidence suggests that IIH is a disease of metabolic dysregulation, androgen excess, and an increased risk of cardiovascular morbidity. Here we evaluate systemic and adipose specific metabolic determinants of the IIH phenotype. METHODS In fasted, matched IIH (n = 97) and control (n = 43) patients, we assessed glucose and insulin homeostasis and leptin levels. Body composition was assessed along with an interrogation of adipose tissue function via nuclear magnetic resonance metabolomics and RNA sequencing in paired omental and subcutaneous biopsies in a case-control study. RESULTS We demonstrate an insulin- and leptin-resistant phenotype in IIH in excess of that driven by obesity. Adiposity in IIH is preferentially centripetal and is associated with increased disease activity and insulin resistance. IIH adipocytes appear transcriptionally and metabolically primed toward depot-specific lipogenesis. CONCLUSION These data show that IIH is a metabolic disorder in which adipose tissue dysfunction is a feature of the disease. Managing IIH as a metabolic disease could reduce disease morbidity and improve cardiovascular outcomes. FUNDING This study was supported by the UK NIHR (NIHR-CS-011-028), the UK Medical Research Council (MR/K015184/1), Diabetes UK, Wellcome Trust (104612/Z/14/Z), the Sir Jules Thorn Award, and the Midlands Neuroscience Teaching and Research Fund.
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Affiliation(s)
- Connar Sj Westgate
- Institute of Metabolism and Systems Research, College of Medical and Dental Sciences, University of Birmingham, Birmingham, United Kingdom.,Centre for Endocrinology, Diabetes and Metabolism, Birmingham Health Partners, Birmingham, United Kingdom
| | - Hannah F Botfield
- Institute of Inflammation and Ageing, College of Medical and Dental Sciences, University of Birmingham, Birmingham, United Kingdom
| | - Zerin Alimajstorovic
- Institute of Metabolism and Systems Research, College of Medical and Dental Sciences, University of Birmingham, Birmingham, United Kingdom.,Centre for Endocrinology, Diabetes and Metabolism, Birmingham Health Partners, Birmingham, United Kingdom
| | - Andreas Yiangou
- Institute of Metabolism and Systems Research, College of Medical and Dental Sciences, University of Birmingham, Birmingham, United Kingdom.,Department of Neurology, University Hospitals Birmingham National Health Service (NHS) Foundation Trust, Queen Elizabeth Hospital, Birmingham, United Kingdom
| | - Mark Walsh
- School of Life Sciences, University of Warwick, Coventry, United Kingdom
| | - Gabrielle Smith
- Institute of Metabolism and Systems Research, College of Medical and Dental Sciences, University of Birmingham, Birmingham, United Kingdom.,Centre for Endocrinology, Diabetes and Metabolism, Birmingham Health Partners, Birmingham, United Kingdom
| | - Rishi Singhal
- Upper GI Unit and Minimally Invasive Unit, Heartlands Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham United Kingdom
| | - James L Mitchell
- Institute of Metabolism and Systems Research, College of Medical and Dental Sciences, University of Birmingham, Birmingham, United Kingdom.,Centre for Endocrinology, Diabetes and Metabolism, Birmingham Health Partners, Birmingham, United Kingdom
| | - Olivia Grech
- Institute of Metabolism and Systems Research, College of Medical and Dental Sciences, University of Birmingham, Birmingham, United Kingdom.,Centre for Endocrinology, Diabetes and Metabolism, Birmingham Health Partners, Birmingham, United Kingdom
| | - Keira A Markey
- Institute of Metabolism and Systems Research, College of Medical and Dental Sciences, University of Birmingham, Birmingham, United Kingdom.,Department of Neurology, University Hospitals Birmingham National Health Service (NHS) Foundation Trust, Queen Elizabeth Hospital, Birmingham, United Kingdom
| | - Daniel Hebenstreit
- School of Life Sciences, University of Warwick, Coventry, United Kingdom
| | - Daniel A Tennant
- Institute of Metabolism and Systems Research, College of Medical and Dental Sciences, University of Birmingham, Birmingham, United Kingdom
| | - Jeremy W Tomlinson
- Oxford Centre for Diabetes, Endocrinology & Metabolism, National Institute for Health Research (NIHR) Oxford Biomedical Research Centre, University of Oxford, Churchill Hospital, Headington, Oxford, United Kingdom
| | - Susan P Mollan
- Birmingham Neuro-Ophthalmology, Ophthalmology Department, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham, United Kingdom
| | - Christian Ludwig
- Institute of Metabolism and Systems Research, College of Medical and Dental Sciences, University of Birmingham, Birmingham, United Kingdom.,Centre for Endocrinology, Diabetes and Metabolism, Birmingham Health Partners, Birmingham, United Kingdom
| | - Ildem Akerman
- Institute of Metabolism and Systems Research, College of Medical and Dental Sciences, University of Birmingham, Birmingham, United Kingdom.,Centre for Endocrinology, Diabetes and Metabolism, Birmingham Health Partners, Birmingham, United Kingdom
| | - Gareth G Lavery
- Institute of Metabolism and Systems Research, College of Medical and Dental Sciences, University of Birmingham, Birmingham, United Kingdom.,Centre for Endocrinology, Diabetes and Metabolism, Birmingham Health Partners, Birmingham, United Kingdom
| | - Alexandra J Sinclair
- Institute of Metabolism and Systems Research, College of Medical and Dental Sciences, University of Birmingham, Birmingham, United Kingdom.,Centre for Endocrinology, Diabetes and Metabolism, Birmingham Health Partners, Birmingham, United Kingdom.,Department of Neurology, University Hospitals Birmingham National Health Service (NHS) Foundation Trust, Queen Elizabeth Hospital, Birmingham, United Kingdom
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35
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Mollan SP, Chong YJ, Grech O, Sinclair AJ, Wakerley BR. Current Perspectives on Idiopathic Intracranial Hypertension without Papilloedema. Life (Basel) 2021; 11:472. [PMID: 34073844 PMCID: PMC8225003 DOI: 10.3390/life11060472] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2021] [Revised: 05/16/2021] [Accepted: 05/18/2021] [Indexed: 02/07/2023] Open
Abstract
The pseudotumor cerebri syndrome embraces disorders characterised by raised intracranial pressure, where the commonest symptom is headache (90%). Idiopathic intracranial hypertension without papilloedema (IIHWOP) is increasingly recognised as a source of refractory headache symptoms and resultant neurological disability. Although the majority of patients with IIHWOP are phenotypically similar to those with idiopathic intracranial hypertension (IIH), it remains uncertain as to whether IIHWOP is nosologically distinct from IIH. The incidence, prevalence, and the degree of association with the world-wide obesity epidemic is unknown. Establishing a diagnosis of IIHWOP can be challenging, as often lumbar puncture is not routinely part of the work-up for refractory headaches. There are published diagnostic criteria for IIHWOP; however, some report uncertainty regarding a pathologically acceptable cut off for a raised lumbar puncture opening pressure, which is a key criterion. The literature provides little information to help guide clinicians in managing patients with IIHWOP. Further research is therefore needed to better understand the mechanisms that drive the development of chronic daily headaches and a relationship to intracranial pressure; and indeed, whether such patients would benefit from therapies to lower intracranial pressure. The aim of this narrative review was to perform a detailed search of the scientific literature and provide a summary of historic and current opinion regarding IIHWOP.
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Affiliation(s)
- Susan P. Mollan
- Birmingham Neuro-Ophthalmology Unit, University Hospitals Birmingham NHS Foundation Trust, Birmingham B15 2TH, UK;
| | - Yu Jeat Chong
- Birmingham Neuro-Ophthalmology Unit, University Hospitals Birmingham NHS Foundation Trust, Birmingham B15 2TH, UK;
| | - Olivia Grech
- Metabolic Neurology, Institute of Metabolism and Systems Research, University of Birmingham, Edgbaston B15 2TT, UK; (O.G.); (A.J.S.); (B.R.W.)
- Centre for Endocrinology, Diabetes and Metabolism, Birmingham Health Partners, Birmingham B15 2TH, UK
| | - Alex J. Sinclair
- Metabolic Neurology, Institute of Metabolism and Systems Research, University of Birmingham, Edgbaston B15 2TT, UK; (O.G.); (A.J.S.); (B.R.W.)
- Centre for Endocrinology, Diabetes and Metabolism, Birmingham Health Partners, Birmingham B15 2TH, UK
- Department of Neurology, University Hospitals Birmingham NHS Foundation Trust, Birmingham B15 2TH, UK
| | - Benjamin R. Wakerley
- Metabolic Neurology, Institute of Metabolism and Systems Research, University of Birmingham, Edgbaston B15 2TT, UK; (O.G.); (A.J.S.); (B.R.W.)
- Centre for Endocrinology, Diabetes and Metabolism, Birmingham Health Partners, Birmingham B15 2TH, UK
- Department of Neurology, University Hospitals Birmingham NHS Foundation Trust, Birmingham B15 2TH, UK
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36
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Mollan SP, Mytton J, Tsermoulas G, Sinclair AJ. Idiopathic Intracranial Hypertension: Evaluation of Admissions and Emergency Readmissions through the Hospital Episode Statistic Dataset between 2002-2020. Life (Basel) 2021; 11:417. [PMID: 34063037 PMCID: PMC8148005 DOI: 10.3390/life11050417] [Citation(s) in RCA: 28] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2021] [Revised: 04/25/2021] [Accepted: 04/30/2021] [Indexed: 12/20/2022] Open
Abstract
With increasing incidence and prevalence of Idiopathic intracranial hypertension in the UK, the aim of this study was to explore emerging themes in Idiopathic intracranial hypertension using the Hospital Episode Statistics dataset and to quantify recent change in hospital admissions and surgeries performed within England. METHODS Hospital Episode Statistics national data was extracted between 1 April 2002 and 31 March 2019, and followed up until 31 March 2020. All those within England with a diagnosis of Idiopathic Intracranial Hypertension were included. Those with secondary causes of raised intracranial pressure such as tumors, hydrocephalus and cerebral venous sinus thrombosis were excluded. RESULTS 28,794 new IIH cases were diagnosed between 1 January 2002 and 31 December 2019. Incidence rose between 2002 to 2019 from 1.8 to 5.2 per 100,000 in the general population. Peak incidence occurred in females aged 25-29 years. Neurosurgical shunt was the commonest procedure performed (6.4%), followed by neovascular venous sinus stenting (1%), bariatric surgery (0.8%) and optic nerve sheath fenestration (0.5%). The portion of the total IIH population requiring a shunt fell from 10.8% in 2002/2003 to 2.46% in 2018/2019. The portion of the total IIH population requiring shunt revision also reduced over time from 4.84% in 2002/2003 to 0.44% in 2018/2019. The mean 30 days emergency readmissions for primary shunt, revision of shunt, bariatric surgery, neurovascular stent, and optic nerve sheath fenestration was 23.1%, 23.7%, 10.6%, 10.0% and 9.74%, respectively. There was a peak 30 days readmission rate following primary shunt in 2018/2019 of 41%. Recording of severe visual impairment fell to an all-time low of 1.38% in 2018/19. CONCLUSIONS Increased awareness of the condition, specialist surgery and expert guidance may be changing admissions and surgical trends in IIH. The high 30 readmission following primary shunt surgery for IIH requires further investigation.
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Affiliation(s)
- Susan P. Mollan
- Birmingham Neuro-Ophthalmology, University Hospitals Birmingham NHS Foundation Trust, Birmingham B15 2TH, UK
| | - Jemma Mytton
- Health Informatics, University Hospitals Birmingham NHS Foundation Trust, Birmingham B15 2TH, UK;
| | - Georgios Tsermoulas
- Department of Neurosurgery, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham B15 2TH, UK;
- Institute of Metabolism and Systems Research, University of Birmingham, Edgbaston, Birmingham B15 2TT, UK
| | - Alex J. Sinclair
- Metabolic Neurology, Institute of Metabolism and Systems Research, University of Birmingham, Edgbaston B15 2TT, UK;
- Centre for Endocrinology, Diabetes and Metabolism, Birmingham Health Partners, Birmingham B15 2TH, UK
- Department of Neurology, University Hospitals Birmingham NHS Foundation Trust, Birmingham B15 2TH, UK
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37
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Aguiar M, Frew E, Mollan SP, Mitchell JL, Ottridge RS, Alimajstorovic Z, Yiangou A, Singhal R, Tahrani AA, Sinclair AJ. The Health Economic Evaluation of Bariatric Surgery Versus a Community Weight Management Intervention Analysis from the Idiopathic Intracranial Hypertension Weight Trial (IIH:WT). Life (Basel) 2021; 11:409. [PMID: 33946177 PMCID: PMC8146846 DOI: 10.3390/life11050409] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2021] [Revised: 04/26/2021] [Accepted: 04/27/2021] [Indexed: 01/10/2023] Open
Abstract
BACKGROUND The Idiopathic Intracranial Hypertension Weight Trial (IIH:WT) established the efficacy of bariatric surgery as compared to a community weight management intervention in reducing intracranial pressure in active IIH. The aim of this cost-effectiveness analysis was to evaluate the economic impact of these weight loss treatments for IIH. METHODS IIH:WT was a five-year randomised, controlled, parallel group, multicentre trial in the United Kingdom, where participants with active IIH and a body mass index ≥35 kg/m2 were randomly assigned (1:1) to receive access to bariatric surgery or a community weight management intervention. All clinical and quality of life data was recorded at baseline, 12 and 24 months. Economic evaluation was performed to assess health-care costs and cost-effectiveness. Evaluations were established on an intention to treat principle, followed by a sensitivity analysis using a per protocol analysis. RESULTS The mean total health care costs were GBP 1353 for the community weight management arm and GBP 5400 for the bariatric surgery arm over 24 months. The majority of costs for the bariatric surgery arm relate to the surgical procedure itself. The 85% who underwent bariatric surgery achieved a 12.5% reduction in intracranial pressure at 24 months as compared to 39% in the community weight management arm; a mean difference of 45% in favour of bariatric surgery. The cost effectiveness of bariatric surgery improved over time. CONCLUSIONS The IIH:WT was the first to compare the efficacy and cost-effectiveness of bariatric surgery with community weight management interventions in the setting of a randomised control trial. The cost-effectiveness of bariatric surgery improved over time and therefore the incremental cost of surgery when offset against the incremental reduction of intracranial pressure improved after 24 months, as compared with 12 months follow up.
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Affiliation(s)
- Magda Aguiar
- Health Economics Unit, Institute of Applied Health Research, University of Birmingham, Birmingham B12 2TT, UK; (M.A.); (E.F.)
| | - Emma Frew
- Health Economics Unit, Institute of Applied Health Research, University of Birmingham, Birmingham B12 2TT, UK; (M.A.); (E.F.)
| | - Susan P. Mollan
- Birmingham Neuro-Ophthalmology, University Hospitals Birmingham NHS Foundation Trust, Queen Elizabeth Hospital, Birmingham B15 2WB, UK
| | - James L. Mitchell
- Institute of Metabolism and Systems Research, College of Medical and Dental Sciences, University of Birmingham, Birmingham B15 2TT, UK; (J.L.M.); (Z.A.); (A.Y.); (A.A.T.); (A.J.S.)
- Department of Neurology, University Hospitals Birmingham NHS Foundation Trust, Queen Elizabeth Hospital, Birmingham B15 2WB, UK
| | - Ryan S. Ottridge
- Birmingham Clinical Trials Unit, College of Medical and Dental Sciences, University of Birmingham, Birmingham B15 2TT, UK;
| | - Zerin Alimajstorovic
- Institute of Metabolism and Systems Research, College of Medical and Dental Sciences, University of Birmingham, Birmingham B15 2TT, UK; (J.L.M.); (Z.A.); (A.Y.); (A.A.T.); (A.J.S.)
- Upper GI Unit and Minimally Invasive Unit, Birmingham Heartlands Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham B9 5SS, UK;
| | - Andreas Yiangou
- Institute of Metabolism and Systems Research, College of Medical and Dental Sciences, University of Birmingham, Birmingham B15 2TT, UK; (J.L.M.); (Z.A.); (A.Y.); (A.A.T.); (A.J.S.)
- Department of Neurology, University Hospitals Birmingham NHS Foundation Trust, Queen Elizabeth Hospital, Birmingham B15 2WB, UK
| | - Rishi Singhal
- Upper GI Unit and Minimally Invasive Unit, Birmingham Heartlands Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham B9 5SS, UK;
- Institute of Cancer and Genomic Sciences, College of Medical and Dental Sciences, University of Birmingham, Birmingham B15 2TT, UK
| | - Abd A. Tahrani
- Institute of Metabolism and Systems Research, College of Medical and Dental Sciences, University of Birmingham, Birmingham B15 2TT, UK; (J.L.M.); (Z.A.); (A.Y.); (A.A.T.); (A.J.S.)
- Centre for Endocrinology, Diabetes and Metabolism, Birmingham Health Partners, Birmingham B15 2GW, UK
- Department of Endocrinology, University Hospitals Birmingham NHS Foundation Trust, Queen Elizabeth Hospital, Birmingham B15 2WB, UK
| | - Alex J. Sinclair
- Institute of Metabolism and Systems Research, College of Medical and Dental Sciences, University of Birmingham, Birmingham B15 2TT, UK; (J.L.M.); (Z.A.); (A.Y.); (A.A.T.); (A.J.S.)
- Department of Neurology, University Hospitals Birmingham NHS Foundation Trust, Queen Elizabeth Hospital, Birmingham B15 2WB, UK
- Centre for Endocrinology, Diabetes and Metabolism, Birmingham Health Partners, Birmingham B15 2GW, UK
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38
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Mollan SP, Tahrani AA, Sinclair AJ. The Potentially Modifiable Risk Factor in Idiopathic Intracranial Hypertension: Body Weight. Neurol Clin Pract 2021; 11:e504-e507. [PMID: 34484948 DOI: 10.1212/cpj.0000000000001063] [Citation(s) in RCA: 30] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2020] [Accepted: 01/06/2021] [Indexed: 01/07/2023]
Abstract
Purpose of Review Idiopathic intracranial hypertension (IIH) prevalence increased in conjunction with rising obesity rates. Here, we highlight the importance of weight management in IIH and introduce glucagon-like peptide 1 (GLP-1) receptor agonists (RAs) as potential treatment strategy for IIH. Recent Findings Weight gain is a risk factor for IIH, and weight loss (via any treatment strategy) plays a key role in IIH management. GLP-1 is an incretin secreted by the distal small intestine in response to a meal. GLP-1 RAs have been shown to improve glycaemic control (no hypoglycaemia) and lower body weight in patients with and without type 2 diabetes. The choroid plexus has been found to express GLP-1 receptors, and treatment with a GLP-1 RA significantly reduces CSF secretion in vitro and intracranial pressure (ICP) in rodents. Summary New research evaluating the pathophysiology of IIH supports GLP-1 RA as a potential treatment for IIH via weight loss dependent and independent mechanism to directly reduce ICP.
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Affiliation(s)
- Susan P Mollan
- Birmingham Neuro-Ophthalmology (SPM), Queen Elizabeth Hospital; Institute of Metabolism and Systems Research (AAT), College of Medical and Dental Sciences, University of Birmingham; Department of Diabetes and Endocrinology (AAT), Queen Elizabeth Hospital, Birmingham; Metabolic Neurology (AJS), Institute of Metabolism and Systems Research, College of Medical and Dental Sciences, University of Birmingham; and Department of Neurology (AJS), University Hospitals Birmingham NHS Foundation Trust, Queen Elizabeth Hospital, United Kingdom
| | - Abd A Tahrani
- Birmingham Neuro-Ophthalmology (SPM), Queen Elizabeth Hospital; Institute of Metabolism and Systems Research (AAT), College of Medical and Dental Sciences, University of Birmingham; Department of Diabetes and Endocrinology (AAT), Queen Elizabeth Hospital, Birmingham; Metabolic Neurology (AJS), Institute of Metabolism and Systems Research, College of Medical and Dental Sciences, University of Birmingham; and Department of Neurology (AJS), University Hospitals Birmingham NHS Foundation Trust, Queen Elizabeth Hospital, United Kingdom
| | - Alexandra J Sinclair
- Birmingham Neuro-Ophthalmology (SPM), Queen Elizabeth Hospital; Institute of Metabolism and Systems Research (AAT), College of Medical and Dental Sciences, University of Birmingham; Department of Diabetes and Endocrinology (AAT), Queen Elizabeth Hospital, Birmingham; Metabolic Neurology (AJS), Institute of Metabolism and Systems Research, College of Medical and Dental Sciences, University of Birmingham; and Department of Neurology (AJS), University Hospitals Birmingham NHS Foundation Trust, Queen Elizabeth Hospital, United Kingdom
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Mitchell JL, Mollan SP, Tsermoulas G, Sinclair AJ. Telemetric monitoring in idiopathic intracranial hypertension demonstrates intracranial pressure in a case with sight-threatening disease. Acta Neurochir (Wien) 2021; 163:725-731. [PMID: 33411042 DOI: 10.1007/s00701-020-04640-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2020] [Accepted: 11/03/2020] [Indexed: 10/22/2022]
Abstract
The understanding of raised intracranial pressure (ICP) is increasing with the directed use of intracranial telemetric ICP monitors. This case uniquely observed ICP changes by telemetric monitoring in a patient with idiopathic intracranial hypertension (IIH), who developed rapid sight-threatening disease. A lumbar drain was inserted, as a temporising measure, and was clamped prior to surgery. This resulted in a rapid rise in ICP, which normalised after insertion of a ventriculoperitoneal shunt. This case highlighted the utility of the ICP monitor and the lumbar drain as a temporising measure to control ICP prior to a definitive procedure as recommended by the IIH consensus guidelines.
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Affiliation(s)
- James L Mitchell
- Metabolic Neurology, Institute, of Metabolism and Systems Research, University of Birmingham, Birmingham, UK
- Department of Neurology, University Hospitals Birmingham, Queen Elizabeth Hospital, Birmingham, UK
| | - Susan P Mollan
- Birmingham Neuro-Ophthalmology, Queen Elizabeth Hospital, Birmingham, UK.
| | - Georgios Tsermoulas
- Department of Neurosurgery, University Hospitals Birmingham, Queen Elizabeth Hospital, Birmingham, UK
| | - Alex J Sinclair
- Metabolic Neurology, Institute, of Metabolism and Systems Research, University of Birmingham, Birmingham, UK
- Department of Neurology, University Hospitals Birmingham, Queen Elizabeth Hospital, Birmingham, UK
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40
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Mollan SP, Grech O, Alimajstorovic Z, Wakerley BR, Sinclair AJ. New horizons for idiopathic intracranial hypertension: advances and challenges. Br Med Bull 2020; 136:118-126. [PMID: 33200788 DOI: 10.1093/bmb/ldaa034] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/28/2020] [Indexed: 02/05/2023]
Abstract
INTRODUCTION Idiopathic intracranial hypertension (IIH) is becoming a recognized condition due to the increasing incidence linked to a global obesity epidemic. SOURCES OF DATA All English papers on PubMed, Cochrane and Scholar between inception until 1 March 2020 were considered. AREAS OF AGREEMENT Studies suggest central adiposity has a pathogenic role. Recent weight gain is a risk factor and weight loss has a key role in management. AREAS OF CONTROVERSY Interpretation of abnormal lumbar puncture opening pressure is debated. There is an increasing recognition of obesity stigma and how this should be approached. GROWING POINTS Further evidence is required for the choice of surgical intervention for fulminant IIH. Education regarding IIH should be evidence based. AREAS TIMELY FOR DEVELOPING RESEARCH Novel research of the pathology of IIH is influencing development of therapies such as glucagon-like peptide-1 receptor agonists and targeting unique androgen signatures. The newly discovered cardiovascular risk requires further attention.
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Affiliation(s)
- Susan P Mollan
- Birmingham Neuro-Ophthalmology, Queen Elizabeth Hospital, Birmingham, UK
| | - Olivia Grech
- Metabolic Neurology, Institute of Metabolism and Systems Research, College of Medical and Dental Sciences, University of Birmingham, Birmingham B15 2TT, UK.,Centre for Endocrinology, Diabetes and Metabolism, Birmingham Health Partners, Birmingham B15 2TH, UK
| | - Zerin Alimajstorovic
- Metabolic Neurology, Institute of Metabolism and Systems Research, College of Medical and Dental Sciences, University of Birmingham, Birmingham B15 2TT, UK.,Centre for Endocrinology, Diabetes and Metabolism, Birmingham Health Partners, Birmingham B15 2TH, UK
| | | | - Alexandra J Sinclair
- Metabolic Neurology, Institute of Metabolism and Systems Research, College of Medical and Dental Sciences, University of Birmingham, Birmingham B15 2TT, UK.,Centre for Endocrinology, Diabetes and Metabolism, Birmingham Health Partners, Birmingham B15 2TH, UK.,Department of Neurology, University Hospitals Birmingham NHS Foundation Trust, Queen Elizabeth Hospital, Birmingham B15 2WB, UK
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Yiangou A, Mitchell JL, Fisher C, Edwards J, Vijay V, Alimajstorovic Z, Grech O, Lavery GG, Mollan SP, Sinclair AJ. Erenumab for headaches in idiopathic intracranial hypertension: A prospective open-label evaluation. Headache 2020; 61:157-169. [PMID: 33316102 PMCID: PMC7898289 DOI: 10.1111/head.14026] [Citation(s) in RCA: 31] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2020] [Revised: 10/14/2020] [Accepted: 10/15/2020] [Indexed: 12/21/2022]
Abstract
Objective To determine the effectiveness of erenumab in treating headaches in idiopathic intracranial hypertension (IIH) in whom papilledema had resolved. Background Disability in IIH is predominantly driven by debilitating headaches with no evidence for the use of preventative therapies. Headache therapy in IIH is an urgent unmet need. Methods A prospective, open‐label study in the United Kingdom was conducted. Adult females with confirmed diagnosis of IIH now in ocular remission (papilledema resolved) with chronic headaches (≥15 days a month) and failure of ≥3 preventative medications received erenumab 4‐weekly (assessments were 3‐monthly). The primary end point was change in monthly moderate/severe headache days (MmsHD) from baseline (30‐day pretreatment period) compared to 12 months. Results Fifty‐five patients, mean (SD) age 35.3 (9) years and mean duration of headaches 10.4 (8.4) years with 3.7 (0.9) preventative treatment failures, were enrolled. Mean baseline MmsHD was 16.1 (4.7) and total monthly headache days (MHD) was (29) 2.3. MmsHD reduced substantially at 12 months by mean (SD) [95% CI] 10.8 (4.0) [9.5, 11.9], p < 0.001 and MHD reduced by 13.0 (9.5) [10.2, 15.7], p < 0.001. Crystal clear days (days without any head pain) increased by 13.1 (9.5) [9.6, 15.3], p < 0.001, headache severity (scale 0–10) fell by 1.3 (1.7) [0.9, 1.9], p < 0.001, and monthly analgesic days reduced by 4.3 (9.2) [1.6, 6.9], p = 0.002. All these measures had improved significantly by 3 months, with a consistent significant response to 12 months. Headache impact test‐6 score and quality of life Short Form‐36 Health Survey significantly improved at 12 months. Sensitivity analysis revealed similar results for patients with and without a prior migraine diagnosis (28/55 (52%) patients) or those with or without medication overuse (27/55 (48%) patients). Conclusions This study provides evidence for the effectiveness of erenumab to treat headaches in IIH patients with resolution of papilledema. It provides mechanistic insights suggesting that calcitonin gene‐related peptide is likely a modulator driving headache and a useful therapeutic target.
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Affiliation(s)
- Andreas Yiangou
- Metabolic Neurology, Institute of Metabolism and Systems Research, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK.,Centre for Endocrinology, Diabetes and Metabolism, Birmingham Health Partners, Birmingham, UK.,Department of Neurology, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - James L Mitchell
- Metabolic Neurology, Institute of Metabolism and Systems Research, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK.,Centre for Endocrinology, Diabetes and Metabolism, Birmingham Health Partners, Birmingham, UK.,Department of Neurology, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Claire Fisher
- Department of Neurology, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Julie Edwards
- Department of Neurology, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Vivek Vijay
- Metabolic Neurology, Institute of Metabolism and Systems Research, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK.,Centre for Endocrinology, Diabetes and Metabolism, Birmingham Health Partners, Birmingham, UK.,Department of Neurology, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Zerin Alimajstorovic
- Metabolic Neurology, Institute of Metabolism and Systems Research, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK.,Centre for Endocrinology, Diabetes and Metabolism, Birmingham Health Partners, Birmingham, UK
| | - Olivia Grech
- Metabolic Neurology, Institute of Metabolism and Systems Research, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK.,Centre for Endocrinology, Diabetes and Metabolism, Birmingham Health Partners, Birmingham, UK
| | - Gareth G Lavery
- Metabolic Neurology, Institute of Metabolism and Systems Research, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK.,Centre for Endocrinology, Diabetes and Metabolism, Birmingham Health Partners, Birmingham, UK
| | - Susan P Mollan
- Birmingham Neuro-Ophthalmology Unit, Ophthalmology Department, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Alexandra J Sinclair
- Metabolic Neurology, Institute of Metabolism and Systems Research, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK.,Centre for Endocrinology, Diabetes and Metabolism, Birmingham Health Partners, Birmingham, UK.,Department of Neurology, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
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42
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Grech O, Mollan SP, Wakerley BR, Alimajstorovic Z, Lavery GG, Sinclair AJ. Emerging themes in idiopathic intracranial hypertension. J Neurol 2020; 267:3776-3784. [PMID: 32700012 PMCID: PMC7674362 DOI: 10.1007/s00415-020-10090-4] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2020] [Revised: 07/14/2020] [Accepted: 07/15/2020] [Indexed: 02/07/2023]
Abstract
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.
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Affiliation(s)
- Olivia Grech
- Metabolic Neurology, Institute of Metabolism and Systems Research, College of Medical and Dental Sciences, University of Birmingham, Birmingham, B15 2TT UK
- Centre for Endocrinology, Diabetes and Metabolism, Birmingham Health Partners, Birmingham, B15 2TH UK
| | - Susan P. Mollan
- Birmingham Neuro-Ophthalmology, Ophthalmology Department, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham, B15 2TH UK
| | | | - Zerin Alimajstorovic
- Metabolic Neurology, Institute of Metabolism and Systems Research, College of Medical and Dental Sciences, University of Birmingham, Birmingham, B15 2TT UK
- Centre for Endocrinology, Diabetes and Metabolism, Birmingham Health Partners, Birmingham, B15 2TH UK
| | - Gareth G. Lavery
- Metabolic Neurology, Institute of Metabolism and Systems Research, College of Medical and Dental Sciences, University of Birmingham, Birmingham, B15 2TT UK
- Centre for Endocrinology, Diabetes and Metabolism, Birmingham Health Partners, Birmingham, B15 2TH UK
| | - Alexandra J. Sinclair
- Metabolic Neurology, Institute of Metabolism and Systems Research, College of Medical and Dental Sciences, University of Birmingham, Birmingham, B15 2TT UK
- Centre for Endocrinology, Diabetes and Metabolism, Birmingham Health Partners, Birmingham, B15 2TH UK
- Department of Neurology, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham, B15 2TH UK
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Calcitonin gene related peptide monoclonal antibody treats headache in patients with active idiopathic intracranial hypertension. J Headache Pain 2020; 21:116. [PMID: 32988380 PMCID: PMC7523364 DOI: 10.1186/s10194-020-01182-7] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2020] [Accepted: 09/08/2020] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND Headache is the dominant factor for quality of life related disability in idiopathic intracranial hypertension (IIH) and typically has migraine-like characteristics. There are currently no evidence-based therapeutics for headache in IIH, and consequently this is an important unmet clinical need. CASE SERIES We report a series of seven patients in whom headaches were the presenting feature of IIH and the headaches had migraine-like characteristics, as is typical in many IIH patients. Papilloedema settled (ocular remission) but headaches continued. These headaches responded markedly to erenumab, a monoclonal antibody targeted against the calcitonin gene related peptide (CGRP) receptor. Of note, there was a recurrence of raised ICP, as evidenced by a return of the papilloedema, however the headaches did not recur whilst treated with erenumab. CONCLUSIONS Those with prior IIH who have their headaches successfully treated with CGRP therapy, should remain under close ocular surveillance (particularly when weight gain is evident) as papilloedema can re-occur in the absence of headache. These cases may suggest that CGRP could be a mechanistic driver for headache in patients with active IIH.
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Virdee J, Larcombe S, Vijay V, Sinclair AJ, Dayan M, Mollan SP. Reviewing the Recent Developments in Idiopathic Intracranial Hypertension. Ophthalmol Ther 2020; 9:767-781. [PMID: 32902722 PMCID: PMC7708542 DOI: 10.1007/s40123-020-00296-0] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2019] [Indexed: 02/07/2023] Open
Abstract
There is increasing evidence and appreciation of idiopathic intracranial hypertension (IIH) in medicine. The pathological processes underlying raised intracranial pressure are being studied, with new insights found in both hormonal dysregulation and the metabolic neuroendocrine axis. These will potentially lead to novel therapeutic targets for IIH. The first consensus guidelines have been published on the investigation and management of adult IIH, and the International Headache Society criteria for headache attributable to IIH have been modified to reflect our evolving understanding of IIH. Randomized clinical trials have been published, and a number of studies in this disease area are ongoing.
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Affiliation(s)
- Jasvir Virdee
- Ophthalmology, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | | | - Vivek Vijay
- Metabolic Neurology, Institute of Metabolism and Systems Research, University of Birmingham, Birmingham, UK.,Centre for Endocrinology, Diabetes and Metabolism, Birmingham Health Partners, Birmingham, UK
| | - Alex J Sinclair
- Metabolic Neurology, Institute of Metabolism and Systems Research, University of Birmingham, Birmingham, UK.,Centre for Endocrinology, Diabetes and Metabolism, Birmingham Health Partners, Birmingham, UK.,Birmingham Neuro-Ophthalmology, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Margaret Dayan
- Newcastle Eye Centre, The Newcastle Upon Tyne Hospitals NHS Foundation Trust, Royal Victoria Infirmary, Newcastle upon Tyne, UK
| | - Susan P Mollan
- Birmingham Neuro-Ophthalmology, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK.
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Alimajstorovic Z, Westgate CSJ, Jensen RH, Eftekhari S, Mitchell J, Vijay V, Seneviratne SY, Mollan SP, Sinclair AJ. Guide to preclinical models used to study the pathophysiology of idiopathic intracranial hypertension. Eye (Lond) 2020; 34:1321-1333. [PMID: 31896803 PMCID: PMC7376028 DOI: 10.1038/s41433-019-0751-1] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2019] [Revised: 10/24/2019] [Accepted: 11/29/2019] [Indexed: 12/21/2022] Open
Abstract
Idiopathic intracranial hypertension (IIH) is characterised by raised intracranial pressure (ICP) and papilloedema in the absence of an identifiable secondary cause typically occurring in young women with obesity. The impact is considerable with the potential for blindness, chronic disabling headaches, future risk of cardiovascular disease and marked healthcare utilisation. There have been marked advances in our understanding the pathophysiology of IIH including the role of androgen excess. Insight into pathophysiological underpinnings has arisen from astute clinical observations, studies, and an array of preclinical models. This article summarises the current literature pertaining to the pathophysiology of IIH. The current preclinical models relevant to gaining mechanistic insights into IIH are then discussed. In vitro and in vivo models which study CSF secretion and the effect of potentially pathogenic molecules have started to glean important mechanistic insights. These models are also useful to evaluate novel therapeutic targets to abrogate CSF secretion. Importantly, in vitro CSF secretion assays translate into relevant changes in ICP in vivo. Models of CSF absorption pertinent to IIH, are less well established but highly relevant and of future interest. There is no fully developed in vivo model of IIH but this remains an area of importance. Progress is being made to improve our understanding of the underlying aetiology in IIH including the characterisation of disease biomarkers and their mechanistic role in driving disease pathology. Preclinical models, used to evaluate IIH mechanisms are yielding important mechanistic insights. Further work to refine these techniques will provide translatable insights into disease aetiology.
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Affiliation(s)
- Zerin Alimajstorovic
- Metabolic Neurology, Institute of Metabolism and Systems Research, College of Medical and Dental Sciences, University of Birmingham, Birmingham, B15 2TT, UK
| | - Connar S J Westgate
- Metabolic Neurology, Institute of Metabolism and Systems Research, College of Medical and Dental Sciences, University of Birmingham, Birmingham, B15 2TT, UK
- Department of Neurology, Danish Headache Centre, Rigshospitalet-Glostrup, Glostrup Research Institute, Valdemar Hansens Vej 5, 2600, Glostrup, Denmark
| | - Rigmor H Jensen
- Department of Neurology, Danish Headache Centre, Rigshospitalet-Glostrup, Glostrup Research Institute, Valdemar Hansens Vej 5, 2600, Glostrup, Denmark
| | - Sajedeh Eftekhari
- Department of Neurology, Danish Headache Centre, Rigshospitalet-Glostrup, Glostrup Research Institute, Valdemar Hansens Vej 5, 2600, Glostrup, Denmark
| | - James Mitchell
- Metabolic Neurology, Institute of Metabolism and Systems Research, College of Medical and Dental Sciences, University of Birmingham, Birmingham, B15 2TT, UK
| | - Vivek Vijay
- Metabolic Neurology, Institute of Metabolism and Systems Research, College of Medical and Dental Sciences, University of Birmingham, Birmingham, B15 2TT, UK
| | - Senali Y Seneviratne
- Metabolic Neurology, Institute of Metabolism and Systems Research, College of Medical and Dental Sciences, University of Birmingham, Birmingham, B15 2TT, UK
| | - Susan P Mollan
- Birmingham Neuro-Ophthalmology, Queen Elizabeth Hospital, Birmingham, UK
| | - Alexandra J Sinclair
- Metabolic Neurology, Institute of Metabolism and Systems Research, College of Medical and Dental Sciences, University of Birmingham, Birmingham, B15 2TT, UK.
- Birmingham Neuro-Ophthalmology, Queen Elizabeth Hospital, Birmingham, UK.
- Centre for Endocrinology, Diabetes and Metabolism, Birmingham Health Partners, Birmingham, B15 2TH, UK.
- Department of Neurology, University Hospitals Birmingham NHS Foundation Trust, Queen Elizabeth Hospital, Birmingham, B15 2WB, UK.
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Mickute G, Staley K, Delaney H, Gardiner O, Hunter A, Keen R, Lockhart L, Meade N, Newman M, Ralston S, Rush E, Upadhyaya S, Regan S, Watts L, Walsh J, White P, Francis RM, Javaid MK. Rare musculoskeletal diseases in adults: a research priority setting partnership with the James Lind Alliance. Orphanet J Rare Dis 2020; 15:117. [PMID: 32430048 PMCID: PMC7238497 DOI: 10.1186/s13023-020-01398-5] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2020] [Accepted: 05/04/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Osteogenesis imperfecta, fibrous dysplasia/McCune-Albright syndrome and X-linked hypophosphatemia are three rare musculoskeletal diseases characterised by bone deformities, frequent fractures and pain. Little high-quality research exists on appropriate treatment and long-term management of these conditions in adults. This is further worsened by limited research funding in rare diseases and a general mismatch between the existing research priorities and those of the patients. This partnership adopted the James Lind Alliance approach to identify the top 10 research priorities for rare musculoskeletal diseases in adults through joint patient, carer and healthcare professional collaboration. RESULTS The initial survey for question collection recruited 198 respondents, submitting a total of 988 questions. 77% of the respondents were patients with a rare musculoskeletal disease. Following out-of-scope question exclusion, repeating query grouping and scientific literature check for answers, 39 questions on treatment and long-term management remained. In the second public survey, 220 respondents, of whom 85% were patients with a rare musculoskeletal disease, their carers, relatives or friends, prioritised these uncertainties, which allowed selection of the top 25. In the last stage, patients, carers and healthcare professionals gathered for a priority setting workshop to reach a consensus on the final top 10 research priorities. These focus on the uncertainties surrounding appropriate treatment and holistic long-term disease management, highlighting several aspects indirect to abnormal bone metabolism, such as extra-skeletal symptoms, psychological care of both patients and their families and disease course through ageing. CONCLUSIONS This James Lind Alliance priority setting partnership is the first to investigate rare bone diseases. The priorities identified here were developed jointly by patients, carers and healthcare professionals. We encourage researchers, funding bodies and other stakeholders to use these priorities in guiding future research for those affected by rare musculoskeletal disorders.
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Affiliation(s)
- Gerda Mickute
- Somerville College, University of Oxford, Oxford, OX2 6HD, UK.
| | - Kristina Staley
- Montague House, 4 St. Mary's Street, Ross on Wye, HR9 5HT, UK
| | | | | | | | - Richard Keen
- Royal National Orthopaedic Hospital, Stanmore, HA7 4LP, UK
| | | | | | | | - Stuart Ralston
- MRC Institute of Genetics and Molecular Medicine, University of Edinburgh, Edinburgh, EH4 2XU, UK
| | | | | | - Sandra Regan
- NIHR Oxford Biomedical Research Centre Project Manager, Oxford, UK
| | - Laura Watts
- NIHR Musculoskeletal Biomedical Research Unit, University of Oxford, Oxford, OX3 7LD, UK
| | - Jennifer Walsh
- Metabolic Bone Centre, Sheffield Teaching Hospitals NHS Foundation Trust, S5 7AU, Sheffield, UK
| | | | - Roger M Francis
- Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, NE1 7RU, UK
| | - M Kassim Javaid
- The Botnar Research Centre, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, OX3 7LD, UK
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47
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Gurney SP, Ramalingam S, Thomas A, Sinclair AJ, Mollan SP. Exploring The Current Management Idiopathic Intracranial Hypertension, And Understanding The Role Of Dural Venous Sinus Stenting. Eye Brain 2020; 12:1-13. [PMID: 32021528 PMCID: PMC6969694 DOI: 10.2147/eb.s193027] [Citation(s) in RCA: 33] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2019] [Accepted: 11/05/2019] [Indexed: 12/12/2022] Open
Abstract
Idiopathic Intracranial Hypertension (IIH) is a debilitating disorder characterised by raised intracranial pressure (ICP), papilloedema with the potential risk of permanent visual loss, and headaches that are profoundly disabling and reduce the quality of life. The first consensus guidelines have been published on investigation and management of adult IIH and one key area of uncertainty is the utility of dural venous sinus stenting for the management of headache and visual loss. There are an increasing number of series published and to help understand the successes and complications. During a patient physician priority setting, the understanding of the best type of intervention to treat IIH was assigned to the top 10 of most desired research questions for the disease. Ultimately randomised clinical trials (RCTs) in neurovascular stenting for IIH would be instructive, as the literature to date may suffer from publication bias. Due to the increasing incidence of IIH, there is no better time to systematically investigate interventions that may reverse the disease process and achieve remission. In this review we discuss the pathophysiology of IIH in relation to venous sinus stenosis, the role of venous sinus stenting with a review of the relevant literature, the advantages and disadvantages of stenting compared with other surgical interventions, and the future of stenting in the treatment of IIH.
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Affiliation(s)
- Sam P Gurney
- Birmingham Neuro-Ophthalmology, Queen Elizabeth Hospital, University Hospitals Birmingham, BirminghamB15 2WB, UK
| | - Sateesh Ramalingam
- Neuroradiology Department, Queen Elizabeth Hospital, University Hospitals Birmingham, BirminghamB15 2WB, UK
| | - Alan Thomas
- Neuroradiology Department, Queen Elizabeth Hospital, University Hospitals Birmingham, BirminghamB15 2WB, UK
| | - Alex J Sinclair
- Metabolic Neurology, Institute of Metabolism and Systems Research, College of Medical and Dental Sciences, University of Birmingham, BirminghamB15 2TT, UK
- Centre for Endocrinology, Diabetes and Metabolism, Birmingham Health Partners, BirminghamB15 2TH, UK
- Department of Neurology, University Hospitals Birmingham NHS Foundation Trust, Queen Elizabeth Hospital, BirminghamB15 2WB, UK
| | - Susan P Mollan
- Birmingham Neuro-Ophthalmology, Queen Elizabeth Hospital, University Hospitals Birmingham, BirminghamB15 2WB, UK
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48
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Mitchell JL, Mollan SP, Vijay V, Sinclair AJ. Novel advances in monitoring and therapeutic approaches in idiopathic intracranial hypertension. Curr Opin Neurol 2019; 32:422-431. [PMID: 30865008 PMCID: PMC6522204 DOI: 10.1097/wco.0000000000000690] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
PURPOSE OF REVIEW The current article appraises the recent developments in idiopathic intracranial hypertension (IIH), with particular attention to novel therapeutic avenues and advanced clinical assessment and monitoring with optical coherence tomography and telemetric intracranial pressure devices. RECENT FINDINGS The incidence of IIH is increasing. The first consensus guidelines for IIH have been published detailing investigation and management algorithms for adult IIH. Improved understanding, clinical assessment and monitoring are emerging with the use of optical coherence tomography. Intracranial pressure telemetry is providing unique insights into the physiology of raised intracranial pressure in IIH. There are now an increasing number of ongoing clinical trials evaluating weight loss methods and novel targeted therapies, such as 11ß-HSD1 inhibition and Glucagon-like peptide 1 (GLP-1) receptor agonists. SUMMARY Several studies are evaluating new therapies for IIH. Monitoring techniques are advancing, aiding diagnosis and allowing the clinician to accurately evaluate changes in papilloedema and intracranial pressure.
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Affiliation(s)
- James L. Mitchell
- Metabolic Neurology, Institute of Metabolism and Systems Research, University of Birmingham
- Department of Neurology, University Hospitals Birmingham
| | | | - Vivek Vijay
- Metabolic Neurology, Institute of Metabolism and Systems Research, University of Birmingham
- Department of Neurology, University Hospitals Birmingham
| | - Alexandra J. Sinclair
- Metabolic Neurology, Institute of Metabolism and Systems Research, University of Birmingham
- Birmingham Neuro-Ophthalmology, Queen Elizabeth Hospital
- Centre for Endocrinology, Diabetes and Metabolism, Birmingham Health Partners, Birmingham, UK
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