Cerebrospinal Fluid Opening Pressure Research Articles

Headache and Other Factors Modifying Cerebrospinal Fluid Opening Pressure in Pediatric Patients.

Cerebrospinal fluid opening pressure values are associated with various neurologic diseases; however, numerous factors can modify this measurement. This study aims to describe factors related to modifications in opening pressure measurements in pediatric patients. Methods: A retrospective analysis of lumbar punctures in pediatric patients conducted by the neuropediatrics group with institutional standardization. Bivariate and linear regression analyses were performed to determine the association between opening pressure and variables included in the study. Results: 544 events, median age 107 months, median opening pressure 19.7 cm H2O. Bivariate analysis found no association with medication use; anesthetics that increased opening pressure were remifentanil (P = .02) and propofol (P = .05), along with a positive linear correlation between opening pressure and age (P < .0001). Multiple linear regression analysis revealed that age, BMI, male gender, and remifentanil use were associated with an increase in opening pressure, whereas corticosteroid withdrawal was associated with a reduction in opening pressure. There is an interaction between age and headache, with an association with increased opening pressure up to around 140 months. Conclusion: This study identifies factors associated with changes in opening pressure, crucial for estimating normal opening pressure values in children. Headaches, anesthetic use, and corticosteroid withdrawal are confirmed as significant factors.

Can optic disc vessel density help in cases of residual disc elevation after shunt surgery in cases of idiopathic intracranial hypertension?

AimTo detect if we can use the reduction in the optic disc vessel density as an indicator to the reduction in intracranial tension in patients with residual optic disc elevation after shunt surgery as fundus examination in those cases is not conclusive.Patients and method21 patients with papilledema due to idiopathic intracranial hypertension underwent shunt surgery. Full neurological and ophthalmological assessments were done. The optic disc vessel density was measured before and 3 months after surgery. Patients were then divided according to the resolution of papilledema into 2 groups: 1) Residual disc elevation group. 2) Completely resolved disc edema group. CSF pressure was measured via lumber puncture preoperative for all patients and 3 months post-operative only for patients with residual disc edema. A comparison between both groups was done.ResultsThere was a highly statistically significant difference between the two groups as regard the papilledema grade (the residual disc elevation group had a higher grade of papilledema) with P-value=0.000. As regard the difference in the preoperative optic disc vessel density between the two groups, there were statistically significant differences (optic disc vessel density was more in the residual disc elevation group). As regard the postoperative optic disc vessel density, there were non-significant differences between the two groups in whole image, inside disc and peripapillary vessel density (either in macro or microvasculature).ConclusionThe optic disc vessel density decreased with normal postoperative CSF opening pressure in cases with residual disc elevation postoperatively. Thus, in cases of residual optic disc swelling after shunt surgery, we can detect the reduction of intracranial pressure by the reduction in the optic disc vessel density which is a safe non-invasive technique. That may help in cases of residual disc elevation.

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

BackgroundRecently, diagnostic criteria including a standardized MRI criterion were presented to identify patients suffering from idiopathic intracranial hypertension (IIH) proposing that IIH might be defined by two out of three objective findings (papilledema, ≥ 25 cm cerebrospinal fluid opening pressure (CSF-OP) and ≥ 3/4 neuroimaging signs).MethodsTo provide independent external validation, we retrospectively applied the proposed diagnostic criteria to our cohort of patients with clinical suspicion of IIH from the Vienna IIH database. Neuroimaging was reevaluated for IIH signs according to standardized definitions by a blinded expert neuroradiologist. We determined isolated diagnostic accuracy of the neuroimaging criterion (≥ 3/4 signs) as well as overall accuracy of the new proposed criteria.ResultsWe included patients with IIH (n = 102) and patients without IIH (no-IIH, n = 23). Baseline characteristics were balanced between IIH and no-IIH groups, but papilledema and CSF-OP were significantly higher in IIH. For the presence of ≥ 3/4 MRI signs, sensitivity was 39.2% and specificity was 91.3% with positive predictive value (PPV) of 95.2% and negative predictive value (NPV) 25.3%. Reclassifying our cohort according to the 2/3 IIH definition correctly identified 100% of patients without IIH, with definite IIH and suggested to have IIH without papilledema by Friedman criteria, respectively.ConclusionThe standardized neuroimaging criteria are easily applicable in clinical routine and provide moderate sensitivity and excellent specificity to identify patients with IIH. Defining IIH by 2/3 criteria significantly simplifies diagnosis without compromising accuracy.

Clinico demographic profile and short-term outcome of Pediatric Idiopathic Intracranial Hypertension in a tertiary care hospital of Bangladesh

Background: Diagnosis of IIH (idiopathic intracranial hypertension) in children is challenging. The pathogenesis of IIH is still largely unknown. The aim of this study to evaluate the clinico-demographic profile and short-term outcome of IIH among Bangladeshi children. Methodology: This observational cohort study was done in pediatric Neurology Department, National Institute of Neurosciences and Hospital Bangladesh from January 2018 to July 2019. Total 19 cases were enrolled who were clinically suspected and/or had normal CSF with opening pressure (OP) above 250 mmH2O. They were further categorized as “definite IIH”, definite IIH without papilledema, and “probable IIH”. Clinical, radiological profile and short-term outcome were analyzed by SPSS version 22. Result: Among them most were probable IIH (74%). Episodic (57.9%), moderate, diffuse headache was the predominant symptom along with vomiting, double vision, unilateral VI nerve palsy and papilledema. Obesity was found in 21% cases. Mean CSF pressure was 21.84+7.62cm H2O and found high in definite IIH. All the cases were treated with acetazolamide and serial LP was done in 4(15.8%) cases. Definite IIH requires longer hospital stay (6.42 ± 2.87days). Recurrence was observed in 10.5% cases and visual impairment was found in 15.8% cases. Conclusion: This study found wide range of diversity between clinical feature and CSF opening pressure in Pediatric IIH and diagnostic confirmation was challenging. Initial treatment response was satisfactory with a low recurrence rate. J Bangladesh Coll Phys Surg 2024; 42: 161-168

Idiopathic intracranial hypertension associated with SARS-CoV-2 infection in an adult male patient: a case report and review of the literature

BackgroundHeadache is a frequent symptom in coronavirus disease 2019 (COVID-19) patients, and idiopathic intracranial hypertension (pseudotumor cerebri) has been reported among patients who underwent lumbar puncture for persistent headaches.Case presentationA 45-year-old black man presented with dyspnea, cough, fever and headache for 05 days followed by blurring of vision associated with worsening of the headache. Physical examination was significant for tachypnea and oxygen desaturation and there were no abnormal neurologic findings. He tested positive for SARS-CoV-2 with nasopharyngeal swab PCR. His CSF opening pressure appeared high with normal CSF analysis and brain magnetic resonance imaging (MRI) revealed prominent subarachnoid space around the optic nerves and bilateral papilledema. He had significant improvement with medical therapy alone.ConclusionIdiopathic intracranial hypertension (IIH) may occur in association with SARS-CoV-2 infection and should be considered when making a differential diagnosis for headache and blurring of vision. COVID-19 may play a role in the development of intracranial hypertension, even in the absence of known risk factors. Early diagnosis and treatment of IIH has paramount importance to prevent vision loss and other morbidities.

Systemic steroids in pediatric pseudotumor cerebri - A case report

Study design: Case report. Purpose: To study the efficacy of systemic steroids in pediatric pseudotumor cerebri. Introduction: Pseudotumor cerebri is a condition caused by elevated intracranial pressure presenting most commonly with headache. It is a diagnosis of exclusion. Methods: A 15-year-old girl presented in our outpatient department with a headache for 3 months, more in the posterior aspect, continuous type with severe intensity, non-radiating. On examination, the best corrected visual acuity in her right eye was 6/9, and her left eye was 6/6 parts. She had a normal anterior segment and normal Intraocular Pressure (IOP). Fundoscopy showed both optic discs edematous, pink in color with blurry disc margins, tortuous disc vessels, and edematous peripapillary area. The rest of the retina was normal. Lumbar puncture showed elevated opening CSF pressure and normal CSF composition. Hence she was diagnosed with IIH. She was started on oral prednisolone 1mg/kgbw once a day dosage, oral acetazolamide 250 mg once a day, topical nepafenac 0.1% one drop thrice a day and timolol 0.5% eye drops twice a day. Discussion: The main goals of treatment are alleviation of symptoms, including headache, and preservation of vision. Steroids were commonly used for treating IIH in the past, but cause significant long-term side effects, such as weight gain, that are undesirable in IIH patients. Furthermore, withdrawal of steroids can cause rebound intracranial hypertension. Thus, steroids should not be used routinely for IIH treatment. Results: By the end of one month, the patient was relieved of symptoms, best corrected visual acuity was 6/6 in both eyes with normal IOP, normal optic disc in both eyes. Conclusion: Steroids are an effective way of managing idiopathic intracranial hypertension in pediatric patients.

Venous sinus stenting for idiopathic intracranial hypertension: An updated Meta-analysis

BackgroundIdiopathic intracranial hypertension (IIH) is characterized by elevated intracranial pressure and primarily affects obese women of reproductive age. Venous sinus stenting (VSS) is a surgical procedure used to treat IIH, but its safety and efficacy are still controversial. MethodsA systematic review and meta-analysis were conducted following PRISMA guidelines. Multiple databases were searched for studies evaluating the safety and efficacy of VSS in IIH patients and meta-analysis was performed to pool the data. ResultsA total of 36 studies involving 1066 patients who underwent VSS were included. After VSS, a significant reduction in trans-stenotic gradient pressure was observed. Patients also showed significantly lower cerebrospinal fluid (CSF) opening pressure. Clinical outcomes demonstrated improvement in tinnitus (95%), papilledema (89%), visual disturbances (88%), and headache (79%). However, 13.7% of patients experienced treatment failure or complications. The treatment failure rate was 8.35%, characterized by worsening symptoms and recurrence of IIH. The complications rate was 5.35%, including subdural hemorrhage, urinary tract infection, stent thrombus formation, and others. ConclusionVSS appears to be a safe and effective treatment option for IIH patients who are unresponsive to medical therapy or have significant visual symptoms. However, long-term outcomes and safety of the procedure require further investigation.

Headache Phenotypes in Idiopathic Intracranial Hypertension and Its Short-Term Outcomes: A Retrospective Case Series Study.

Idiopathic intracranial hypertension (IIH) presents a complex physiopathology, leading into diverse manifestations, notably variable headache phenotypes. Furthermore, its frequent overlap with migraine complicates the evaluation of treatment benefit for IIH-related headache. Our aim was to investigate if there is any relationship between demographic factors, clinical patterns of headache, treatment response, and headache short-term outcome with the headache phenotype of IIH. This study was a retrospective analysis of demographic, clinical, and treatment features of patients with idiopathic intracranial hypertension presenting with headache and evaluation of headache outcomes in the first 12 months following treatment. Thirty-two patients were included (median age of onset 29.0 years (interquartile range 25.0 - 38.5), 90% females, median body mass index 32.5 kg/m2; 87.5% (n = 28) with papilledema; median cerebrospinal fluid opening pressure 36.5 cm H2O). Patients presented with migraine (n = 11, 34.4%), tension-type (n = 9, 28.1%), or a not-classifiable headache (n = 12, 37.5%). Regarding treatment and short-term follow-up (12 months), there was a failure of medical treatment in 43.8% (n = 14) and a reduction of headaches (≥ 50%) in 62.5% (n = 20) of the patients. Among headache phenotypes, there were no significant differences regarding demographics, clinical features, clinical patterns, or treatment response at baseline. Also, there were no differences regarding response to treatment or headache outcomes in 1, 3, 6, and 12 months of follow-up. In our study, migraine and unclassifiable types were the most commonly reported headache phenotypes. Headache phenotype does not appear to be an essential factor in allowing clinical distinction, treatment response, or predicting the short-term headache outcome of this intriguing entity.

Optic Nerve Head and Retinal Changes in Idiopathic Intracranial Hypertension: Correlation with Short-Term Cerebrospinal Fluid Pressure Monitoring.

We aimed to assess the status of the optic nerve and retina by optical coherence tomography (OCT) in a group of patients with idiopathic intracranial hypertension (IIH) on the basis of dynamic changes in intracranial pressure. This observational and cross-sectional study included patients affected by idiopathic intracranial hypertension with papilledema (IIHWP) and patients with idiopathic intracranial hypertension without papilledema (IIHWOP). All participants underwent an OCT examination of the macula and optic nerve head. Parameters related to intracranial pressure, including cerebrospinal fluid (CSF) opening pressure (oCSFp), CSF mean pressure (mCSFp), and pulse wave amplitude (PWA), were included in the analysis. Out of the 22 subjects enlisted for the study, a total of 16 patients suggestive of IIH were finally enrolled. Papilledema was detected in nine subjects (56.2%) and seven patients were affected by IIHWOP (43.7%). The OCT examination showed a higher mean RNFL thickness in IIHWP patients in comparison to IIHWOP in both eyes (p < 0.05 and p < 0.01, respectively). Intracranial pressure (ICP) measurements showed that IIHWP had higher values of oCSFp, mCSFp, and PWA compared to IIHWOP (p = 0.0001, p = 0.0001, and p = 0.0001, respectively). In addition, ICP parameters significantly correlated with RNFL. Clinical parameters suggestive of idiopathic intracranial hypertension are associated with retina and optic nerve OCT parameters. OCT is a useful tool to detect these alterations in a non-invasive fashion.

Clinical Predictors of Pulsatile Tinnitus in Patients With Idiopathic Intracranial Hypertension: An Age-Matched Cohort Study.

Pulsatile tinnitus (PT) occurs in many but not all patients with idiopathic intracranial hypertension (IIH). It is poorly understood why some patients with IIH develop PT, yet others do not. The purpose of this study was to determine if any clinical findings differ between those with and without PT in IIH, potentially shedding light on a pathophysiologic mechanism. Age-matched cohort analysis of patients with documented IIH and presence or absence of PT was performed, collecting data including body mass index (BMI), blood pressure, visual acuity, cerebrospinal fluid (CSF) opening pressure, sleep apnea, migraines, and transient visual obscurations, among others. Independent-sample t test and χ2 test were used to analyze continuous and binary variables, respectively, with multivariate analysis conducted including variables statistically significant on univariate analysis. Eighty subjects with IIH met the inclusion criteria (40 PT+, 40 PT-). CSF opening pressure showed no significant difference between the two groups. The PT+ cohort was found to have an average BMI of 45.1 kg/m 2 , which was significantly higher than the PT- group (37.7 kg/m 2 ; p = 0.0023). PT+ pulse pressure (60.1 mm Hg) was also significantly higher than the PT- group (51.6 mm Hg; p = 0.019). PT+ patients were also significantly more likely to have sleep apnea ( p < 0.001) and migraines ( p = 0.0036). Multiple logistic regression revealed an adjusted odds ratio of 13.9 for sleep apnea, 4.1 for migraines, and 1.01 for every increase in unit of BMI. Among patients with IIH, presence of PT is associated with higher BMI and pulse pressure, and increased incidence of sleep apnea and migraines. Given no significant difference in CSF pressures between the two groups, PT may not be a product of increased disease severity but may be related to sequelae of obesity, such as increased pulse pressure and sleep apnea.

Severe bilateral papilledema after sigmoid sinus constriction surgery: a case report

BackgroundPapilledema is a common sign of various diseases in the eye. It could result from any conditions of increased intracranial pressure (ICP). Underlying the etiology of papilledema and appropriate treatment in time is essential.Case reportWe present a case of severe bilateral papilledema after sigmoid sinus constriction surgery. A 25-year-old female presented with a 1-month history of bilateral blurred vision, headache, and vomiting. The patient had a history of right-side sigmoid sinus constriction surgery for pulsatile tinnitus (PT) one month before in another hospital. Fundus examination showed severe bilateral papilledema. Lumbar puncture showed an elevated cerebrospinal fluid (CSF) opening pressure of 29 cm H2O. Neuroimaging examination demonstrated the right sigmoid sinus filling defect as changes after surgery. We referred the patient to the initial surgeon, who repaired the sigmoid sinus on the right side by removing the implanted gelatin sponge, as diuretic treatment could not be effective. Intracranial hypertension symptoms and signs improved soon after eliminating sigmoid sinus stenosis. Neuroimaging showed resolved right sigmoid sinus stenosis after the second surgery. CSF opening pressure was 14.5 cm H2O at the 1-month follow-up. Fundus examination showed entirely resolved papilledema. Three years of follow-up showed no recurrence.ConclusionsThis is the first clinical report of intracranial hypertension associated with sigmoid sinus constriction surgery. Although rare, rapid detection and adequate etiology management could lead to a good prognosis. It highlights the need for ophthalmologists to be aware of the diagnostic approach to papilledema and enhance cooperation with multidisciplinary departments. The most likely cause of the intracranial hypertension was dominant sinus surgical constriction by mechanical external compression, as confirmed by the complete clinical remission following the second operation to remove the implanted gelatin sponge. Thus, this case also highlights the importance of selecting the appropriate therapeutic option for PT. Surgical sinus constriction should no longer be considered a viable option for PT treatment.

Clinical, radiological profile and outcomes of patients with idiopathic intracranial hypertension: a prospective study in the South Indian population

Objective: To describe the clinical, radiological characteristics and outcomes of patients with Idiopathic intracranial hypertension (IIH) at 6 months in a cohort of South Indian patients. Methods: We did a prospective study on patients presented to our institute with the symptomatology of IIH. A detailed history regarding headache, visual symptoms were noted. A complete neurological examination including examination of the fundus, CSF opening pressure, MRI brain, and MR cerebral venography were performed for all subjects. The patients were followed-up for 6 months to assess treatment response. Results: We evaluated 49 patients, the majority were females, and 38.7% had grade 1 obesity. Headache was the most common clinical presentation. The most common MRI abnormality was empty sella turcica, noted in 47%. There was a significant positive correlation between CSF opening pressure and headache severity (R2= 0.165, p = 0.018), as well as between CSF opening pressure and the grade of papilledema (R2=0.245, p=0.001). Of the cases, 95% responded to medical management, and three patients of fulminant IIH underwent lumbar-peritoneal shunting. At 6 months, 60% had persistent headaches. Only 8.7% had persistent visual symptoms, and only one had optic atrophy. There was no significant correlation between the follow-up grade of papilledema and the patient’s BMI. No significant correlation was found between the amount of weight lost and the improvement in the Numerical Rating Scale (NRS) score at 6 months. Conclusion: Headache in IIH is multifactorial and a significant cause of disability. The overall prognosis for vision is good. IIH should be suspected in any obese woman with headaches since it is one of the preventable causes of blindness.

A case of reversible isolated cognition impairment in meningoencephalitis without abnormal MRI findings

AbstractBackgroundWe report a case of meningoencephalitis with reversible isolated cognition impairment without abnormal MRI findings.MethodA 75‐year‐old man presented with confusion including bizarre behavior 2 days ago. Before visiting the hospital, his son found the patient naked and under the blanket saying it was cold. Fever didn’t occur. Mental status was alert without awareness. On neurologic examination, mutism was found. Muscle power on both upper and lower limbs was normal. Routine laboratory test showed that leukocytes count was normal but eosinophils were increased to 14.0%. Initial brain MRI including DWI and contrast enhanced image revealed no enhanced structural lesions. Initial K‐MMSE score was 4 points while the previous K‐MMSE score 3‐months‐ago was 25 points. There was no epileptic form discharge in EEG. CSF study demonstrated that WBC count was 18/L. protein was 42.6mg/dL, and glucose was 103mg/dL. CSF opening pressure was 5cmH2O. Culture study including gram stain, AFB stain, PAS stain showed no growth of aerobe, anaerobe, fungus and hyphae. Mycobacterium tuberculosis PCR and HSV PCR were negative. ADA was under 3 IU/I. Serum paraneoplastic antibodies were all negative.ResultThe patient showed only isolated cognition impairment without fever and there was no evidence of meningoencephalitis on the contrast enhanced MRI. Although the patient revealed CNS infection with unknown cause in CSF profile, it has some possibilities; 1) Aseptic meningoencephalitis with viral infection, 2) Bacterial meningoencephalitis with early stage, 3) Parasitic meningoencephalitis, 4) Autoimmune meningoencephalitis. Because of the negative findings in autoimmune antibody test, autoimmune meningoencephalitis was less likely. After treatment with acyclovir 0.6g for 7days, ceftriaxone 4g, vancomycin 2.5g and Ampicillin 8g for 10 days, confusion and mutism were improved with K‐MMSE 18 points.ConclusionMany reports have been published on meningoencephalitis accompanied by fever, altered mentality, seizure, muscle weakness and abnormal MRI findings respectively. However there have been few cases of meningoencephalitis with isolated cognition impairment and normal MRI simultaneously. If it is a change of consciousness and cognition impairment caused by meningoencephalitis, it can be reversible with proper treatment. Therefore, if only sudden onset isolated CNS symptom with normal brain MR finding, it is essential to check CSF profile.

Clinical characteristics, treatment, and outcome of low-risk non-HIV-associated cryptococcal meningitis: A retrospective cohort study.

Although non-human immunodeficiency virus (HIV)-associated cryptococcal meningitis (CM) is a severe disease, there are still some non-HIV CM patients with a low risk of therapeutic failure. Recognizing clinical characteristics of low-risk non-HIV-associated CM may enable clinicians to treat non-HIV-associated CM more reasonably. According to the definition of low-risk non-HIV-associated CM in the 2010 Infectious Diseases Society of America guideline, a total of 220 non-HIV CM patients were divided into two groups (Group 1: 35 low-risk patients and Group 2: 185 non-low-risk patients). Clinical characteristics, treatment, and outcome were compared between the two groups. Compared with non-low-risk patients, low-risk patients had a lower rate of headache (82.9% vs. 95.7%, P=.012), cerebrospinal fluid (CSF) opening pressure (OP) at baseline (CSF OP<250-mm H2O, 60.0% vs. 32.4%, P=.001), and baseline CSF cryptococcal count (median, 0 vs. 2376, P<.001), higher baseline CSF white blood cell (median, 130 vs. 90, P=.029) and CSF protein (median, 0.87 vs. 0.73, P=.011). Multivariate analysis showed that baseline CSF OP<250-mm H2O (OR: 2.545, 95% CI 1.168, 5.545, P=.019) was independently associated with low-risk for non-HIV-associated CM. The lengths of AMB-d-based induction therapy of low-risk patients (median, 20 days) were shorter (P<.001) than that of non-low-risk patients (median, 38 days). The successful outcome rate of low-risk patients was higher than non-low-risk patients (97.1% vs. 54.6%, P<.001). We demonstrated that non-HIV-associated CM patients with baseline CSF OP< 250-mm H2O were prone to the low-risk status.

Bibrachial amyotrophy as a rare manifestation of intraspinal fluid collection: a case report and systematic review.

Intraspinal cerebrospinal fluid (CSF) collection has been reported as a rare cause of lower motor neuron (LMN) disorder. We report a case of bibrachial diplegia associated with intraspinal CSF collection and perform a systematic literature review. A 52-year-old man developed a bibrachial amyotrophy over 6years, confirmed by the presence of cervical subacute neurogenic changes at electromyography (EMG). Brain magnetic resonance imaging (MRI) revealed cerebral siderosis, while spine MRI showed a ventral longitudinal intraspinal fluid collection (VLISFC) from C2 to L2. No CSF leakage was localized at myelography; a conservative treatment was chosen. We searched for all published cases until 30th April 2023 and extrapolated data of 44 patients reported in 27 publications. We observed a male predominance, a younger disease onset compared to amyotrophic lateral sclerosis, and a quite long disease duration, highlighting a slow disease progression. LMN signs were more frequently bilateral, mostly involving C5-C6 myotomes. Around 61% of patients presented additional symptoms, but only three referred to a history of headache. Accordingly, CSF opening pressure was mostly normal. Spinal MRI revealed the presence of VLISFC and in some cases myelomalacia. EMG patterns displayed both chronic and subacute neurogenic change in the cervical region. The disease course mainly depended on the treatment choice, which was mostly represented by a surgical approach when a specific dural defect was detected by imaging. Bibrachial diplegia due to VLISFC can be a treatable cause of focal amyotrophy and presents some clinical and radiological "red flags" which cannot be missed by a clinical neurologist.

Abstract 084: Intracranial Onyx Resolute Stenting In Idiopathic Intracranial Hypertension Patient With Pre‐existing Nickel Allergy: Case Report

Introduction Idiopathic intracranial hypertension (IIH) is a pathology involving an increase in intracranial pressure leading to symptoms including papilledema, tinnitus, and elevated cerebrospinal fluid opening pressure. Recent research has identified venous sinus stenosis as a cause of IIH, a common treatment of which is venous stenting and angioplasty. An adverse event of this procedure is in‐stent stenosis (ISS), due to either neointimal hyperplasia or hypersensitivity to an element in the stent. There has been speculation regarding whether nickel in intracranial stents is a cause of concern, due to its potential to cause a Type IV hypersensitivity reaction and ISS, which is an indicator of future stroke. The purpose of this case report is to determine if the cobalt‐based alloy Onyx Resolute intracranial stents can safely treat IIH in patients with allergic contact dermatitis to nickel. Methods We present a 38‐year old woman who presented with migraines and IIH with papilledema and severe pulsatile tinnitus. Headaches had been present for 5‐10 years. Ophthalmology consult revealed bilateral papilledema, upon which an MRI and MRV revealed venous stenosis. There was a 17mmHg pressure gradient measured in the patient. Patient could not tolerate acetazolamide, with kidney stones and loss of sheen in hair. Cerebral angiogram indicated right transverse‐sigmoid junction stenosis and atretic left venous sinus. The patient had an Onyx Resolute stent placed in the right transverse sigmoid junction. The Onyx Resolute stent is a Zotarolimus‐eluting stent made up of a cobalt‐based shell and a platinum‐Iridium core and is not recommended for patients with a hypersensitivity to nickel, cobalt, or chromium, but has a lower nickel content than a self‐expanding stent. Results Patient underwent cerebral angiogram, revealing right transverse‐sigmoid junction stenosis with a 17mmHg pressure gradient. Stenting and angioplasty were performed; this reduced the venous sinus pressure in the R transverse sinus (pre‐stenotic segment) from 43 mm Hg to 24 mm Hg with resolution of the R transverse‐sigmoid junction pressure gradient. Patient was treated with prasugrel (Effient) for one month. At the one‐month follow‐up, the patient reported an improvement of symptoms, with near‐resolution of her prior headaches in terms of severity and frequency following her procedure. Visual acuity is at baseline, pending formal follow‐up assessment for papilledema. Follow‐up CT Head Venogram with and without contrast showed a patent R transverse to sigmoid venous stent. The patient was continued on aspirin 81mg daily and prasugrel 5mg daily and is to continue follow‐up with yearly ophthalmologic exams. Conclusion Although there is speculation regarding the use of metal intracranial stents in patients allergic to nickel, our patient has shown that it is safe to use the Onyx Resolute intracranial stent despite a pre‐existing nickel hypersensitivity.

Simple detecting of elevated ICP through liquor flow after lumbar puncture

Elevated intracranial pressure (ICP) is defined as a cerebrospinal fluid (CSF) opening pressure (OP) greater than 25 cmH2O. When a diagnostic lumbar puncture is performed it is useful to estimate also intracranial pressure. To do this it is required a presence of pressure gauges, which are currently the gold standard, not available in most resource-constrained contexts. We decided to evaluate whether it is possible to estimate it simply by counting the drops of cerebrospinal liquor, which are collected after lumbar puncture, according to Poiseuille's law. Was examined a sample of 52 patients, aged between 18 and 85 years, belonging to the emergency room of “Santa Maria delle Grazie” Hospital in Pozzuoli (Naples) who needed a diagnostic lumbar puncture (LP). The ICP was initially measured using a standard narrow-gauge manometer by attaching it to the spinal needle. After removing the pressure gauge, the number of drops of cerebrospinal fluid flowing from the spinal needle in 30 seconds was counted. A statistical analysis was made with linear regression and ROC analysis. OP as measured by standard manometry was raised on 17 occasions with CSF drop rate median of 47 drops/30 seconds and range 30–74 drops/30 seconds. OP was normal on 35 occasions with CSF drop rate median of 23 drops/30 seconds with range of 14-34 drops/30 seconds. A linear regression analysis was performed which resulted in a Pearson correlation of 0.936 an adjusted R square of 0.874 (see Fig. 1). Analysis through ANOVA documented an F of 355.301 with p < 0.01 and Dubin Watson of 1.642. The analysis through ROC showed an AUC of 0.980, with a sensitivity of 100% and a specificity of 91% if chosen as a limit, 29 drops in 30 seconds (Youden Index of 0.9140). Therefore, we have concluded, that although there are several precautions, like patient's position, it is technically feasible to indirectly estimate cerebrospinal fluid pressure with good accuracy by counting the drops of cerebrospinal fluid flowing from a 22 G spinal needle.

A Case Series on Clinical Profile, Risk Factors and Management of Idiopathic Intracranial Hypertension

Introduction Idiopathic intracranial hypertension (IIH) occurs when there is raised intracranial pressure (ICP) of unknown etiology and is diagnosed when all other causes of raised ICP have been excluded1 . IIH most commonly affects women of child-bearing age and overweight women2 . However, men, women of all ages and children of both genders are affected3 . Previously the terms like pseudo tumor cerebri and benign intracranial hypertension were used; however, in view of impending loss of vision it cannot be considered benign. Hence the term IIH is used nowadays. The diagnosis of IIH was made using modified Dandy criteria which includes presence of raised intracranial pressure, papilloedema, normal magnetic resonance imaging (MRI) and elevated CSF opening pressure with normal CSF composition. In the absence of papilledema, the diagnosis is challenging and requires specific neuroimaging criteria to be fulfilled.

Development and validation of a machine learning model to predict prognosis in HIV-negative cryptococcal meningitis patients: a multicenter study.

To predict prognosis in HIV-negative cryptococcal meningitis (CM)patients by developing and validating a machine learning (ML)model. This study involved 523 HIV-negative CM patients diagnosed between January 1, 1998, and August 31, 2022, by neurologists from 3 tertiary Chinese centers. Prognosis was evaluated at 10weeks after the initiation of antifungal therapy. The final prediction model for HIV-negative CM patients comprised 8 variables: Cerebrospinal fluid(CSF) cryptococcal count, CSF white blood cell (WBC), altered mental status, hearing impairment, CSF chloride levels, CSF opening pressure (OP), aspartate aminotransferase levels at admission, and decreased rate of CSF cryptococcal count within 2weeks after admission. The areas under the curve (AUCs) in the internal, temporal, and external validation sets were 0.87 (95% CI 0.794-0.944), 0.92 (95% CI 0.795-1.000), and 0.86 (95% CI 0.744-0.975), respectively. An artificial intelligence(AI) model was trained to detect and count cryptococci, and the mean average precision (mAP) was 0.993. A ML model for predicting prognosis in HIV-negative CM patients was built and validated, and the model might provide a reference for personalized treatment of HIV-negative CM patients. The change in the CSF cryptococcal count in the early phase of HIV-negative CM treatment can reflect the prognosis of the disease. In addition, utilizing AI to detect and count CSF cryptococci in HIV-negative CM patients can eliminate the interference of human factors in detecting cryptococci in CSF samples and reduce the workload of the examiner.

Optic disc vessel density changes after shunt surgery in idiopathic intracranial hypertension

AimTo detect the change in optic disc vessel density in patients with idiopathic intracranial hypertension (IIH) after shunt surgery. Patients and methodTwenty-one patients with IIH underwent shunt surgery. Patients were subjected to full ophthalmic and neurological examinations. Optic disc vessel density was measured using optical coherence tomography angiography (OCT-A) before and two months after surgery. ResultsThe age of patients ranged from 27 to 48 years old, with a mean of (34.85 ± 6.87). Visual acuity ranged between 0.2 and 0.9 by log Mar, with a mean of (0.64±o.20). The mean deviation (MD) of the perimeter ranged from -22.9 to 0 dB, with a mean of (-9.77 ± 7.23 dB). With respect to the grade of papilledema, 15 eyes (35.7%) were of grade II, 21 eyes (50.0%) were of grade III, and 6 eyes (14.3%) were grade IV.Intracranial pressure measured by lumbar puncture (LP) prior to surgery ranged from 30 to 40 cm, with a mean of 35.43 cm. Except for right transverse sinus hypoplasia in 6 patients (28.6%), MRV was normal. In 15 patients (71.4%), lumboperitoneal shunt was performed, while ventriculoperitoneal shunt was performed in 6 patients (28.6%).After surgery, the optical disc vessel density was decreased in all patients. This decrease was highly significant for the whole image, the inner disc, the peripapillary, superior, and inferior hemispheres. Moreover, this reduction affected both optic disc microvasculature (referred to as capillary vessel density) and macro vasculature (also known as all vessel density).There were positive correlations between the CSF opening pressures and the preoperative optic disc vessel density of the whole image and inside disc with a P-value (0.002, 0.009), respectively. In addition, there was a positive correlation between the opening CSF pressures and the reduction in whole image vessel density after surgery with a P-value of 0.000. ConclusionOptic disc vessel density decreased after shunt surgery in patients with IIH. Consequently, optic disc vessel density can be used as a biomarker for the reduction of CSF opening pressure.