Treatment Of Idiopathic Intracranial Hypertension Research Articles

Headache with Isolated Sixth Cranial Nerve Palsy in an Overweight Woman: A Case of Idiopathic Intracranial Hypertension

Idiopathic intracranial hypertension (IIH), also known as pseudotumour cerebri, has an estimated incidence of 1 to 2 in 100,000 people per year. IIH commonly affects obese young women, where its pathogenesis, however, is not clearly understood. Patients present to the emergency department with a wide array of presentations. In light of this, we present a case of isolated sixth cranial nerve palsy in a non-obese young woman due to IIH in which brain imaging studies showed no abnormality; however, lumbar puncture reveals an opening pressure of more than 50  cmH2O. This case would help to alert physicians to consider IIH as one of the differential diagnoses when encountering such cases, as an uncommon presentation in the non-obese patient, and prompt referral is important to avoid unnecessary delay in the treatment of IIH.

Idiopathic Intracranial Hypertension After Abrupt Cessation of Medication: A Case Report of Abrupt Glucagon-Like Peptide-1 (GLP-1) Receptor Agonist Cessation and Review of the Literature.

The purpose of this review is two-fold: (1) to discuss a case report of idiopathic intracranial hypertension (IIH) after abrupt cessation of a glucagon-like peptide-1 (GLP-1) receptor agonist with resultant rapid weight gain and (2) to review the literature regarding the potential role of GLP-1 receptor agonists in the treatment of IIH as well as potential pitfalls. GLP-1 receptor agonists have become widely used to treat obesity. Obesity is a known risk factor for the development of IIH, though the precise pathophysiology is unclear. GLP-1 receptor agonists may help treat IIH by promoting weight loss, lipolysis of adipose tissue, and potentially decreasing the secretion of CSF, as was seen in rat models. Abrupt cessation of GLP-1 receptor agonists can result in regaining lost weight rapidly. In the case that we present, the patient stopped duraglutide abruptly due to lack of insurance coverage and regained the weight she had lost within a month. She subsequently developed IIH. GLP-1 receptor agonists have the potential to help treat IIH; however, this class of medication needs to be used carefully, as cessation of the medication and resultant rapid weight gain can result in IIH.

Challenges in the use of Venous Sinus Stenting in the Treatment of Idiopathic Intracranial Hypertension and Pulsatile Tinnitus

Although numerous case series and meta-analyses have shown the efficacy of venous sinus stenting (VSS) in the treatment of idiopathic intracranial hypertension and idiopathic intracranial hypertension-associated pulsatile tinnitus, there remain numerous challenges to be resolved. There is no widespread agreement on candidacy; pressure gradient and failed medical treatment are common indications, but not all clinicians require medical refractoriness as a criterion. Venous manometry, venography, and cerebral angiography are essential tools for patient assessment, but again disagreements exist regarding the best, or most appropriate, diagnostic imaging choice. Challenges with the VSS technique also exist, such as stent choice and deployment. There are considerations regarding postprocedural balloon angioplasty and pharmacologic treatment, but there is insufficient evidence to formalize postoperative decision making. Although complications of VSS are relatively rare, they include in-stent stenosis, hemorrhage, and subdural hematoma, and the learning curve for VSS presents specific challenges in navigating venous anatomy, emphasizing the need for wider availability of high-quality training. Recurrence of symptoms, particularly stent-adjacent stenosis, poses challenges, and although restenting and cerebrospinal fluid-diverting procedures are options, there is a need for clearer criteria for retreatment strategies. Despite these challenges, when comparing VSS with traditional cerebrospinal fluid-diverting procedures, VSS emerges as a favorable option, with strong clinical outcomes, lower complication rates, and cost-effectiveness. Further research is necessary to refine techniques and indications and address specific aspects of VSS to overcome these challenges.

National trends in the endovascular and surgical treatment of idiopathic intracranial hypertension

BackgroundThe pattern of surgical treatments for Idiopathic Intracranial Hypertension (IIH) in the United States is not well-studied, specifically the trend of utilizing endovascular venous stenting (EVS) as an emerging technique. MethodsIn this cross-sectional study, we aimed to explore the national trend of utilizing different procedures for the treatment of IIH including EVS, Optic Nerve Sheath Fenestration (ONSF), and CSF Shunting, with a focus on novel endovascular procedures. Moreover, we explored rates of 90-day readmission and length of hospital stay following different procedures, besides the effects of sociodemographic and clinical parameters on procedure choice. Results36,437 IIH patients were identified from records between 2010 and 2018. Those in the EVS group were 29 years old on average, and 93.4 % were female. Large academic hospital setting was independently associated with higher EVS utilization, while other factors were not predictive of procedure choice. The proportion of EVS use in IIH hospitalizations increased significantly from 2010 to 2018 (P < 0.001), while there was a relative decline in the frequency of shunting procedures (P = 0.001), with ONSF utilization remaining stable (P = 0.39). The rate of 90-day readmission and length of hospital stay were considerably lower following EVS compared to other procedures (Ps < 0.001). ConclusionThis study presents novel population-level data on national trends in the frequency and outcome of EVS for IIH therapy. EVS was associated with shorter length of hospital stays and fewer readmission rates. In addition, a continuous increase in venous stenting compared to other procedures suggests an increasing role for endovascular therapies in IIH.

Visualization of Optic Nerve Structural Patterns in Papilledema Using Deep Learning Variational Autoencoders.

To visualize and quantify structural patterns of optic nerve edema encountered in papilledema during treatment. A novel bi-channel deep-learning variational autoencoder (biVAE) model was trained using 1498 optical coherence tomography (OCT) scans of 125 subjects over time from the Idiopathic Intracranial Hypertension Treatment Trial (IIHTT) and 791 OCT scans of 96 control subjects from the University of Iowa. An independent test dataset of 70 eyes from 70 papilledema subjects was used to evaluate the ability of the biVAE model to quantify and reconstruct the papilledema spatial patterns from input OCT scans using only two variables. The montage color maps of the retinal nerve fiber layer (RNFL) and total retinal thickness (TRT) produced by the biVAE model provided an organized visualization of the variety of morphological patterns of optic disc edema (including differing patterns at similar thickness levels). Treatment effects of acetazolamide versus placebo in the IIHTT were also demonstrated in the latent space. In image reconstruction, the mean signed peripapillary retinal nerve fiber layer thickness (pRNFLT) difference ± SD was -0.12 ± 17.34 µm, the absolute pRNFLT difference was 13.68 ± 10.65 µm, and the RNFL structural similarity index reached 0.91 ± 0.05. A wide array of structural patterns of papilledema, integrating the magnitude of disc edema with underlying disc and retinal morphology, can be quantified by just two latent variables. A biVAE model encodes structural patterns, as well as the correlation between channels, and may be applied to visualize individuals or populations with papilledema throughout treatment.

Identification of the characteristic visual field loss patterns in optic neuropathies

Visual fields support physicians in the diagnosis and progression tracking of optic neuropathies, enabling the visualization of the site of the optic nerve or optic pathways damage. Furthermore, the identification of the underlying patterns of different optic neuropathies can strengthen the diagnosis or help the clinicians for the patient's prognosis. Different abnormalities have been described and associated to neuroophthalmological diseases, such as central and ceco‐central scotomas related to hereditary optic neuropathies as Leber and dominant optic atrophy diseases which are mostly affected in the macular retinal ganglion cells and the papillomacular bundle. Altitudinal defects are usually associated with ischemic optic neuropathies, and in the big field of glaucoma the most commonly abnormalities are the arcuate and the nasal step.Related to this topic, artificial Intelligence is gaining traction, implementing, and testing different approaches to the automatic detection of visual field loss patterns in distinct diseases. For example, application of archetype analysis for the detection of glaucoma progression or for the assessment of efficacy in idiopathic intracranial hypertension treatment trial.

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.

Long-term efficacy of venous sinus stenting in the treatment of idiopathic intracranial hypertension.

Previous studies have suggested that cerebral dural sinus stenosis could be a possible underlying cause of idiopathic intracranial hypertension (IIH). Venous sinus stenting (VSS) has emerged as a potential alternative for treating IIH related to dural sinus stenosis. However, most of the documented studies have been conducted in Western countries. In this study, we present the results of 16 Chinese IIH patients who underwent VSS treatment in our single center. We prospectively collected angiographic and manometric data from IIH patients who underwent angioplasty/stenting. All patients had confirmed dural sinus stenosis and had failed maximal medical therapy (MMT). Demographic, clinical, and radiological presentation, as well as long-term follow-up outcomes were collected retrospectively. A total of 16 patients who underwent VSS were enrolled in the present study. Demographic data revealed a mean age of 40 (range 20-55), with 69% (11/16) being female, and a mean body mass index (BMI) of 27.05 (range 19.18-38.04) kg/m2 . All patients presented with papilledema and visual disturbances. During a median follow-up period of 47.5 months, 93.75% (15/16) of patients reported improvement in symptoms, although only 37.5% (6/16) experienced complete resolution. Headaches, blurred vision, and amaurosis related to increased pressure improved in 100% (8/8), 81.25% (13/16), and 75% (3/4) of patients, respectively. However, one patient suffered cerebral infarction and secondary epilepsy soon after VSS, and another patient had recurrence of symptoms due to stent wall thrombosis 2 years later. The significance of venous sinus stenosis in the development of IIH may be undervalued. Our study, based on a Chinese case series, affirms the long-term safety and effectiveness of VSS in treating IIH patients with relatively lower BMI than those from Western countries.

Endoscopic Endonasal Optic Nerve Decompression in Idiopathic Intracranial Hypertension: When to Implement Optic Nerve Sheath Fenestration.

Idiopathic intracranial hypertension (IIH) is a syndrome characterized with increased intracranial pressure and normal cerebrospinal fluid (CSF) composition. Treatment is mainly conservative, whereas CSF diversion surgery is the most frequently used surgical intervention. Endoscopic endonasal optic nerve decompression (EOND) is a newer surgical treatment of this patient group. This study presents a single clinic's case series with comparative results of unilateral an bilateral EOND with or without optic nerve fenestration. Sixteen patients with IIH syndrome who underwent 18 EOND procedures by a single neurosurgeon were evaluated with MRI and digitally subtracted angiography preoperatively. Both preoperative and postoperative visual acuity and perimetry and fundoscopy examinations were routinely performed. All patients underwent sphenoidotomy using the endoscopic binostril approach; however, unilateral or bilateral optic nerve decompression and accompanying optic sheath fenestration was determined on a case-by-case basis, after which all patients were also evaluated for the outcome of headaches. Most of the patients were female, and the mean age was 30.28 ± 9.78 years. CSF pressure was increased in all patients (406.43 ± 112.91 mm of H 2 O), and the follow-up period was 61.72 ± 21.67 months. In patients with unilateral EOND, visual fields improved in 83%, visual acuity in 70%, headache in 75%, and papilledema in 27% of cases. In patients with bilateral EOND, perimetry improved in 86%, visual acuity in 43%, headache in 50%, and papilledema in 57% of cases. EOND is an effective surgical option in the treatment of IIH. Bilateral decompression is preferable in patients with bilateral visual involvement, and optic nerve fenestration may prove to be helpful in patients with IIH whose primary complaint is headache.

[Misconceptions in diagnosis and treatment of papilledema caused by idiopathic intracranial hypertension].

Papilledema refers to the swelling of the optic disk due to increased intracranial pressure. In clinical practice, papilledema is often confused with optic disc edema. Idiopathic intracranial hypertension (IIH) is a major cause of papilledema and there are still misconceptions about the etiology of IIH, the classification and examination of papilledema, and the treatment of IIH. This article elaborates on the misunderstandings that may exist in the diagnosis and treatment of papilledema, in order to lay a foundation for the standardized diagnosis and treatment of papilledema in China.

Archetypal analysis of longitudinal visual fields for idiopathic intracranial hypertension patients presenting in a clinic setting.

We previously applied archetypal analysis (AA) using visual fields (VF) from the Idiopathic Intracranial Hypertension Treatment Trial (IIHTT) to derive a model, which quantified patterns (or archetypes [ATs] of VF loss), anticipated recovery, and identified residual VF deficits. We hypothesized that AA could produce similar results using IIH VFs collected in clinical practice. We applied AA to 803 VFs from 235 eyes with IIH from an outpatient neuro-ophthalmology clinic and created a clinic-derived model of ATs, with the relative weight (RW) and average total deviation (TD) for each AT. We also created a combined-derived model from an input dataset containing the clinic VFs and 2862 VFs from the IIHTT. We used both models to decompose clinic VF into ATs of varying percent weight (PW), correlated presentation AT PW with mean deviation (MD), and evaluated final visit VFs considered "normal" by MD ≥ -2.00 dB for residual abnormal ATs. The 14-AT clinic-derived and combined-derived models revealed similar patterns of VF loss previously identified in the IIHTT model. AT1 (a normal pattern) was most prevalent in both models (RW = 51.8% for clinic-derived; 35.4% for combined-derived). Presentation AT1 PW correlated with final visit MD (r = 0.82, p < 0.001 for the clinic-derived model; r = 0.59, p < 0.001 for the combined-derived model). Both models showed ATs with similar patterns of regional VF loss. The most common patterns of VF loss in "normal" final visit VFs using each model were clinic-derived AT2 (mild global depression with enlarged blind spot; 44/125 VFs; 34%) and combined-derived AT2 (near-normal; 93/149 VFs; 62%). AA provides quantitative values for IIH-related patterns of VF loss that can be used to monitor VF changes in a clinic setting. Presentation AT1 PW is associated with the degree of VF recovery. AA identifies residual VF deficits not otherwise indicated by MD.

Classifying Papilledema Using Machine Learning – Modernizing Frisén Grading (S12.001)

<h3>Objective:</h3> We hypothesize that machine learning (ML) can quantify papilledema and detect a treatment effect on papilledema due to idiopathic intracranial hypertension (IIH). <h3>Background:</h3> ML can differentiate papilledema from normal optic discs. Currently, papilledema severity is assessed using the descriptive, ordinal Frisén scale. <h3>Design/Methods:</h3> We trained a convolutional neural network (CNN) to autonomously assign a Frisén grade using 2608 fundus photos from fellow eyes of 158 participants in the IIH Treatment Trial (IIHTT) and both eyes from eight clinic patients with grade 4 or 5 papilledema. Experts in classifying papilledema previously graded the photos. Our validation set consisted of 2969 photos of the IIHTT study eyes (for each participant, the eye with worse vision). To investigate the change over time, we divided study eyes into treatment groups, acetazolamide + diet (ACZ) vs. placebo + diet. <h3>Results:</h3> ML produced continuous values from 0–5, which identified photos that contained features from more than one Frisén grade. Activation maps showed the model focused on the optic disc. The average predicted Frisén grade correlated strongly with ground truth (r = 0.80, p &lt; 0.001; mean absolute error = 0.49). At presentation, treatment groups had similar ML Frisén grades. The average ML Frisén grade for the ACZ treatment group (1.6, 95% CI 1.5–1.8) was significantly lower (p &lt; 0.01) than for the placebo group (2.2, 95% CI 1.9–2.5) at the six month trial outcome. This difference was noted as early as one month (p = 0.03). <h3>Conclusions:</h3> Supervised ML of fundus photos successfully grades the degree of papilledema and tracks the changes, reflecting the effects of ACZ therapy. Given the increasing availability of fundus photography, neurologists will be able to utilize ML to quantify papilledema on a continuous scale that incorporates the descriptive features of the Frisén grade to monitor treatment of papilledema. <b>Disclosure:</b> Mr. Branco has nothing to disclose. Jui-Wang Wang has nothing to disclose. Dr. Elze has nothing to disclose. Mona Garvin has nothing to disclose. Mr. Szanto has nothing to disclose. Dr. Kardon has received personal compensation in the range of $50,000-$99,999 for serving as an Expert Witness for 19 different law firms. The institution of Dr. Kardon has received research support from NIH. The institution of Dr. Kardon has received research support from Veterans Administration RR&amp;D Division. Dr. Kardon has received intellectual property interests from a discovery or technology relating to health care. Dr. Pasquale has received personal compensation for serving as an employee of Eyenovia. Dr. Pasquale has received personal compensation for serving as an employee of Twenty Twenty. Dr. Pasquale has received personal compensation for serving as an employee of Skye Biosciences. Dr. Pasquale has received personal compensation for serving as an employee of Character Biosciences. Dr. Pasquale has received personal compensation in the range of $0-$499 for serving on a Scientific Advisory or Data Safety Monitoring board for The Glaucoma Foundation. The institution of Dr. Pasquale has received personal compensation in the range of $50,000-$99,999 for serving on a Scientific Advisory or Data Safety Monitoring board for The Glaucoma Foundation. The institution of Dr. Pasquale has received research support from NEI. Dr. Kupersmith has nothing to disclose.

Teaching Neuro Images : Meningoencephalocele and CSF leak in chronic idiopathic intracranial hypertension

A 63-year-old woman with epilepsy and chronic headaches was admitted for status epilepticus. A lumbar puncture revealed increased opening pressure of 320 mm H2O and bacterial meningitis. MRI brain demonstrated a partial empty sella, tortuous optic nerve sheaths, flattening of the optic papillae, and numerous prominent arachnoid granulations, consistent with chronic idiopathic intracranial hypertension (IIH), as well as bright CSF signal and brain parenchyma within a left meningoencephalocele (figure, A). A CT cisternogram confirmed communication of the subarachnoid space of the meningoencephalocele with the left sphenoid sinus through a small osseous defect (figure, B). While most CSF leaks are related to trauma, IIH is increasingly recognized as a cause of spontaneous leaks.1,2 While the increased opening pressure may have been due to her acute meningitis, her headache symptoms and MRI findings are suggestive of longstanding intracranial hypertension. Monitoring and medical treatment of IIH must accompany surgical repair to avoid recurrence.2

National Trends of Cerebral Venous Sinus Stenting for the Treatment of Idiopathic Intracranial Hypertension.

Cerebral venous sinus stenting (VSS) has emerged as a new surgical procedure for the treatment of severe idiopathic intracranial hypertension (IIH), and its popularity has been anecdotally on the rise. This study explores recent temporal trends of VSS and other surgical IIH treatments in the United States. Adult patients with IIH were identified from the 2016-2020 National Inpatient Sample databases, and surgical procedures and hospital characteristics were recorded. Temporal trends of procedure numbers for VSS, CSF shunts, and optic nerve sheath fenestrations (ONSFs) were assessed and compared. A total of 46,065 (95% CI 44,710-47,420) patients with IIH were identified, of whom 7,535 patients (95% CI 6,982-8,088) received surgical IIH treatments. VSS procedures increased 80% (150 [95% CI 55-245] to 270 [95% CI 162-378] per year, p < 0.001). Concurrently, the number of CSF shunts decreased by 19% (1,365 [95% CI 1,126-1,604] to 1,105 [95% CI 900-1,310] per year, p < 0.001), and ONSF procedures decreased by 54% (65 [95% CI 20-110] to 30 [95% CI 6-54] per year, p < 0.001). Practice patterns for surgical IIH treatment in the United States are rapidly evolving, and VSS is becoming increasingly common. These findings highlight the urgency of randomized controlled trials to investigate the comparative effectiveness and safety of VSS, CSF shunts, ONSF, and standard medical treatments.

Abstract Number ‐ 12: First‐In‐Human Endovascular Treatment of Idiopathic Intracranial Hypertension Using a Miniature Biomimetic Transdural Shunt.

Introduction Successful percutaneous transvenous deployment of a miniature valved biomimetic transdural endovascular shunt (CereVasc eShunt, Auburndale, MA, USA) via an inferior petrosal sinus approach was recently described for treatment of post‐subarachnoid hemorrhage communicating hydrocephalus.The endovascular shunt replicates the function of the arachnoid granulation by draining cerebrospinal fluid (CSF) from the cerebello‐pontine angle cistern to the ipsilateral internal jugular vein. Idiopathic intracranial hypertension (IIH), usually resulting from venous transverse sinus stenosis, can be treated with pharmacological inhibition of CSF production, surgical ventriculoperitoneal shunting, or using venous stent angioplasty. In IIH, elevated CSF pressure can act to exacerbate venous sinus stenosis, resulting in worsening CSF reabsorption, thereby perpetuating a vicious cycle. The authors sought to evaluate the role of the minimally invasive eShunt approach in IIH management. Methods A 50‐year‐old male patient with history of dyslipidemia and IIH initially presented 6 years ago with diplopia initially treated with poorly tolerated acetazolamide and periodic lumbar punctures with subsequent symptom improvement. The patient was admitted following rapid evolution of sudden onset horizontal diplopia and headache. Brain magnetic resonance revealed flattening of the posterior sclera, partially empty Sella Turcica, enhancement of the prelaminar optic nerves and enlarged Meckel´s cave. Lumbar puncture was performed with opening pressure of 28 cmH2O. Cerebral angiography with 3D venography confirmed bilateral transverse sinus stenosis, though without a significant pressure gradient. Results The patient declined surgical ventriculoperitoneal shunting and was approved for compassionate use of eShunt by regulatory and bioethics committees.He underwent successful endovascular transdural deployment of the eShunt, which he tolerated well and was discharged at 48 hours post‐procedure with rapid symptomatic headache relief. Upon 30‐day follow‐up repeat brain MRI showed improvement of the prominent subarachnoid space around both optic nerves and sustained improvement of his pre‐procedural headache and diplopia.A repeat lumbar puncture revealed a lowed opening pressure of 20 cmH2O and MRI cisternography confirmed maintained patency of the biomimetic valve with accumulation of Gadolinium‐enhanced CSF drainage through the eShunt into the jugular bulb. Conclusions The current report describes the first‐in‐human use of the eShunt device for treatment of IIH resulting in sustained symptomatic relief along with decrease in CSF pressure and pre‐laminar optic nerve edema. The current results, which require confirmation in a larger cohort with longer follow‐up, are encouraging and suggest a possible role for minimally invasive endovascular transdural eshunt placement in the management of IIH.

Visual outcomes of idiopathic intracranial hypertension in a neuro-ophthalmology clinic in Jeddah, Saudi Arabia.

Idiopathic intracranial hypertension (IIH) is a disorder with elevated intracranial pressure more than 250 mm H2O, without evidence of meningeal inflammation, space-occupying lesion, or venous thrombosis. In this study, we aim to study the clinical profile, evaluation, management, and visual outcome in a hospital-based population of IIH cases in Jeddah. This is a retrospective observational cohort study that included the medical records of all patients referred to neuro-ophthalmology service for evaluation of papilledema. The medical records have been reviewed from October 2018 to February 2020 at Jeddah Eye Hospital, Saudi Arabia. A total of 51 patients presented with papilledema in the studied period. Forty-seven patients met our inclusion criteria and were included in the study. The study found that the incidence rate of IIH is 16:100 of the referred cases to the neuro-ophthalmology clinic. Most of the patients were females (41, 91.2%), with a mean age of presentation of 32 ± 11 years. The most common presenting symptom was headache (40 patients, 88.8%), followed by transient visual obscuration (TVO) (20 patients, 44.4%), and reduced visual acuity (15 patients, 33.3%). All 45 patients were started on medical treatment with oral acetazolamide with four patients (8.8%) shifted to topiramate because of the lack of response or intolerance to acetazolamide while four patients (8.8%) underwent lumbar-peritoneal shunt because of inadequate control of the disease despite the treatment with medical therapy. For both eyes, the change in visual acuity across all assessment points was statistically significant. Nevertheless, there were no significant changes in the visual field findings among all of the compared assessment points. The present study has shown that IIH-related papilledema is common in young female patients with headaches, TVOs, and reduced visual acuity. Those are the most common symptoms in our IIH population. Medical treatment and monitoring of IIH is efficient and should be considered to enhance the prognosis of IIH-related complications. In addition, the visual acuity and the visual field should be frequently monitored for these patients.

Technical and clinical success after venous sinus stenting for treatment of idiopathic intracranial hypertension using a novel guide catheter for access: Case series and initial multi-center experience.

Venous sinus stenting is a well established alternative to cerebrospinal fluid diversion for the treatment of idiopathic intracranial hypertension (IIH) with associated venous sinus stenosis. During this procedure, distal guide catheter placement within the venous sinuses may be desirable to facilitate stent delivery. We report our initial experience using the TracStar LDP™ (Imperative Care, Campbell, USA, 0.088-inch inner diameter) as the guide catheter for intracranial access during venous sinus stenting. A multi-institutional retrospective chart review of a prospectively maintained IRB-approved database was performed. Consecutive patients who underwent venous sinus stenting from 1/1/2020-9/6/2021 for IIH were included. Patient characteristics, procedural details, TracStar distal reach, outcomes, and complications were collected and analyzed. Fifty-eight patients were included. The mean age was 33.8 years and 93.1% of patients were female. Visual changes prompted evaluation in 86.2% of patients. Stent placement was successful in all patients. The TracStar LDP catheter was advanced to the location of stent placement in 97.9% of cases in which it was attempted. The large 0.088-inch inner diameter lumen enabled compatibility with all desired stent sizes ranging from six to 10 millimeters. Gradient pressure across transverse sinus stenosis dropped from an average of 19.5 mmHg pre-procedure to 1.7 mmHg post-stent placement (p < 0.001). Clinical improvement was achieved in 87.9% (51/58) of patients. There were no catheter-related complications. The TracStar LDP is a safe and effective access platform for reaching treatment locations in patients who present with idiopathic intracranial hypertension and who are candidates for venous sinus stent placement.

Neuroimaging in the diagnosis and treatment of intracranial pressure disorders.

To review the clinical features, proposed pathophysiology, and the role of medical imaging in the diagnosis and treatment of idiopathic intracranial hypertension and spontaneous intracranial hypotension. The authors conducted a narrative review of the current literature on intracranial hypertension and hypotension syndromes, with a focus on imaging findings and role of neurointerventional radiology as a therapeutic option for these pathologies. Idiopathic intracranial hypertension commonly presents in obese women of childbearing age, being headache and papilledema the main clinical manifestations. Characteristic radiological findings consist of increased cerebrospinal fluid around the optic nerve, partially empty sella turcica and stenosis of the transverse sinuses. Transverse sinus stenting is a treatment alternative that has proven valuable utility in the recent years. Spontaneous intracranial hypotension in most of cases presents with orthostatic headache and has predilection for female population. The typical radiological features in the brain consist of subdural fluid collections, enhancement of the dura, engorgement of the venous structures, pituitary enlargement, and sagging of the brain. In this pathology, a cerebrospinal fluid leak in the spine associated with a defect in the dura, meningeal diverticulum, or a cerebrospinal fluid-venous leak must be actively ruled out. Neurologic complaints secondary to changes in intracranial pressure exhibit certain clinical features that in combination with fairly specific radiological patterns allow a highly accurate diagnosis. The diverse specialists in neurosciences should be aware of the multiple image modalities in the study of these syndromes as well as the treatment alternatives by neurointerventional radiology.

Stenting versus medical treatment for idiopathic intracranial hypertension: a matched-control study

BackgroundThis prospective cohort study compared the outcomes of stenting and medical treatment for patients with idiopathic intracranial hypertension (IIH) and venous sinus stenosis (VSS).MethodsIn this single-center cohort study, patients with...

Cerebral Venous Sinus Stenting for the Treatment of Idiopathic Intracranial Hypertension in a Child

AbstractIdiopathic intracranial hypertension (IIH) is a disease characterized by an increase in the opening pressure of the cerebrospinal fluid (CSF) associated with symptoms of elevated intracranial pressure (ICP). The condition is more prevalent in women and typically managed clinically. Surgical treatment is reserved for select refractory cases. The well-established surgical procedures for the management of IIH are CSF shunting and fenestration of the optic nerve sheath. These procedures, however, are associated with high rates of complication and recurrence.More recently, venous sinus angioplasty with stents has been employed in cases with documented narrowing of the sigmoid-transverse sinuses. This technique is associated with a significant reduction in the venous pressure gradient at the stenosis site, alleviating the symptoms of intracranial hypertension.We report a case of a previously healthy 12-year-old patient who presented with 10-day history of headaches, blurring of vision, nausea and vomiting, which evolved with worsening of the visual acuity and papilledema. Imaging scans disclosed stenosis of the right transverse and sigmoid sinuses. The patient underwent stenting of the stenotic venous segments and showed good evolution, with significant clinical improvement within 24 hours of the procedure.