Cerebrospinal Fluid Opening Pressure Research Articles

Primary balloon angioplasty of venous Sinus stenosis in idiopathic intracranial hypertension.

Venous sinus stenosis (VSS) stenting has emerged as an effective treatment for patients with Idiopathic Intracranial Hypertension (IIH). However, stenting carries risk of in-stent stenosis/thrombosis and cumulative bleeding risk from long-term dual antiplatelet (DAPT) use. Thus, we investigated the potential safety and efficacy of primary balloon angioplasty as an alternative to stenting in IIH. A prospectively maintained single-center registry of IIH patients undergoing endovascular procedures was queried. Inclusion criteria included patients with confirmed IIH and angiographically demonstrable VSS who underwent interventions from 2012- 2021. Patients were dichotomized into primary balloon angioplasty (Group A) and primary stenting (Group S), comparing clinical outcomes using bivariate analyses. 62 patients were included with median age of 33 [IQR 26-37], 74% females. Group A (9/62) and Group S (53/62) had similar baseline characteristics. Papilledema improvement was higher in Group S at 6 weeks and 6 months (44 vs. 93, p = 0.002 and 44 vs. 92%, p = 0.004), with similar improvements across all symptoms. Group S had higher mean post-procedure venous pressure gradient change (8 vs. 3 mmHg, p = 0.02) and a lower CSF opening pressure at 6 months (23 vs. 36 cmH2O, p < 0.001). VPS rescue rate was higher in Group A (44 vs. 2%, p = 0.001). There was only one procedural complications; a subdural hematoma in Group A. Primary VSS balloon angioplasty provides a marginal and short-lived improvement of IIH symptoms compared to stenting. These findings suggest a cautious and limited role for short-term rescue angioplasty in poor shunting and stenting candidates with refractory IIH.

Teaching NeuroImage: Thickened and Enhanced Cauda Equina as a Manifestation of Acute Lymphoblastic Leukemia Relapse.

A 20-year-old man with a history of B-cell acute lymphoblastic leukemia (ALL) in remission reported a 2-week history of bilateral lower limb weakness. Electrophysiologic examination showed prolonged latency of F-wave of bilateral tibial nerves. The CSF opening pressure was increased (>30 cm/H20), with elevated protein level (1683 mg/L, RI 150–400 mg/L), decreased glucose concentration (5.94 mg/dL, RI 50.4–80.64 mg/dL), and pleocytosis (854/mm3, RI < 10/mm3) in CSF. Flow cytometry assays for detecting minimal residual disease in CSF disclosed numerous lymphoblasts (CD45+, CD19+, CD34+, CD10+, CD38±, and CD20−), and lumbosacral MRI showed thickened and homogeneously enhanced cauda equina, which were consistent with nervous system relapse of B-cell ALL (Figure).1 Cauda equina involvement as a manifestation of ALL relapse is rare, and lumbosacral MRI markedly improved diagnosis.

Clinical and Radiological Profile of 122 Cases of Idiopathic Intracranial Hypertension in a Tertiary Care Centre of India: An Observational Study.

Idiopathic intracranial hypertension (IIH) is well-described entity in literature. However, large studies on clinical and radiological profile are still very few from the Indian subcontinent. To analyze the clinical and radiological profile of IIH and correlation of various clinical and radiological parameters with papilledema and CSF opening pressure. Hospital-based observational, descriptive study. This study analyzed 122 patients admitted in the department of Neurology (from January 2014 to December 2018) for detailed history, clinical examination, and neuroimaging. CSF manometry and routine CSF analysis were done. All participants met the modified Dandy criteria. Patients with secondary causes of raised ICP and primary ocular pathology were excluded. Descriptive statistics and Chi-square test. Among 122 cases 86 (70.49%) were females. The mean age was 33 years. 62 (50.82%) cases were obese. Headache was the most common symptom (114/122; 93.44%). Bilateral papilledema was noted in 114 (93.44%) cases. Higher grades of papilledema had a correlation with higher CSF opening pressure. Empty sella was the most common radiological finding (100/122; 81.97%). All radiological findings except empty sella had a correlation with higher CSF opening pressure. IIH typically affects obese females of childbearing age group. However, it is not uncommon in the nonobese and male sex. Obesity may not be a dominant risk factor for the development of IIH in the Indian subcontinent. Cases with normal BMI and male sex with clinical features of raised intracranial pressure and normal neuroimaging should also be evaluated for IIH. Cases with refractory headache and empty sella on MRI should be evaluated for IIH.

Infantile idiopathic intracranial hypertension: case report and review of the literature

BackgroundIdiopathic intracranial hypertension is an infrequent condition of childhood, and is extremely rare in infants, with only 26 cases described. The etiology is still unknown. Typical clinical manifestations change with age, and symptoms are atypical in infants, thus the diagnosis could be late. This is based on increased opening pressure at lumbar puncture, papilloedema and normal cerebral MRI. The measurement of cerebrospinal fluid opening pressure in infants is an issue because many factors may affect it, and data about normal values are scanty. The mainstay of treatment is acetazolamide, which allows to relieve symptoms and to avoid permanent visual loss if promptly administered.Case presentationWe report the case of an 8-month-old infant admitted because of vomit, loss of appetite and irritability; later, also bulging anterior fontanel was observed. Cerebral MRI and cerebrospinal fluid analysis resulted negative and after two lumbar punctures he experienced initial symptom relief. Once the diagnosis of idiopathic intracranial hypertension was made, he received oral acetazolamide, and corticosteroids, with progressive symptom resolution.ConclusionsInfantile idiopathic intracranial hypertension is extremely rare, and not well described yet. Bulging anterior fontanel in otherwise healthy infants with normal neuroimaging should be always considered suggestive, but can be a late sign, while irritability and anorexia, especially if associated with vomiting, may represent an early sign. In such cases, lumbar puncture should be always done, hopefully with cerebrospinal fluid opening pressure measurement, which is among coded diagnostic criteria, but whose threshold is controversial in infants. Early diagnosis, timely treatment and strict follow-up help to prevent vision loss or death of affected infants.

Correlation of palpation anterior fontanometry and cerebrospinal fluid opening pressure in early childhood hydrocephalus.

The anterior fontanelle (AF) tension has been a traditional clinical method of indirect assessment of intracranial pressure (ICP). How does this time-tested bedside assessment technique compare with an objective ventricular cerebrospinal fluid (CSF) opening pressure? To determine the correlation of palpation anterior fontanometry and CSF opening pressure in early childhood hydrocephalus. Children diagnosed with hydrocephalus who were planned for CSF diversion using ventriculo-peritoneal (V-P) shunt were prospectively studied over 18 months. The AF tension was assessed by palpation preoperatively and graded. The CSF opening pressure was measured using sterile disposable plastic manometers after ventricular cannulation intraoperatively. Data obtained were analysed using SPSS version 21. Student's t-test, Mann-Whitney U test and ANOVA were used to determine associations based on normality tests. A P < 0.05 was considered significant for associations. Fifty-two children were operated on with AF patency rate of 88.5%. Their age ranged between 2 weeks and 18 months with a mean age of 7.1 ± 5.1 months. The fontanelle tension was tense, full and normal in 63.0%, 26.1% and 10.9% of patients, respectively. The mean CSF opening pressure of 20.5 ± 8.5 cm of H2O was higher than the expected ICP for the age group (t-test 4.754, P = 0.000). All 28 patients with CSF opening pressure >15 cm of H2O had a tense fontanelle, but 10.9% of children with raised ICP have normal AF tension. The mean ICP increases as palpation AF tension increases, but a normal AF tension does not rule out raised ICP.

Comparison of Optic Nerve Sheath Diameters Measured by Optic Ultrasonography Before and After Lumbar Puncture in Idiopathic Intracranial Hypertension Patients.

Idiopathic intracranial hypertension (IIH) symptoms include headache, blurred vision, and papilledema which may lead to permanent vision loss unless diagnosed and treated. Definitive diagnosis of IIH usually requires the measurement of intracranial pressure (ICP) via lumbar puncture (LP) which is an invasive and unwanted technique for patients. In our study, optic nerve sheath diameters (ONSD) were measured before and after lumbar puncture in IIH patients and the relationship of these measurements with ICP changes was evaluated as well as the effect of decreasing cerebrospinal fluid (CSF) pressure after a lumbar puncture on ONSD. Thus, we want to investigate whether optic nerve ultrasonography (USG) is a useful tool instead of the invasive LP for the diagnosis of IIH. A total of 25 patients who applied to the neurology clinics of Ankara Numune Training and Research Hospital between May 2014 and December 2015 and were diagnosed with IIH were included in the study. The control group consisted of 22 individuals who applied with complaints other than headaches, visual impairment or tinnitus. Optic nerve sheath diameters were measured from both eyes before and after the LP. After pre-LP measurements were taken, opening and closing CSF pressure was measured. In the control group, ONSD was measured with optic USG. Mean age of the IIH group and the control group was determined as 34.8±11.5 and 45.8±13.3 years, respectively. In the patient group, mean CSF opening pressure was 33.9±8.0 cm H2O and mean closing pressure was 18.1±4.7 cm H2O. Mean ONSD measured pre-LP was 7.1±1.0 mm in the right eye and 6.9±0.7 mm in the left eye, while mean post-LP ONSD was 6.7±0.9 mm in the right eye and 6.4±0.8 mm in the left eye. There was a statistically significant difference between ONSD values before and after the LP (p=0.006 for the right eye, p<0.001 for the left eye). In the control group, mean ONSD was 5.4±0.7 mm in the right eye and 5.5±0.6 mm in the left eye, and a statistically significant difference was found between ONSD values before and after the LP (p<0.001 for the right eye and left eye). A significant positive correlation was determined between left ONSD measurements before the LP and CSF opening pressure (r=0.501, p=0.011). In the present study, it was found that ONSD measurement by optic USG significantly displays increased ICP, and decreasing pressure via LP is rapidly reflecting ONSD measurement. Based on these findings, it is suggested that ONSD measurements by optic USG, a non-invasive method, can be used in the diagnosis and follow-up of IIH patients.

Idiopathic intracranial hypertension secondary to iron‐deficiency anaemia

AbstractPurposeTo present a case of idiopathic intracranial hypertension (IIH) in a 21‐year‐old female patient in whom iron‐deficiency anaemia was the primary risk factor.MethodsCase report and review of the scientific literature.ResultsA 21‐year‐old female presented to eye casualty with a 3‐day history of intermittent blurring of vision in both eyes. She denied any significant headache. Visual acuity was 6/6 in both eyes, colour vision was normal and there was no RAPD. However, dilated fundal examination revealed bilateral optic disc oedema. A CT scan of brain/orbits demonstrated a partially empty sella and mild vertical tortuosity of the optic nerves. A lumbar puncture was performed and the CSF opening pressure was elevated at 30cmH2O. These findings were consistent with a diagnosis of IIH. The patient lacked common risk factors for IIH: her body mass index was not elevated and she had not previously been prescribed tetracycline antibiotics, hormonal contraceptives or high‐dose vitamin A derivatives. However, she did have a history of excessive consumption of the oral analgesic Nurofen Plus (ibuprofen plus codeine). This had caused profound iron‐deficiency anaemia and her haemoglobin level two weeks prior to this presentation was 71 g/L. A review of the literature found three retrospective studies that examined the role of anaemia in IIH. While one study did not find any statistically significant associated between anaemia and IIH, two found that treating anaemia is associated with a faster recovery and better prognosis in patients with IIH. Correction of anaemia alone can lead to resolution of IIH.ConclusionsIdiopathic intracranial hypertension is a complex condition and the most important neurological manifestation is papilloedema, which may lead to progressive optic atrophy and visual loss. Anaemia appears to be a risk factor for IIH and a full blood count should be included in the routine investigation of these patients.

A case report of a brain herniation secondary to cryptococcal meningitis with elevated intracranial pressure in a patient with Human Immunodeficiency Virus/Acquired immunodeficiency syndrome (HIV/AIDS)

BackgroundCryptococcal meningitis is a major opportunistic infection in individuals with HIV. The worldwide annual incidence is estimated to be approximately one million cases per year, with the most significant burden in sub-Saharan Africa. HIV-associated cryptococcal meningitis continues to have a high mortality rate despite widespread availability and use of HAART.Case36-year-old male with a past medical history of AIDS and a CD4 count of 35 cells/mm3 presented with altered mental status initially thought to be related to using crystalline methamphetamine as reported by EMS. However, a lumbar puncture performed in the emergency department showed elevated CSF opening pressure of 29 cmH2O and positive CSF and serum cryptococcal antigen. The patient was admitted and commenced treatment according to the current IDSA guideline but continued to have waxing and waning mental status. On the fourth day of admission, he complained of headache, had a witnessed seizure, and was taken emergently for a CT scan of the brain, which was negative for any acute intracranial process, but suffered a cardiac arrest before it could be done. He was intubated and transferred to the intensive care unit. CT brain follow-up showed anoxic encephalopathy, development of marked cerebral edema, and complete effacement of the basilar cisterns, suggestive of downward transtentorial herniation; he continued to deteriorate and expired on the seventh day of admission.Objectives1.Describe a case of brain death secondary to increased intracranial pressure due to cryptococcal meningitis in a patient with HIV/AIDS.2.Explain the mechanisms of elevation in intracranial pressure in patients with cryptococcal meningitis.3.Discuss the options for managing elevated intracranial pressure in patients with cryptococcal meningitis.4.Create awareness in the medical community about the importance of prompt and efficient management of increased intracranial pressure in patients with cryptococcal meningitis.ConclusionThis case highlights the importance of aggressive management of elevated intracranial pressure in cryptococcal meningitis. It reiterates the need for more data regarding the optimal timing and frequency of therapeutic lumbar puncture and the use of temporary lumbar drainage catheters and ventriculostomy to manage this potentially fatal complication.

Clinical Manifestations, Neuroimaging Findings, and Treatment of Idiopathic Intracranial Hypertension in a Nepalese Tertiary Centre

Introduction: Idiopathic Intracranial Hypertension is characterized by headache, visual impairment, papilledema, and increased cerebrospinal fluid opening pressure. We aim to evaluate clinical manifestations, neuroimaging findings, and treatment of Idiopathic Intracranial Hypertension in a Nepalese tertiary center. Materials and Methods: We retrospectively included patients with the diagnosis of Idiopathic Intracranial Hypertension who were admitted to the Neurology department of Tribhuvan University Teaching Hospital from 2019 June to 2021 May and presented to the Neuro-ophthalmology outpatient clinic of the hospital for follow-up. Results: Out of 16 Idiopathic Intracranial Hypertension patients, 12(75%) patients had either headache or ocular pain. Reduced visual acuity and progressive visual loss were found in 44% of patients. Normal CSF opening pressure was found in 19%, 44% had CSF opening pressure at a range of 20-30 cm H20 and &gt; 30 cm H20 in 37.5%. 15 Idiopathic Intracranial Hypertension patients (93.7%) were subtyped as Typical and 1 patient was diagnosed as Fulminant Idiopathic Intracranial Hypertension. Acetazolamide was used for treatment in 15 patients and 1 patient needed ventriculoperitoneal shunting. 56% Seven patients (44%) had some abnormal findings: partial empty sella (44%), and tortuous optic nerve (31%), flattened posterior eyeball (31%), and hypoplastic transverse sinus (19%). Conclusions: Idiopathic Intracranial Hypertension is an uncommon diagnosis but should be suspected in patients with chronic headaches with visual impairment. In low-resource settings, proper history along with neurological and ophthalmological examinations can even detect the early features and timely referral can save the vision and disability of Idiopathic Intracranial Hypertension patients.

Digital manometry to measure cerebrospinal fluid pressure during lumbar puncture.

Accurate cerebrospinal fluid (CSF) pressure measurements are critical for diagnosis and treatment of pathologic processes involving the central nervous system. Measuring opening CSF pressure using an analog device takes several minutes, which can be burdensome in a busy practice. The purpose of this study was to compare accuracy of a digital pressure measurement device with analog manometry, the reference gold standard. Secondary purpose included an assessment of possible time savings. This study was a retrospective, cross-sectional investigation of 71 patients who underwent image-guided lumbar puncture (LP) with opening CSF pressure measurement at a single institution from June 2019 to September 2019. Exclusion criteria were examinations without complete data for both the digital and analog measurements or without recorded needle gauge. All included LPs and CSF pressures were measured with the patient in the left lateral decubitus position, legs extended. Acquired data included (1) digital and analog CSF pressures and (2) time required to measure CSF pressure. A total of 56 procedures were analyzed in 55 patients. There was no significant difference in mean CSF pressures between devices: 22.5 cm H2O digitally vs 23.1 analog (p = .7). Use of the digital manometer resulted in a time savings of 6min (438s analog vs 78s digital, p < .001). Cerebrospinal fluid pressure measurements obtained with digital manometry demonstrate comparable accuracy to the reference standard of analog manometry, with an average time savings of approximately 6min per case.

103. An Association Between Abnormal CSF Analysis and Inpatient Mortality in Cryptococcal Meningitis, a Tertiary Care Center Experience

Abstract Background Cryptococcal meningitis (CM) is a life-threatening condition that requires prompt recognition and management. With high morbidity in mind, we elected to compare the key CSF analysis, blood culture and serum cryptococcal antigen (CrAg) to prognosticate the probability of mortality in this population. Table 1. Comparison of demographics, serum and CSF analysis Methods We retrospectively reviewed all charts of patients admitted to our tertiary care center from 10/2005 to 10/2017. Inclusion criteria encompassed patients with positive CSF CrAg, positive CSF cultures, India ink, cytopathology, or CSF cell count &amp;gt;5 with CNS symptoms, positive serum CrAg titer or blood cultures. Results Sixty patients who met the inclusion criteria were divided into the survivor (n=41) and the non-survivor (n=19) groups based on the inpatient mortality. There was no difference in age, sex, and immune status between the two groups. The median CSF nucleated cell counts in the non-survivor group was 39 cells/µL with median lymphocyte 59.5% whereas in the survivor group was 72 cells/µL with median lymphocyte 76% (P&amp;lt; 0.001 and 0.04 respectively). The median CSF glucose was 27 mg/ml in the non-survivor compared to 35 mg/ml in the survivor group (P=0.02). Median CSF CrAg was higher at 1:1024 in the non-survivor group whereas the survivor group was 1:256 (P &amp;lt; 0.01). CSF opening pressure (cm H2O), blood culture, and serum CrAg level were not statistically significant between the two groups. Conclusion Low CSF cell count, low glucose, and high CSF CrAg were independently associated with inpatient mortality in CM. This is in line with the prior findings. A novel finding in this study is significantly decreased median CSF lymphocyte % in the non-survivor group. Serum CrAg titer, positive blood cultures, and median CSF protein were not statistically significant between the two groups. However, a study with a larger sample size may be needed to confirm these findings. Disclosures All Authors: No reported disclosures

Optical Coherence Tomography to Monitor Rebound Intracranial Hypertension with Increased Papilledema after Lumbar Puncture

Objective: We report that lumbar puncture (LP) with removal of cerebrospinal fluid (CSF) induced rebound intracranial hypertension with increased papilledema as monitored by optical coherence tomography (OCT). Background: Severe papilledema causes visual field loss and central vision damage if untreated. Fundoscopy is a key to diagnose papilledema, but is not sensitive enough to monitor therapeutic effects. Methods: OCT was applied to follow a 24-year-old woman with headache, visual dysfunction, severe bilateral papilledema, and elevated CSF opening pressure. She was first treated with serial LP, which led to symptom deterioration, increased CSF pressure, and increased the retinal nerve fiber layer (RNFL) thickness. She was then successfully treated with acetazolamide and furosemide. Results: OCT showed reduction of RNFL thickness directly after LP with CSF removal, accompanied with reduced CSF pressure. Increased RNFL thickness accompanied with worsened headache, visual dysfunction, and increased CSF pressure was observed on the next day after LP. Less than 24 h after start of medication, the symptoms had reversed and RNFL thickness was reduced. The patient was symptom-free 2 weeks after starting on medical treatment. Papilledema had vanished on fundoscopy 6 weeks after the therapy, and RNFL thickness was normalized at 3 months of follow-up. Conclusion: This case provides evidence that OCT is an objective and sensitive tool to monitor papilledema and its response to therapy, and thereby important to help in correct clinical decision-making.

Evolution of MRI Findings in Patients with Idiopathic Intracranial Hypertension after Venous Sinus Stenting.

The correlation between imaging findings and clinical status in patients with idiopathic intracranial hypertension is unclear. We aimed to examine the evolution of idiopathic intracranial hypertension-related MR imaging findings in patients treated with venous sinus stent placement. Thirteen patients with idiopathic intracranial hypertension (median age, 26.9 years) were assessed for changes in the CSF opening pressure, transstenotic pressure gradient, and symptoms after venous sinus stent placement. Optic nerve sheath diameter, posterior globe flattening and/or optic nerve protrusion, empty sella, the Meckel cave, tonsillar ectopia, the ventricles, the occipital emissary vein, and subcutaneous fat were evaluated on MR imaging before and 6 months after venous sinus stent placement. Data are expressed as percentages, medians, or correlation coefficients (r) with P values. Although all patients showed significant reductions of the CSF opening pressure (31 versus 21 cm H2O; P = .005) and transstenotic pressure gradient (22.5 versus 1.5 mm Hg; P = .002) and substantial improvement of clinical symptoms 6 months after venous sinus stent placement, a concomitant reduction was observed only for posterior globe involvement (61.5% versus 15.4%; P = .001), optic nerve sheath diameter (6.8 versus 6.1 mm; P < .001), and subcutaneous neck fat (8.9 versus 7.4 mm; P = .001). Strong correlations were observed between decreasing optic nerve sheath diameters and improving nausea/emesis (right optic nerve sheath diameter, r = 0.592, P = .033; left optic nerve sheath diameter, r = 0.718, P = .006), improvement of posterior globe involvement and decreasing papilledema (r = 0.775, P = .003), and decreasing occipital emissary vein diameter and decreasing headache frequency (r = 0.74, P = .035). Decreasing transstenotic pressure gradient at 6 months strongly correlated with decreasing empty sella (r = 0.625, P = .022) and regressing cerebellar ectopia (r = 0.662, P = .019). Most imaging findings persist long after normalization of intracranial pressure and clinical improvement. However, MR imaging findings related to the optic nerve may reflect treatment success.

External lumbar drainage in progressive pediatric idiopathic intracranial hypertension.

Pediatric idiopathic intracranial hypertension (IIH) is characterized by increased intracranial pressure despite normal cerebrospinal fluid and neuroimaging findings. Initial management is typically medical; however, nearly 10% of children will eventually require surgery for persistent headache and/or vision loss. External lumbar drainage, which is a considerably safer treatment option, has not been adequately analyzed in children with medically refractory IIH. The authors conducted a single-institution retrospective analysis of children with medically refractory IIH who had undergone external lumbar drain (ELD) placement because of worsening papilledema, reflected as increased retinal nerve fiber layer (RNFL) thickness on optical coherence tomography (OCT) testing. The main outcome measures were effects of external lumbar drainage on papilledema resolution, symptoms, and vision. The authors analyzed the medical records of 13 children with IIH (11 girls, mean age 15.0 ± 2.3 years) whose mean CSF opening pressure was 45.5 ± 6.8 cm H2O. In all children, the average global RNFL thickness in both eyes significantly increased at ELD placement (right eye 371.8 ± 150.2 μm, left eye 400.3 ± 96.9 μm) compared with presentation thickness (right eye 301.6 ± 110.40 μm, left eye 350.2 ± 107.7 μm) despite acetazolamide medical therapy (20-30 mg/kg/day), leading to ELD placement after 9.5 ± 6.9 days (range 3-29 days). After ELD insertion, there was headache resolution, gradual and continuous improvement in optic disc thickness, and preservation of good vision. ELD placement in children with medically refractory IIH who demonstrated worsening papilledema with increased RNFL thickening on OCT testing typically results in symptom relief and disc edema resolution with good visual outcome, often preventing the need for additional definitive surgeries that carry greater failure and morbidity risks.

How do presentation age and CSF opening pressure level affect long-term prognosis of pseudotumor cerebri syndrome in children? Experience of a single tertiary clinic.

Diagnosis and treatment of pseudotumor cerebri syndrome in children is still a challenge for clinicians. The aim of this study is to reveal the influence of presentation age and CSF opening pressure on long-term prognosis of pseudotumor cerebri and share our clinical data of the very young age (≤ 5-year) group. This retrospective study includes the patients followed by the Marmara University Pediatric Neurology Clinic between years 2012 and 2020 diagnosed with definite, probable, or suggestive pseudotumor cerebri syndrome according to modified Friedman criteria. Patients were classified into three groups according to presentation age: group 1: ≤ 5years old; group 2: 6-10years; and group 3 > 10years old. CSF opening pressure was also categorized into three groups as CSF < 20 cmH20; CSF 20-30 cmH20; and CSF > 30 cmH20. One hundred three patients, 62.1% female (n = 64), were enrolled in the study. Group 1 consisted of 16 patients (60% male), group 2 consisted of 30 patients (63.3% female), and group 3 consisted of 57 patients (66.7% female). The mean CSF opening pressure did not differ between the three age groups in our study (p > 0.05). Treatment response was not correlated with CSF opening pressure. Papilledema presence and level of CSF opening pressure were independent of age (p > 0.05). Age at presentation and CSF opening pressure at diagnosis are not any predictive factors that influence long-term prognosis of pseudotumor cerebri syndrome in children. Evaluation and follow-up of children should be done in personalized approach.

The Pre-Lumbar puncture Intracranial Hypertension Scale (PLIHS): A practical scale to identify subjects with normal cerebrospinal fluid pressure in the management of idiopathic intracranial hypertension

BackgroundIdiopathic Intracranial Hypertension (IIH) diagnosis requires lumbar puncture to measure cerebrospinal fluid (CSF) pressure. The Pre-Lumbar puncture Intracranial Hypertension Scale (PLIHS) is aimed to detect cases that will show raised or normal CSF opening pressure. MethodsRetrospective analysis of records of patients who underwent lumbar puncture for suspect IIH. The target was CSF opening pressure ≥ 250 mmH2O, whereas a set of known neurological, neuro-ophthalmological and neuro-radiological parameters, plus obesity, were used as predictors in a logistic regression model. The PLIHS was based on significant predictors and a cut-off was validated using chi-squared test around CSF opening pressure ≥ 250 and < 200 mmH2O. ResultsRecords of 162 patients were included: CSF opening pressure was <200 mmH2O in 40 and ≥ 250 mmH2O in 95 patients; 85 fulfilled IIH diagnosis. PLIHS is based on Frisén grade 2 or higher papilledema, tinnitus, empty sella, perioptic subarachnoid space distension, and obesity. Score range is 0–7: correlation with CSF opening pressure is 0.508 (p < .001), and PLIHS score is different between subjects not diagnosed with IIH, and those diagnosed with IIH both with and without papilledema (p < .001). PLIHS score ≤ 2 identifies cerebrospinal fluid pressure < 200 mmH2O; PLIHS score ≥ 3 identifies CSF opening pressure ≥ 250 mmH2O, IIH diagnosis, visual acuity ≤0.7, and optic nerve atrophy. ConclusionsThe PLIHS, can be used to identify patients who will particularly need LP, thus helping with the organization of the diagnostic work-up by optimising healthcare resources and potentially limit the likelihood to incur in LP-related adverse events.

Ultrasound monitoring for minocyclineinduced idiopathic intracranial hypertension

We report a rare case of idiopathic intracranial hypertension following oral minocycline therapy for the treatment of acne. A 29-year-old, non-obese female, with a history of minocycline use for 1 month for treatment of acne presented with headache and transient blurred vision for 3 weeks. She was found to have bilateral disc edema with normal visual acuity and color vision. Magnetic resonance imaging of the brain was normal with partially empty sella features and enlarged tortuous optic nerve in both eyes. Cerebrospinal fluid opening pressure was high. Ultrasound B-scan was done to serially monitor the optic nerve sheath diameter. She improved significantly after stopping the minocycline and following intracranial pressure lowering measures. Idiosyncratic reaction of intracranial hypertension with minocycline can be symptomatic as early as 1 week. Consultants should be aware of this as early consult with ophthalmologists/neurologists can prevent visual loss. A simple ultrasound B-scan can prove to be a vital non-invasive tool in monitoring these patients.

Eye-Neck Integrated Ultrasound in Idiopathic Intracranial Hypertension and Cerebral Venous Sinus Thrombosis.

Background: The clinical presentation of cerebral venous sinus thrombosis (CVST) overlaps with that of idiopathic intracranial hypertension (IIH), but no screening tool exists. We investigated the role of eye-neck integrated ultrasound in the diagnosis and differentiation of IIH and CVST.Methods: Twenty IIH patients, 30 CVST patients, and 40 healthy controls were retrospectively analyzed. The ultrasonographic optic nerve sheath diameter (ONSD) and hemodynamic characteristics of the internal jugular veins (IJVs) were recorded. The cerebrospinal fluid opening pressure was measured after ultrasonic examination.Results: The ONSD was significantly larger in IIH patients than in controls (4.71 ± 0.41 vs. 3.93 ± 0.24 mm, p < 0.001). The ONSD cut-off for IIH diagnosis was 4.25 mm (AUC = 0.978; 95% CI: 0.95–1.0, p < 0.001, sensitivity: 90%, specificity: 93%). In the CVST group, 22 (73.3%) patients had elevated intracranial pressure (ICP); the mean ONSD was significantly higher in patients with increased ICP than in those without (4.43 ± 0.33 vs. 3.95 ± 0.17 mm, p < 0.001). The mean blood flow volume (BFV) was significantly reduced in CVST patients (425.17 ± 349.83 mL/min) compared to that in controls (680.37 ± 233.03 mL/min, p < 0.001) and IIH patients (617.67 ± 282.96 mL/min, p = 0.008). The optimal BFV cut-off for predicting CVST was 527.28 mL/min (AUC = 0.804, 95% CI: 0.68–0.93, p < 0.001, sensitivity: 80%, specificity: 78%). The velocity of the unilateral IJVs-J3 segment decreased or remained constant during deep inspiration (abnormal respiratory modulate blood flow test, ARMT) in 32.5% of controls, with no bilateral ARMT. The prevalence of bilateral ARMT was 25% in IIH patients (χ2 = 12.9, p = 0.005) and 27% in CVST patients (χ2 = 17.6, p = 0.001).Conclusion: Eye-neck integrated ultrasound is an easily available bedside technique to assess ICP and hemodynamic characteristics of IJVs. ONSD measurement can identify patients with increased ICP, and reduced IJV BFV may aid the differentiation of CVST and IIH.

Sensorineural Hearing Loss and Tinnitus Characteristics in Patients With Idiopathic Intracranial Hypertension.

To characterize patterns of sensorineural hearing loss (SNHL) and tinnitus in patients with idiopathic intracranial hypertension (IIH). Retrospective chart review. Tertiary referral center. Adult patients diagnosed with IIH via lumbar puncture (LP) between 2010 and 2020 who had available audiograms. The study included a total of 40 patients; 33 women, and 7 men with a median age of 43. Diagnostic LP and audiogram. Otologic symptoms, ophthalmologic signs, hearing thresholds, cerebrospinal fluid opening pressures. The most commonly reported symptoms were tinnitus in 28 (70%, 23 pulsatile and 5 tonal), aural fullness in 11 (28%), and vertigo in 10 (25%). Twenty-nine patients had ophthalmologic examinations and 18 had evidence of papilledema. Twenty-five (63%) patients had hearing loss in at least one ear at one frequency range. Patients presented with both unilateral and bilateral hearing loss across low, middle, and high frequency ranges. No significant association was observed between hearing loss threshold and LP opening pressure except for 250 Hz in the left ear. After stratification by tinnitus group (pulsatile, tonal, and no tinnitus), no significant difference was found between mean hearing loss threshold at different frequencies. In addition, no significant mean age difference was identified in patients within each tinnitus group. There was no classic pattern or presentation for hearing loss in our IIH patients. They developed sudden, unilateral, or bilateral SNHL in low, middle, or high frequency range. The degree of hearing loss did not correlate with CSF opening pressure.

Role of tumor necrosis factor-alpha in the pathophysiology of idiopathic intracranial hypertension.

Although the pathogenesis of idiopathic intracranial hypertension (IIH) is still poorly understood, the contribution of inflammatory mechanisms has been proposed in its pathophysiology. This study aimed to measure serum tumor necrosis factor-α (TNF-α) levels in patients with IIH and to examine its relationship with clinical and ophthalmological parameters and cerebrospinal fluid (CSF) opening pressure. Thirty-six IIH patients and 30healthy subjects were enrolled in the study. Patients were subjected to complete neurological, general, and ophthalmological assessments. Serum TNF-α levels were measured for patients and controls using the enzyme-linked immunosorbent assay. Serum TNF-α levels were significantly higher in IIH patients compared to healthy controls (p value <.001). Serum TNF-α level was significantly negatively correlated with grade of perimetry and CSF opening pressure (r=-.36, p value=.02), (r=-.37, p value=.02) respectively. However, serum TNF-α was not significantly correlated either with age at onset, disease duration, BMI, headache severity, relapse rate, visual acuity, or papilloedema grade. Serum TNF-α was found to be a significant predictor of the severity of the visual field affection in IIH patients, as one-grade increase of the perimetric grading was associated with a decrease in serum TNF-α by 13.96ng/ml. Altered serum TNF-α levels may suggest the potential involvement of pro-inflammatory mechanisms in the pathogenesis of IIH. Serum TNF-α level may be an indicator of the severity of the visual field affection in IIH.