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Hsu HT, Cheng HC, Hou TW, Tzeng YS, Fuh JL, Chen SP, Chen WT, Lee WJ, Pai YW, Lee YC, Lirng JF, Wang SJ, Wang YF. Idiopathic intracranial hypertension in Asians: a retrospective dual-center study. J Headache Pain 2024; 25:144. [PMID: 39232671 PMCID: PMC11373263 DOI: 10.1186/s10194-024-01852-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2024] [Accepted: 08/29/2024] [Indexed: 09/06/2024] Open
Abstract
BACKGROUND There have been limited data on idiopathic intracranial hypertension (IIH) in Asians and there remain uncertainties whether a cerebrospinal fluid (CSF) pressure of 250 mm CSF is an optimum diagnostic cutoff. The aims of the present study included (1) characterization of IIH patients in Taiwan, (2) comparisons among different diagnostic criteria for IIH, and (3) comparisons between patients with CSF pressures of > 250 and 200-250 mm CSF. METHODS This retrospective study involved IIH patients based on the modified Dandy criteria from two tertiary medical centers in Taiwan. Clinical manifestations were retrieved from electronic medical records, and findings on ophthalmologic examination and magnetic resonance images (MRIs) were reviewed. RESULTS A total of 102 patients (71 F/31 M, mean age 33.4 ± 12.2 years, mean CSF pressure 282.5 ± 74.5 mm CSF) were identified, including 46 (45.1%) with obesity (body-mass index ≥ 27.5), and 57 (62.6%) with papilledema. Overall, 80 (78.4%), 55 (53.9%), 51 (50.0%), and 58 (56.9%) patients met the Second and Third Edition of International Classification of Headache Disorders, Friedman, and Korsbæk criteria, respectively. Patients in the 200-250 mm CSF group (n = 40) were less likely to have papilledema (48.5% vs. 70.7%, p = 0.035), transient visual obscuration (12.5% vs. 33.9%, p = 0.005), and horizontal diplopia (10.0% vs. 30.6%, p = 0.006), and had fewer signs on MRIs (2.2 ± 1.3 vs. 2.8 ± 1.0, p = 0.021) when compared with those with CSF pressures > 250 mm CSF (n = 62). However, the percentages of patients with headache (95.0% vs. 87.1%, p = 0.109) at baseline, chronic migraine at six months (31.6% vs. 25.0%, p = 0.578), and visual field defect (86.7% vs. 90.3%, p = 0.709) were similar. CONCLUSIONS It was found that obesity and papilledema were less common in Asian IIH patients when compared with Caucasian patients. Although patients with CSF pressures of 200-250 mm CSF had a less severe phenotype, the risks of having headache or visual loss were comparable to those in the > 250 mm CSF group. It is possible that a diagnostic cutoff of > 200 mm CSF could be more suitable for Asians, although further studies are still needed.
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Grants
- 110-2321-B-010-005, 111-2321-B-A49-004, 111-2314-B-075 -086 -MY3, 111-2321-B-A49-011, and 112-2321-B-075-007 National Science and Technology Council
- 109-2314-B-075 -054 and 110-2314-B-075 -041 -MY3 National Science and Technology Council
- MOHW112-TDU-B-211-144001 Ministry of Health and Welfare
- V108C-092, V109C-096, V110C-111, V111C-161, V112C-078, V113C-123, and V112D67-003-MY3 Taipei Veterans General Hospital
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Affiliation(s)
- Hsiang-Ting Hsu
- Department of Neurology, Neurological Institute, Taipei Veterans General Hospital, Taipei, Taiwan
- College of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Hui-Chen Cheng
- College of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
- Department of Ophthalmology, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Tsung-Wei Hou
- Department of Neurology, Neurological Institute, Taichung Veterans General Hospital, Taichung, Taiwan
| | - Yi-Shiang Tzeng
- Department of Neurology, Neurological Institute, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Jong-Ling Fuh
- Department of Neurology, Neurological Institute, Taipei Veterans General Hospital, Taipei, Taiwan
- College of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
- Brain Research Center, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Shih-Pin Chen
- Department of Neurology, Neurological Institute, Taipei Veterans General Hospital, Taipei, Taiwan
- College of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
- Brain Research Center, National Yang Ming Chiao Tung University, Taipei, Taiwan
- Division of Translational Research, Department of Medical Research, Taipei Veterans General Hospital, Taipei, Taiwan
- Institute of Clinical Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Wei-Ta Chen
- Department of Neurology, Neurological Institute, Taipei Veterans General Hospital, Taipei, Taiwan
- College of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
- Brain Research Center, National Yang Ming Chiao Tung University, Taipei, Taiwan
- Department of Neurology, Keelung Hospital, Ministry of Health and Welfare, Keelung, Taiwan
| | - Wei-Ju Lee
- College of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
- Department of Neurology, Neurological Institute, Taichung Veterans General Hospital, Taichung, Taiwan
- Brain Research Center, National Yang Ming Chiao Tung University, Taipei, Taiwan
- Department of Post-Baccalaureate Medicine, College of Medicine, National Chung Hsing University, Taichung, Taiwan
| | - Yen-Wei Pai
- Department of Neurology, Neurological Institute, Taichung Veterans General Hospital, Taichung, Taiwan
- Department of Post-Baccalaureate Medicine, College of Medicine, National Chung Hsing University, Taichung, Taiwan
| | - Yi-Chung Lee
- Department of Neurology, Neurological Institute, Taipei Veterans General Hospital, Taipei, Taiwan
- College of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
- Brain Research Center, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Jiing-Feng Lirng
- College of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
- Brain Research Center, National Yang Ming Chiao Tung University, Taipei, Taiwan
- Department of Radiology, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Shuu-Jiun Wang
- Department of Neurology, Neurological Institute, Taipei Veterans General Hospital, Taipei, Taiwan
- College of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
- Brain Research Center, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Yen-Feng Wang
- Department of Neurology, Neurological Institute, Taipei Veterans General Hospital, Taipei, Taiwan.
- College of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan.
- Brain Research Center, National Yang Ming Chiao Tung University, Taipei, Taiwan.
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Markowitz D, Aamodt WW, Hamedani AG. Social Determinants of Health in Idiopathic Intracranial Hypertension. J Neuroophthalmol 2024; 44:346-349. [PMID: 38170607 DOI: 10.1097/wno.0000000000002073] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2024]
Abstract
BACKGROUND Idiopathic intracranial hypertension (IIH) disproportionately affects women from socioeconomically disadvantaged communities, but specific social determinants of health have not been examined. METHODS We used data from the National Institutes of Health's All of Us Research Program, an ongoing nationwide study of more than 300,000 diverse individuals in the United States. Height and weight were measured at baseline, and participants completed questionnaires about demographics, health care access, and quality of life. Women aged 18-50 years with IIH were identified through electronic health record data, excluding those with venous thrombosis, meningitis, hydrocephalus, or central nervous system neoplasms. We used logistic regression to compare questionnaire responses for IIH cases and controls, adjusting for age, race, ethnicity, annual income, and body mass index (BMI). RESULTS We included 416 women with IIH and 107,111 women without IIH. The mean age was 38 years, and 49.3% identified as non-White. After adjusting for age, race/ethnicity, and BMI, women with IIH were more likely to be unemployed (odds ratio [OR] 1.40, 95% confidential interval [CI]: 1.14-1.71) and report delaying care because of difficulty affording copays (OR 1.47, 95% CI: 1.02-2.10) or specialist care (OR 1.52, 95% CI: 1.06-2.18). They also delayed care because of rural residence (OR 2.08, 95% CI: 1.25-3.47) and transportation limitations (OR 2.23, 95% CI: 1.55-3.20). Although women with IIH were more likely to be non-Hispanic Black (OR 1.66, 95% CI: 1.32-2.09), this association lost significance when controlling for BMI and income (OR 1.27, 95% CI: 0.96-1.68). CONCLUSIONS Women with IIH experience adverse social determinants of health beyond those associated with obesity alone.
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Affiliation(s)
- Daniel Markowitz
- Drexel University School of Medicine (DM), Philadelphia, Pennsylvania; Departments of Neurology (WWA, AGH), Ophthalmology (AGH), and Biostatistics, Epidemiology, and Informatics (AGH), Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
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Zhou C, Zhou Y, Liu L, Jiang H, Wei H, Zhou C, Ji X. Progress and recognition of idiopathic intracranial hypertension: A narrative review. CNS Neurosci Ther 2024; 30:e14895. [PMID: 39097911 PMCID: PMC11298205 DOI: 10.1111/cns.14895] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2024] [Revised: 06/03/2024] [Accepted: 07/19/2024] [Indexed: 08/06/2024] Open
Abstract
BACKGROUND Idiopathic intracranial hypertension (IIH) mainly affects obese young women, causing elevated intracranial pressure, headaches, and papilledema, risking vision loss and severe headaches. Despite weight loss as the primary treatment, the underlying mechanisms remain unclear. Recent research explores novel therapeutic targets. AIMS This review aimed to provide a comprehensive understanding of IIH's pathophysiology and clinical features to inform pathogenesis and improve treatment strategies. METHODS Recent publications on IIH were searched and summarized using PubMed, Web of Science, and MEDLINE. RESULTS The review highlights potential pathomechanisms and therapeutic advances in IIH. CONCLUSION IIH incidence is rising, with growing evidence linking it to metabolic and hormonal disturbances. Early diagnosis and treatment remain challenging.
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Affiliation(s)
- Chenxia Zhou
- Department of NeurologyXuanwu Hospital, Capital Medical UniversityBeijingChina
- Neurology and Intracranial Hypertension and Cerebral Venous Disease CenterNational Health Commission of China, Xuanwu Hospital, Capital Medical UniversityBeijingChina
| | - Yifan Zhou
- Laboratory of Brain Disorders, Ministry of Science and Technology, Collaborative Innovation Center for Brain DisordersBeijing Institute of Brain Disorders, Beijing Advanced Innovation Center for Big Data‐based Precision Medicine, Capital Medical UniversityBeijingChina
| | - Lu Liu
- Department of NeurologyXuanwu Hospital, Capital Medical UniversityBeijingChina
- Neurology and Intracranial Hypertension and Cerebral Venous Disease CenterNational Health Commission of China, Xuanwu Hospital, Capital Medical UniversityBeijingChina
- Zhongguancun Xirui Institute of Precision Medicine for Heart and Brain TumorsBeijingChina
| | - Huimin Jiang
- Laboratory of Brain Disorders, Ministry of Science and Technology, Collaborative Innovation Center for Brain DisordersBeijing Institute of Brain Disorders, Beijing Advanced Innovation Center for Big Data‐based Precision Medicine, Capital Medical UniversityBeijingChina
| | - Huimin Wei
- Beijing Advanced Innovation Center for Big Data‐Based Precision MedicineSchool of Biological Science and Medical Engineering, Beihang UniversityBeijingChina
| | - Chen Zhou
- Neurology and Intracranial Hypertension and Cerebral Venous Disease CenterNational Health Commission of China, Xuanwu Hospital, Capital Medical UniversityBeijingChina
- Laboratory of Brain Disorders, Ministry of Science and Technology, Collaborative Innovation Center for Brain DisordersBeijing Institute of Brain Disorders, Beijing Advanced Innovation Center for Big Data‐based Precision Medicine, Capital Medical UniversityBeijingChina
| | - Xunming Ji
- Neurology and Intracranial Hypertension and Cerebral Venous Disease CenterNational Health Commission of China, Xuanwu Hospital, Capital Medical UniversityBeijingChina
- Laboratory of Brain Disorders, Ministry of Science and Technology, Collaborative Innovation Center for Brain DisordersBeijing Institute of Brain Disorders, Beijing Advanced Innovation Center for Big Data‐based Precision Medicine, Capital Medical UniversityBeijingChina
- Department of NeurosurgeryXuanwu Hospital, Capital Medical UniversityBeijingChina
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Colman BD, Boonstra F, Nguyen MN, Raviskanthan S, Sumithran P, White O, Hutton EJ, Fielding J, van der Walt A. Understanding the pathophysiology of idiopathic intracranial hypertension (IIH): a review of recent developments. J Neurol Neurosurg Psychiatry 2024; 95:375-383. [PMID: 37798095 DOI: 10.1136/jnnp-2023-332222] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/17/2023] [Accepted: 09/15/2023] [Indexed: 10/07/2023]
Abstract
Idiopathic intracranial hypertension (IIH) is a condition of significant morbidity and rising prevalence. It typically affects young people living with obesity, mostly women of reproductive age, and can present with headaches, visual abnormalities, tinnitus and cognitive dysfunction. Raised intracranial pressure without a secondary identified cause remains a key diagnostic feature of this condition, however, the underlying pathophysiological mechanisms that drive this increase are poorly understood. Previous theories have focused on cerebrospinal fluid (CSF) hypersecretion or impaired reabsorption, however, the recent characterisation of the glymphatic system in many other neurological conditions necessitates a re-evaluation of these hypotheses. Further, the impact of metabolic dysfunction and hormonal dysregulation in this population group must also be considered. Given the emerging evidence, it is likely that IIH is triggered by the interaction of multiple aetiological factors that ultimately results in the disruption of CSF dynamics. This review aims to provide a comprehensive update on the current theories regarding the pathogenesis of IIH.
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Affiliation(s)
- Blake D Colman
- Department of Neuroscience, Monash University Faculty of Medicine Nursing and Health Sciences, Clayton, Victoria, Australia
- Department of Neurology, Alfred Hospital, Melbourne, Victoria, Australia
| | - Frederique Boonstra
- Department of Neuroscience, Monash University Faculty of Medicine Nursing and Health Sciences, Clayton, Victoria, Australia
| | - Minh Nl Nguyen
- Department of Neuroscience, Monash University Faculty of Medicine Nursing and Health Sciences, Clayton, Victoria, Australia
- Department of Neurology, Alfred Hospital, Melbourne, Victoria, Australia
| | | | - Priya Sumithran
- Department of Surgery, Monash University Faculty of Medicine Nursing and Health Sciences, Clayton, Victoria, Australia
- Department of Endocrinology, Alfred Hospital, Melbourne, Victoria, Australia
| | - Owen White
- Department of Neurology, Alfred Hospital, Melbourne, Victoria, Australia
- Department of Neuroscience, Monash University Central Clinical School, Clayton, Victoria, Australia
| | - Elspeth J Hutton
- Department of Neuroscience, Monash University Faculty of Medicine Nursing and Health Sciences, Clayton, Victoria, Australia
- Department of Neurology, Alfred Hospital, Melbourne, Victoria, Australia
| | - Joanne Fielding
- Department of Neuroscience, Monash University Faculty of Medicine Nursing and Health Sciences, Clayton, Victoria, Australia
| | - Anneke van der Walt
- Department of Neuroscience, Monash University Faculty of Medicine Nursing and Health Sciences, Clayton, Victoria, Australia
- Department of Neurology, Alfred Hospital, Melbourne, Victoria, Australia
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Toshniwal SS, Kinkar J, Chadha Y, Khurana K, Reddy H, Kadam A, Acharya S. Navigating the Enigma: A Comprehensive Review of Idiopathic Intracranial Hypertension. Cureus 2024; 16:e56256. [PMID: 38623134 PMCID: PMC11016992 DOI: 10.7759/cureus.56256] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2024] [Accepted: 03/16/2024] [Indexed: 04/17/2024] Open
Abstract
An unidentified source of increased intracranial pressure is a hallmark of idiopathic intracranial hypertension (IIH), also referred to as pseudotumor cerebri. It mainly affects young, obese women, yet it can happen to anyone, regardless of age, gender, or weight. IIH presents with symptoms such as headaches, visual disturbances, and pulsatile tinnitus and can lead to severe complications, including vision loss, if left untreated. Diagnosis involves clinical evaluation, neuroimaging, and lumbar puncture, while management options include medical interventions and surgical procedures. This review provides a comprehensive overview of IIH, including its etiology, clinical presentation, epidemiology, complications, management approaches, and challenges. Increased awareness among healthcare professionals, standardized diagnostic criteria, and further research efforts are essential for improving outcomes and quality of life for individuals with IIH.
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Affiliation(s)
- Saket S Toshniwal
- Medicine, Jawaharlal Nehru Medical College, Datta Meghe Institute of Higher Education & Research, Wardha, IND
| | - Jiwan Kinkar
- Neurology, Jawaharlal Nehru Medical College, Datta Meghe Institute of Higher Education & Research, Nagpur, IND
| | - Yatika Chadha
- Psychiatry, Jawaharlal Nehru Medical College, Datta Meghe Institute of Higher Education & Research, Wardha, IND
| | - Kashish Khurana
- Medicine, Jawaharlal Nehru Medical College, Datta Meghe Institute of Higher Education & Research, Wardha, IND
| | - Harshitha Reddy
- Medicine, Jawaharlal Nehru Medical College, Datta Meghe Institute of Higher Education & Research, Wardha, IND
| | - Abhinav Kadam
- Medicine, Jawaharlal Nehru Medical College, Datta Meghe Institute of Higher Education & Research, Wardha, IND
| | - Sourya Acharya
- Medicine, Jawaharlal Nehru Medical College, Datta Meghe Institute of Higher Education & Research, Wardha, IND
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Jirapanyayut P, March de Ribot F, March de Ribot A. Idiopathic intracranial hypertension in two twin sisters. BMJ Case Rep 2024; 17:e256423. [PMID: 38367985 PMCID: PMC10875562 DOI: 10.1136/bcr-2023-256423] [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: 02/19/2024] Open
Abstract
Idiopathic intracranial hypertension (IIH) is a condition of unknown aetiology characterised by an increase in the intracranial pressure. Familial cases of IIH are rare and not well-understood. We present two monozygotic twins who developed IIH two years apart. The case involves two monozygotic female twins developing IIH in their 50s. They presented with a history of blurry vision and headaches. The diagnosis included the neurological, radiological and ophthalmological examination, excluding other causes. Both patients received treatment with acetazolamide, successfully resolving the papilloedema and restoring a normal visual field. This case highlights the occurrence of IIH among twins presenting at similar periods, emphasising the potential genetic influence. Clinicians should alert and educate the family regarding the risk factors and potential symptoms of this condition in the unlikely occurrence that other family members are affected.
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Shaia JK, Sharma N, Kumar M, Chu J, Maatouk C, Talcott K, Singh R, Cohen DA. Changes in Prevalence of Idiopathic Intracranial Hypertension in the United States Between 2015 and 2022, Stratified by Sex, Race, and Ethnicity. Neurology 2024; 102:e208036. [PMID: 38181397 PMCID: PMC11097766 DOI: 10.1212/wnl.0000000000208036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2023] [Accepted: 10/13/2023] [Indexed: 01/07/2024] Open
Abstract
BACKGROUND AND OBJECTIVES With the obesity epidemic within the United States, the prevalence of idiopathic intracranial hypertension (IIH) is predicted to rise. IIH prevalence and racial disparities have rarely been reported in the United States. The purpose of this study was to evaluate the prevalence of IIH in a large national database while stratifying by sex, age, race, and ethnicity. METHODS This was a cross-sectional epidemiologic evaluation conducted in the TriNetX US Collaborative network using data from 2015 to 2022. Patients with an International Classification of Diseases code of IIH and papilledema or unspecified papilledema were included in the study. Any secondary cause of intracranial hypertension including cerebral neoplasms and hydrocephalus were excluded from the study. IIH trends were later compared with TriNetX cohort obesity trends. Prevalence and prevalence odds ratios (ORs) were calculated in Microsoft Excel and R Studio. RESULTS Among 85 million patients in this database, a 1.35 times increase in the prevalence of IIH occurred between 2015 and 2022 from 7.3 (95% CI 6.9-7.7) individuals per 100,000 to 9.9 (95% CI 9.5-10.3) individuals per 100,000 in 2022. In 2022, Black female individuals had the highest prevalence of IIH with 22.7 individuals per 100,000 compared with the 13.7 White female individuals per 100,000. Patients aged 11-17 years showed the largest growth of IIH prevalence with female individuals increasing by 10 individuals per 100,000 by 2022. Overall, Black and Hispanic patients had the largest prevalence OR of IIH at 1.66 (95% CI 1.49-1.85) and 1.33 (95% CI 1.14-1.56), respectively, compared with White female patients. DISCUSSION IIH is a rapidly increasing health care concern for the US population, particularly among adolescent patients. Black and Hispanic female individuals are most predominately affected by this incapacitating disorder.
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Affiliation(s)
- Jacqueline K Shaia
- From the Case Western Reserve University School of Medicine (J.K.S., N.S., M.K., J.C., C.M.); Center for Ophthalmic Bioinformatics Research at the Cole Eye Institute (J.K.S., N.S., M.K., J.C., C.M., K.T., R.S.), Cleveland; Cole Eye Institute (K.T., D.A.C.), Cleveland Clinic, OH; and Cleveland Clinic Martin Hospitals (R.S.), Stuart, FL
| | - Neha Sharma
- From the Case Western Reserve University School of Medicine (J.K.S., N.S., M.K., J.C., C.M.); Center for Ophthalmic Bioinformatics Research at the Cole Eye Institute (J.K.S., N.S., M.K., J.C., C.M., K.T., R.S.), Cleveland; Cole Eye Institute (K.T., D.A.C.), Cleveland Clinic, OH; and Cleveland Clinic Martin Hospitals (R.S.), Stuart, FL
| | - Madhukar Kumar
- From the Case Western Reserve University School of Medicine (J.K.S., N.S., M.K., J.C., C.M.); Center for Ophthalmic Bioinformatics Research at the Cole Eye Institute (J.K.S., N.S., M.K., J.C., C.M., K.T., R.S.), Cleveland; Cole Eye Institute (K.T., D.A.C.), Cleveland Clinic, OH; and Cleveland Clinic Martin Hospitals (R.S.), Stuart, FL
| | - Jeffrey Chu
- From the Case Western Reserve University School of Medicine (J.K.S., N.S., M.K., J.C., C.M.); Center for Ophthalmic Bioinformatics Research at the Cole Eye Institute (J.K.S., N.S., M.K., J.C., C.M., K.T., R.S.), Cleveland; Cole Eye Institute (K.T., D.A.C.), Cleveland Clinic, OH; and Cleveland Clinic Martin Hospitals (R.S.), Stuart, FL
| | - Christopher Maatouk
- From the Case Western Reserve University School of Medicine (J.K.S., N.S., M.K., J.C., C.M.); Center for Ophthalmic Bioinformatics Research at the Cole Eye Institute (J.K.S., N.S., M.K., J.C., C.M., K.T., R.S.), Cleveland; Cole Eye Institute (K.T., D.A.C.), Cleveland Clinic, OH; and Cleveland Clinic Martin Hospitals (R.S.), Stuart, FL
| | - Katherine Talcott
- From the Case Western Reserve University School of Medicine (J.K.S., N.S., M.K., J.C., C.M.); Center for Ophthalmic Bioinformatics Research at the Cole Eye Institute (J.K.S., N.S., M.K., J.C., C.M., K.T., R.S.), Cleveland; Cole Eye Institute (K.T., D.A.C.), Cleveland Clinic, OH; and Cleveland Clinic Martin Hospitals (R.S.), Stuart, FL
| | - Rishi Singh
- From the Case Western Reserve University School of Medicine (J.K.S., N.S., M.K., J.C., C.M.); Center for Ophthalmic Bioinformatics Research at the Cole Eye Institute (J.K.S., N.S., M.K., J.C., C.M., K.T., R.S.), Cleveland; Cole Eye Institute (K.T., D.A.C.), Cleveland Clinic, OH; and Cleveland Clinic Martin Hospitals (R.S.), Stuart, FL
| | - Devon A Cohen
- From the Case Western Reserve University School of Medicine (J.K.S., N.S., M.K., J.C., C.M.); Center for Ophthalmic Bioinformatics Research at the Cole Eye Institute (J.K.S., N.S., M.K., J.C., C.M., K.T., R.S.), Cleveland; Cole Eye Institute (K.T., D.A.C.), Cleveland Clinic, OH; and Cleveland Clinic Martin Hospitals (R.S.), Stuart, FL
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Huda F, Abdelmonem A, Dehghani Firouzabadi F, Srinivas Dola VN, Sheikhy A, Taheri MR. The role of arachnoid granulations in idiopathic intracranial hypertension. Neuroradiol J 2023; 36:651-656. [PMID: 37102274 PMCID: PMC10649532 DOI: 10.1177/19714009231173109] [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: 04/28/2023] Open
Abstract
OBJECTIVES Idiopathic intracranial hypertension (IIH) is a disease defined by elevated intracranial pressure (ICP) without an established etiology. Arachnoid granulations (AG) are conduits for CSF resorption from the subarachnoid space to the venous system. AG have been implicated to play a central role in maintaining CSF homeostasis. We tested the hypothesis that patients with fewer visible AG on MRI are more likely to present with IIH. METHODS In this institutional review board (Institutional Review Board)-approved retrospective chart review study, 65 patients with a clinical diagnosis of idiopathic intracranial hypertension were compared to 144 control patients who met inclusion/exclusion criteria. Patients' signs and symptoms pertaining to IIH were obtained through the electronic medical record Brain MR images were reviewed for the number and distribution of AGs indenting the dural venous sinuses. The presence of imaging and clinical findings associated with long standing increased ICP was noted. Propensity score method (with inverse probability weighting technique) was used to compare case and control groups. RESULTS In the control group, the number of AG indenting the dural venous sinuses on MRI (NAG) was lower in women compared to men when matched for age (20-45 yo) and BMI (>30 kg/m2). The NAG was lower in 20-45 yo females in the IIH group as compared to the 20-45 yo females in the control group. This statistically significant difference persists when controlled for BMI. In contrast, the NAG in >45 yo females in the IIH group trended higher compared to the >45 yo females in the control group. CONCLUSION Our results suggest that alterations in arachnoid granulations could play a role in the development of IIH.
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Affiliation(s)
- Fahimul Huda
- Department of Radiology, The George Washington University Hospital, Washington, DC, USA
| | - Ahmed Abdelmonem
- Department of Radiology, The George Washington University Hospital, Washington, DC, USA
| | | | | | - Ali Sheikhy
- Tehran University of Medical Sciences Non-Communicable Disease Research Center, Tehran, Iran
| | - M Reza Taheri
- Department of Radiology, The George Washington University Hospital, Washington, DC, USA
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Eshtiaghi A, Margolin EA, Micieli JA. Idiopathic Intracranial Hypertension and Socioeconomic Status in the Greater Toronto Area, Canada. J Neuroophthalmol 2023; 43:197-201. [PMID: 35921276 DOI: 10.1097/wno.0000000000001680] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Previous studies have identified an association between obesity and socioeconomic variables such as poverty, minority status, and a low level of education. Because obesity is a major risk factor for the development of idiopathic intracranial hypertension (IIH), this study aims to identify and assess relationships between socioeconomic and geographic variables in patients with IIH in Canada. METHODS A retrospective chart review was performed to identify female patients with IIH presenting to 2 neuro-ophthalmology clinics in Toronto between 2014 and 2022. Consecutive female patients younger than 50 years who did not have IIH were identified as controls. Patient age, body mass index (BMI), and postal code were obtained from electronic medical records. Patient postal codes were then converted to geographic dissemination areas based on the 2016 Canadian census, and data on socioeconomic outcomes were collected from Statistics Canada. RESULTS Three hundred twenty-two female patients with IIH (mean age: 32.3 ± 10) and 400 female controls (mean age: 33.9 ± 9) were included. The mean BMI was 35.0 ± 8 for patients with IIH and 26.7 ± 7 for control patients ( P < 0.00001). There was a significant difference between dissemination areas resided by patients with IIH and control patients for median income ($34640 vs $36685 CAD, P = 0.02) and rate of postsecondary degree attainment (57.7% vs 60.5%, P = 0.01). There were no significant differences in the percentage of visible minorities, percentage of immigrants, knowledge of official languages, percentage of married individuals, average household size, or unemployment rate. There was a weak but significant inverse relationship between the rate of postsecondary degree attainment in dissemination areas resided by patients with IIH and their BMI ( P = 0.01, R 2 = 0.02). CONCLUSION Patients with IIH reside in geographic areas with lower average levels of income and education than control patients. Patients with lower levels of education may be at higher risk of elevated BMI and therefore disease incidence and progression.
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Affiliation(s)
- Arshia Eshtiaghi
- Faculty of Medicine (AE), Department of Ophthalmology and Vision Sciences (EM, JAM), Division of Neurology (EM, JAM), Department of Medicine, University of Toronto, Toronto, Canada; and Kensington Vision and Research Centre (JAM), Toronto, Canada
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Anemia and Idiopathic Intracranial Hypertension: A Case-Control Study. J Neuroophthalmol 2023; 43:63-68. [PMID: 36166812 DOI: 10.1097/wno.0000000000001664] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Idiopathic intracranial hypertension (IIH) is a condition that mostly affects obese women of childbearing age but has been reported to be temporally related to new diagnoses of anemia. Despite these reports, the association between anemia and IIH remains controversial. The present study aimed to understand the strength of association between anemia and IIH through a case-control design. METHODS Consecutive IIH patients were recruited from neuro-ophthalmology clinics and matched by age and sex to consecutive patients attending neuro-ophthalmology clinics with diagnoses other than IIH. Complete blood counts (CBCs) were reviewed within 6 months of neuro-ophthalmology presentation, and anemia was diagnosed by hemoglobin of <120 g/L in women and <130 g/L in men. Anemia was classified as microcytic (mean corpuscular volume (MCV) < 80 fL), normocytic (MCV 80-100 fL), and macrocytic (MCV > 100 fL) as well as mild (hemoglobin >110 g/L), moderate (hemoglobin 80-109 g/L), and severe (hemoglobin <80 g/L). RESULTS One hundred twenty-three IIH patients and 113 controls were included in the study. More IIH patients than controls had anemia (22.8%, 28/123 vs 10.6%, 12/113, P = 0.01) with an odds ratio of 2.48 (95% CI: 1.19, 5.16). There were no differences in severity of anemia or MCV between IIH patients and controls, with anemia most often being mild (57.1%, 16/28 vs 75%, 9/12) and normocytic (50.0%, 14/28 vs 50.0%, 6/12). However, 17.9% (5/28) of IIH patients had severe anemia compared with zero in the control group. IIH patients had a higher mean platelet count than controls ( P < 0.001), and there were no differences on leukocyte counts. CONCLUSION Idiopathic intracranial hypertension patients have a higher prevalence of anemia compared with non-IIH neuro-ophthalmology patients. The anemia was mostly mild and may be explained by other factors related to worse health status and obesity, including low socioeconomic status, poor nutrition, and polycystic ovary syndrome. However, as a CBC is a widely available test and anemia may influence the IIH disease course, we propose that this test be obtained in all patients with new papilledema.
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11
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Heath Jeffery RC, Chen FK. Peripapillary hyperreflective ovoid mass-like structures: Multimodal imaging-A review. Clin Exp Ophthalmol 2023; 51:67-80. [PMID: 36300762 PMCID: PMC10099767 DOI: 10.1111/ceo.14182] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2022] [Revised: 10/04/2022] [Accepted: 10/21/2022] [Indexed: 11/07/2022]
Abstract
Peripapillary hyperreflective ovoid mass-like structures (PHOMS) are a laterally bulging herniation of distended axons into the peripapillary region above the level of Bruch's membrane opening. Increased use of enhanced depth imaging-optical coherence tomography (EDI-OCT) in our evaluation of the optic nerve head (ONH) and greater recognition of the vast range of optic nerve pathologies with which PHOMS is associated provides convincing evidence that PHOMS is not just buried optic disc drusen (ODD) as previously described. The frequent coexistence of PHOMS with ODD, papilloedema, anterior ischaemic optic neuropathy, tilted optic disc syndrome, inflammatory demyelinating disorders and other diseases associated with axoplasmic stasis provides insight into its underlying pathophysiology. The present review will discuss the role of key imaging modalities in the differential diagnosis of PHOMS, explore the current literature on the relationship between PHOMS and common neuro-ophthalmic conditions, and highlight the gaps in our knowledge, with respect to disease classification and prognosis, to pave the way for future directions of research.
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Affiliation(s)
- Rachael C Heath Jeffery
- Centre for Ophthalmology and Visual Science (incorporating Lions Eye Institute), The University of Western Australia, Nedlands, Western Australia, Australia.,Royal Victorian Eye and Ear Hospital (Centre for Eye Research Australia), East Melbourne, Victoria, Australia
| | - Fred K Chen
- Centre for Ophthalmology and Visual Science (incorporating Lions Eye Institute), The University of Western Australia, Nedlands, Western Australia, Australia.,Royal Victorian Eye and Ear Hospital (Centre for Eye Research Australia), East Melbourne, Victoria, Australia.,Ophthalmology, Department of Surgery, The University of Melbourne, East Melbourne, Victoria, Australia.,Department of Ophthalmology, Royal Perth Hospital, Western Australia, Australia
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12
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Mollan SP, Mitchell JL, Yiangou A, Ottridge RS, Alimajstorovic Z, Cartwright DM, Hickman SJ, Markey KA, Singhal R, Tahrani AA, Frew E, Brock K, Sinclair AJ. Association of Amount of Weight Lost After Bariatric Surgery With Intracranial Pressure in Women With Idiopathic Intracranial Hypertension. Neurology 2022; 99:e1090-e1099. [PMID: 35790425 PMCID: PMC9536743 DOI: 10.1212/wnl.0000000000200839] [Citation(s) in RCA: 18] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2021] [Accepted: 04/22/2022] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND AND OBJECTIVES The idiopathic intracranial hypertension randomized controlled weight trial (IIH:WT) established that weight loss through bariatric surgery significantly reduced intracranial pressure when compared with a community weight management intervention. This substudy aimed to evaluate the amount of weight loss required to reduce intracranial pressure and to explore the effect of different bariatric surgical approaches. METHODS IIH:WT was a multicenter randomized controlled trial. Adult women with active idiopathic intracranial hypertension and a body mass index ≥35 kg/m2 were randomized to bariatric surgery or a community weight management intervention (1:1). This per-protocol analysis evaluated the relationship between intracranial pressure, weight loss, and the weight loss methods. A linear hierarchical regression model was used to fit the trial outcomes, adjusted for time, treatment arm, and weight. RESULTS Sixty-six women were included, of whom 23 had received bariatric surgery by 12 months; the mean age was 31 (SD 8.7) years in the bariatric surgery group and 33.2 (SD 7.4) years in the dietary group. Baseline weight and intracranial pressure were similar in both groups with a mean weight of 119.5 (SD 24.1) and 117.9 (SD 19.5) kg and mean lumbar puncture opening pressure of 34.4 (SD 6.3) and 34.9 (SD 5.3) cmCSF in the bariatric surgery and dietary groups, respectively. Weight loss was significantly associated with reduction in intracranial pressure (R2 = 0.4734, p ≤ 0.0001). Twenty-four percentage of weight loss (weight loss of 13.3 kg [SD 1.76]) was associated with disease remission (intracranial pressure [ICP] ≤ 25 cmCSF). Roux-en-Y gastric bypass achieved greater, more rapid, and sustained ICP reduction compared with other methods. DISCUSSION The greater the weight loss, the greater the reduction in ICP was documented. Twenty four percentage of weight loss was associated with disease remission. Such magnitude of weight loss was unlikely to be achieved without bariatric surgery, and hence, consideration of referral to a bariatric surgery program early for those with active idiopathic intracranial hypertension may be appropriate. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT02124486; ISRCTN registry number ISRCTN40152829; doi.org/10.1186/ISRCTN40152829. CLASSIFICATION OF EVIDENCE This study provides Class II evidence that weight loss after bariatric surgery results in reduction in intracranial pressure in adult women with idiopathic intracranial hypertension. This study is Class II because of the use of a per-protocol analysis.
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Affiliation(s)
- Susan P Mollan
- From the Birmingham Neuro-Ophthalmology (S.P.M.), University Hospitals Birmingham NHS Foundation Trust, Queen Elizabeth Hospital; Metabolic Neurology (J.L.M., A.Y., Z.A., K.A.M., A.J.S.), Institute of Metabolism and Systems Research, College of Medical and Dental Sciences, University of Birmingham; Department of Neurology (J.L.M., A.Y., A.J.S.), University Hospitals Birmingham NHS Foundation Trust, Queen Elizabeth Hospital; Centre for Endocrinology (J.L.M., A.Y., A.A.T., A.J.S.), Diabetes and Metabolism, Birmingham Health Partners; Birmingham Clinical Trials Unit (R.S.O.); Institute of Metabolism and Systems Research (Z.A., D.M.C., A.A.T., A.J.S.), College of Medical and Dental Sciences, University of Birmingham, Birmingham, United Kingdom; Department of Neurology (S.J.H.), Royal Hallamshire Hospital, Sheffield, United Kingdom; Upper GI Unit and Minimally Invasive Unit (R.S.), Birmingham Heartlands Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham; Institute of Cancer and Genomic Sciences (R.S.), University of Birmingham; Department of Endocrinology (A.A.T.), University Hospitals Birmingham NHS Foundation Trust, Queen Elizabeth Hospital; Health Economics Unit (E.F.), Institute of Applied Health Research, University of Birmingham; and Cancer Research UK Clinical Trials Unit (K.B.), University of Birmingham, Birmingham, United Kingdom.
| | - James L Mitchell
- From the Birmingham Neuro-Ophthalmology (S.P.M.), University Hospitals Birmingham NHS Foundation Trust, Queen Elizabeth Hospital; Metabolic Neurology (J.L.M., A.Y., Z.A., K.A.M., A.J.S.), Institute of Metabolism and Systems Research, College of Medical and Dental Sciences, University of Birmingham; Department of Neurology (J.L.M., A.Y., A.J.S.), University Hospitals Birmingham NHS Foundation Trust, Queen Elizabeth Hospital; Centre for Endocrinology (J.L.M., A.Y., A.A.T., A.J.S.), Diabetes and Metabolism, Birmingham Health Partners; Birmingham Clinical Trials Unit (R.S.O.); Institute of Metabolism and Systems Research (Z.A., D.M.C., A.A.T., A.J.S.), College of Medical and Dental Sciences, University of Birmingham, Birmingham, United Kingdom; Department of Neurology (S.J.H.), Royal Hallamshire Hospital, Sheffield, United Kingdom; Upper GI Unit and Minimally Invasive Unit (R.S.), Birmingham Heartlands Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham; Institute of Cancer and Genomic Sciences (R.S.), University of Birmingham; Department of Endocrinology (A.A.T.), University Hospitals Birmingham NHS Foundation Trust, Queen Elizabeth Hospital; Health Economics Unit (E.F.), Institute of Applied Health Research, University of Birmingham; and Cancer Research UK Clinical Trials Unit (K.B.), University of Birmingham, Birmingham, United Kingdom
| | - Andreas Yiangou
- From the Birmingham Neuro-Ophthalmology (S.P.M.), University Hospitals Birmingham NHS Foundation Trust, Queen Elizabeth Hospital; Metabolic Neurology (J.L.M., A.Y., Z.A., K.A.M., A.J.S.), Institute of Metabolism and Systems Research, College of Medical and Dental Sciences, University of Birmingham; Department of Neurology (J.L.M., A.Y., A.J.S.), University Hospitals Birmingham NHS Foundation Trust, Queen Elizabeth Hospital; Centre for Endocrinology (J.L.M., A.Y., A.A.T., A.J.S.), Diabetes and Metabolism, Birmingham Health Partners; Birmingham Clinical Trials Unit (R.S.O.); Institute of Metabolism and Systems Research (Z.A., D.M.C., A.A.T., A.J.S.), College of Medical and Dental Sciences, University of Birmingham, Birmingham, United Kingdom; Department of Neurology (S.J.H.), Royal Hallamshire Hospital, Sheffield, United Kingdom; Upper GI Unit and Minimally Invasive Unit (R.S.), Birmingham Heartlands Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham; Institute of Cancer and Genomic Sciences (R.S.), University of Birmingham; Department of Endocrinology (A.A.T.), University Hospitals Birmingham NHS Foundation Trust, Queen Elizabeth Hospital; Health Economics Unit (E.F.), Institute of Applied Health Research, University of Birmingham; and Cancer Research UK Clinical Trials Unit (K.B.), University of Birmingham, Birmingham, United Kingdom
| | - Ryan S Ottridge
- From the Birmingham Neuro-Ophthalmology (S.P.M.), University Hospitals Birmingham NHS Foundation Trust, Queen Elizabeth Hospital; Metabolic Neurology (J.L.M., A.Y., Z.A., K.A.M., A.J.S.), Institute of Metabolism and Systems Research, College of Medical and Dental Sciences, University of Birmingham; Department of Neurology (J.L.M., A.Y., A.J.S.), University Hospitals Birmingham NHS Foundation Trust, Queen Elizabeth Hospital; Centre for Endocrinology (J.L.M., A.Y., A.A.T., A.J.S.), Diabetes and Metabolism, Birmingham Health Partners; Birmingham Clinical Trials Unit (R.S.O.); Institute of Metabolism and Systems Research (Z.A., D.M.C., A.A.T., A.J.S.), College of Medical and Dental Sciences, University of Birmingham, Birmingham, United Kingdom; Department of Neurology (S.J.H.), Royal Hallamshire Hospital, Sheffield, United Kingdom; Upper GI Unit and Minimally Invasive Unit (R.S.), Birmingham Heartlands Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham; Institute of Cancer and Genomic Sciences (R.S.), University of Birmingham; Department of Endocrinology (A.A.T.), University Hospitals Birmingham NHS Foundation Trust, Queen Elizabeth Hospital; Health Economics Unit (E.F.), Institute of Applied Health Research, University of Birmingham; and Cancer Research UK Clinical Trials Unit (K.B.), University of Birmingham, Birmingham, United Kingdom
| | - Zerin Alimajstorovic
- From the Birmingham Neuro-Ophthalmology (S.P.M.), University Hospitals Birmingham NHS Foundation Trust, Queen Elizabeth Hospital; Metabolic Neurology (J.L.M., A.Y., Z.A., K.A.M., A.J.S.), Institute of Metabolism and Systems Research, College of Medical and Dental Sciences, University of Birmingham; Department of Neurology (J.L.M., A.Y., A.J.S.), University Hospitals Birmingham NHS Foundation Trust, Queen Elizabeth Hospital; Centre for Endocrinology (J.L.M., A.Y., A.A.T., A.J.S.), Diabetes and Metabolism, Birmingham Health Partners; Birmingham Clinical Trials Unit (R.S.O.); Institute of Metabolism and Systems Research (Z.A., D.M.C., A.A.T., A.J.S.), College of Medical and Dental Sciences, University of Birmingham, Birmingham, United Kingdom; Department of Neurology (S.J.H.), Royal Hallamshire Hospital, Sheffield, United Kingdom; Upper GI Unit and Minimally Invasive Unit (R.S.), Birmingham Heartlands Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham; Institute of Cancer and Genomic Sciences (R.S.), University of Birmingham; Department of Endocrinology (A.A.T.), University Hospitals Birmingham NHS Foundation Trust, Queen Elizabeth Hospital; Health Economics Unit (E.F.), Institute of Applied Health Research, University of Birmingham; and Cancer Research UK Clinical Trials Unit (K.B.), University of Birmingham, Birmingham, United Kingdom
| | - David M Cartwright
- From the Birmingham Neuro-Ophthalmology (S.P.M.), University Hospitals Birmingham NHS Foundation Trust, Queen Elizabeth Hospital; Metabolic Neurology (J.L.M., A.Y., Z.A., K.A.M., A.J.S.), Institute of Metabolism and Systems Research, College of Medical and Dental Sciences, University of Birmingham; Department of Neurology (J.L.M., A.Y., A.J.S.), University Hospitals Birmingham NHS Foundation Trust, Queen Elizabeth Hospital; Centre for Endocrinology (J.L.M., A.Y., A.A.T., A.J.S.), Diabetes and Metabolism, Birmingham Health Partners; Birmingham Clinical Trials Unit (R.S.O.); Institute of Metabolism and Systems Research (Z.A., D.M.C., A.A.T., A.J.S.), College of Medical and Dental Sciences, University of Birmingham, Birmingham, United Kingdom; Department of Neurology (S.J.H.), Royal Hallamshire Hospital, Sheffield, United Kingdom; Upper GI Unit and Minimally Invasive Unit (R.S.), Birmingham Heartlands Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham; Institute of Cancer and Genomic Sciences (R.S.), University of Birmingham; Department of Endocrinology (A.A.T.), University Hospitals Birmingham NHS Foundation Trust, Queen Elizabeth Hospital; Health Economics Unit (E.F.), Institute of Applied Health Research, University of Birmingham; and Cancer Research UK Clinical Trials Unit (K.B.), University of Birmingham, Birmingham, United Kingdom
| | - Simon J Hickman
- From the Birmingham Neuro-Ophthalmology (S.P.M.), University Hospitals Birmingham NHS Foundation Trust, Queen Elizabeth Hospital; Metabolic Neurology (J.L.M., A.Y., Z.A., K.A.M., A.J.S.), Institute of Metabolism and Systems Research, College of Medical and Dental Sciences, University of Birmingham; Department of Neurology (J.L.M., A.Y., A.J.S.), University Hospitals Birmingham NHS Foundation Trust, Queen Elizabeth Hospital; Centre for Endocrinology (J.L.M., A.Y., A.A.T., A.J.S.), Diabetes and Metabolism, Birmingham Health Partners; Birmingham Clinical Trials Unit (R.S.O.); Institute of Metabolism and Systems Research (Z.A., D.M.C., A.A.T., A.J.S.), College of Medical and Dental Sciences, University of Birmingham, Birmingham, United Kingdom; Department of Neurology (S.J.H.), Royal Hallamshire Hospital, Sheffield, United Kingdom; Upper GI Unit and Minimally Invasive Unit (R.S.), Birmingham Heartlands Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham; Institute of Cancer and Genomic Sciences (R.S.), University of Birmingham; Department of Endocrinology (A.A.T.), University Hospitals Birmingham NHS Foundation Trust, Queen Elizabeth Hospital; Health Economics Unit (E.F.), Institute of Applied Health Research, University of Birmingham; and Cancer Research UK Clinical Trials Unit (K.B.), University of Birmingham, Birmingham, United Kingdom
| | - Keira A Markey
- From the Birmingham Neuro-Ophthalmology (S.P.M.), University Hospitals Birmingham NHS Foundation Trust, Queen Elizabeth Hospital; Metabolic Neurology (J.L.M., A.Y., Z.A., K.A.M., A.J.S.), Institute of Metabolism and Systems Research, College of Medical and Dental Sciences, University of Birmingham; Department of Neurology (J.L.M., A.Y., A.J.S.), University Hospitals Birmingham NHS Foundation Trust, Queen Elizabeth Hospital; Centre for Endocrinology (J.L.M., A.Y., A.A.T., A.J.S.), Diabetes and Metabolism, Birmingham Health Partners; Birmingham Clinical Trials Unit (R.S.O.); Institute of Metabolism and Systems Research (Z.A., D.M.C., A.A.T., A.J.S.), College of Medical and Dental Sciences, University of Birmingham, Birmingham, United Kingdom; Department of Neurology (S.J.H.), Royal Hallamshire Hospital, Sheffield, United Kingdom; Upper GI Unit and Minimally Invasive Unit (R.S.), Birmingham Heartlands Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham; Institute of Cancer and Genomic Sciences (R.S.), University of Birmingham; Department of Endocrinology (A.A.T.), University Hospitals Birmingham NHS Foundation Trust, Queen Elizabeth Hospital; Health Economics Unit (E.F.), Institute of Applied Health Research, University of Birmingham; and Cancer Research UK Clinical Trials Unit (K.B.), University of Birmingham, Birmingham, United Kingdom
| | - Rishi Singhal
- From the Birmingham Neuro-Ophthalmology (S.P.M.), University Hospitals Birmingham NHS Foundation Trust, Queen Elizabeth Hospital; Metabolic Neurology (J.L.M., A.Y., Z.A., K.A.M., A.J.S.), Institute of Metabolism and Systems Research, College of Medical and Dental Sciences, University of Birmingham; Department of Neurology (J.L.M., A.Y., A.J.S.), University Hospitals Birmingham NHS Foundation Trust, Queen Elizabeth Hospital; Centre for Endocrinology (J.L.M., A.Y., A.A.T., A.J.S.), Diabetes and Metabolism, Birmingham Health Partners; Birmingham Clinical Trials Unit (R.S.O.); Institute of Metabolism and Systems Research (Z.A., D.M.C., A.A.T., A.J.S.), College of Medical and Dental Sciences, University of Birmingham, Birmingham, United Kingdom; Department of Neurology (S.J.H.), Royal Hallamshire Hospital, Sheffield, United Kingdom; Upper GI Unit and Minimally Invasive Unit (R.S.), Birmingham Heartlands Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham; Institute of Cancer and Genomic Sciences (R.S.), University of Birmingham; Department of Endocrinology (A.A.T.), University Hospitals Birmingham NHS Foundation Trust, Queen Elizabeth Hospital; Health Economics Unit (E.F.), Institute of Applied Health Research, University of Birmingham; and Cancer Research UK Clinical Trials Unit (K.B.), University of Birmingham, Birmingham, United Kingdom
| | - Abd A Tahrani
- From the Birmingham Neuro-Ophthalmology (S.P.M.), University Hospitals Birmingham NHS Foundation Trust, Queen Elizabeth Hospital; Metabolic Neurology (J.L.M., A.Y., Z.A., K.A.M., A.J.S.), Institute of Metabolism and Systems Research, College of Medical and Dental Sciences, University of Birmingham; Department of Neurology (J.L.M., A.Y., A.J.S.), University Hospitals Birmingham NHS Foundation Trust, Queen Elizabeth Hospital; Centre for Endocrinology (J.L.M., A.Y., A.A.T., A.J.S.), Diabetes and Metabolism, Birmingham Health Partners; Birmingham Clinical Trials Unit (R.S.O.); Institute of Metabolism and Systems Research (Z.A., D.M.C., A.A.T., A.J.S.), College of Medical and Dental Sciences, University of Birmingham, Birmingham, United Kingdom; Department of Neurology (S.J.H.), Royal Hallamshire Hospital, Sheffield, United Kingdom; Upper GI Unit and Minimally Invasive Unit (R.S.), Birmingham Heartlands Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham; Institute of Cancer and Genomic Sciences (R.S.), University of Birmingham; Department of Endocrinology (A.A.T.), University Hospitals Birmingham NHS Foundation Trust, Queen Elizabeth Hospital; Health Economics Unit (E.F.), Institute of Applied Health Research, University of Birmingham; and Cancer Research UK Clinical Trials Unit (K.B.), University of Birmingham, Birmingham, United Kingdom
| | - Emma Frew
- From the Birmingham Neuro-Ophthalmology (S.P.M.), University Hospitals Birmingham NHS Foundation Trust, Queen Elizabeth Hospital; Metabolic Neurology (J.L.M., A.Y., Z.A., K.A.M., A.J.S.), Institute of Metabolism and Systems Research, College of Medical and Dental Sciences, University of Birmingham; Department of Neurology (J.L.M., A.Y., A.J.S.), University Hospitals Birmingham NHS Foundation Trust, Queen Elizabeth Hospital; Centre for Endocrinology (J.L.M., A.Y., A.A.T., A.J.S.), Diabetes and Metabolism, Birmingham Health Partners; Birmingham Clinical Trials Unit (R.S.O.); Institute of Metabolism and Systems Research (Z.A., D.M.C., A.A.T., A.J.S.), College of Medical and Dental Sciences, University of Birmingham, Birmingham, United Kingdom; Department of Neurology (S.J.H.), Royal Hallamshire Hospital, Sheffield, United Kingdom; Upper GI Unit and Minimally Invasive Unit (R.S.), Birmingham Heartlands Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham; Institute of Cancer and Genomic Sciences (R.S.), University of Birmingham; Department of Endocrinology (A.A.T.), University Hospitals Birmingham NHS Foundation Trust, Queen Elizabeth Hospital; Health Economics Unit (E.F.), Institute of Applied Health Research, University of Birmingham; and Cancer Research UK Clinical Trials Unit (K.B.), University of Birmingham, Birmingham, United Kingdom
| | - Kristian Brock
- From the Birmingham Neuro-Ophthalmology (S.P.M.), University Hospitals Birmingham NHS Foundation Trust, Queen Elizabeth Hospital; Metabolic Neurology (J.L.M., A.Y., Z.A., K.A.M., A.J.S.), Institute of Metabolism and Systems Research, College of Medical and Dental Sciences, University of Birmingham; Department of Neurology (J.L.M., A.Y., A.J.S.), University Hospitals Birmingham NHS Foundation Trust, Queen Elizabeth Hospital; Centre for Endocrinology (J.L.M., A.Y., A.A.T., A.J.S.), Diabetes and Metabolism, Birmingham Health Partners; Birmingham Clinical Trials Unit (R.S.O.); Institute of Metabolism and Systems Research (Z.A., D.M.C., A.A.T., A.J.S.), College of Medical and Dental Sciences, University of Birmingham, Birmingham, United Kingdom; Department of Neurology (S.J.H.), Royal Hallamshire Hospital, Sheffield, United Kingdom; Upper GI Unit and Minimally Invasive Unit (R.S.), Birmingham Heartlands Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham; Institute of Cancer and Genomic Sciences (R.S.), University of Birmingham; Department of Endocrinology (A.A.T.), University Hospitals Birmingham NHS Foundation Trust, Queen Elizabeth Hospital; Health Economics Unit (E.F.), Institute of Applied Health Research, University of Birmingham; and Cancer Research UK Clinical Trials Unit (K.B.), University of Birmingham, Birmingham, United Kingdom
| | - Alexandra Jean Sinclair
- From the Birmingham Neuro-Ophthalmology (S.P.M.), University Hospitals Birmingham NHS Foundation Trust, Queen Elizabeth Hospital; Metabolic Neurology (J.L.M., A.Y., Z.A., K.A.M., A.J.S.), Institute of Metabolism and Systems Research, College of Medical and Dental Sciences, University of Birmingham; Department of Neurology (J.L.M., A.Y., A.J.S.), University Hospitals Birmingham NHS Foundation Trust, Queen Elizabeth Hospital; Centre for Endocrinology (J.L.M., A.Y., A.A.T., A.J.S.), Diabetes and Metabolism, Birmingham Health Partners; Birmingham Clinical Trials Unit (R.S.O.); Institute of Metabolism and Systems Research (Z.A., D.M.C., A.A.T., A.J.S.), College of Medical and Dental Sciences, University of Birmingham, Birmingham, United Kingdom; Department of Neurology (S.J.H.), Royal Hallamshire Hospital, Sheffield, United Kingdom; Upper GI Unit and Minimally Invasive Unit (R.S.), Birmingham Heartlands Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham; Institute of Cancer and Genomic Sciences (R.S.), University of Birmingham; Department of Endocrinology (A.A.T.), University Hospitals Birmingham NHS Foundation Trust, Queen Elizabeth Hospital; Health Economics Unit (E.F.), Institute of Applied Health Research, University of Birmingham; and Cancer Research UK Clinical Trials Unit (K.B.), University of Birmingham, Birmingham, United Kingdom
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Bell S. Case Report of Idiopathic Intracranial Hypertension in Pregnancy. J Obstet Gynecol Neonatal Nurs 2022; 51:612-619. [PMID: 35988696 DOI: 10.1016/j.jogn.2022.07.009] [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: 12/13/2021] [Revised: 07/24/2022] [Accepted: 07/27/2022] [Indexed: 10/15/2022] Open
Abstract
Idiopathic intracranial hypertension (IIH) is a disease of increased intracranial pressure with an unknown cause that is seen most often in women during their childbearing years. Women can be under care for IIH when they become pregnant, or it may occur during pregnancy. In the past, women with IIH who became pregnant were often counseled to terminate their pregnancies, to give birth early, and even to be sterilized to prevent future pregnancies. Today, multiple therapeutic options are available. In this case report, I describe the case of a woman with IIH who was treated with a cerebral spinal fluid shunt and gave birth to two sets of twins. This case report adds new information to the limited nursing literature currently available on this disease.
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Morden FTC, Tan C, Carrazana E, Viereck J, Liow KK, Ghaffari-Rafi A. Characterizing idiopathic intracranial hypertension socioeconomic disparities and clinical risk factors: A retrospective case-control study. Clin Neurol Neurosurg 2021; 208:106894. [PMID: 34455402 DOI: 10.1016/j.clineuro.2021.106894] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2021] [Revised: 08/07/2021] [Accepted: 08/12/2021] [Indexed: 11/28/2022]
Abstract
INTRODUCTION Against the backdrop of the diverse minority-majority state of Hawaii, this study seeks to better characterize associations between idiopathic intracranial hypertension (IIH) with sociodemographic variables and medical comorbidities. METHODS A retrospective case-control study was conducted by utilizing 54 IIH patients and 216 age-, sex-, and race-matched controls, 216 unmatched controls, and 63 age-, sex-, and race-matched migraine patients. RESULTS Relative to controls, IIH were 25 years younger (p < 0.0001) and 10.18 kg/m2 heavier (p < 0.0001), as well as exhibited greater odds of the following variables (p < 0.05): female (odds ratio [OR]: 8.87), the lowest income quartile (OR: 2.33), Native Hawaiian or other Pacific Islander (NHPI; OR: 2.23), Native American or Alaskan Native (OR: 16.50), obesity class 2 (35.0-39.9 kg/m2; OR: 4.10), obesity class 3 (>40 kg/m2; OR: 6.10), recent weight gain (OR: 11.66), current smoker (OR: 2.48), hypertensive (OR: 3.08), and peripheral vascular disease (OR: 16.42). Odds of IIH were reduced (p < 0.05) for patients who were Asian (OR: 0.27) or students (OR: 0.30;). Unique from Whites, NHPI IIH patients exhibited greater odds (p < 0.05) for being from lower socioeconomic status and currently smoking, as well as potential association with seizures (p = 0.08). Compared to migraines, IIH headaches were at increased odds of occurring (p < 0.05) occipitally, for greater than 15 days per month, aggravated by postural changes, and comorbid with dizziness and tinnitus. CONCLUSIONS These results not only better characterize IIH, but also highlight socioeconomic and racial disparities in diagnosis.
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Affiliation(s)
| | - Charissa Tan
- University of Hawaii at Mānoa, John A. Burns School of Medicine, Honolulu, HI, USA
| | - Enrique Carrazana
- University of Hawaii at Mānoa, John A. Burns School of Medicine, Honolulu, HI, USA; Hawaii Pacific Neuroscience, Brain Research, Innovation and Translation Lab, Honolulu, HI, USA
| | - Jason Viereck
- University of Hawaii at Mānoa, John A. Burns School of Medicine, Honolulu, HI, USA; Hawaii Pacific Neuroscience, Brain Research, Innovation and Translation Lab, Honolulu, HI, USA
| | - Kore Kai Liow
- University of Hawaii at Mānoa, John A. Burns School of Medicine, Honolulu, HI, USA; Hawaii Pacific Neuroscience, Brain Research, Innovation and Translation Lab, Honolulu, HI, USA
| | - Arash Ghaffari-Rafi
- University of Hawaii at Mānoa, John A. Burns School of Medicine, Honolulu, HI, USA; University of California, Davis, School of Medicine, Department of Neurological Surgery, Sacramento, CA, USA.
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Sundholm A, Burkill S, Waldenlind E, Bahmanyar S, Nilsson Remahl AIM. A national Swedish case-control study investigating incidence and factors associated with idiopathic intracranial hypertension. Cephalalgia 2021; 41:1427-1436. [PMID: 34407644 PMCID: PMC8619724 DOI: 10.1177/03331024211024166] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
OBJECTIVE To study the incidence of idiopathic intracranial hypertension in Sweden and to explore whether previously proposed risk factors are associated with idiopathic intracranial hypertension by investigating the odds of exposure one year prior to diagnosis in patients compared to controls. METHODS Using Swedish health care registers and validated diagnostic algorithms, idiopathic intracranial hypertension patients diagnosed between 2000-2016 were compared with randomly selected matched controls, five from the general population and five with obesity. RESULTS We identified 902 idiopathic intracranial hypertension patients and 4510 matched individuals in each control group. Mean incidence among inhabitants ≥18 years of age was 0.71 per 100,000; rising from 0.53 in 2000-2005 to 0.95 in 2012-2016. There were increased odds for idiopathic intracranial hypertension patients compared to general population for exposure to: kidney failure (odds ratio =13.2 (4.1-42.0)), arterial hypertension (odds ratio =17.5 (10.5-29.3)), systemic lupus erythematosus (odds ratio =13.8 (4.3-44.7)), tetracyclines, sulphonamides, lithium, and corticosteroids. In obese controls, odds ratios were also significantly increased for these exposures. Hormonal contraceptive use and exposure to pregnancy did not appear to be associated factors for idiopathic intracranial hypertension development. CONCLUSIONS The incidence of idiopathic intracranial hypertension in Sweden is lower relative to reports from other countries but is on the rise. This case-control study confirms several previously reported risk factors associated with idiopathic intracranial hypertension.
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Affiliation(s)
- Anna Sundholm
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden and Department of Neurology, 59562Karolinska University Hospital, Karolinska University Hospital, Stockholm, Sweden
| | - Sarah Burkill
- Saw Swee Hock School of Public Health, 37580National University of Singapore, National University of Singapore, Singapore
| | - Elisabet Waldenlind
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden and Department of Neurology, 59562Karolinska University Hospital, Karolinska University Hospital, Stockholm, Sweden
| | - Shahram Bahmanyar
- Centre for Pharmacoepidemiology, Department of Medicine, Solna, Karolinska Institutet, Stockholm, Sweden and Centre for Phychiatry Research, Karolinska Institutet, Stockholm, Sweden
| | - A Ingela M Nilsson Remahl
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden and Department of Neurology, 59562Karolinska University Hospital, Karolinska University Hospital, Stockholm, Sweden
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Krishnadas N, Taylor B. Incidence of idiopathic intracranial hypertension in Southern Tasmania, Australia. BMJ Neurol Open 2021; 3:e000145. [PMID: 34250485 PMCID: PMC8230989 DOI: 10.1136/bmjno-2021-000145] [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: 02/28/2021] [Accepted: 06/01/2021] [Indexed: 11/04/2022] Open
Abstract
Introduction Anecdotally, the incidence of idiopathic intracranial hypertension (IIH) is increasing, linked to an increase in the obesity rate in Australian society. However, formal incidence and prevalence studies are rare. We therefore sought to determine the incidence and clinical features of IIH in Southern Tasmania, Australia. Method Neurology discharge summaries and lumbar puncture referrals from the single tertiary referral centre in this region were screened for an IIH diagnosis. All regional neurologists were surveyed to capture patients diagnosed through private neurology clinics. A retrospective review of medical records was conducted to confirm the diagnosis and determine whether patients met the Modified Dandy Criteria (MDC). Patients were included if they were above the age of 18 years and received a new diagnosis of IIH between June 2016 and June 2018. Population statistics were obtained from the Australian Bureau of Statistics. Results IIH incidence was 5.4/100 000. All patients were females, aged between 18 and 45 years. Headache was the most commonly reported symptom, with high rates of pre-existing or concurrent migraine diagnoses. Weight loss and commencement of oral acetazolamide were the most common treatment approaches. Four patients were medically refractory and required surgical intervention. Conclusion The incidence of IIH in Southern Tasmania is comparable with the incidence reported in subgroups of females of childbearing age in recent prior studies. The demographic, diagnostic and therapeutic data presented can inform future local health service provision and serve as a baseline for ongoing assessment of change in incidence and treatment of IIH at a community level.
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Affiliation(s)
- Natasha Krishnadas
- Department of Neurology, Royal Hobart Hospital, Hobart, Tasmania, Australia
| | - Bruce Taylor
- Department of Neurology, Royal Hobart Hospital, Hobart, Tasmania, Australia.,Menzies Institute for Medical Research, The University of Tasmania, Hobart, Tasmania, Australia
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OCT Based Interpretation of the Optic Nerve Head Anatomy and Prevalence of Optic Disc Drusen in Patients with Idiopathic Intracranial Hypertension (IIH). Life (Basel) 2021; 11:life11060584. [PMID: 34205357 PMCID: PMC8234108 DOI: 10.3390/life11060584] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2021] [Revised: 06/07/2021] [Accepted: 06/17/2021] [Indexed: 12/19/2022] Open
Abstract
We aimed to systematically examine the optic nerve head anatomy in patients with idiopathic intracranial hypertension (IIH) using a standardized optical coherence tomography (OCT) protocol. The study retrospectively included 32 patients diagnosed from 2014 to 2021 with IIH. Using OCT, in accordance with a standardized scanning protocol for patients with optic disc drusen, the presence of optic disc drusen, prelaminar hyperreflective lines, peripapillary hyperreflective ovoid mass-like structures, the retinal nerve fiber layer thickness, and macular ganglion cell layer volume was obtained. Optic disc drusen were found in 3.1%, hyperreflective lines in 31.3%, and peripapillary hyperreflective ovoid mass-like structures in 81.3% of all IIH patients at least three months after the time of diagnosis. We found no significant differences in retinal nerve fiber layer thickness or macular ganglion cell layer volume in patients with hyperreflective lines or PHOMS respectively compared to patients without hyperreflective lines (p = 0.1285 and p = 0.1835). In conclusion, the prevalence of optic disc drusen in IIH patients is similar to the reported prevalence in the general population. The high prevalence of hyperreflective lines and peripapillary hyperreflective ovoid mass-like structures in IIH patients suggest these structures be a result of crowding in the optic nerve head caused by papilledema.
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Mollan SP, Sinclair AJ. Outcomes measures in idiopathic intracranial hypertension. Expert Rev Neurother 2021; 21:687-700. [PMID: 34047224 DOI: 10.1080/14737175.2021.1931127] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Introduction: Idiopathic intracranial hypertension is a condition characterized by raised intracranial pressure, papilledema, and normal neuroimaging (aside from radiological signs of raised intracranial pressure). Symptoms of idiopathic intracranial hypertension include chronic headaches and for some, visual loss. New treatments are unmet clinical needs.Areas covered: The aim of this review is to present the evidence base and considered opinion on outcome measures to determine successful management of idiopathic intracranial hypertension.Expert opinion: Less invasive measures of disease activity such as optical coherence tomography will continue to grow in this field, both as a measure of papilledema, and potentially as a surrogate for intracranial pressure and visual function. As a highly disabling aspect of the disease is headache, treatment outcomes for headache morbidity need to be appropriately chosen and standardized to allow comparison between trials.
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Affiliation(s)
- Susan P Mollan
- Birmingham Neuro-Ophthalmology, Queen Elizabeth Hospital, Birmingham, United Kingdom (UK)
| | - Alexandra J Sinclair
- Birmingham Neuro-Ophthalmology, Queen Elizabeth Hospital, Birmingham, United Kingdom (UK).,Metabolic Neurology, Institute of Metabolism and Systems Research, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK.,Centre for Endocrinology, Diabetes and Metabolism, Birmingham Health Partners, Birmingham, UK.,Department of Neurology, University Hospitals Birmingham NHS Foundation Trust, Queen Elizabeth Hospital, Birmingham, UK
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Friedman DI. Bariatric Surgery in Patients With Idiopathic Intracranial Hypertension-The Silver Bullet? JAMA Neurol 2021; 78:652-654. [PMID: 33900371 DOI: 10.1001/jamaneurol.2021.0364] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Affiliation(s)
- Deborah I Friedman
- Department of Neurology, University of Texas Southwestern Medical Center, Dallas.,Department of Ophthalmology, University of Texas Southwestern Medical Center, Dallas
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