Symptoms Of Idiopathic Intracranial Hypertension Research Articles

Clinical outcomes of bariatric surgery in patients with obesity and idiopathic intracranial hypertension.

Obesity is a major risk factor for idiopathic intracranial hypertension (IIH). Effective therapeutics for preventing disease progression and alleviating symptoms are limited. This study aims to examine the effects of bariatric surgery on clinical outcomes of IIH. We retrospectively collected data from the medical record of 97 patients with obesity and an existing diagnosis of IIH who underwent primary bariatric surgery at the Cleveland Clinic health system in the USA between 2005 and 2023. Pre- and postoperative data on presence of symptoms and clinical markers of IIH (headaches, visual field defects, papilledema, visual symptoms), intracranial pressure, andusage of IIH medications were compared. A total of 97 patients (98% female, median age 46.7years, median BMI 48.3kg/m2) with IIH who underwent bariatric surgery including Roux-en-Y gastric bypass (n = 66, 68%), sleeve gastrectomy (n = 27, 27.8%), and gastric banding (n = 4, 4.1%) were analyzed. In a median follow-up time of 3.0years, the median total weight loss was 24% (interquartile range, 13-33%). There was a significant improvement in headache, papilledema, visual field deficits, and visual symptoms after bariatric surgery. The mean lumbar opening pressure before and after bariatric surgery was 34.8 ± 8.2cm CSF and 24.2 ± 7.6cm CSF, respectively, with a mean reduction of 10.7 cm CSF (95% confidence interval, 4.7 to 16.6), p = 0.003. The dosage of acetazolamide and topiramate, as well as the number of medications taken for IIH, decreased significantly after bariatric surgery (p < 0.001). For patients who have obesity, bariatric surgery is a viable treatment modality for alleviation or improvement of symptoms of IIH.

Evaluation of sleep quality in patients with idiopathic intracranial hypertension

ABSTRACT Objective: Idiopathic intracranial hypertension (IIH) is a condition that has no known cause and progresses with increased cerebrospinal fluid (CSF) pressure. Sleep apnea or other sleep disorders may occur with increased intracranial pressure (ICP). This study aims to determine the relationship between the signs and symptoms of IIH and sleep quality. Patients and Methods: Three self-reported questionnaires, namely The Pittsburgh Sleep Quality Index (PSQI), the Epworth Sleepiness Scale (ESS), and the Beck Depression Inventory (BDI)) were administered to 31 IIH patients and the same number of controls and the scores were compared. Scores were analyzed according to the presence of symptoms in the IIH group. The correlation of these scores with ICP was evaluated. Results: Between the two groups, the IIH group had significantly higher PSQI scores (p=0.009). Also, a significant relationship was shown between papilledema and PSQI scores (p=0.017); patients with papilledema had lower PSQI scores than patients without papilledema. BMI values were higher in patients without papilledema (p = 0.031). In the IIH group, PSQI and BDI scores had a positive correlation (r = 0.638, p &lt; 0.001). Conclusion: Sleep quality is impaired in patients with IIH, and the effect of being overweight in this deterioration is more pronounced than presence of papilledema.

Foundations of the Diagnosis and Management of Idiopathic Intracranial Hypertension and Pulsatile Tinnitus

Venous sinus stenosis has garnered increasing academic attention as a potential etiology of idiopathic intracranial hypertension (IIH) and pulsatile tinnitus (PT). The complex anatomy of the cerebral venous sinuses and veins plays a crucial role in the pathophysiology of these conditions. Venous sinus stenosis, often found in the superior sagittal or transverse sinus, can lead to elevated intracranial pressure (ICP) and characteristic IIH symptoms. Stenosis, variations in dural venous anatomy, and flow dominance patterns contribute to aberrant flow and subsequent PT. Accurate imaging plays a vital role in diagnosis, and magnetic resonance (MR) venography is particularly useful for detecting stenosis. Management strategies for IIH and PT focus on treating the underlying disease, weight management, medical interventions, and, in severe cases, surgical or endovascular procedures. Recently, venous sinus stenting has gained interest as a minimally invasive treatment option for IIH and PT. Stenting addresses venous sinus stenosis, breaking the feedback loop between elevated ICP and stenosis, thus reducing ICP and promoting cerebrospinal fluid outflow. The correction and resolution of flow aberrances can also mitigate or resolve PT symptoms. While venous sinus stenting remains an emerging field, initial results are promising. Further research is needed to refine patient selection criteria and evaluate the long-term efficacy of stenting as compared to traditional treatments.

Clinical Characteristics of Idiopathic Intracranial Hypertension in Older Adults.

Idiopathic intracranial hypertension (IIH) is a condition that classically affects obese women of child-bearing age. However, it is sometimes encountered in older patients. The purpose of this study was to help clinicians better understand how this disease can present differently in these age groups. This is a retrospective chart review from a single academic center of baseline characteristics of adult patients diagnosed with IIH based on the modified Dandy criteria. The patients were divided into 2 groups: (1) those 18-44 years old and (2) those older than 45 years at diagnosis. One hundred sixty-seven patients were identified; 135 in the younger group and 32 in the older group. The younger group had a higher rate of headaches (90% vs 63%, P = 0.0004), higher body mass index (38.9 vs 36.1, P = 0.046), higher opening pressure (38 vs 31 cm H2O, P = 0.005), and thicker peripapillary retinal nerve fiber layer average thickness (right eye 178 vs 131 μm, P = 0.02; left eye 184 vs 136 μm, P = 0.045). The older group had higher rates of empty sella (90% vs 62%, P = 0.0039). In addition in the younger group, there was a trend toward higher rates of pulsatile tinnitus (63% vs 45%, P = 0.08), transient visual obscurations (50% vs 32%, P = 0.07), and lower rates of spontaneous cerebrospinal fluid leak (4% vs 13%, P = 0.08). Sex, rates of obesity, other MRI findings typical of elevated intracranial pressure, frequency and Frisen grading of papilledema, and visual field loss were not statistically different between the groups. The older age group had milder signs and symptoms of IIH and a higher prevalence of empty sella than the younger group, but otherwise had typical characteristics. These findings suggest that IIH in the older age group may represent milder chronic disease that was previously undiagnosed.

Characterizing a new clinical phenotype: the co-existence of cerebral venous outflow and connective tissue disorders.

There is increasing recognition of connective tissue disorders and their influence on disease in the general population. A conserved clinical phenotype involving connective tissue disorders and idiopathic intracranial hypertension (IIH) and associated cerebral venous outflow disorders (CVD) has not been previously described. A single-institution retrospective review of a prospectively maintained database of patients with connective tissue disorders and CVD was performed. A total of 86 patients were identified. The majority of these patients carried a diagnosis of Ehlers-Danlos syndrome (55%) and most were non-obese (mean body mass index 29.7 kg/m2), Caucasian (90%) females (87%). Most prevalent presenting symptoms included pressure headache (98%), dizziness (90%), tinnitus (92%), and cognitive dysfunction (69%). Aside from CVD and IIH, the most common associated conditions were postural orthostatic tachycardia syndrome (POTS; 55.8%), cerebrospinal fluid (CSF) leaks (51.2%), dysautonomia (45.3%), cranio-cervical instability (37.2%), mast cell activation syndrome (25.6%), and tethered cord syndrome (23.3%). Allergies to medications (87.2%) and surgical tape (19.8%) were also frequent. Despite significantly lower opening pressures on lumbar puncture, headache severity and quality of life scores were reported with the same severity of classic IIH patients, suggesting an underlying hypersensitivity to intracranial pressures and cerebral venous congestion. There is a rare but conserved clinical phenotype that has not been described previously that presents with severe IIH symptoms in predominantly young, non-obese Caucasian women with a high associated incidence of dysautonomia, POTS, craniocervical instability, and CSF leaks, among others.

Concomitant optic disk drusen and papilledema due to idiopathic intracranial hypertension in a pediatric cohort

BackgroundOptic disk drusen (ODD) in pediatric patients typically presents with pseudopapilledema. Diagnosing concomitant papilledema due to idiopathic intracranial hypertension (IIH) in these patients can be challenging. The purpose of this study was to evaluate the incidence and clinical features of papilledema due to IIH among pediatric patients with a new diagnosis of ODD and to discuss the clinical and paraclinical findings that helped diagnose this group. MethodsThe medical records of children <15 years of age with ODD confirmed by B-scan ultrasound at their first visit over a 4-year period (2019-2022) were reviewed retrospectively. Patients with concurrent IIH were identified, and the demographic and clinical characteristics were reviewed. ResultsA total of 83 children with confirmed ODD at the initial presentation were included, of whom 4 (4.8%) were diagnosed with concomitant IIH. Patients ranged in age from 7 to 15 years; 3 of the 4 were female, and 3 had IIH-related symptoms at presentation (1 was asymptomatic). None of the 4 patients had papilledema greater than Frisen grade 2. ConclusionsWe recommend that clinicians review pertinent IIH symptoms and risk factors in children with ODD and follow the standard workup for IIH in suspicious cases. In asymptomatic patients with a new diagnosis of ODD, we recommend obtaining a follow-up optic nerve evaluation and optical coherence tomography scan to detect any significant interval change that might serve as a possible indicator of concomitant papilledema.

Doxycycline-Induced Intracranial Hypertension Presenting as Unilateral Pulsatile Tinnitus.

Pulsatile tinnitus (PT) is increasingly recognized as a cardinal symptom of idiopathic intracranial hypertension (IIH). However, clinicians should remain aware of other causes of nonidiopathic or secondary intracranial hypertension manifesting as PT. We present 2 patients with isolated PT (without accompanying headache, blurred vision, and papilledema) thought to be secondary to tetracycline-induced intracranial hypertension. To our knowledge, these are the first cases of PT as the presenting symptom of this condition. A 41-year-old female (body mass index [BMI] 29 kg/m2) with ocular rosacea was initially treated with minocycline. Shortly after transitioning to oral doxycycline and erythromycin eye ointment, she noted left-sided PT. Her PT resolved after discontinuing doxycycline. In a second case, a 39-year-old female (BMI 19 kg/m2) with acne presented with a three-year history of left-sided PT while on long-term oral doxycycline for many years. She denied visual or auditory changes and atypical headaches. MRI findings were concerning for intracranial hypertension. Three months later, the patient was seen by neuro-ophthalmology, with findings suggesting prior papilledema. The patient reported PT improvement after discontinuing doxycycline. This case series highlights 2 cases of isolated PT as the sole symptom of intracranial hypertension that resolved with tetracycline cessation. The presentation and unexpected improvement following tetracycline discontinuation are atypical compared with previous reports of tetracycline-induced intracranial hypertension. Clinicians should maintain a high index of suspicion for all types of intracranial hypertension (idiopathic and secondary), even in patients with a lower BMI. Current and prior medications should be reviewed when considering the etiology of intracranial hypertension.

Stenting for Venous Sinus Stenosis in Patients With Idiopathic Intracranial Hypertension: An Updated Systematic Review and Meta-Analysis of the Literature.

Although venous sinus stenting (VSS) improves cerebrospinal fluid reabsorption and decreases intracranial pressure in patients with idiopathic intracranial hypertension (IIH), the underlying pathophysiology of IIH is not well understood. We present a review and meta-analysis of the literature on VSS for IIH treatment, focusing on the rates of restenosis and symptom recurrence. We performed a systematic review of PubMed and Embase databases between January 1, 2011, and December 31, 2021. Articles including ≥5 patients with IIH and venous sinus stenosis treated with VSS and post-treatment rates of restenosis (de novo stenosis at a different anatomic location along the dural sinuses or restenosis within or adjacent to the stent) were selected. Demographic, procedural, and outcomes data were collected and analyzed. Mean values for variables collected were pooled, and a mean value was calculated with a 95% CI. Twenty-four articles were included, comprising 694 patients and 781 VSS cases. The mean age was 33.9 (CI, 31.5-36.2) years. The mean body mass index was 35.3 (CI, 32.9-37.7) kg/m 2 . Before VSS, 98.8% (CI, 96.8%-100.0%) of patients experienced headaches, 87.7% (CI, 80.6%-95.5%) had visual acuity issues, 78.7% (CI, 69.9%-88.5%) had papilledema, 58.3% (CI, 46.0%-73.9%) had tinnitus, and 98.8% (96.4%-100.0%) had symptoms refractory to previous therapies. After VSS, 77.7% (CI, 71.1%-84.95%) experienced symptom improvement and 22.3% (CI, 15.1%-29.0%) had persistent or worsened symptoms. Pooled restenosis rate was 17.7% (CI, 14.9%-20.9%). VSS is effective in alleviating IIH signs and symptoms, but the associated high rates of restenosis and persistent symptoms highlight the need for further investigation of this procedure and other adjunctive treatments for IIH.

Post-operative weight loss in venous sinus stenting patients: A multi-center review, systematic review, and meta-analysis.

Idiopathic intracranial hypertension (IIH) can result in headaches, pulsatile tinnitus, papilledema, and other neurological symptoms. Weight loss can alleviate some symptoms of IIH. This study aims to investigate the effect of venous sinus stenting on post-operative weight and body mass index (BMI) changes among IIH patients. The secondary objective is to investigate the relationship between post-operative weight changes and papilledema resolution. Patients with papilledema undergoing venous sinus stenting for IIH were retrospectively reviewed from two comprehensive North American cerebrovascular centers. Patient demographics, surgical course, post-operative outcomes, and weight were analyzed. A systematic review and meta-analysis of post-operative weight in stented IIH patients was conducted. Twenty-eight patients with a diagnosis of IIH and papilledema who underwent venous sinus stenting were identified across two institutions. Patients had a mean pre-operative weight of 103.2 kg, which decreased to 101.5 kg at 3-month follow up (p = 0.0757). Patients at 6-month follow-up saw a weight decrease to 97.4 kg (p = 0.0066). Patients who saw papilledema resolution saw a mean greater decrease in weight (-4.5%) at 6-month follow up than those whose papilledema did not resolve (-1.7%), although this was insignificant (p = 0.1091). A total of 41 patients were included in the meta-analysis. Patients had an average of 1.1 increase in BMI at 3-month follow up. This study shows that venous sinus stenting leads to modest weight reduction in IIH patients, and those with resolved papilledema experience slightly greater weight loss. Further research is necessary to determine the clinical significance of these findings.

Impact of Pregnancy on Papilledema and Vision Loss in Idiopathic Intracranial Hypertension Patients: A Chart Review and Case Series of 13 Patients.

Studies suggest that weight gain is a prominent risk factor for recurrence of papilledema in idiopathic intracranial hypertension (IIH). Given this information, the significant weight gain that occurs during pregnancy, and the fact that pharmacologic therapy is many times discontinued, raises concerns for worsening edema and vision loss. To examine the impact of pregnancy weight gain on IIH, a retrospective chart review of patients with IIH and pregnancy was performed. Compared with previous studies, we 1) quantified findings with optical coherence tomography (OCT) and Humphrey visual field (HVF) data, 2) Included baseline data before pregnancy, 3) determined excess pregnancy weight gain using body mass index-adjusted weight gain goals, and 4) correlated worsening in IIH symptoms with changes in papilledema. Charts were reviewed for patients with diagnoses of IIH who had at least 2 visits with neuro-ophthalmology during pregnancy. Thirteen patients met inclusion criteria. Data were compared from baseline visits before pregnancy, pregnancy visits, and postpregnancy visits. Comparisons of HVF mean deviation (MD), OCT retinal nerve fiber layer (RNFL), and Max OCT RNFL during pregnancy were not significant compared with baseline ( P = 0.51, 0.41, and 0.25). Three patients were found to have increased papilledema during pregnancy (Max Avg OCT RNFL of 152.5, 129, and 123.5 μm) of which 2 developed new reproducible mild visual field defects (HVF ∆MD -1.78 and -4.49). All patients showed more than the 6% weight gain, typically observed in recurrent IIH. Eleven patients gained more than their weight from initial diagnosis. Eight patients had excess pregnancy weight gain. Six patients discontinued pharmacologic therapy for IIH. Weight gain seems to carry a lower risk in IIH patients when associated with pregnancy. This is suggested by the high rate of stable or even decreased disc edema in patients despite medication discontinuation and excess pregnancy weight gain. We postulate these findings may be related to changes in weight distribution or endocrine changes during pregnancy.

Endoscopic endonasal optic nerve sheath decompression (EONSD) for idiopathic intracranial hypertension: Technical details and meta-analysis

BackgroundThe neurosurgical management of idiopathic intracranial hypertension (IIH) remains controversial. Although shunting and newer endovascular stenting techniques are part of the neurosurgical armamentarium to treat medically refractory IIH symptoms, optic nerve sheath fenestration has traditionally been performed by ophthalmologists. ObjectiveWe present a detailed cadaveric dissection that simulates the endoscopic endonasal optic nerve sheath decompression (EONSD) technique along with the literature review. MethodsEONSD was performed in four freshly injected cadaveric specimens. Additionally, a systematic review from different electronic databases has been done. ResultsBilateral EONSD was performed in all specimens without significant technical difficulties. Based on our experience, there is no need to expose the periorbita or orbital apex. The primary anatomic landmarks were the optic canal, the lateral opticocarotid recess, the tuberculum, the limbus, and the clinoid segment of the internal carotid artery. Based on the systematic review, 68 patients (77.9% female) underwent EONSD, with a mean age of 33.4 ± 6.9 years in adult patients. Follow-up ranged from 3 to 58 months across different studies. The pooled meta-analysis showed headache, papilledema, and visual disturbance improvement in 78% [95%CI 0.65–0.90], 72% [95%CI 0.61–0.83], and 88% [95%CI 0.80–0.96] of cases who underwent EONSD, respectively. The subgroup analysis showed there was no statistically significant difference between unilateral and bilateral EONSD in terms of different measured outcomes. ConclusionEONSD is a feasible surgical procedure that may obviate the need for shunting in patients with IIH. Although clinical studies showed that EONSD is a safe and effective technique, further studies are required to establish the preferences of either unilateral or bilateral approaches.

Seizures as the initial manifestation of Idiopathic Intracranial Hypertension (P2-9.001)

<h3>Objective:</h3> To describe the clinical and radiologic characteristics of 5 patients with seizure as a symptom of idiopathic intracranial hypertension (IIH). <h3>Background:</h3> Patients with IIH may have atypical presentations and may not meet the classic IIH diagnostic criteria. Recent reports suggest an association between IIH and seizures in patients with temporal encephaloceles, which are frequently observed in temporal lobe epilepsy and might be an epileptogenic focus. The aim of this study is to report patients with presumed IIH and seizures associated with encephaloceles. <h3>Design/Methods:</h3> NA <h3>Results:</h3> We report 5 patients (34–79 years old; 4 women, 1 man; body mass index mean 44.6 (25.6–60.6)) with generalized or focal epilepsy associated with encephaloceles in the basal frontal lobe or inferomedial temporal lobe. Three patients with temporal lobe encephaloceles had interictal epileptiform activity or focal temporal slowing in one or both temporal lobes. Other radiological findings included signs of chronic intracranial hypertension. Three patients had rhinorrhea from spontaneous cerebrospinal fluid (CSF) leak; all denied visual symptoms. One patient had mild papilledema, and 4 patients had chronic peripapillary changes suggesting previous papilledema. Three patients had a lumbar puncture opening pressure between 26 and 28 cm H₂O. <h3>Conclusions:</h3> These cases suggest that seizures related to basal encephaloceles likely result from untreated chronic intracranial hypertension, as can be seen in untreated or chronic IIH. Skull base meningoencephaloceles and spontaneous CSF leak are two manifestations of the same bony defects that are likely part of the expanding IIH spectrum. The diagnosis of IIH remains presumptive, especially without papilledema. Radiological findings of chronic intracranial hypertension in patients with isolated seizures should prompt funduscopic examination looking for papilledema and skull base imaging screening for basal encephaloceles that may help guide epilepsy treatment. <b>Disclosure:</b> Dr. Bouthour has nothing to disclose. Dr. Al-Balushi has nothing to disclose. Dr. Dattilo has nothing to disclose. Dr. Newman has received personal compensation in the range of $10,000-$49,999 for serving as a Consultant for GenSight. Dr. Newman has received personal compensation in the range of $500-$4,999 for serving as a Consultant for Chiesi. Dr. Newman has received personal compensation in the range of $500-$4,999 for serving as a Consultant for Neurophoenix. Dr. Newman has received personal compensation in the range of $500-$4,999 for serving as a Consultant for Stoke. Dr. Newman has received personal compensation in the range of $500-$4,999 for serving as a Consultant for Avidity. Dr. Newman has received personal compensation in the range of $0-$499 for serving on a Scientific Advisory or Data Safety Monitoring board for Neurodiem. The institution of Dr. Newman has received research support from GenSight. The institution of Dr. Newman has received research support from Chiesi/Santhera. The institution of Dr. Newman has received research support from NINDS/NIH. Dr. Newman has received publishing royalties from a publication relating to health care. Dr. Newman has received publishing royalties from a publication relating to health care. Dr. Newman has received publishing royalties from a publication relating to health care. Dr. Biousse has received personal compensation in the range of $500-$4,999 for serving as a Consultant for Gensights Biologic. Dr. Biousse has received personal compensation in the range of $0-$499 for serving as a Consultant for Neurophoenix. The institution of Dr. Biousse has received research support from NIH. Dr. Biousse has received publishing royalties from a publication relating to health care. Dr. Biousse has received publishing royalties from a publication relating to health care.

Abstract Number ‐ 74: Venous Thrombectomy as Treatment for Central Venous Sinus Thrombosis presenting as symptomatic Idiopathic Intracranial Hypertension

Introduction Thrombosis of the cerebral venous sinus (CVST) is an uncommon form of stroke which primarily affects young adults, usually females. Patients with CVST present with either symptoms related to increased intracranial pressure secondary to venous congestion or focal brain injury from infarction or haemorrhage. Treatment of CVST currently involves anticoagulation with venous thrombectomy (VT) used as salvage therapy in refractory CVST. However, the clinical outcomes of patients with symptoms of idiopathic intracranial hypertension (IIH), secondary to CVST, pre‐ and post‐ VT has not been documented. In this case study we present two cases where patients presented with symptoms of IIH secondary to CVST who subsequently underwent VT salvage therapy. Methods We retrospectively analysed institutional data of patients who underwent VT for CVST from 2017–2022. Patients who presented with well documented symptoms of IIH without cerebral infarction or haemorrhage were included. Clinical outcomes including neuroimaging, retinal nerve fibre layer (RNFL) thickness from optical coherence tomography (OCT), visual acuity and use of medications including acetazolamide and anticoagulation were recorded. The technical aspects of the VT procedure are also described. Results Two patients were identified (2 women) that fit the study criteria. Both patients were taking the oral contraceptive pill. They both presented similarly with papilledema and symptoms of IIH including; headache, diplopia and nausea. There was symptomatic progress in both patients despite medical management with anticoagulation and acetazolamide. Patient A, a 39‐year‐old lady, was found to have a severe sagittal sinus thrombosis involving the entire sinus. Her lumbar puncture revealed an opening pressure of 31 cmH2O. She underwent urgent VT which revealed a highly organised thrombus and as such minimal change was achieved with repeated passes, however, her post‐op imaging showed partial recanalization of the right transverse sinus. Patient B, a 26‐year‐old lady, had a partially occlusive right transverse sinus thrombosis extending into the jugular vein. Manometry revealed elevated venous pressures. She underwent VT with alteplase injection to the site of thrombosis. After multiple passes, recanalization of the right transverse sinus was achieved. Post‐operative OCTs demonstrated a significant reduction in RNFLs bilaterally in both patients. Both patients also experienced resolution of symptoms over a few days and remained asymptomatic with gradually decreasing doses of acetazolamide. Conclusions VT may be a safe and effective treatment option in patients with medically refractory CVST who present with symptoms of IIH. In both patients there was marked improvement in symptoms and RNFL thickness after the procedure.

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.

Idiopathic Intracranial Hypertension: Incidental Discovery Versus Symptomatic Presentation.

We aim to compare the clinical characteristics, disease course and visual outcomes between Canadian patients with idiopathic intracranial hypertension (IIH) who were incidentally discovered and those who sought care due to symptoms of IIH. Retrospective chart review of consecutive IIH patients conducted at tertiary neuro-ophthalmology clinics. Patients were divided into Group 1 (incidentally discovered disease) and Group 2 (patients seeking medical care due to symptoms of intracranial hypertension). One hundred eighty-six patients were included in the study; of which, 75 (40.3%; Group-1) were incidentally discovered and 111 presented due to symptoms of IIH (Group-2). There were no differences in proportion of females (P = 0.101), age (P = 0.450), body mass index (P = 0.386), MRI findings of empty or partially empty sella (P = 0.41), and sella grade (P = 0.704). Group-1 patients were less likely to have experienced headache (P = 0.001), transient visual obscurations (P < 0.001), and diplopia (P = 0.026) at presentation. Group-1 patients were less likely to receive medical (P < 0.001) and surgical (P = 0.004) treatment. There was no difference in proportion of patients who lost weight between the groups (P = 0.848). At baseline, Group-1 patients exhibited better visual acuity (P = 0.001), Humphrey mean deviation (P < 0.001) and retinal nerve fiber layer thickness (P < 0.001). Group-1 patients continued to have better visual acuity (P = 0.002) and Humphrey mean deviation (P < 0.001) at final follow-up. A significant portion of IIH patients were incidentally discovered. This group exhibited a favorable prognosis and only a minority of these patients required treatment. The way in which patients enter the medical system may be a valuable way to risk stratify IIH patients.

Complete Ophthalmoplegia: A Rare Presentation of Idiopathic Intracranial Hypertension

Idiopathic intracranial hypertension (IIH) is a disorder defined by clinical criteria that include signs and symptoms produced by raised intracranial tension (headache, papilloedema and vision loss), raised intracranial tension and normal CSF composition with no other cause of intracranial hypertension evident on neuroimaging. The most common symptom of IIH is headache; the most common sign is papilloedema and visual field loss. Here, we report a case of IIH which presented without headache, with visual loss and complete ophthalmoplegia in one eye and sixth cranial nerve palsy in other eye. There was no improvement in vision of patient on medical management and she was planned for a CSF diversion procedure. We highlight the various treatment options available for IIH and the importance of timely diagnosis and urgent treatment.

Popping the balloon: Abrupt onset of a spinal CSF leak and spontaneous intracranial hypotension in idiopathic intracranial hypertension, a case report.

Spontaneous intracranial hypotension (SIH) is a debilitating neurologic condition that is often thought of as separate from idiopathic intracranial hypertension (IIH). The unique case presented here details a spontaneous spinal cerebrospinal fluid (CSF) leak that developed abruptly following a CSF pressure elevating maneuver in a patient with pre-existing intracranial hypertension, raising the possibility of a causative link between the two conditions. A 40-year-old woman with symptomatic IIH developed a dural tear of a thoracic spinal nerve root sleeve during an episode of Valsalva maneuver leading to a CSF leak and development of symptomatic SIH. This was successfully treated with epidural blood and fibrin glue patch and the patient is now symptom-free. The implication of a possible causative link between elevated CSF pressure and subsequent development of dural rupture and SIH raises important questions regarding the pathophysiology of SIH in some cases. Furthermore, it suggests that there could be a potential prophylactic benefit of CSF pressure lowering medications in preventing the development of SIH in patients with IIH.

Idiopathic Intracranial Hypertension: Current Neuroophthalmologic Points

Idiopathic intracranial hypertension (ICH) is a neuroophophthalmologic syndrome, the main ophthalmologic symptoms of which are vision loss and bilateral swelling of optic nerve disks (OD). The article provides a review covering various aspects of ICH. Epidemiology: ICH occurs mainly in women aged 20–45 years with body overweight. In this group of patients world incidence is 12–20 per 100 000 of population per year. In the total population it represents 0.5–2 cases per 100 000 of population per year. The eightfold gender predominance of women with ICH is observed. Etiology is not fully known until present time. The reliable connection between obesity in childbearing age women and menstrual cycle disorders as evidences of hormonal changes has been established. The probable mechanisms of increase of ICP are supposed: hyperproduction of and disturbances of its absorption, CSF mechanical pressure on the optic nerve sheath; restriction of venous outflow from the brain due to the pathology of venous sinuses; stimulating effect of abundant vitamin A in diet resulting in the fat tissue formation with the development of obesity; expression of the protein aquaporin, involved in the regulation of body mass and water metabolism in the subarachnoid space. Clinical manifestations. Ophthalmologic symptoms of ICH: transient visual impairment, sustained loss of visual acuity, photopsy, retrobulbar pain, diplopia. Non-ophthalmologic symptoms: headache, throbbing tinnitus, hearing loss, dizziness. Diagnostics. The valuable diagnostic data can be obtained by visual field investigation, ophthalmoscopic examination with revealing of bilateral OD-edema, OD and retinal optical coherent tomography, orbital ultrasound examination, brain MRI with venography. Treatment. Non-drug therapy: weight loss, lowcalorie diet with limited water and salt intake. Drug therapy: long-term oral use of carbonic anhydrase inhibitors (acetazolamide, topiramate). High doses of steroids (methylprednisone) are used for short-term treatment of patients with fulminant disease type before surgery. Surgery: bypass surgery, cerebral venous sinus stenting and fenestrations of the optic nerve sheath: bariatric surgery with reducing of stomach volume.

Posterior fossa volume in idiopathic intracranial hypertension: a magnetic resonance imaging-based study.

The etiology of idiopathic intracranial hypertension (IIH) is uncertain. Studies suggest the fundamental cause of the Chiari 1 malformation, a congenitally hypoplastic posterior fossa, may explain the genesis of IIH in some patients. To assess the hypothesis that linear and volumetric measurements of the posterior fossa (PF) can be used as predictors of IIH. A retrospective analysis of magnetic resonance imaging (MRI) studies on 27 patients with IIH and 14 matched controls was performed. A volumetric sagittal magnetization prepared rapid acquisition gradient echo sequence was used to derive 10 linear cephalometric measurements. Total intracranial and bony posterior fossa volumes (PFVs) were derived by manual segmentation. The ratio of PFV to total intracranial volume was calculated. In total, 41 participants were included, all women. Participants with IIH had higher median body mass index (BMI). No significant differences in linear cephalometric measurements, total intracranial volumes, and PFVs between the groups were identified. Linear measurements were not predictive of volumetric measurements. However, on multivariate logistic regression analysis, the likelihood of IIH decreased significantly per unit increase in relative PFV (odds ratio [OR]=3.66 × 10-50; 95% confidence interval [CI]=1.39 × 10-108 to 1.22 × 10-5; P = 0.04). Conversely, the likelihood of IIH increased per unit BMI increase (OR=1.19; 95% CI=1.04-1.47; P = 0.02). MRI-based volumetric measurements imply that PF alterations may be partly responsible for the development of IIH and Chiari 1 malformations. Symptoms of IIH may arise due to an interplay between these and metabolic, hormonal, or other factors.

IDIOPATHIC INTRACRANIAL HYPERTENSION IN UNIVERSITY HOSPITAL IN SAUDI ARABIA, RETROSPECTIVE STUDY

Background: Idiopathic intracranial hypertension (IIH) is one of headache syndromes that is female predominate and associated with increase intracranial pressure without obvious etiology, it has variable clinical presentation, and it needs high index of suspicion to reach diagnosis even with presence of well-established diagnostic criteria. Visual symptoms, which range from visual obscuration to blindness significantly,affect the outcome of this disease. Unfortunately, there is limited literature about IHH in Middle East and in Saudi Arabia in particular. In this retrospective study, we try to shed the light on pseudo-tumor cerebri in university hospital in Saudi Arabia. Methodology: This is a retrospective study conducted among 105 patients with IIH admitted to the university hospital in Saudi Arabia. Data on age, gender, as well as about symptoms, obesity, medication and surgeries, and CT/MRI results was collected. Results: The mean age of patients was 37.72 years old with standard deviation of 13.48 where 96.2 % of patients were females. Headache is the more common symptom presented by 96.2 % of patients followed with blurred vision and papilledema (85.7 %) and over weight (77.1 %). Considering medications taken by patients because of IIH, we found that main medications was Diamox which prescribed to 96.2 % with mean dose of 942.3 mg. Regarding surgical intervention, 4.8 % had a surgery of VP-shunt and 1.9 % had optic nerve fenestration Conclusion: We concluded that IIH incidence is higher among young women with higher body weight and associated with the use of hormonal contraceptives. The main symptoms of IIH are headache with papilledema and visual disturbances. Acetazolamide is the most common prescribed medication for IIH patients while 6.6 % of patients need surgical procedures.