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Ng JJ, Saikali LM, Zapatero ZD, Massenburg BB, Wu M, Romeo DJ, Heuer GG, Bartlett SP, Taylor JA, Swanson JW, Lang SS. Vaulting further: cranial vault expansion for craniocerebral disproportion without primary craniosynostosis. Childs Nerv Syst 2024:10.1007/s00381-024-06517-2. [PMID: 38922367 DOI: 10.1007/s00381-024-06517-2] [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: 03/19/2024] [Accepted: 06/20/2024] [Indexed: 06/27/2024]
Abstract
PURPOSE Treatment of subjects with refractory idiopathic intracranial hypertension (IIH) or shunted hydrocephalus with chronic shunt complications is challenging. What is the role for cranial vault expansion, particularly utilizing posterior vault distraction osteogenesis (PVDO), in these cases? This study assesses medium-term efficacy of cranial vault expansion in this unique patient population. METHODS A retrospective review was conducted of patients who underwent cranial vault expansion from 2008 to 2023 at the Children's Hospital of Philadelphia. Subjects who did not have a diagnosis of primary craniosynostosis were included in the study. Demographic information, medical history, and perioperative details were collected from medical records. Primary outcomes were the rate of CSF diversion procedures and resolution of presenting signs and symptoms. Secondary outcomes were perioperative and 90-day complications and reoperation requirement. RESULTS Among 13 included subjects, nine (69.2%) patients had a primary diagnosis of shunted hydrocephalus and 4 (30.8%) patients had IIH. Twelve (92.3%) subjects underwent posterior vault distraction osteogenesis (PVDO) and one (7.7%) underwent posterior vault remodeling (PVR). All 4 patients with IIH demonstrated symptomatic improvement following PVDO, including resolution of headaches, vomiting, and/or papilledema. Among 9 patients with shunted hydrocephalus, CSF diversion requirement decreased from 2.7 ± 1.6 procedures per year preoperatively to 1.2 ± 1.8 per year following cranial vault expansion (p = 0.030). The mean postoperative follow-up was 4.1 ± 2.1 years and four (30.8%) patients experienced complications within 90 days of surgery, including infection (n = 2), CSF leak (n = 1), and elevated ICP requiring lumbar puncture (n = 1). Four (30.8%) patients underwent repeat cranial vault expansion for recurrence of ICP-related symptoms. At most recent follow-up, 7 of 9 patients with shunted hydrocephalus demonstrated symptomatic improvement. CONCLUSION Cranial vault expansion reduced intracranial hypertension-related symptomology as well as the rate of CSF diversion-related procedures in patients with refractory IIH and shunted hydrocephalus without craniosynostosis, and should be considered in those who have significant shunt morbidity.
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Affiliation(s)
- Jinggang J Ng
- Division of Plastic, Reconstructive and Oral Surgery, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Linda M Saikali
- Division of Plastic, Reconstructive and Oral Surgery, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Zachary D Zapatero
- Division of Plastic, Reconstructive and Oral Surgery, Children's Hospital of Philadelphia, Philadelphia, PA, USA
- Division of Plastic Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Benjamin B Massenburg
- Division of Plastic, Reconstructive and Oral Surgery, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Meagan Wu
- Division of Plastic, Reconstructive and Oral Surgery, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Dominic J Romeo
- Division of Plastic, Reconstructive and Oral Surgery, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Gregory G Heuer
- Division of Neurosurgery, Children's Hospital of Philadelphia, Department of Neurosurgery, University of Pennsylvania Perelman School of Medicine, 3401 Civic Center Blvd, Philadelphia, PA, 19104, USA
| | - Scott P Bartlett
- Division of Plastic, Reconstructive and Oral Surgery, Children's Hospital of Philadelphia, Philadelphia, PA, USA
- Division of Plastic Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Jesse A Taylor
- Division of Plastic, Reconstructive and Oral Surgery, Children's Hospital of Philadelphia, Philadelphia, PA, USA
- Division of Plastic Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Jordan W Swanson
- Division of Plastic, Reconstructive and Oral Surgery, Children's Hospital of Philadelphia, Philadelphia, PA, USA
- Division of Plastic Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Shih-Shan Lang
- Division of Neurosurgery, Children's Hospital of Philadelphia, Department of Neurosurgery, University of Pennsylvania Perelman School of Medicine, 3401 Civic Center Blvd, Philadelphia, PA, 19104, USA.
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Marcotte JH, Moncman RF, Branche MJ, Siegal TL, Patel RA, Turtz AR. Tension pneumocephalus following bariatric surgery: case report. Br J Neurosurg 2023; 37:1315-1318. [PMID: 33393846 DOI: 10.1080/02688697.2020.1866166] [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: 08/11/2020] [Accepted: 12/15/2020] [Indexed: 10/22/2022]
Abstract
Bariatric surgery is an effective treatment for patients with idiopathic intracranial hypertension (IIH), a condition that is associated with skull base defects. A 55-year-old woman presented with symptoms of intractable nausea and vomiting, followed by headache and confusion two weeks after an elective laparoscopic vertical sleeve gastrectomy procedure. She had a presumed diagnosis of IIH and a remote history of CSF oto/rhinorrhea treated with a lumbar peritoneal (LP) shunt. Computed tomography (CT) scan of the head revealed tension pneumocephalus with midline shift and dehiscence of the tegmen. The patient underwent emergent craniotomy for decompression of the air-filled temporal lobe, clamping of the LP shunt, and repair of the skull base defect. Caution should be exercised in obese patients with a history of CSF leak secondary to a middle fossa skull base defect when being evaluated for bariatric surgery.
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Affiliation(s)
- Joseph H Marcotte
- Department of General Surgery, Cooper University Hospital, Camden, NJ, USA
| | - Ryan F Moncman
- Department of Neurological Surgery, Cooper University Hospital, Camden, NJ, USA
| | - Marc J Branche
- Department of Radiology, Cooper University Hospital, Camden, NJ, USA
| | - Todd L Siegal
- Department of Radiology, Cooper University Hospital, Camden, NJ, USA
| | - Rohit A Patel
- Department of Bariatric Surgery, Cooper University Hospital, Camden, NJ, USA
| | - Alan R Turtz
- Department of Neurological Surgery, Cooper University Hospital, Camden, NJ, USA
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Castelnuovo P, Valentini M, Sileo G, Battaglia P, Bignami M, Turri-Zanoni M. Management of recurrent cerebrospinal fluid leak, current practices and open challenges. A systematic literature review. ACTA OTORHINOLARYNGOLOGICA ITALICA : ORGANO UFFICIALE DELLA SOCIETA ITALIANA DI OTORINOLARINGOLOGIA E CHIRURGIA CERVICO-FACCIALE 2023; 43:S14-S27. [PMID: 37698096 PMCID: PMC10159643 DOI: 10.14639/0392-100x-suppl.1-43-2023-02] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/09/2023] [Accepted: 01/17/2023] [Indexed: 09/13/2023]
Abstract
Cerebrospinal fluid leak (CSFL) is a rare pathological condition which requires prompt and adequate management due to the high rate of associated major complications. At present, CSFL can be successfully treated through endoscopic endonasal approaches with success rates higher than 90%. Despite this, CSFL recurrence may occur, and its management is critical and still represents a matter of debate. A systematic review of the literature on the management of recurrent CSFL was conducted. It included a cohort of 1,083 cases of CSFL treated with surgical or conservative approaches; 112 cases of recurrence were reported for an overall recurrence rate of 10.3%. Most of the leaks were localised in the anterior skull base (68.3%) and identification of recurrent CSFL may be troublesome. Therefore, the entire skull base must be meticulously examined and long-term follow-up is mandatory. The risk for CSFL recurrence is higher in patients affected by idiopathic intracranial hypertension (IIH), but its role in CSFL recurrence is yet to be understood. Recurrent CSFL must be repaired as soon as possible in order to reduce the risk of intracranial complications. The use of early post-operative CSF diversion by lumbar drain (LD) is currently a matter of debate even in case of CSFL recurrences.
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Affiliation(s)
- Paolo Castelnuovo
- Unit of Otorhinolaryngology, Department of Biotechnologies and Life Sciences, University of Insubria, ASST Sette Laghi, Varese, Italy
- Head and Neck Surgery & Forensic Dissection Research center (HNS&FDRc), Department of Biotechnology and Life Sciences, University of Insubria, Varese, Italy
| | - Marco Valentini
- Unit of Otorhinolaryngology, Department of Biotechnologies and Life Sciences, University of Insubria, ASST Sette Laghi, Varese, Italy
| | - Giorgio Sileo
- Unit of Otorhinolaryngology, Department of Biotechnologies and Life Sciences, University of Insubria, ASST Sette Laghi, Varese, Italy
| | - Paolo Battaglia
- Unit of Otorhinolaryngology, Department of Biotechnologies and Life Sciences, University of Insubria, ASST Sette Laghi, Varese, Italy
- Head and Neck Surgery & Forensic Dissection Research center (HNS&FDRc), Department of Biotechnology and Life Sciences, University of Insubria, Varese, Italy
| | - Maurizio Bignami
- Head and Neck Surgery & Forensic Dissection Research center (HNS&FDRc), Department of Biotechnology and Life Sciences, University of Insubria, Varese, Italy
- Unit of Otorhinolaryngology, Department of Biotechnologies and Life Sciences, University of Insubria, ASST Lariana, Como, Italy
| | - Mario Turri-Zanoni
- Unit of Otorhinolaryngology, Department of Biotechnologies and Life Sciences, University of Insubria, ASST Sette Laghi, Varese, Italy
- Head and Neck Surgery & Forensic Dissection Research center (HNS&FDRc), Department of Biotechnology and Life Sciences, University of Insubria, Varese, Italy
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Hermes SM, Bharadwaj M, Miller NR, Waslo C, Husain FA, Wolfe BM, Tanne E. Long-Term Outcomes of Bariatric Surgery in Idiopathic Intracranial Hypertension Patients. Neurologist 2023; 28:87-93. [PMID: 35593904 DOI: 10.1097/nrl.0000000000000446] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
BACKGROUND Idiopathic intracranial hypertension (IIH), a rare neurological disorder, has limited effective long-term treatments. Bariatric surgery has shown short-term promise as a management strategy, but long-term efficacy has not been evaluated. We investigated IIH-related outcomes 4 to 16 years postsurgery. MATERIALS AND METHODS This cross-sectional retrospective cohort study included Intracranial Hypertension Registry (IHR) participants with existing medical records that completed a bariatric surgery questionnaire at least 4 years postsurgery. Two physicians independently evaluated the IIH disease course at bariatric surgery and at the time of the questionnaire using detailed medical records. Determinations of improvements were based on within-participant comparisons between the 2 time points. IIH-related outcomes were then combined with bariatric surgery information and outcomes to assess the relationship between weight loss and alterations in IIH. RESULTS Among participants that underwent bariatric surgery and met study criteria (n=30) the median body mass index (BMI) at the time of surgery was 45.0 [interquartile range (IQR): 39.8-47.0], dropped to a postsurgical nadir of 27.3 (IQR: 22.8-33.1), and rose to 33.4 (IQR: 29.9-41.7) at the time of the questionnaire. Improvements in the IIH disease course at time of the questionnaire occurred in 37% of participants. However, there was a notable association between durable weight loss and IIH improvement as 90% (9 of 10) of participants that attained and maintained a BMI of 30 or below displayed improvement. CONCLUSIONS Attaining and maintaining a BMI of 30 or below was associated with long-term improvement in the IIH disease course, including improved disease management and amelioration of signs and symptoms of participants of the IHR.
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Affiliation(s)
- Sam M Hermes
- Intracranial Hypertension Registry, Casey Eye Institute
| | | | - Nick R Miller
- Intracranial Hypertension Registry, Casey Eye Institute
| | - Carin Waslo
- Intracranial Hypertension Registry, Casey Eye Institute
| | - Farah A Husain
- Division of Bariatric Surgery, School of Medicine, Oregon Health and Science University, Portland, OR
| | - Bruce M Wolfe
- Division of Bariatric Surgery, School of Medicine, Oregon Health and Science University, Portland, OR
| | - Emanuel Tanne
- Intracranial Hypertension Registry, Casey Eye Institute
- Intracranial Hypertension Research Foundation, Vancouver, WA
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Falardeau J. New Options (or not) for Treatment of Idiopathic Intracranial Hypertension. Curr Neurol Neurosci Rep 2022; 22:257-264. [PMID: 35332515 DOI: 10.1007/s11910-022-01188-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/24/2022] [Indexed: 11/30/2022]
Abstract
PURPOSE OF REVIEW Idiopathic intracranial hypertension (IIH) is a disorder primarily affecting obese women of childbearing age and, if left untreated, can lead to irreversible vision loss. No consensus exists on the best management strategy for IIH. Weight loss is advocated and few useful medical options exist. There is an unmet need to discover new treatment options for this increasingly prevalent condition. This article reviews the recent advances and research on the treatment of IIH. RECENT FINDINGS Venous sinus stenting (VSS) is now performed in many experienced centers, and there is growing interest in bariatric surgery as a treatment modality. Newly approved anti-obesity drugs are showing effectiveness in weight loss, and novel targeted disease-modifying IIH therapies are being explored. Further evaluation of these novel therapeutic strategies as well as studies exploring the use of anti-obesity drugs in IIH is needed. While VSS is gaining popularity due to its efficacy and low complication rate, there is insufficient evidence to support any surgical procedure over another. Bariatric surgery is appealing for patients with non-sight-threatening IIH and needs to be further explored.
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Affiliation(s)
- Julie Falardeau
- Department of Ophthalmology, Oregon Health and Science University, 3303 S Bond Avenue, 11th floor, Portland, OR, 97239, USA.
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6
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Bridging the Gap between Ophthalmology and Emergency Medicine in Community-Based Emergency Departments (EDs): A Neuro-Ophthalmology Guide for ED Practitioners. Clin Pract 2021; 11:919-932. [PMID: 34940005 PMCID: PMC8700032 DOI: 10.3390/clinpract11040106] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2021] [Revised: 10/28/2021] [Accepted: 11/19/2021] [Indexed: 01/13/2023] Open
Abstract
Coordination of care for patients with neuro-ophthalmic disorders can be very challenging in the community emergency department (ED) setting. Unlike university- or tertiary hospital-based EDs, the general ophthalmologist is often not as familiar with neuro-ophthalmology and the examination of neuro-ophthalmology patients in the acute ED setting. Embracing image capturing of the fundus, using a non-mydriatic camera, may be a game-changer for communication between ED physicians, ophthalmologists, and tele-neurologists. Patient care decisions can now be made with photographic documentation that is then conveyed through HIPAA-compliant messaging with accurate and useful information with both ease and convenience. Likewise, external photos of the anterior segment and motility are also helpful. Finally, establishing clinical and imaging guidelines for common neuro-ophthalmic disorders can help facilitate complete and appropriate evaluation and treatment.
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7
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Raggi A, Bianchi Marzoli S, Ciasca P, Cammarata G, Melzi L, Chiapparini L, Erbetta A, Ciceri E, Faragò G, Gioppo A, Usai S, D'Amico D. The Pre-Lumbar puncture Intracranial Hypertension Scale (PLIHS): A practical scale to identify subjects with normal cerebrospinal fluid pressure in the management of idiopathic intracranial hypertension. J Neurol Sci 2021; 429:118058. [PMID: 34461550 DOI: 10.1016/j.jns.2021.118058] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2021] [Revised: 08/05/2021] [Accepted: 08/24/2021] [Indexed: 10/20/2022]
Abstract
BACKGROUND Idiopathic Intracranial Hypertension (IIH) diagnosis requires lumbar puncture to measure cerebrospinal fluid (CSF) pressure. The Pre-Lumbar puncture Intracranial Hypertension Scale (PLIHS) is aimed to detect cases that will show raised or normal CSF opening pressure. METHODS Retrospective analysis of records of patients who underwent lumbar puncture for suspect IIH. The target was CSF opening pressure ≥ 250 mmH2O, whereas a set of known neurological, neuro-ophthalmological and neuro-radiological parameters, plus obesity, were used as predictors in a logistic regression model. The PLIHS was based on significant predictors and a cut-off was validated using chi-squared test around CSF opening pressure ≥ 250 and < 200 mmH2O. RESULTS Records of 162 patients were included: CSF opening pressure was <200 mmH2O in 40 and ≥ 250 mmH2O in 95 patients; 85 fulfilled IIH diagnosis. PLIHS is based on Frisén grade 2 or higher papilledema, tinnitus, empty sella, perioptic subarachnoid space distension, and obesity. Score range is 0-7: correlation with CSF opening pressure is 0.508 (p < .001), and PLIHS score is different between subjects not diagnosed with IIH, and those diagnosed with IIH both with and without papilledema (p < .001). PLIHS score ≤ 2 identifies cerebrospinal fluid pressure < 200 mmH2O; PLIHS score ≥ 3 identifies CSF opening pressure ≥ 250 mmH2O, IIH diagnosis, visual acuity ≤0.7, and optic nerve atrophy. CONCLUSIONS The PLIHS, can be used to identify patients who will particularly need LP, thus helping with the organization of the diagnostic work-up by optimising healthcare resources and potentially limit the likelihood to incur in LP-related adverse events.
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Affiliation(s)
- Alberto Raggi
- Fondazione IRCCS Istituto Neurologico Carlo Besta, Neurology, Public Health and Disability Unit, Milano, Italy.
| | - Stefania Bianchi Marzoli
- Istituto Auxologico Italiano IRCCS, Neuro-ophthalmology Center - Scientific Institute Capitanio Hospital, Milano, Italy.
| | - Paola Ciasca
- Istituto Auxologico Italiano IRCCS, Neuro-ophthalmology Center - Scientific Institute Capitanio Hospital, Milano, Italy.
| | - Gabriella Cammarata
- Istituto Auxologico Italiano IRCCS, Neuro-ophthalmology Center - Scientific Institute Capitanio Hospital, Milano, Italy.
| | - Lisa Melzi
- Istituto Auxologico Italiano IRCCS, Neuro-ophthalmology Center - Scientific Institute Capitanio Hospital, Milano, Italy.
| | - Luisa Chiapparini
- Fondazione IRCCS Istituto Neurologico Carlo Besta, Neuroradiology Unit, Milano, Italy.
| | - Alessandra Erbetta
- Fondazione IRCCS Istituto Neurologico Carlo Besta, Neuroradiology Unit, Milano, Italy.
| | - Elisa Ciceri
- Fondazione IRCCS Istituto Neurologico Carlo Besta, Radiodiagnostic and Interventional Neuroradiology, Milano, Italy.
| | - Giuseppe Faragò
- Papa Giovanni XXII Hospital, Neuroradiology Department, Bergamo, Italy.
| | - Andrea Gioppo
- ASST Santi Paolo e Carlo, P.O San Carlo, Radiologia II - Neurodiagnostica-Neurointerventistica, Milano, Italy.
| | - Susanna Usai
- Fondazione IRCCS Istituto Neurologico Carlo Besta, Neuroalgology Unit, Milano, Italy.
| | - Domenico D'Amico
- Fondazione IRCCS Istituto Neurologico Carlo Besta, Neuroalgology Unit, Milano, Italy.
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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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Nguyen DT, Helleringer M, Klein O, Jankowski R, Rumeau C. The relationship between spontaneous cerebrospinal fluid leak and idiopathic intracranial hypertension. Eur Ann Otorhinolaryngol Head Neck Dis 2020; 138:177-182. [PMID: 33257267 DOI: 10.1016/j.anorl.2020.11.003] [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: 10/22/2022]
Abstract
Surgical treatment of spontaneous cerebrospinal fluid (CSF) leak is now performed by ENT surgeons, endonasal endoscopy being preferred to craniotomy as less invasive. However, it is often the symptom of underlying idiopathic intracranial hypertension, which lies outside the traditional sphere of ENT competence. Surgery is a necessary step, but should not obscure the need to treat the underlying pathology. This treatment is complex, and requires multidisciplinary team-work between otorhinolaryngologist, ophthalmologist, neurologist, neurosurgeon, radiologist, dietician, endocrinologist and psychotherapist. The present update details this multidisciplinary management to which the ENT surgeons must be attentive before and after spontaneous CSF leak repair.
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Affiliation(s)
- D-T Nguyen
- Service d'ORL et chirurgie cervico-faciale, hôpitaux de Brabois, CHRU de Nancy, rue du Morvan, 54500 Vandoeuvre-lès-Nancy, France.
| | - M Helleringer
- Service de neurochirurgie, CHRU de Nancy, hôpital Central, 29, avenue du Maréchal-de-Lattre-de-Tassigny, 54035 Nancy, France
| | - O Klein
- Service de neurochirurgie, CHRU de Nancy, hôpital Central, 29, avenue du Maréchal-de-Lattre-de-Tassigny, 54035 Nancy, France
| | - R Jankowski
- Service d'ORL et chirurgie cervico-faciale, hôpitaux de Brabois, CHRU de Nancy, rue du Morvan, 54500 Vandoeuvre-lès-Nancy, France
| | - C Rumeau
- Service d'ORL et chirurgie cervico-faciale, hôpitaux de Brabois, CHRU de Nancy, rue du Morvan, 54500 Vandoeuvre-lès-Nancy, France; EA3450 DevAH, développement adaptation et handicap, université de Lorraine, 9, avenue de la Forêt-de-Haye, 54505 Lorraine, France
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10
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López T, Trébol J, Sastre JA. Laparoscopic bariatric surgery in a patient with idiopathic intracranial hypertension and lumboperitoneal shunt: Anesthetic implications. Saudi J Anaesth 2020; 14:510-513. [PMID: 33447195 PMCID: PMC7796751 DOI: 10.4103/sja.sja_190_20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2020] [Accepted: 03/08/2020] [Indexed: 12/02/2022] Open
Abstract
Idiopathic intracranial hypertension (IIH) typically affects obese young women. Treatment is mainly medical, but some cases require surgery; ventriculoperitoneal (VPS) or lumboperitoneal shunts (LPS) being the most common procedures. Although bariatric surgery is not the first-line surgical treatment, it can be useful in refractory cases and allows treating the major underlying risk factor and its comorbidities. Laparoscopic bariatric surgery is the gold standard; however, literature in patients with shunts is scarce. In the present study, we report the case of a morbidly obese female with IIH treated with an LPS and with refractory headache, scheduled for laparoscopic Roux-en-Y gastric bypass. LPS position was checked before surgery (abdominal X-ray) and during pneumoperitoneum was clamped. Anesthetic management was guided to minimize increases in intracranial pressure (ICP). Surgery and anesthesia were uneventful. Three months later, headaches disappeared and analgesics were discontinued. In conclusion, laparoscopic bariatric surgery may be an option for IIH. It is safe in patients with LPS, although concerns should be taken into account (avoid any damage to the shunt, limit digestive tract contents spillage, and strict vigilance for early detection of intracranial hypertension signs). Although valve system could prevent pressure complications, the catheter can be clamped to avoid retrograde insufflation of CO2 or digestive tract content.
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Affiliation(s)
- Teresa López
- Department of Anaesthesiology, Salamanca University Hospital, Salamanca, Spain
| | - Jacobo Trébol
- Department of General and Digestive Surgery, Salamanca University Hospital, Salamanca, Spain
| | - José A Sastre
- Department of Anaesthesiology, Salamanca University Hospital, Salamanca, Spain
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11
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Abdelbaki TN, Gomaa M. Outcome of idiopathic intracranial hypertension after laparoscopic sleeve gastrectomy. Surg Obes Relat Dis 2020; 16:1195-1201. [PMID: 32409117 DOI: 10.1016/j.soard.2020.03.032] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2020] [Revised: 03/24/2020] [Accepted: 03/29/2020] [Indexed: 01/16/2023]
Abstract
BACKGROUND Idiopathic intracranial hypertension (IIH) predominantly affects young, obese women and presents with signs and symptoms of increased intracranial pressure, such as headaches and visual impairment. OBJECTIVE We aim to present our experience in the management of IIH. SETTING University Hospital. METHODS Obese IIH patients who had a laparoscopic sleeve gastrectomy during the study period (2 years) were included. Data were retrieved from prospectively collected database. Headaches, visual alterations, and medications or interventions used to treat are discussed. RESULTS The study included 16 obese women with IIH. Mean age was 31 ± 2 years (range, 25-44 yr) and mean body mass index was 46 ± 4 kg/m2 (range, 42-53 kg/m2). Main symptoms and signs were chronic headaches (14), impaired vision (15), vision loss (1), papilledema (6), and field defects in 4 patients. Symptoms were present for a mean of 5 years (4-11). History of medical treatment with carbonic anhydrase inhibitor (acetazolamide) and thecoperitoneal shunting was present in 12 and 9 patients, respectively. Mean lumbar puncture opening pressure was 41.2 ± 21- (range, 30-64) cm water. At 12 months after laparoscopic sleeve gastrectomy, body mass index and percentage excess weight loss were 27.8 ± 1 kg/m2 and 75.2 ± 2%, respectively. Symptoms gradually improved with complete resolution in all but 2 patients (87.5%). CONCLUSION The present work emphasizes the role of bariatric surgery in the management of obese patients with IIH. Larger, prospective, controlled studies are needed.
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Affiliation(s)
- Tamer N Abdelbaki
- General Surgery Department, Alexandria University Faculty of Medicine, Alexandria, Egypt.
| | - Mohamed Gomaa
- Ophthalmology Department, Alexandria University Faculty of Medicine, Alexandria, Egypt
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Metabolic Concepts in Idiopathic Intracranial Hypertension and Their Potential for Therapeutic Intervention. J Neuroophthalmol 2020; 38:522-530. [PMID: 29985799 PMCID: PMC6215484 DOI: 10.1097/wno.0000000000000684] [Citation(s) in RCA: 70] [Impact Index Per Article: 17.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND Traditional risk factors associated with idiopathic intracranial hypertension (IIH) include obesity, weight gain, and female sex. The incidence of IIH is increasing and yet the underlying trigger and the fueling pathological mechanisms are still poorly understood. EVIDENCE ACQUISITION Review of ophthalmology, neurology, general surgery, obesity, endocrinology, nutrition, and neurosurgery literature was made. RESULTS The facts that implicate sex and obesity in IIH and headache are examined. The role of fat distribution in IIH is questioned, and the concept of adipose tissue functioning as an endocrine organ driving IIH is discussed. The impact of androgen metabolism in IIH is reviewed as is the emerging role of glucagon-like-peptide-1 analogues in modulating intracranial pressure. This introduces the concept of developing targeted disease-modifying therapeutic strategies for IIH. CONCLUSIONS This review will discuss the possible role of the adipose/gut/brain metabolism axis in IIH and speculate how this may impact the pathogenesis of IIH and therapeutic opportunities.
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Sun WYL, Switzer NJ, Dang JT, Gill R, Shi X, de Gara C, Birch D, Nataraj A, Karmali S. Idiopathic intracranial hypertension and bariatric surgery: a systematic review. Can J Surg 2020; 63:E123-E128. [PMID: 32195557 DOI: 10.1503/cjs.016616] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023] Open
Abstract
Background Idiopathic intracranial hypertension (IIH) is a rare condition typically affecting women with obesity who are of child-bearing age. Patients commonly present with headaches, visual disturbances, pulsatile tinnitus and papilledema. The association between IIH and obesity has been well established in the literature, suggesting that weight loss may contribute to improving IIH. For patients with severe obesity for whom conservative management is not successful, bariatric surgery is an effective modality for weight loss. We aimed to systematically review the literature to determine the efficacy of bariatric surgery in the treatment of IIH Methods We conducted a comprehensive search of MEDLINE, Embase, Scopus, the Cochrane Library and Web of Science (limited to studies in humans published in English between January 1946 and July 2015). Results Twelve primary studies (n = 39 patients) were included in the systematic review. All patients had a preoperative diagnosis of IIH. Preoperative body mass index (BMI) was 47.4 ± 3.6 kg/m2 ; BMI improved to 33.7 ± 2.1 kg/m2 and 33.9 ± 11.6 kg/m2 at 6 and 12 months postoperatively, respectively. Lumbar puncture opening pressures decreased from 34.4 ± 6.9 cmH2O to 14.0 ± 3.6 cmH2O after surgery. Common symptoms of IIH improved after bariatric surgery: headaches (100% preoperatively v. 10% postoperatively), visual complaints (62% v. 44%), tinnitus (56% v. 3%) and papilledema (62% v. 8%). Conclusion Bariatric surgery appears to lead to considerable improvement in IIH. Idiopathic intracranial hypertension is not a well-publicized comorbidity of obesity, but its presence may be considered as an indication for bariatric surgery.
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Affiliation(s)
- Warren Y. L. Sun
- From the Department of Surgery, Division of General Surgery, University of Alberta, Edmonton, Alta. (Sun, Switzer, Dang, de Gara, Birch, Karmali); the Department of Surgery, Division of General Surgery, University of Calgary, Calgary, Alta. (Gill); the Centre for the Advancement of Minimally Invasive Surgery, Royal Alexandra Hospital, Edmonton, Alta. (Shi, de Gara, Birch, Karmali); and the Division of Neurosurgery, Department of Surgery, University of Alberta, Edmonton, Alta. (Nataraj)
| | - Noah J. Switzer
- From the Department of Surgery, Division of General Surgery, University of Alberta, Edmonton, Alta. (Sun, Switzer, Dang, de Gara, Birch, Karmali); the Department of Surgery, Division of General Surgery, University of Calgary, Calgary, Alta. (Gill); the Centre for the Advancement of Minimally Invasive Surgery, Royal Alexandra Hospital, Edmonton, Alta. (Shi, de Gara, Birch, Karmali); and the Division of Neurosurgery, Department of Surgery, University of Alberta, Edmonton, Alta. (Nataraj)
| | - Jerry T. Dang
- From the Department of Surgery, Division of General Surgery, University of Alberta, Edmonton, Alta. (Sun, Switzer, Dang, de Gara, Birch, Karmali); the Department of Surgery, Division of General Surgery, University of Calgary, Calgary, Alta. (Gill); the Centre for the Advancement of Minimally Invasive Surgery, Royal Alexandra Hospital, Edmonton, Alta. (Shi, de Gara, Birch, Karmali); and the Division of Neurosurgery, Department of Surgery, University of Alberta, Edmonton, Alta. (Nataraj)
| | - Richdeep Gill
- From the Department of Surgery, Division of General Surgery, University of Alberta, Edmonton, Alta. (Sun, Switzer, Dang, de Gara, Birch, Karmali); the Department of Surgery, Division of General Surgery, University of Calgary, Calgary, Alta. (Gill); the Centre for the Advancement of Minimally Invasive Surgery, Royal Alexandra Hospital, Edmonton, Alta. (Shi, de Gara, Birch, Karmali); and the Division of Neurosurgery, Department of Surgery, University of Alberta, Edmonton, Alta. (Nataraj)
| | - Xinzhe Shi
- From the Department of Surgery, Division of General Surgery, University of Alberta, Edmonton, Alta. (Sun, Switzer, Dang, de Gara, Birch, Karmali); the Department of Surgery, Division of General Surgery, University of Calgary, Calgary, Alta. (Gill); the Centre for the Advancement of Minimally Invasive Surgery, Royal Alexandra Hospital, Edmonton, Alta. (Shi, de Gara, Birch, Karmali); and the Division of Neurosurgery, Department of Surgery, University of Alberta, Edmonton, Alta. (Nataraj)
| | - Christopher de Gara
- From the Department of Surgery, Division of General Surgery, University of Alberta, Edmonton, Alta. (Sun, Switzer, Dang, de Gara, Birch, Karmali); the Department of Surgery, Division of General Surgery, University of Calgary, Calgary, Alta. (Gill); the Centre for the Advancement of Minimally Invasive Surgery, Royal Alexandra Hospital, Edmonton, Alta. (Shi, de Gara, Birch, Karmali); and the Division of Neurosurgery, Department of Surgery, University of Alberta, Edmonton, Alta. (Nataraj)
| | - Daniel Birch
- From the Department of Surgery, Division of General Surgery, University of Alberta, Edmonton, Alta. (Sun, Switzer, Dang, de Gara, Birch, Karmali); the Department of Surgery, Division of General Surgery, University of Calgary, Calgary, Alta. (Gill); the Centre for the Advancement of Minimally Invasive Surgery, Royal Alexandra Hospital, Edmonton, Alta. (Shi, de Gara, Birch, Karmali); and the Division of Neurosurgery, Department of Surgery, University of Alberta, Edmonton, Alta. (Nataraj)
| | - Andrew Nataraj
- From the Department of Surgery, Division of General Surgery, University of Alberta, Edmonton, Alta. (Sun, Switzer, Dang, de Gara, Birch, Karmali); the Department of Surgery, Division of General Surgery, University of Calgary, Calgary, Alta. (Gill); the Centre for the Advancement of Minimally Invasive Surgery, Royal Alexandra Hospital, Edmonton, Alta. (Shi, de Gara, Birch, Karmali); and the Division of Neurosurgery, Department of Surgery, University of Alberta, Edmonton, Alta. (Nataraj)
| | - Shahzeer Karmali
- From the Department of Surgery, Division of General Surgery, University of Alberta, Edmonton, Alta. (Sun, Switzer, Dang, de Gara, Birch, Karmali); the Department of Surgery, Division of General Surgery, University of Calgary, Calgary, Alta. (Gill); the Centre for the Advancement of Minimally Invasive Surgery, Royal Alexandra Hospital, Edmonton, Alta. (Shi, de Gara, Birch, Karmali); and the Division of Neurosurgery, Department of Surgery, University of Alberta, Edmonton, Alta. (Nataraj)
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NICULA C, SUCIU C, BULBOACĂ AE. Pseudotumor cerebri-Case report. BALNEO RESEARCH JOURNAL 2020. [DOI: 10.12680/balneo.2020.315] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
An 46-year-old Caucasian woman was diagnosed with idiopathic intracranial hypertension (IIH) after presenting with papilledema and bilateral visual blurring. Lumbar puncture revealed an opening pressure of more than 550 mmH2O. Cerebral magnetic resonance imaging (MRI) showed bilateral flattening of the posterior sclera, enhancement of the prelaminar optic nerve, distension of the perioptic subarachnoid space, intraocular protrusion of the prelaminar optic nerve and empty sella. The main purpose of the treatment was to release the symptoms and preserve the vision. It was initiated the general treatment with Mannitol 20%, 250 ml/day, Acetazolamide 2x500 mg/day and B-vitamins. After discharge the patient followed a treatment with acetazolamide 2x250 mg/ daily doses and oral potassium supplements 30 mg bid/day.
Key words: pseudotumor cerebri, idiopatic intracranial hypertension, papilledema,
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Affiliation(s)
- Cristina NICULA
- University of Medicine and Pharmacy “Iuliu Hațieganu”, Faculty of Medicine, Department of Ophthalmology, Cluj-Napoca, Romania 2. Emergency County Eye Hospital, Cluj-Napoca, Romania
| | - Corina SUCIU
- 2. Emergency County Eye Hospital, Cluj-Napoca, Romania
| | - Adriana Elena BULBOACĂ
- 3. University of Medicine and Pharmacy “Iuliu Hațieganu”, Faculty of Medicine, Department of Pathophysiology, Cluj-Napoca, Romania
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Merola J, Selezneva L, Perkins R, Lang J, Barry J, Leach P. Cerebrospinal fluid diversion versus bariatric surgery in the management of idiopathic intracranial hypertension. Br J Neurosurg 2019; 34:9-12. [PMID: 31805794 DOI: 10.1080/02688697.2019.1698012] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
Background: Idiopathic intracranial hypertension (IIH) is a condition affecting predominantly young women with increased body mass index (BMI). Obesity with the related metabolic and biochemical complications are thought to be involved in the pathogenesis of the condition. The aim of this study is to evaluate the safety, outcomes and economic implications of two treatment options for IIH.Methods: We retrospectively analysed cases of morbidly obese IIH patients treated by cerebrospinal fluid (CSF) shunting procedures between 2006 and 2016 in our department and compared their outcome with that of 69 patients undergoing bariatric surgery between 2015 and 2016.Results: A total of 42 female patients with IIH underwent de-novo shunting procedures during the study period. There was a high rate of shunt revisions (67%) and further weight gain in the majority of patients who had the insertion of CSF shunts. Of the 69 female patients undergoing bariatric surgery 4.3% required interventions related to their surgery with a significantly fewer number of hospital inpatient days. Furthermore, in the patients undergoing bariatric surgery, there was a significant improvement in all obesity-related complications.Conclusions: CSF shunting procedures do not address the aetiological factor of IIH and are associated with high rates of morbidity and further weight gain. Bariatric surgery is not only efficacious in the management of patients with IIH but is associated with significant improvements in other obesity-related comorbidities. Bariatric surgery is safe and more cost-effective than CSF shunting.
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Affiliation(s)
- Joseph Merola
- Neurosciences Department, University Hospital of Wales, Cardiff, UK
| | | | - Ryan Perkins
- Morriston Hospital, Welsh Institute of Metabolic and Obesity Surgery, Abertawe Bro Morgannwg NHS Trust, Swansea, UK
| | - Jozsef Lang
- Neurosciences Department, University Hospital of Wales, Cardiff, UK
| | - Jonathan Barry
- Morriston Hospital, Welsh Institute of Metabolic and Obesity Surgery, Swansea, UK
| | - Paul Leach
- Neurosurgery, University Hospital Wales, Cardiff, UK
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The role of obesity, sleep apnea, and elevated intracranial pressure in spontaneous cerebrospinal fluid leaks. Curr Opin Otolaryngol Head Neck Surg 2019; 27:349-355. [DOI: 10.1097/moo.0000000000000562] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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17
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Treatment of idiopathic intracranial hypertension with bariatric surgery. NEUROLOGÍA (ENGLISH EDITION) 2019. [DOI: 10.1016/j.nrleng.2018.09.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
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Postoperative management of patients with spontaneous cerebrospinal fluid leak. Curr Opin Otolaryngol Head Neck Surg 2019; 27:361-368. [PMID: 31361610 DOI: 10.1097/moo.0000000000000559] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE OF REVIEW To explore key management principles and outcomes following surgical intervention for spontaneous CSF leaks of the lateral skull base. RECENT FINDINGS Outcomes following surgery for spontaneous CSF leaks of the lateral skull base depend on the surgical approach utilized. The approach reported most frequently in the literature is currently the middle fossa approach. Mean leak recurrence rates, regardless of approach, were approximately 6%. The lowest leak recurrence rates were associated with the combined middle cranial fossa-transmastoid approach. A multilayer closure was employed in all of the reviewed investigations, but the choice of reconstructive material did not significantly affect outcomes. Direct surgical complications rates, overall, were low at less than 2%. Meningitis, intracranial hemorrhage, and perioperative seizure activity were only rarely encountered. A concomitant diagnosis of idiopathic intracranial hypertension was found to be associated with increased rates of leak recurrence and sequential leak development at other skull base sites. SUMMARY Postoperative management of patients with spontaneous CSF leaks of the lateral skull base has unique challenges. Observation of key treatment principles can lead to good outcomes and limit morbidity. A high index of suspicion should exist for concomitant idiopathic intracranial hypertension.
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White O, Yalamanchili S. IIH: Optic Nerve Sheath Fenestration Versus Shunt Placement. Neuroophthalmology 2019. [DOI: 10.1007/978-3-319-98455-1_8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
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Bongetta D, Zoia C, Luzzi S, Maestro MD, Peri A, Bichisao G, Sportiello D, Canavero I, Pietrabissa A, Galzio RJ. Neurosurgical issues of bariatric surgery: A systematic review of the literature and principles of diagnosis and treatment. Clin Neurol Neurosurg 2018; 176:34-40. [PMID: 30500756 DOI: 10.1016/j.clineuro.2018.11.009] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2018] [Revised: 11/09/2018] [Accepted: 11/11/2018] [Indexed: 02/06/2023]
Abstract
Bariatric surgery is gaining popularity as the treatment of choice of morbid obesity since this condition is constantly increasing over the last decades. Several complications have emerged as the number of surgeries and follow-up data increase. No systematic review of the neurosurgery-related potential complications has been performed to date. Objective of this work is to fill this gap. We reviewed the literature for bariatric surgery-related complications involving the neurosurgical practice. Moreover, we present explicative cases dealing with peri- and post-operative therapeutic precautions. Three pathological mechanisms emerged. The first is related to intracranial pressure alterations and may imply either intracranial hypertension or hypotension syndromes in the operative or post-operative periods. The second is the deficiency of macro- and micro-nutrients which are potential risk factors for neuro- or myelo-encephalopathies, fetal malformations and spine disorders. The third is a dysregulation of both autonomic and endocrine / pituitary control. Neurosurgeons must be aware of the several, multifactorial neurosurgery-related complications of bariatric surgery as their prevalence is likely to be higher in the next few years.
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Affiliation(s)
- Daniele Bongetta
- Neurosurgery Unit, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy; Department of Clinical-Surgical, Diagnostic and Pediatric Sciences, University of Pavia, Italy.
| | - Cesare Zoia
- Neurosurgery Unit, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Sabino Luzzi
- Neurosurgery Unit, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy; Department of Emergency and Organ Transplantation, University of Bari "Aldo Moro", Italy
| | - Mattia Del Maestro
- Neurosurgery Unit, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy; Department of Life, Health and Environmental Sciences (MESVA), University of L'Aquila, Italy
| | - Andrea Peri
- General Surgery Unit II, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Germana Bichisao
- Anesthesia and Intensive Care Unit I, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Debora Sportiello
- Anesthesia and Intensive Care Unit I, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | | | - Andrea Pietrabissa
- Department of Clinical-Surgical, Diagnostic and Pediatric Sciences, University of Pavia, Italy; General Surgery Unit II, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Renato J Galzio
- Neurosurgery Unit, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy; Department of Clinical-Surgical, Diagnostic and Pediatric Sciences, University of Pavia, Italy
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Abstract
PURPOSE OF REVIEW This review presents a critical appraisal of current therapeutic strategies for patients with idiopathic intracranial hypertension (IIH). We present the reader with the most recent evidence to support medical and surgical interventions in patients with IIH and provide recommendations about treatment initiation and escalation. We also indicate areas where knowledge gaps exist regarding therapeutic efficacy and superiority of one intervention over another. RECENT FINDINGS A double-masked, randomized prospective study of medical management of patients with mild IIH (Idiopathic Intracranial Hypertension Treatment Trial-IIHTT) has established that acetazolamide therapy has additional efficacy when compared to weight loss alone. Furthermore, management of IIH-related headache, even in patients with papilledema, may require treatment other than ICP lowering for patients to experience symptomatic relief. Finally, a number of uncontrolled interventional studies have shown transverse sinus stenting to be a potentially effective treatment for medically refractory IIH. Medical therapy with acetazolamide should be considered in addition to structured weight loss in patients with mild IIH. Surgical treatment for patients with vision-threatening disease IIH can be performed by either optic nerve sheath fenestration or cerebrospinal fluid diversion, with venous sinus stenting emerging as an alternate therapy. Headache relief from ICP lowering therapy is variable and often not sustained.
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Affiliation(s)
- Sivashakthi Kanagalingam
- Department of Surgery, Division of Ophthalmology, Dartmouth-Hitchcock Medical Center, Lebanon, NH, USA
| | - Prem S Subramanian
- Department of Ophthalmology, School of Medicine, University of Colorado Anschutz Medical Campus, 1675 Aurora Court, Mailstop F-731, Aurora, CO, 80045, USA.
- Department of Neurology, University of Colorado Anschutz Medical Campus, Aurora, CO, USA.
- Department of Neurosurgery, University of Colorado Anschutz Medical Campus, Aurora, CO, USA.
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Chatziralli I, Theodossiadis P, Theodossiadis G, Asproudis I. Perspectives on diagnosis and management of adult idiopathic intracranial hypertension. Graefes Arch Clin Exp Ophthalmol 2018; 256:1217-1224. [PMID: 29619550 DOI: 10.1007/s00417-018-3970-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2017] [Revised: 02/19/2018] [Accepted: 03/26/2018] [Indexed: 01/03/2023] Open
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Cazzo E, Gestic MA, Utrini MP, Chaim FDM, Chaim FHM, Cândido EC, Jarolavsky LBDS, de Almeida AMN, Pareja JC, Chaim EA. Bariatric surgery as a treatment for pseudotumor cerebri: case study and narrative review of the literature. SAO PAULO MED J 2018; 136:182-187. [PMID: 28562736 PMCID: PMC9879540 DOI: 10.1590/1516-3180.2016.0305060117] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/05/2017] [Accepted: 01/06/2017] [Indexed: 01/29/2023] Open
Abstract
CONTEXT Pseudotumor cerebri occurs when there is an increase in intracranial pressure without an underlying cause, usually leading to loss of vision. It is most commonly observed in obese women of child-bearing age. CASE REPORT A 46-year-old woman presented at our service with idiopathic intracranial hypertension that had been diagnosed two years earlier, which had led to chronic refractory headache and an estimated 30% loss of visual acuity, associated with bilateral papilledema. She presented partial improvement of the headache with acetazolamide, but the visual loss persisted. Her intracranial pressure was 34 cmH2O. She presented a body mass index of 39.5 kg/m2, also associated with high blood pressure. Computed tomography of the cranium with endovenous contrast did not show any abnormalities. She underwent Roux-en-Y gastric bypass with uneventful postoperative evolution. One month following surgery, she presented a 24% excess weight loss. An ophthalmological examination revealed absence of visual loss and remission of the papilledema. There were no new episodes of headache following the surgery. There was also complete resolution of high blood pressure. The intracranial pressure decreased to 24 cmH2O, six months after the surgery. CONCLUSION Although the condition is usually associated with obesity, there are few reports of bariatric surgery among individuals with pseudotumor cerebri. In cases studied previously, there was high prevalence of resolution or improvement of the disease following bariatric surgery. There is no consensus regarding which technique is preferable. Thus, further research is necessary in order to establish a specific algorithm.
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Affiliation(s)
- Everton Cazzo
- MD, MSc, PhD. Assistant Professor, Department of Surgery, Faculdade de Ciências Médicas da Universidade Estadual de Campinas (FCM-UNICAMP), Campinas (SP), Brazil.
| | - Martinho Antonio Gestic
- MD, MSc. Assistant Lecturer, Department of Surgery, Faculdade de Ciências Médicas da Universidade Estadual de Campinas (FCM-UNICAMP), Campinas (SP), Brazil.
| | - Murillo Pimentel Utrini
- MD. Assistant Lecturer, Department of Surgery, Faculdade de Ciências Médicas da Universidade Estadual de Campinas (FCM-UNICAMP), Campinas (SP), Brazil.
| | - Felipe David Mendonça Chaim
- MD, MSc. Assistant Physician, Department of Surgery, Faculdade de Ciências Médicas da Universidade Estadual de Campinas (FCM-UNICAMP), Campinas (SP), Brazil.
| | - Fábio Henrique Mendonça Chaim
- MD. Resident Physician, Department of Surgery, Faculdade de Ciências Médicas da Universidade Estadual de Campinas (FCM-UNICAMP), Campinas (SP), Brazil.
| | - Elaine Cristina Cândido
- BSc, MSc. Assistant Nurse, Bariatric Surgery Outpatient Clinic, Hospital de Clínicas da Universidade Estadual de Campinas (HC-UNICAMP), Campinas (SP), Brazil.
| | - Luciana Bueno da Silveira Jarolavsky
- BSc. Head Nurse, Bariatric Surgery Outpatient Clinic, Hospital de Clínicas da Universidade Estadual de Campinas (HC-UNICAMP), Campinas (SP), Brazil.
| | - Ana Maria Neder de Almeida
- BSc. Attending Psychologist, Bariatric Surgery Outpatient Clinic, Hospital de Clínicas da Universidade Estadual de Campinas (HC-UNICAMP), Campinas (SP), Brazil.
| | - José Carlos Pareja
- MD, PhD. Associate Professor, Department of Surgery, Faculdade de Ciências Médicas da Universidade Estadual de Campinas (FCM-UNICAMP), Campinas (SP), Brazil.
| | - Elinton Adami Chaim
- MD, MSc, PhD. Full Professor. Department of Surgery, Faculdade de Ciências Médicas da Universidade Estadual de Campinas (FCM-UNICAMP), Campinas (SP), Brazil.
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Long-term management and outcomes after repair of cerebrospinal fluid rhinorrhea related to idiopathic intracranial hypertension. Curr Opin Otolaryngol Head Neck Surg 2018; 26:46-51. [DOI: 10.1097/moo.0000000000000424] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Manfield JH, Yu KKH, Efthimiou E, Darzi A, Athanasiou T, Ashrafian H. Bariatric Surgery or Non-surgical Weight Loss for Idiopathic Intracranial Hypertension? A Systematic Review and Comparison of Meta-analyses. Obes Surg 2017; 27:513-521. [PMID: 27981458 PMCID: PMC5237659 DOI: 10.1007/s11695-016-2467-7] [Citation(s) in RCA: 61] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Background Idiopathic intracranial hypertension (IIH) is associated with obesity and weight loss by any means is considered beneficial in this condition. Objectives This study aims to appraise bariatric surgery vs. non-surgical weight-loss (medical, behavioural and lifestyle) interventions in IIH management. Methods A systematic review and meta-analyses of surgical and non-surgical studies. Results Bariatric surgery achieved 100% papilloedema resolution and a reduction in headache symptoms in 90.2%. Non-surgical methods offered improvement in papilloedema in 66.7%, visual field defects in 75.4% and headache symptoms in 23.2%. Surgical BMI decrease was 17.5 vs. 4.2 for non-surgical methods. Conclusions Whilst both bariatric surgery and non-surgical weight loss offer significant beneficial effects on IIH symptomatology, future studies should address the lack of prospective and randomised trials to establish the optimal role for these interventions. Electronic supplementary material The online version of this article (doi:10.1007/s11695-016-2467-7) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- James H Manfield
- Department of Neurosurgery, Royal Preston Hospital, Preston, Lancashire, UK
| | - Kenny K-H Yu
- Department of Neurosurgery, Royal Preston Hospital, Preston, Lancashire, UK
| | - Evangelos Efthimiou
- Department of Bariatric Surgery, Chelsea and Westminster Hospital, London, UK
| | - Ara Darzi
- Department of Surgery and Cancer, Imperial College London, 3rd Floor Chelsea and Westminster Hospital Campus, 369 Fulham Road, London, SW10 9NH, UK
| | - Thanos Athanasiou
- Department of Surgery and Cancer, Imperial College London, 3rd Floor Chelsea and Westminster Hospital Campus, 369 Fulham Road, London, SW10 9NH, UK
| | - Hutan Ashrafian
- Department of Bariatric Surgery, Chelsea and Westminster Hospital, London, UK. .,Department of Surgery and Cancer, Imperial College London, 3rd Floor Chelsea and Westminster Hospital Campus, 369 Fulham Road, London, SW10 9NH, UK.
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Zhou D, Meng R, Zhang X, Guo L, Li S, Wu W, Duan J, Song H, Ding Y, Ji X. Intracranial hypertension induced by internal jugular vein stenosis can be resolved by stenting. Eur J Neurol 2017; 25:365-e13. [PMID: 29114973 DOI: 10.1111/ene.13512] [Citation(s) in RCA: 48] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2017] [Accepted: 11/02/2017] [Indexed: 11/29/2022]
Abstract
BACKGROUND AND PURPOSE Idiopathic intracranial hypertension (IIH) is characterized by abnormally elevated intracranial pressure (ICP) without identifiable etiology. Recently, however, a subset of patients with presumed IIH have been found with isolated internal jugular vein (IJV) stenosis in the absence of intracranial abnormalities. METHODS Fifteen consecutive patients were screened from 46 patients suspected as IIH and were finally confirmed as isolated IJV stenosis. The stenotic IJV was corrected with stenting when the trans-stenotic mean pressure gradient (∆MPG) was equal to or higher than 5.44 cmH2 O. Dynamic magnetic resonance venography, computed tomographic venography and digital subtraction angiography of the IJV, ∆MPG, ICP, Headache Impact Test 6 and the Frisén papilledema grade score before and after stenting were compared. RESULTS All the stenotic IJVs were corrected by stenting. ∆MPG decreased and the abnormal collateral veins disappeared or shrank immediately. Headache, tinnitus, papilledema and ICP were significantly ameliorated at 14 ± 3 days of follow-up (all P < 0.01). At 12 ± 5.6 months of outpatient follow-up, headache disappeared in 14 out of 15 patients (93.3%), visual impairments were recovered in 10 of 12 patients (83.3%) and tinnitus resolved in 10 out of 11 patients (90.9%). In 12 out of 15 cases, the Frisén papilledema grade scores declined to 1 (0-2). The stented IJVs in all 15 patients kept to sufficient blood flows on computed tomographic venography follow-up without stenting-related adverse events. CONCLUSIONS Non-thrombotic IJV stenosis may be a potential etiology of IIH. Stenting seems to be a promising option to address the issue of intracranial hypertension from the etiological level, particularly after medical treatment failure.
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Affiliation(s)
- D Zhou
- Departments of Neurology, Neurosurgery, and Ophthalmology, Xuanwu Hospital, Capital Medical University, Beijing, China.,Beijing Institute for Brain Disorders, Beijing, China
| | - R Meng
- Departments of Neurology, Neurosurgery, and Ophthalmology, Xuanwu Hospital, Capital Medical University, Beijing, China.,Beijing Institute for Brain Disorders, Beijing, China
| | - X Zhang
- Departments of Neurology, Neurosurgery, and Ophthalmology, Xuanwu Hospital, Capital Medical University, Beijing, China.,Beijing Institute for Brain Disorders, Beijing, China
| | - L Guo
- Departments of Neurology, Neurosurgery, and Ophthalmology, Xuanwu Hospital, Capital Medical University, Beijing, China.,Beijing Institute for Brain Disorders, Beijing, China
| | - S Li
- Departments of Neurology, Neurosurgery, and Ophthalmology, Xuanwu Hospital, Capital Medical University, Beijing, China.,Beijing Institute for Brain Disorders, Beijing, China
| | - W Wu
- Departments of Neurology, Neurosurgery, and Ophthalmology, Xuanwu Hospital, Capital Medical University, Beijing, China.,Beijing Institute for Brain Disorders, Beijing, China
| | - J Duan
- Departments of Neurology, Neurosurgery, and Ophthalmology, Xuanwu Hospital, Capital Medical University, Beijing, China.,Beijing Institute for Brain Disorders, Beijing, China
| | - H Song
- Departments of Neurology, Neurosurgery, and Ophthalmology, Xuanwu Hospital, Capital Medical University, Beijing, China.,Beijing Institute for Brain Disorders, Beijing, China
| | - Y Ding
- Beijing Institute for Brain Disorders, Beijing, China.,Department of Neurosurgery, Wayne State University School of Medicine, Detroit, MI, USA
| | - X Ji
- Departments of Neurology, Neurosurgery, and Ophthalmology, Xuanwu Hospital, Capital Medical University, Beijing, China.,Beijing Institute for Brain Disorders, Beijing, China
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Holbrook J, Saindane AM. Imaging of Intracranial Pressure Disorders. Neurosurgery 2017; 80:341-354. [PMID: 27471977 DOI: 10.1227/neu.0000000000001362] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2016] [Accepted: 05/26/2016] [Indexed: 01/03/2023] Open
Abstract
Intracranial pressure (ICP) is the pressure inside the bony calvarium and can be affected by a variety of processes, such as intracranial masses and edema, obstruction or leakage of cerebrospinal fluid, and obstruction of venous outflow. This review focuses on the imaging of 2 important but less well understood ICP disorders: idiopathic intracranial hypertension and spontaneous intracranial hypotension. Both of these ICP disorders have salient imaging findings that are important to recognize to help prevent their misdiagnosis from other common neurological disorders.
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Affiliation(s)
- John Holbrook
- Department of Radiology and Imaging Sciences, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Amit M Saindane
- Department of Radiology and Imaging Sciences, Emory University School of Medicine, Atlanta, Georgia, USA
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Hoffmann J. Impaired cerebrospinal fluid pressure. HANDBOOK OF CLINICAL NEUROLOGY 2017; 146:171-185. [PMID: 29110769 DOI: 10.1016/b978-0-12-804279-3.00011-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/24/2023]
Abstract
Abnormalities of cerebrospinal fluid (CSF) pressure are relatively common and may lead to a variety of symptoms, with headache usually being the most prominent one. The clinical presentation of alterations in CSF pressure may vary significantly and show a striking similitude to several primary headache syndromes. While an increase in CSF pressure may be of primary or secondary origin, a pathologic decrease of CSF pressure is usually the result of a meningeal rupture with a resulting leakage of CSF. The pathophysiologic mechanisms of idiopathic intracranial hypertension (IIH) remain largely unknown. However recent evidence indicates that an abnormality in CSF outflow and absorption is likely to play a significant role. Treatment usually consists of a combination of weight loss and a pharmacologic approach using carbonic anhydrase inhibitors. Recent results of the first randomized, double-blind, placebo-controlled trial (RCT) with acetazolamide proved its efficacy in reducing headache and visual disturbances. Clinical evidence suggests efficacy for topiramate and furosemide but no RCT has been conducted to date to confirm these results. In contrast to IIH, spontaneous intracranial hypotension frequently remits spontaneously without specific treatment. If necessary, treatment options range from conservative methods to epidural blood or fibrin sealant patches and surgical interventions.
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Affiliation(s)
- Jan Hoffmann
- Department of Systems Neuroscience, University Medical Center Hamburg-Eppendorf, Hamburg, Germany.
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Ottridge R, Mollan SP, Botfield H, Frew E, Ives NJ, Matthews T, Mitchell J, Rick C, Singhal R, Woolley R, Sinclair AJ. Randomised controlled trial of bariatric surgery versus a community weight loss programme for the sustained treatment of idiopathic intracranial hypertension: the Idiopathic Intracranial Hypertension Weight Trial (IIH:WT) protocol. BMJ Open 2017; 7:e017426. [PMID: 28963303 PMCID: PMC5623580 DOI: 10.1136/bmjopen-2017-017426] [Citation(s) in RCA: 51] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
INTRODUCTION Effective treatments are lacking for idiopathic intracranial hypertension (IIH), a condition characterised by raised intracranial pressure (ICP) and papilloedema, and found primarily in obese women. Weight loss and lowering body mass index (BMI) have been shown to lower ICP and improve symptoms in IIH; however, weight loss is typically not maintained, meaning IIH symptoms return. The Idiopathic Intracranial Hypertension Weight Trial (IIH:WT) will assess whether bariatric surgery is an effective long-term treatment for patients with IIH with a BMI over 35 kg/m2. The National Institute for Health and Care Excellence recommends bariatric surgery in people with a BMI over 35 kg/m2 and a qualifying comorbidity; currently IIH does not qualify as a comorbidity. METHODS AND ANALYSIS IIH:WT is a multicentre, open-label, randomised controlled clinical trial of 64 participants with active IIH and a BMI over 35 kg/m2. Participants will be randomised in a 1:1 ratio to bariatric surgery or a dietary weight loss programme and followed up for 5 years. The primary outcome measure is ICP at 12 months. Secondary outcome measures include ICP at 24 and 60 months, and IIH symptoms, visual function, papilloedema, headache, quality of life and cost-effectiveness at 12, 24 and 60 months. TRIAL REGISTRATION NUMBER IIH:WT is registered as ISRCTN40152829 and on ClinicalTrials.gov as NCT02124486 and is in the pre-results stage.
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Affiliation(s)
- Ryan Ottridge
- Birmingham Clinical Trials Unit, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
| | - Susan P Mollan
- Birmingham Neuro-Ophthalmology Unit, University Hospitals Birmingham, Queen Elizabeth Hospital, Birmingham, UK
| | - Hannah Botfield
- Institute of Metabolism and Systems Research, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
| | - Emma Frew
- Institute of Applied Health Research, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
| | - Natalie J Ives
- Birmingham Clinical Trials Unit, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
| | - Tim Matthews
- Birmingham Neuro-Ophthalmology Unit, University Hospitals Birmingham, Queen Elizabeth Hospital, Birmingham, UK
| | - James Mitchell
- 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
| | - Caroline Rick
- Birmingham Clinical Trials Unit, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
| | - Rishi Singhal
- Upper GI and Minimally Invasive Unit, Heartlands Hospital, Birmingham, UK
| | - Rebecca Woolley
- Birmingham Clinical Trials Unit, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
| | - Alexandra J Sinclair
- 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
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Abstract
BACKGROUND Most patients with idiopathic intracranial hypertension (IIH) are obese. Weight loss is felt to be an important factor in improving IIH. The mechanism by which weight loss leads to a reduction in elevated intracranial pressure is unclear. Evidence from prospective studies evaluating the role of weight loss in IIH is lacking. EVIDENCE ACQUISITION We performed a detailed review of the published literature regarding the association of IIH and obesity, including proposed pathogenetic mechanisms, and the effect of weight loss and weight-loss interventions in IIH. References were identified by searching PubMed with the terms idiopathic intracranial hypertension and weight loss. Additional citations were found in the identified references. RESULTS Over 90% of IIH patients are obese or overweight. The risk of IIH increases as a function of body mass index (BMI) and weight gain over the preceding year. The risk of IIH-induced vision loss also increases with increasing BMI, especially with BMI >40 kg/m. Several mechanisms have been proposed linking obesity to the development of IIH but the pathophysiology remains unknown. Published studies and clinical observations strongly support weight loss as an effective treatment, although there are no prospective controlled trials. Weight loss in the range of 6%-10% often leads to IIH remission. Weight loss of ≥5% at 1 year is achieved in roughly 50%-70% of patients if they are enrolled in a high-intensity lifestyle modification program and in 20%-35% of patients if they direct their own weight loss. Weight is typically regained over 1-3 years but about a third of patients maintain ≥5% weight loss over the long term. Patients treated initially with lifestyle modification therapy show a modest persisting benefit over self-directed patients. Selected commercial weight loss programs also may improve long-term maintenance of weight loss. New antiobesity drugs significantly improve the proportion of obese patients who have ≥5% loss of weight at 1 year. CONCLUSIONS Obesity is an important contributing factor for the development of IIH, although the pathophysiological mechanism linking obesity to IIH is unknown. The risk of developing IIH and associated visual loss increases with increasing BMI. Weight loss is an effective treatment for IIH. Long-term maintenance of initial weight loss is helped modestly by lifestyle modification programs and possibly by selected commercial weight loss programs. New antiobesity drugs may provide further options for IIH therapy in the future.
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Abstract
Idiopathic intracranial hypertension (IIH) is a disorder of elevated intracranial pressure of unknown cause occurring predominantly in young women of childbearing age. The typical patient symptom profile is the presence of daily headache, pulse synchronous tinnitus, transient visual obscurations, and papilledema with its associated visual loss. Although surgical procedures are performed for those who fail medical therapy, their relative efficacy remains unclear. The main morbidity of IIH is from visual loss. This visual loss is present in most patients and can usually be reversed if recognized early in the patients' course and treated.
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Stevens SM, Rizk HG, Golnik K, Andaluz N, Samy RN, Meyer TA, Lambert PR. Idiopathic intracranial hypertension: Contemporary review and implications for the otolaryngologist. Laryngoscope 2017; 128:248-256. [PMID: 28349571 DOI: 10.1002/lary.26581] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/16/2017] [Indexed: 11/11/2022]
Abstract
OBJECTIVES 1) Review controversies pertaining to the pathophysiology, diagnosis, and treatment of idiopathic intracranial hypertension. 2) Discuss the evolving role of otolaryngologists in managing this disease and related disorders. DATA SOURCES Primary literature review, Centers for Disease Control and Prevention website, International Classification of Headache Disorders, Second Edition. METHODS A comprehensive review of the primary literature was performed from 1990 to 2016 utilizing keywords idiopathic intracranial hypertension, pseudotumor cerebri, benign intracranial hypertension, spontaneous cerebrospinal fluid leak, and encephalocele. Articles were included at the discretion of the authors based on novel and/or historical contributions to the literature. RESULTS The incidence of idiopathic intracranial hypertension is increasing along with the obesity epidemic. Undiagnosed patients may present to otolaryngologists with pulsatile tinnitus, dizziness, sleep apnea, and spontaneous cerebrospinal fluid leaks. Although diagnosis is predicated upon imaging findings and lumbar puncture, radiographic signs including empty sella, optic nerve dilation, and globe flattening may suggest the diagnosis. The most effective intervention is weight loss combined with acetazolamide. Surgery is reserved for severe or refractory symptoms and can be highly morbid. Otolaryngologists are increasingly responsible for managing a number of secondary disorders including cerebrospinal fluid rhinorrhea and otorrhea. Failure to manage intracranial hypertension may lead to adverse surgical outcomes. CONCLUSIONS The knowledge base for idiopathic intracranial hypertension has greatly expanded over the past 25 years. This disease is associated with a number of conditions directly relevant to otolaryngologists. A keen understanding of this disorder and its management may optimize outcomes in a growing number of patients. Laryngoscope, 128:248-256, 2018.
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Affiliation(s)
- Shawn M Stevens
- Department of Otolaryngology-Head and Neck Surgery, University of Cincinnati, Cincinnati, Ohio, U.S.A
| | - Habib G Rizk
- Department of Otolaryngology-Head and Neck Surgery, Medical University of South Carolina, Charleston, South Carolina, U.S.A
| | - Karl Golnik
- Department of Ophthalmology, Cincinnati Eye Institute, Cincinnati, Ohio, U.S.A
| | - Norberto Andaluz
- Division of Skull Base Surgery, Mayfield Brain & Spine, Cincinnati, Ohio, U.S.A
| | - Ravi N Samy
- Department of Otolaryngology-Head and Neck Surgery, University of Cincinnati College of Medicine and Neurosensory Disorders Center at University of Cincinnati Neuroscience Institute, Cincinnati, Ohio, U.S.A
| | - Ted A Meyer
- Department of Otolaryngology-Head and Neck Surgery, Medical University of South Carolina, Charleston, South Carolina, U.S.A
| | - Paul R Lambert
- Department of Otolaryngology-Head and Neck Surgery, Medical University of South Carolina, Charleston, South Carolina, U.S.A
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An update on idiopathic intracranial hypertension. Acta Neurochir (Wien) 2017; 159:491-499. [PMID: 28013373 DOI: 10.1007/s00701-016-3050-7] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2016] [Accepted: 12/06/2016] [Indexed: 10/20/2022]
Abstract
BACKGROUND Idiopathic intracranial hypertension (IIH) is still a grey area in the knowledge of the aetiology, diagnosis and management of neurosurgical diseases. The definition of IIH has been reviewed over time and many hypotheses have been expressed as cause of the disease. The literature supplies very little evidence-based information to guide our decision-making process when it comes to treat the disease. In this review we sum up the latest information regarding the aetiology and therapy of IIH. Additionally, we make an attempt to unify the diagnostic criteria of Dandy, Friedman and Wall established from 1937 to date. METHOD In this narrative review, we attempt to update the current standpoint to IIH, evaluate the input until now and consider future directions for research. The vast majority of the literature consisted of cohort studies, case control studies, systematic reviews and other narrative reviews. RESULTS Pathophysiology: The incidence of IIH is steadily increasing. Several pathophysiological theories have been proposed in the literature based on the flow of cerebrospinal fluid. DIAGNOSIS We attempt to fuse all the three diagnostic approaches published in the literature that detect IIH, while preserving the individual characteristics of each approach. TREATMENT Based on evidence-based trials, the current use of acetazolamide in comparison with placebo or with topiramate has been evaluated. In the interventions' field, there seems to be a consonance about the alarming symptoms and what the most suitable operation is in each case. There is some disagreement about the indications for venous sinus transversus stenting and its risk/benefit ratio. CONCLUSIONS Until now there is no class I guideline to which our decision-making can be based on for the management of IIH. A lack of systematic reviews and randomised control trials has been noted. If we focused our research on that, we could develop a standardised treatment protocol.
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Bäuerle J, Egger K, Harloff A. Idiopathische intrakranielle Hypertension. DER NERVENARZT 2017; 88:191-200. [DOI: 10.1007/s00115-016-0279-6] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Gordon LK. Optic Nerve. Handb Exp Pharmacol 2017; 242:369-386. [PMID: 27787712 DOI: 10.1007/164_2016_19] [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: 06/06/2023]
Abstract
Optic nerve diseases arise from many different etiologies including inflammatory, neoplastic, genetic, infectious, ischemic, and idiopathic. Understanding some of the characteristics of the most common optic neuropathies along with therapeutic approaches to these diseases is helpful in designing recommendations for individual patients. Although many optic neuropathies have no specific treatment, some do, and it is those potentially treatable or preventable conditions which need to be recognized in order to help patients regain their sight or develop a better understanding of their own prognosis. In this chapter several diseases are discussed including idiopathic intracranial hypertension, optic neuritis, ischemic optic neuropathies, hereditary optic neuropathies, trauma, and primary tumors of the optic nerve. For each condition there is a presentation of the signs and symptoms of the disease, in some conditions the evaluation and diagnostic criteria are highlighted, and where possible, current therapy or past trials are discussed.
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Affiliation(s)
- Lynn K Gordon
- Stein Eye Institute, David Geffen School of Medicine at UCLA, Los Angeles, CA, 90095, USA.
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Lawton AW, Frisard NE. Visual Loss, Retinal Hemorrhages, and Optic Disc Edema Resulting From Thiamine Deficiency Following Bariatric Surgery Complicated by Prolonged Vomiting. Ochsner J 2017; 17:112-114. [PMID: 28331457 PMCID: PMC5349621] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/06/2023] Open
Abstract
BACKGROUND Vision loss resulting from thiamine deficiency is a recognized complication of bariatric surgery. Most patients with such vision loss have Wernicke encephalopathy with characteristic changes seen on neuroimaging. Other patients may have retinal hemorrhages, optic disc edema, and peripheral neuropathy without Wernicke encephalopathy. The risk for thiamine deficiency is potentiated by the presence of prolonged vomiting. CASE REPORT A 37-year-old female presented with abrupt onset of vision loss and peripheral neuropathy following bariatric surgery. She had a history of prolonged vomiting postoperatively. Examination of the posterior segment of the eye revealed optic disc edema and large retinal hemorrhages bilaterally. Metabolic workup demonstrated thiamine deficiency. She responded quickly to parenteral thiamine therapy with recovery of normal vision and resolution of ophthalmologic findings. CONCLUSION Patients who undergo bariatric surgery and have a thiamine deficiency can present with visual symptoms and ophthalmologic findings only visible by fundoscopy prior to developing more severe and potentially irreversible complications from the vitamin deficiency. Early detection of intraocular changes resulting from thiamine deficiency and initiation of therapy could prevent more devastating neurologic manifestations. Our case supports the consideration of a prospective study aimed at determining the true incidence of ocular and visual changes such as retinal hemorrhage, optic disc edema, and peripapillary telangiectasia in patients following bariatric surgery.
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Affiliation(s)
- Andrew W. Lawton
- Department of Ophthalmology, Ochsner Clinic Foundation, New Orleans, LA
| | - Nicholas E. Frisard
- Department of Ophthalmology, Louisiana State University Health Sciences Center, New Orleans, LA
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Kalyvas AV, Hughes M, Koutsarnakis C, Moris D, Liakos F, Sakas DE, Stranjalis G, Fouyas I. Efficacy, complications and cost of surgical interventions for idiopathic intracranial hypertension: a systematic review of the literature. Acta Neurochir (Wien) 2017; 159:33-49. [PMID: 27830325 DOI: 10.1007/s00701-016-3010-2] [Citation(s) in RCA: 47] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2016] [Accepted: 10/27/2016] [Indexed: 10/20/2022]
Abstract
BACKGROUND To define the efficacy, complication profile and cost of surgical options for treating idiopathic intracranial hypertension (IIH) with respect to the following endpoints: vision and headache improvement, normal CSF pressure restoration, papilloedema resolution, relapse rate, operative complications, cost of intervention and quality of life. METHODS A systematic review of the surgical treatment of IIH was carried out. Cochrane Library, MEDLINE and EMBASE databases were systematically searched from 1985 to 2014 to identify all relevant manuscripts written in English. Additional studies were identified by searching the references of retrieved papers and relative narrative reviews. RESULTS Forty-one (41) studies were included (36 case series and 5 case reports), totalling 728 patients. Three hundred forty-one patients were treated with optic nerve sheath fenestration (ONSF), 128 patients with lumboperitoneal shunting (LPS), 72 patients with ventriculoperitoneal shunting (VPS), 155 patients with venous sinus stenting and 32 patients with bariatric surgery. ONSF showed considerable efficacy in vision improvement, while CSF shunting had a superior headache response. Venous sinus stenting demonstrated satisfactory results in both vision and headache improvement along with the best complication profile and low relapse rate, but longer follow-up periods are needed. The complication rate of bariatric surgery was high when compared to other interventions and visual outcomes have not been reported adequately. ONSF had the lowest cost. CONCLUSIONS No surgical modality proved to be clearly superior to any other in IIH management. However, in certain contexts, a given approach appears more justified. Therefore, a treatment algorithm has been formulated, based on the extracted evidence of this review. The traditional treatment paradigm may need to be re-examined with sinus stenting as a first-line treatment modality.
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El Mekabaty A, Obuchowski NA, Luciano MG, John S, Chung CY, Moghekar A, Jones S, Hui FK. Predictors for venous sinus stent retreatment in patients with idiopathic intracranial hypertension. J Neurointerv Surg 2016; 9:1228-1232. [PMID: 27965382 DOI: 10.1136/neurintsurg-2016-012803] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2016] [Revised: 11/16/2016] [Accepted: 11/17/2016] [Indexed: 12/30/2022]
Abstract
BACKGROUND Venous sinus stenting for dural sinus stenoses is an emerging alternative to cerebrospinal fluid diversion in cases of medically refractory idiopathic intracranial hypertension. Juxta-stent 're-stenoses' have been reported and managed alternatively with ventricular shunting or stent revision. Identification of factors that might predispose patients to recurrent narrowing may help to select or exclude patients with idiopathic intracranial hypertension for venous sinus stenting. METHODS We retrospectively reviewed a prospectively maintained database spanning December 2011 to May 2015 of all patients with idiopathic intracranial hypertension who were screened for possible venous sinus stenting, including only patients who received a stent, noting symptomatic improvements, changes in opening lumbar puncture pressure, demographic characteristics, and any subsequent intervention after stent placement. Fisher's exact test and logistic regression were used to test each of seven potential predictors for retreatment. RESULTS There were eight revisions in 31 patients (25.8%). Among Caucasians, 8.0% required a revision compared with 100% of African-Americans (p<0.001). The c-index for race was 0.857. Body mass index (BMI) was also a significant predictor of revision (p=0.031): among class III obese patients the revision rate was 46.2% compared with 16.7% among class I and II obese patients and 0% among overweight to normal weight patients. CONCLUSIONS BMI was a significant predictor of revision, suggesting that higher BMI may have a higher risk of revision. The small number of African-Americans in the study makes interpretation of the practical significance of the revision rate in these patients uncertain. None of the other studied factors was statistically significant.
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Affiliation(s)
- Amgad El Mekabaty
- Department of Radiology, Johns Hopkins University, Baltimore, Maryland, USA
| | | | - Mark G Luciano
- Department of Neurosurgery, Johns Hopkins University, Baltimore, Maryland, USA
| | - Seby John
- Cerebrovascular Center, Neurological Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Charlotte Y Chung
- Department of Surgery, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Abhay Moghekar
- Department of Neurology, Johns Hopkins University, Baltimore, Maryland, USA
| | - Stephen Jones
- Imaging Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Ferdinand K Hui
- Department of Radiology, Johns Hopkins University, Baltimore, Maryland, USA
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Treatment of idiopathic intracranial hypertension with bariatric surgery. Neurologia 2016; 34:493-495. [PMID: 27939118 DOI: 10.1016/j.nrl.2016.10.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2016] [Revised: 10/03/2016] [Accepted: 10/13/2016] [Indexed: 11/23/2022] Open
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41
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Farmen AH, Ringstad G, Kerty E. [Idiopathic intracranial hypertension as a cause of headache]. TIDSSKRIFT FOR DEN NORSKE LEGEFORENING 2016; 136:1895-1898. [PMID: 27929555 DOI: 10.4045/tidsskr.16.0222] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022] Open
Abstract
Idiopathic intracranial hypertension (IIH) is characterised by increased intracranial pressure with normal cerebrospinal fluid, and no evidence of space occupying process, meningeal pathology or venous thrombosis. The condition is associated with obesity, especially in women of childbearing age. IIH is a rare but serious cause of headache, and constitutes a differential diagnosis for sudden-onset headache, particularly if the patient has visual disturbances not related to migraine and reports pulsatile tinnitus, cranial nerve palsy or radiculopathy.
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Affiliation(s)
- Anette Huuse Farmen
- Nevrologisk avdeling Oslo universitetssykehus, Rikshospitalet * Nåværende adresse: Nevrologisk avdeling Sykehuset Innlandet Lillehammer
| | - Geir Ringstad
- Nevroradiologisk enhet Klinikk for radiologi og nukleærmedisin Oslo universitetssykehus, Rikshospitalet
| | - Emilia Kerty
- Nevrologisk avdeling Oslo universitetssykehus, Rikshospitalet og Universitetet i Oslo
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Abstract
BACKGROUND As the prevalence of obesity increases, so, too, do the prevalences of weight-related diseases and surgical procedures to promote weight loss. It is important for neuro-ophthalmologists to be familiar with these procedures and possible downstream effects on afferent and efferent visual function. EVIDENCE ACQUISITION Review of ophthalmology, neurology, general surgery, obesity, endocrinology, nutrition, psychiatry, and neurosurgery literature. RESULTS Bariatric surgery is a safe and effective treatment for weight loss in obese individuals. There is Level IV evidence that it is associated with improvement in idiopathic intracranial hypertension (IIH). Laboratory nutrient deficiencies are common following some types of bariatric procedures. Symptomatic deficiencies are less common but can be devastating. Thiamine deficiency can cause nystagmus and other symptoms in weeks to months after surgery, whereas B12 or copper deficiency can cause optic neuropathy in years to decades following bariatric surgery. CONCLUSIONS Bariatric surgery is a potential treatment for IIH. Postoperative vitamin deficiencies may cause nystagmus, optic neuropathy, nyctalopia, and/or ophthalmoparesis weeks to years after surgery.
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Abstract
Aims: The aim was to identify Pseudotumor cerebri treatment options and assess their efficacy. Setting and Design: Review article. Materials and Methods: Existing literature and the authors’ experience were reviewed. Results: Treatment options range from observation to surgical intervention. Weight loss and medical treatment may be utilized in cases without vision loss or in combination with surgical treatment. Cerebrospinal fluid shunting procedures and/or optic nerve sheath decompression is indicated for severe vision loss or headache unresponsive to medical management. The recent use of endovascular stenting of transverse sinus stenoses has also demonstrated benefit in patients with pseudotumor cerebri. Conclusion: While each treatment form may be successful individually, a multimodal approach is typically utilized with treatments selected on a case-by-case basis.
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Mollan SP, Ali F, Hassan-Smith G, Botfield H, Friedman DI, Sinclair AJ. Evolving evidence in adult idiopathic intracranial hypertension: pathophysiology and management. J Neurol Neurosurg Psychiatry 2016; 87:982-92. [PMID: 26888960 PMCID: PMC5013119 DOI: 10.1136/jnnp-2015-311302] [Citation(s) in RCA: 146] [Impact Index Per Article: 18.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/01/2015] [Accepted: 01/19/2016] [Indexed: 01/12/2023]
Abstract
Idiopathic intracranial hypertension (IIH) is a rare but important disease associated with significant morbidity. There is an expected rise in prevalence in line with the escalating global burden of obesity. Modern revisions in the terminology and diagnostic criteria for IIH help guide clinicians in investigations and researchers in standardising recruitment criteria for clinical trials. The pathophysiology of IIH is incompletely characterised; suggested underpinning mechanisms include the role of cerebrospinal fluid regulation as well as metabolic and endocrinological perspectives. Recent treatment trials are providing insights into the management but debate still surrounds key areas in treatment. This review will provide an up-to-date discussion on the potential pathogenic mechanisms and management of IIH.
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Affiliation(s)
- Susan P Mollan
- Birmingham Neuro-Ophthalmology Unit, Ophthalmology Department, University Hospitals Birmingham NHS Trust, Queen Elizabeth Hospital Birmingham, Birmingham, UK
| | - Fizzah Ali
- Neurometabolism, Institute of Metabolism and Systems Research, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
| | - Ghaniah Hassan-Smith
- Neurometabolism, Institute of Metabolism and Systems Research, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK Neurology Department, University Hospitals Birmingham NHS Trust, Queen Elizabeth Hospital Birmingham, Birmingham, UK
| | - Hannah Botfield
- Neurometabolism, Institute of Metabolism and Systems Research, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
| | - Deborah I Friedman
- Department of Neurology and Neurotherapeutics, University of Texas Southwestern Medical Center, Dallas, Texas, USA Department of Ophthalmology, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Alexandra J Sinclair
- Neurometabolism, Institute of Metabolism and Systems Research, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK Neurology Department, University Hospitals Birmingham NHS Trust, Queen Elizabeth Hospital Birmingham, Birmingham, UK
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De Luca M, Angrisani L, Himpens J, Busetto L, Scopinaro N, Weiner R, Sartori A, Stier C, Lakdawala M, Bhasker AG, Buchwald H, Dixon J, Chiappetta S, Kolberg HC, Frühbeck G, Sarwer DB, Suter M, Soricelli E, Blüher M, Vilallonga R, Sharma A, Shikora S. Indications for Surgery for Obesity and Weight-Related Diseases: Position Statements from the International Federation for the Surgery of Obesity and Metabolic Disorders (IFSO). Obes Surg 2016; 26:1659-96. [PMID: 27412673 PMCID: PMC6037181 DOI: 10.1007/s11695-016-2271-4] [Citation(s) in RCA: 183] [Impact Index Per Article: 22.9] [Reference Citation Analysis] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Affiliation(s)
- Maurizio De Luca
- Director Department of Surgery, Montebelluna Treviso Hospital, Montebelluna, Treviso, Italy.
| | | | - Jacques Himpens
- The European School of Laparoscopic Surgery, Brussels, Belgium
| | | | | | | | - Alberto Sartori
- Director Department of Surgery, Montebelluna Treviso Hospital, Montebelluna, Treviso, Italy
| | | | | | | | | | - John Dixon
- Baker IDI Heart and Diabetes Institute, Melbourne, Australia
| | | | | | | | | | - Michel Suter
- University Hospital of Lausanne, Lausanne, Switzerland
| | | | - Mattias Blüher
- Department of Medicine, University of Leipzig, Leipzig, Germany
| | | | - Arya Sharma
- Obesity Research Management, University of Alberta, Edmonton, Canada
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Jensen RH, Radojicic A, Yri H. The diagnosis and management of idiopathic intracranial hypertension and the associated headache. Ther Adv Neurol Disord 2016; 9:317-26. [PMID: 27366239 PMCID: PMC4916517 DOI: 10.1177/1756285616635987] [Citation(s) in RCA: 44] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023] Open
Abstract
Idiopathic intracranial hypertension (IIH) is a challenging disorder with a rapid increasing incidence due to a close relation to obesity. The onset of symptoms is often insidious and patients may see many different specialists before the IIH diagnosis is settled. A summary of diagnosis, symptoms, headache characteristics and course, as well as existing evidence of treatment strategies is presented and strategies for investigations and management are proposed.
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Affiliation(s)
- Rigmor Højland Jensen
- Danish Headache Center, Department of Neurology, Rigshospitalet-Glostrup, University of Copenhagen, Denmark
| | | | - Hanne Yri
- Danish Headache Center, Department of Neurology, University of Copenhagen, Rigshospitalet-Glostrup, 2600 Glostrup, Denmark
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Menger RP, Kalakoti P, Nanda A. Lumbopleural Shunting as an Alternative Cerebrospinal Fluid Diversion Modality for Management of Idiopathic Intracranial Hypertension: Is It Time for a Change? World Neurosurg 2016; 90:632-635. [DOI: 10.1016/j.wneu.2016.01.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2016] [Accepted: 01/08/2016] [Indexed: 10/22/2022]
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Markey KA, Uldall M, Botfield H, Cato LD, Miah MAL, Hassan-Smith G, Jensen RH, Gonzalez AM, Sinclair AJ. Idiopathic intracranial hypertension, hormones, and 11β-hydroxysteroid dehydrogenases. J Pain Res 2016; 9:223-32. [PMID: 27186074 PMCID: PMC4847593 DOI: 10.2147/jpr.s80824] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Idiopathic intracranial hypertension (IIH) results in raised intracranial pressure (ICP) leading to papilledema, visual dysfunction, and headaches. Obese females of reproductive age are predominantly affected, but the underlying pathological mechanisms behind IIH remain unknown. This review provides an overview of pathogenic factors that could result in IIH with particular focus on hormones and the impact of obesity, including its role in neuroendocrine signaling and driving inflammation. Despite occurring almost exclusively in obese women, there have been a few studies evaluating the mechanisms by which hormones and adipokines exert their effects on ICP regulation in IIH. Research involving 11β-hydroxysteroid dehydrogenase type 1, a modulator of glucocorticoids, suggests a potential role in IIH. Improved understanding of the complex interplay between adipose signaling factors such as adipokines, steroid hormones, and ICP regulation may be key to the understanding and future management of IIH.
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Affiliation(s)
- Keira A Markey
- Neurometabolism, Institute of Metabolism and Systems Research, University of Birmingham, Birmingham, UK
| | - Maria Uldall
- Danish Headache Center, Clinic of Neurology, Rigshospitalet-Glostrup, University of Copenhagen, Glostrup, Denmark
| | - Hannah Botfield
- Neurometabolism, Institute of Metabolism and Systems Research, University of Birmingham, Birmingham, UK
| | - Liam D Cato
- Neurometabolism, Institute of Metabolism and Systems Research, University of Birmingham, Birmingham, UK
| | - Mohammed A L Miah
- Neurometabolism, Institute of Metabolism and Systems Research, University of Birmingham, Birmingham, UK
| | - Ghaniah Hassan-Smith
- Neurometabolism, Institute of Metabolism and Systems Research, University of Birmingham, Birmingham, UK
| | - Rigmor H Jensen
- Danish Headache Center, Clinic of Neurology, Rigshospitalet-Glostrup, University of Copenhagen, Glostrup, Denmark
| | - Ana M Gonzalez
- Neurometabolism, Institute of Metabolism and Systems Research, University of Birmingham, Birmingham, UK
| | - Alexandra J Sinclair
- Neurometabolism, Institute of Metabolism and Systems Research, University of Birmingham, Birmingham, UK
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Julayanont P, Karukote A, Ruthirago D, Panikkath D, Panikkath R. Idiopathic intracranial hypertension: ongoing clinical challenges and future prospects. J Pain Res 2016; 9:87-99. [PMID: 26929666 PMCID: PMC4767055 DOI: 10.2147/jpr.s60633] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023] Open
Abstract
Idiopathic intracranial hypertension (IIH) is an uncommon disorder characterized by increased intracranial pressure without radiological or laboratory evidence of intracranial pathology except empty sella turcica, optic nerve sheath with filled out cerebrospinal fluid spaces, and smooth-walled nonflow-related venous sinus stenosis or collapse. This condition typically affects obese women. The incidence of IIH is increasing with the rising prevalence of obesity. Persistent headache is the most common symptom. Visual impairment is a serious complication that may not be recognized by the patients. This paper reviews clinical manifestations, diagnostic challenges, and current treatments of IIH in adults. Various imaging modalities have been studied on their validity for detection of IIH and papilledema. This review also includes new studies on medical, surgical, and interventional management of this condition. Acetazolamide and topiramate are the only two medications that have been studied in randomized controlled trials about their efficacy in treatment of IIH. In patients who have severe visual impairment or progressive visual deterioration despite medical management, surgical or interventional treatment may be considered. The efficacy and complications of cerebrospinal fluid diversion, optic nerve sheath fenestration, and endovascular venous stenting reported in the last 3 decades have been summarized in this review. Finally, the prospective aspects of biomarkers and treatments are proposed for future research.
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Affiliation(s)
- Parunyou Julayanont
- Department of Neurology, Texas Tech University Health Science Center, Lubbock, TX, USA
| | - Amputch Karukote
- Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Doungporn Ruthirago
- Department of Neurology, Texas Tech University Health Science Center, Lubbock, TX, USA
| | - Deepa Panikkath
- Department of Internal Medicine, Texas Tech University Health Science Center, Lubbock, TX, USA
| | - Ragesh Panikkath
- Department of Internal Medicine, Texas Tech University Health Science Center, Lubbock, TX, USA
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50
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Markey KA, Mollan SP, Jensen RH, Sinclair AJ. Understanding idiopathic intracranial hypertension: mechanisms, management, and future directions. Lancet Neurol 2016; 15:78-91. [PMID: 26700907 DOI: 10.1016/s1474-4422(15)00298-7] [Citation(s) in RCA: 271] [Impact Index Per Article: 33.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2015] [Revised: 09/07/2015] [Accepted: 10/13/2015] [Indexed: 01/10/2023]
Abstract
Idiopathic intracranial hypertension is a disorder characterised by raised intracranial pressure that predominantly affects young, obese women. Pathogenesis has not been fully elucidated, but several causal factors have been proposed. Symptoms can include headaches, visual loss, pulsatile tinnitus, and back and neck pain, but the clinical presentation is highly variable. Although few studies have been done to support evidence-based management, several recent advances have the potential to enhance understanding of the causes of the disease and to guide treatment decisions. Investigators of the Idiopathic Intracranial Hypertension Treatment Trial (IIHTT) reported beneficial effects of acetazolamide in patients with mild visual loss. Studies have also established weight loss as an effective disease-modifying treatment, and further clinical trials to investigate new treatments are underway. The incidence of idiopathic intracranial hypertension is expected to increase as rates of obesity increase; efforts to reduce diagnostic delays and identify new, effective approaches to treatment will be key to meeting the needs of a growing number of patients.
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Affiliation(s)
- Keira A Markey
- Neurometabolism Institute of Metabolism and Systems Research, College of Medical and Dental Sciences, University of Birmingham, Edgbaston, Birmingham, UK
| | - Susan P Mollan
- Neurometabolism Institute of Metabolism and Systems Research, College of Medical and Dental Sciences, University of Birmingham, Edgbaston, Birmingham, UK; Birmingham Neuro-Ophthalmology Unit, Ophthalmology Department, University Hospitals Birmingham NHS Trust, Queen Elizabeth Hospital Birmingham, Birmingham, UK
| | - Rigmor H Jensen
- Danish Headache Centre, Department of Neurology, Glostrup Hospital, University of Copenhagen, Copenhagen, Denmark
| | - Alexandra J Sinclair
- Neurometabolism Institute of Metabolism and Systems Research, College of Medical and Dental Sciences, University of Birmingham, Edgbaston, Birmingham, UK.
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