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Lowe M, Berman G, Sumithran P, Mollan SP. Current Understanding of the Pathophysiology of Idiopathic Intracranial Hypertension. Curr Neurol Neurosci Rep 2025; 25:31. [PMID: 40237861 PMCID: PMC12003586 DOI: 10.1007/s11910-025-01420-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/05/2025] [Indexed: 04/18/2025]
Abstract
PURPOSE OF REVIEW Development of safe targeted therapies for idiopathic intracranial hypertension requires a thorough understanding of recent evidence discovering the pathophysiology of the condition. The aim is to provide a review of studies that inform on the underpinning mechanisms that have been associated with idiopathic intracranial hypertension. RECENT FINDINGS People living with active idiopathic intracranial hypertension and obesity have been found to have with insulin resistance, hyperleptinaemia, and adverse cardiovascular outcomes. Clinically their adipose tissue is predominantly located in the truncal region and on detailed laboratory analysis the cells are primed for weight gain. There is evidence of androgen excess, altered glucocorticoid regulation and changes in pro-inflammatory cytokines. There are distinct alterations in metabolic pathways found in serum, urine and cerebrospinal fluid, that resolve following disease remission. These findings are associated with raised intracranial pressure and are likely secondary to cerebrospinal fluid hypersecretion. Idiopathic intracranial hypertension has a profile of systemic metabolic changes, endocrine dysfunction and cardiovascular risk profile distinct from that associated with obesity alone. These systemic metabolic changes are likely to contribute to dysregulation of cerebrospinal fluid dynamics, primarily hypersecretion but with a possible additional effect of reduced clearance resulting in the core feature of raised intracranial pressure.
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Affiliation(s)
- Michael Lowe
- Department of Neurology, Institute of Neurological Sciences, Queen Elizabeth University Hospital, Glasgow, G51 4 TF, UK
| | - Gabriele Berman
- Birmingham Neuro-Ophthalmology, University Hospitals Birmingham NHS Foundation Trust, Birmingham, B15 2GW, UK
| | - Priya Sumithran
- Dept of Surgery, School of Translational Medicine, Monash University, Melbourne, 3004, Australia
- Dept of Endocrinology and Diabetes, Alfred Health, Melbourne, 3004, Australia
| | - Susan P Mollan
- Birmingham Neuro-Ophthalmology, University Hospitals Birmingham NHS Foundation Trust, Birmingham, B15 2GW, UK.
- Metabolism and Systems Research, School of Medical Sciences, University of Birmingham, Birmingham, Edgbaston, B15 2 TT, UK.
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Niantiarno FH, Morisako H, Nagahama A, Ikegami M, Goto T. Simple Reconstruction Method of Dural Defects for Minimal Anterior and Posterior Combined Transpetrosal Approach. World Neurosurg 2025; 196:123795. [PMID: 39955051 DOI: 10.1016/j.wneu.2025.123795] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2025] [Accepted: 02/08/2025] [Indexed: 02/17/2025]
Abstract
BACKGROUND The minimal anterior posterior combined (MAPC) transpetrosal approach is a valuable technique for accessing petroclival lesions with supra-infratentorial extensions. However, dural reconstruction following this approach presents significant challenges owing to subtemporal and presigmoid dural and transtentorial incisions, dural shrinkage resulting from coagulation, and spatial constraints. METHODS This study retrospectively examined 25 patients who underwent MAPC transpetrosal approach between 2022 and 2024. We employed a simplified method of dural reconstruction using a fat graft and a sternocleidomastoid muscle-periosteum-temporal fascia flap without suturing. An absorbable polyglycolic acid material was fixed along the flap using fibrin glue to reinforce the sealing of the dura (question number 4, reviewer #1). The evaluation was conducted with a focus on subcutaneous cerebrospinal fluid (S-CSF) collection based on postoperative magnetic resonance imaging findings, and the strategies employed to address this complication were assessed. RESULTS Of the 25 cases examined, 16 showed no evidence of S-CSF accumulation (grade 0). Two patients were classified as grade 1, while 7 patients exhibited grade 2 S-CSF collection. None of the patients experienced cerebrospinal fluid (CSF) leakage through the surgical incision nor did they develop CSF rhinorrhea or otorrhea. All instances of S-CSF accumulation resolved spontaneously within 2-6 weeks, without requiring surgical intervention. Only 1 patient with a history of repeat surgery required CSF diversion via a lumbar drain postoperatively. CONCLUSIONS The simple dural reconstruction method using autologous fat graft and sternocleidomastoid temporal fascia flap demonstrated promising results in terms of preventing CSF-related complications following the MAPC transpetrosal approach.
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Affiliation(s)
- Fajar Herbowo Niantiarno
- Department of Neurosurgery, Osaka Metropolitan University Graduate School of Medicine, Osaka, Japan; Department of Neurosurgery, Ministry of Health General Hospital of Surabaya, Surabaya, Indonesia
| | - Hiroki Morisako
- Department of Neurosurgery, Osaka Metropolitan University Graduate School of Medicine, Osaka, Japan.
| | - Atsufumi Nagahama
- Department of Neurosurgery, Osaka Metropolitan University Graduate School of Medicine, Osaka, Japan
| | - Masaki Ikegami
- Department of Neurosurgery, Osaka Metropolitan University Graduate School of Medicine, Osaka, Japan
| | - Takeo Goto
- Department of Neurosurgery, Osaka Metropolitan University Graduate School of Medicine, Osaka, Japan
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Chen L, Li W, Ma X, Qu X, Zheng D, Liu Z. Cerebrospinal fluid flow dynamics and volume changes are related with sigmoid sinus wall dehiscence-pulsatile tinnitus with idiopathic intracranial hypertension. Magn Reson Imaging 2025; 117:110315. [PMID: 39716685 DOI: 10.1016/j.mri.2024.110315] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2024] [Revised: 12/17/2024] [Accepted: 12/17/2024] [Indexed: 12/25/2024]
Abstract
PURPOSE To evaluate cerebrospinal fluid (CSF) flow dynamics and volume changes of pulsatile tinnitus (PT) patients induced by sigmoid sinus wall dehiscence (SSWD) with intracranial hypertension. METHODS Thirty-five SSWD-PT patients coexisted with intracranial hypertension and 35, age-, gender-, and handedness-matched healthy volunteers were prospectively enrolled and performed MRI. Clinical data were collected. CSF flow dynamics were evaluated by phase-contrast magnetic resonance imaging (PC-MRI) and CSF volume was measured using ITK-SNAP software. RESULTS Compared with controls, the body mass index (BMI) of PT patients increased significantly (P = 0.046). Among CSF flow dynamics, PT patients presented significantly decreased mean flux (MF) (P = 0.017), mean velocity (MV) (P = 0.038), peak velocity (PV) (P = 0.023), and significantly increased regurgitant fraction (RF) (P = 0.010) than controls. There were no significant differences in other CSF flow dynamics parameters between the groups. CSF volume of PT patients was significantly increased than controls (P = 0.024). RF and CSF volume had potential diagnostic value. The AUC, sensitivity, specificity and accuracy of RF and CSF volume were 0.678, 68.6 %, 60.0 %, 61.4 % and 0.656, 68.6 %, 57.1 %, 55.7 %, respectively. The combined diagnostic efficacy of RF and CSF volume was highest, and the AUC, sensitivity, specificity and accuracy were 0.733, 74.3 %, 62.9 %, 67.1 % respectively. CONCLUSION SSWD-PT patients present CSF flow dynamics and volume changes, which may be related to the occurrence of PT. In addition to structural abnormalities, the combination of RF and CSF volume can be innovative as a complementary index to identify SSWD as the accurate etiology of PT.
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Affiliation(s)
- Lanyue Chen
- Department of Radiology, Beijing Tongren Hospital, Capital Medical University, Beijing 100730, China
| | - Wei Li
- Department of Radiology, Chongqing Iron and Steel General Hospital, Chongqing 400080, China
| | - Xiaobo Ma
- Department of Otolaryngology Head and Neck surgery, Beijing Tongren Hospital, Capital Medical University, Beijing 100730, China
| | - Xiaoxia Qu
- Department of Radiology, Beijing Tongren Hospital, Capital Medical University, Beijing 100730, China
| | - Dandan Zheng
- Department of Clinical and Technical Support, Philips (China) Investment Co., Ltd., Beijing Branch, Beijing 100600, China.
| | - Zhaohui Liu
- Department of Radiology, Beijing Tongren Hospital, Capital Medical University, Beijing 100730, China.
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Arkoudis NA, Davoutis E, Siderakis M, Papagiannopoulou G, Gouliopoulos N, Tsetsou I, Efthymiou E, Moschovaki-Zeiger O, Filippiadis D, Velonakis G. Idiopathic intracranial hypertension: Imaging and clinical fundamentals. World J Radiol 2024; 16:722-748. [PMID: 39801664 PMCID: PMC11718525 DOI: 10.4329/wjr.v16.i12.722] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/27/2024] [Revised: 11/15/2024] [Accepted: 12/11/2024] [Indexed: 12/27/2024] Open
Abstract
Neuroimaging is a paramount element for the diagnosis of idiopathic intracranial hypertension, a condition characterized by signs and symptoms of raised intracranial pressure without the identification of a mass or hydrocephalus being recognized. The primary purpose of this review is to deliver an overview of the spectrum and the specific role of the various imaging findings associated with the condition while providing imaging examples and educational concepts. Clinical perspectives and insights into the disease, including treatment options, will also be discussed.
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Affiliation(s)
- Nikolaos-Achilleas Arkoudis
- Research Unit of Radiology and Medical Imaging, School of Medicine, National and Kapodistrian University of Athens, Athens 11528, Greece
- 2nd Department of Radiology, Attikon University General Hospital, National and Kapodistrian University of Athens, Chaidari 12462, Greece
| | - Efstathia Davoutis
- School of Medicine, National and Kapodistrian University of Athens, Athens 11527, Greece
| | - Manos Siderakis
- Department of Radiology, Agios Savas Anticancer Hospital, Athens 11522, Greece
| | - Georgia Papagiannopoulou
- 2nd Department of Neurology, Attikon University General Hospital, School of Medicine, National and Kapodistrian University of Athens, Chaidari 12462, Greece
| | - Nikolaos Gouliopoulos
- 2nd Department of Ophthalmology, “Attikon” University Hospital, School of Medicine, National and Kapodistrian University of Athens, Chaidari 12462, Greece
| | - Ilianna Tsetsou
- Department of Imaging and Interventional Radiology, “Sotiria” General and Chest Diseases Hospital of Athens, Athens 11527, Greece
| | - Evgenia Efthymiou
- Research Unit of Radiology and Medical Imaging, School of Medicine, National and Kapodistrian University of Athens, Athens 11528, Greece
- 2nd Department of Radiology, Attikon University General Hospital, School of Medicine, National and Kapodistrian University of Athens, Chaidari 12462, Greece
| | - Ornella Moschovaki-Zeiger
- 2nd Department of Radiology, Attikon University General Hospital, School of Medicine, National and Kapodistrian University of Athens, Chaidari 12462, Greece
| | - Dimitrios Filippiadis
- 2nd Department of Radiology, Attikon University General Hospital, School of Medicine, National and Kapodistrian University of Athens, Chaidari 12462, Greece
| | - Georgios Velonakis
- Research Unit of Radiology and Medical Imaging, School of Medicine, National and Kapodistrian University of Athens, Athens 11528, Greece
- 2nd Department of Radiology, Attikon University General Hospital, School of Medicine, National and Kapodistrian University of Athens, Chaidari 12462, Greece
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Riedel CS, Norager NH, Bertelsen M, Mikkelsen R, Juhler M, Hansen TS. Elevated systemic venous pressures as a possible pathology in prepubertal pediatric idiopathic intracranial hypertension. Childs Nerv Syst 2024; 40:4203-4209. [PMID: 39254866 PMCID: PMC11579111 DOI: 10.1007/s00381-024-06594-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/19/2024] [Accepted: 08/25/2024] [Indexed: 09/11/2024]
Abstract
BACKGROUND Pediatric idiopathic intracranial hypertension (IIH) is a rare and challenging condition. As implied by the nomenclature, the etiologies remain unknown, and multiple etiologies are being investigated. In this study, we explored the potential role of increased systemic or cerebral venous pressure in the pathogenesis. METHOD An observational cohort study following the STROBE guidelines, including prepubertal children with clinical symptoms and imaging findings consistent with IIH referred to the neurosurgical department, was conducted. The patients underwent a comprehensive diagnostic protocol, including MRI, continuous intracranial pressure (ICP) monitoring, and endovascular venography with venous pressure measurements. RESULTS The study included 11 consecutive patients (six boys and five girls) with an average age of 2.3 years, and an average BMI of 18.4. Among these, one patient was found to have venous stenosis with a gradient; the other 10 patients presented with normal intracranial anatomy. All patients exhibited elevated venous pressures, with an average superior sagittal sinus pressure of 18.9 mmHg, average internal jugular vein pressure of 17.0 mmHg, and average central venous pressure of 15.9 mmHg. Daytime ICP averaged 12.9 mmHg, whereas nighttime ICP averaged 17.2 mmHg with either A- or B-waves in 10 of the 11 patients. Despite pathological ICP, only three patients had papilledema. CONCLUSIONS All patients had an increased systemic venous pressure, indicating a possible pathological factor for prepubertal IIH. Additionally, our findings show that young children often only partly meet the Friedman criteria due to a lack of papilledema, emphasizing the need for pediatric-specific diagnostic criteria. Further large-scale studies are needed to confirm these findings and to explore the underlying reasons for this increase in venous pressure and potential new treatment avenues.
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Affiliation(s)
- Casper Schwartz Riedel
- Department of Neurosurgery, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark.
| | | | - Maria Bertelsen
- Department of Paediatrics, Aarhus University Hospital, Aarhus, Denmark
| | - Ronni Mikkelsen
- Department of Neuroradiology, Aarhus University Hospital, Aarhus, Denmark
| | - Marianne Juhler
- Department of Neurosurgery, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
- Department of Neurosurgery, Aarhus University Hospital, Aarhus, Denmark
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Dix C, Hunt BJ. The changing face of cerebral venous sinus thrombosis-emerging new causes and treatments. J Thromb Haemost 2024; 22:3346-3354. [PMID: 39260741 DOI: 10.1016/j.jtha.2024.08.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2024] [Revised: 08/21/2024] [Accepted: 08/26/2024] [Indexed: 09/13/2024]
Abstract
Cerebral venous sinus thrombosis (CVST) is an uncommon site of venous thromboembolism. CVST more commonly affects younger people and women, in stark contrast to other forms of venous thrombosis in which incidence increases with age and overall affects men. Traditional risk factors for the development of CVST include endogenous and exogenous estrogen (combined oral contraceptives and pregnancy and the puerperium), thrombophilias, and rare hematologic disorders. New and emerging risk factors include obesity, polycystic ovary syndrome, COVID-19 infection, and vaccine-induced thrombocytopenia and thrombosis and vaccine-induced thrombocytopenia and thrombosis-like disorders. Management centers around anticoagulation, management of the underlying cause, and consideration of invasive measures including endovascular thrombolysis and/or thrombectomy and craniectomy for severe cases. This review discusses the emerging risk factors and their identification, evidence for treatment including the use of direct oral anticoagulants, and the role of invasive management options.
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Affiliation(s)
- Caroline Dix
- Department of Clinical Haematology, Alfred Hospital, Melbourne, Victoria, Australia; Department of Clinical Haematology, Austin Hospital, Heidelberg, Victoria, Australia.
| | - Beverley J Hunt
- Thrombosis and Haemophilia Centre, Guy's & St Thomas' NHS Foundation Trust, London, United Kingdom. https://twitter.com/bhwords
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Ng H, Huhulea EN, Jain A, Fortunato M, Subah G, Sacknovitz A, Spirollari E, Rosenberg JB, Bauerschmidt A, Mayer SA, Gandhi CD, Al-Mufti F. Exploring the Obesity Paradox in All Subtypes of Intracranial Hemorrhage: A Retrospective Cohort Analysis of 13,000 Patients. Brain Sci 2024; 14:1200. [PMID: 39766399 PMCID: PMC11675038 DOI: 10.3390/brainsci14121200] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2024] [Revised: 11/26/2024] [Accepted: 11/28/2024] [Indexed: 01/11/2025] Open
Abstract
BACKGROUND/OBJECTIVES Recent studies reveal an "obesity paradox", suggesting better clinical outcomes after intracranial hemorrhage for obese patients compared to patients with a healthy BMI. While this paradox indicates improved survival rates for obese individuals in stroke cases, it is unknown whether this trend remains true across all forms of intracranial hemorrhage. Therefore, the objective of our study was to investigate the incidence, characteristics, and outcomes of hospitalized obese patients with intracranial hemorrhage. METHODS The National Inpatient Sample (NIS) database was queried for data from 2015 to 2019 to identify adult patients aged 18 years and older with a primary diagnosis of non-traumatic intracranial hemorrhage. Using International Classification of Disease 10th Edition codes, patients were stratified by BMI categories: healthy weight, overweight, class I-II obesity, and class III obesity. The cohorts were examined for demographic characteristics, comorbidities, stroke severity, inpatient complications, interventions, and clinical outcomes, including length of stay (LOS), discharge disposition, and inpatient mortality. RESULTS Of 41,960 intracranial hemorrhage patients identified, 13,380 (33.0%) also had an obese BMI. Class I-II obese intracranial hemorrhage patients were more likely to be of white race (OR: 1.101, 95% CI: 1.052, 1.152, p < 0.001), less likely to be female (OR: 0.773, 95% CI: 0.740, 0.808, p < 0.001), and more likely to have diabetes mellitus (OR: 1.545, 95% CI: 1.477, 1.616, p < 0.001) and hypertension (OR: 1.828, 95% CI: 1.721, 1.943, p < 0.001) in comparison to healthy-weight patients. In a matched cohort analysis adjusting for demographics and severity, intracranial hemorrhage patients with class I-II obesity had a shorter length of stay (LOS) (OR 0.402, 95% CI: 0.118, 0.705, p < 0.001), reduced inpatient mortality (OR 0.847, 95% CI: 0.798, 0.898, p < 0.001), and more favorable discharge disposition (OR 1.395, 95% CI: 1.321, 1.474, p < 0.001) compared to their healthy-weight counterparts. Furthermore, these patients were less likely to require decompressive hemicraniectomy (OR 0.697, 95% CI: 0.593, 0.820, p < 0.001). Following an analysis of individual ICH subtypes, obese subarachnoid hemorrhage (SAH) patients demonstrated reduced mortality (OR: 0.692, 95% CI: 0.577-0.831, p < 0.001) and LOS (OR: 0.070, 95% CI: 0.466-0.660, p = 0.039), with no differences in discharge disposition. Similarly, intracerebral hemorrhage patients demonstrated reduced mortality (OR: 0.891, 95% CI: 0.827-0.959, p = 0.002) and LOS (OR: 0.480, 95% CI: 0.216-0.743, p < 0.001). Other ICH subtypes showed improved discharge outcomes (OR: 1.504, 95% CI: 1.368-1.654, p < 0.001), along with decreased mortality (OR: 0.805, 95% CI: 0.715-0.907, p < 0.001) and LOS (OR: -10.313, 95% CI: -3.599 to -2.449, p < 0.001). CONCLUSIONS Intracranial hemorrhage patients with class I-II obesity exhibited more favorable clinical outcomes than those who were of a healthy weight or overweight. Despite its association with risk factors contributing to intracranial hemorrhage, class I-II obesity was associated with improved outcomes, lending support to the existence of the obesity paradox in stroke.
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Affiliation(s)
- Helen Ng
- School of Medicine, New York Medical College, Valhalla, NY 10595, USA
| | - Ellen N. Huhulea
- School of Medicine, New York Medical College, Valhalla, NY 10595, USA
| | - Ankita Jain
- School of Medicine, New York Medical College, Valhalla, NY 10595, USA
- Department of Neurosurgery, Westchester Medical Center, Valhalla, NY 10595, USA
| | - Michael Fortunato
- School of Medicine, New York Medical College, Valhalla, NY 10595, USA
| | - Galadu Subah
- School of Medicine, New York Medical College, Valhalla, NY 10595, USA
- Department of Neurosurgery, Westchester Medical Center, Valhalla, NY 10595, USA
| | - Ariel Sacknovitz
- School of Medicine, New York Medical College, Valhalla, NY 10595, USA
- Department of Neurosurgery, Westchester Medical Center, Valhalla, NY 10595, USA
| | - Eris Spirollari
- School of Medicine, New York Medical College, Valhalla, NY 10595, USA
- Department of Neurosurgery, Westchester Medical Center, Valhalla, NY 10595, USA
| | - Jon B. Rosenberg
- Department of Neurology, Westchester Medical Center, Valhalla, NY 10595, USA
| | - Andrew Bauerschmidt
- Department of Neurology, Westchester Medical Center, Valhalla, NY 10595, USA
| | - Stephan A. Mayer
- Department of Neurology, Westchester Medical Center, Valhalla, NY 10595, USA
| | - Chirag D. Gandhi
- School of Medicine, New York Medical College, Valhalla, NY 10595, USA
- Department of Neurosurgery, Westchester Medical Center, Valhalla, NY 10595, USA
| | - Fawaz Al-Mufti
- School of Medicine, New York Medical College, Valhalla, NY 10595, USA
- Department of Neurology, Westchester Medical Center, Valhalla, NY 10595, USA
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Ohira S, Komori M. A Case of Bilateral Idiopathic Temporal Cerebrospinal Fluid Leakage With Multiple Fistulas in the Middle and Posterior Cranial Fossae Closed Using the Transmastoid Approach. Cureus 2024; 16:e70742. [PMID: 39493073 PMCID: PMC11530735 DOI: 10.7759/cureus.70742] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/02/2024] [Indexed: 11/05/2024] Open
Abstract
Although idiopathic temporal cerebrospinal fluid (CSF) leaks are a relatively rare condition, its incidence has been increasing in the United States in recent years. Fistulas commonly occur in the middle cranial fossa (MCF), and the MCF approach is recommended for multiple or large fistulas. Here, we present a case of bilateral temporal CSF leaks and multiple fistulas. The patient had small fistulas in the middle and posterior cranial fossae, which were successfully treated using the transmastoid (TM) approach, and proper postoperative management of CSF pressure resulted in favorable outcomes. The TM approach is particularly advantageous for addressing fistulas located in the posterior cranial fossa. Furthermore, in cases with multiple fistulas, a high likelihood exists that underlying factors such as idiopathic CSF hypertension, obesity, and obstructive sleep apnea (OSA) may be contributing to the condition. Managing these underlying factors effectively can lead to favorable outcomes. Despite the lower prevalence of idiopathic temporal CSF leak cases in Japan compared to the United States, the incidence of this condition is expected to rise globally owing to the increasing rates of obesity and OSA.
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Affiliation(s)
- Shinya Ohira
- Department of Otolaryngology, St. Marianna University School of Medicine, Kawasaki, JPN
| | - Manabu Komori
- Department of Otolaryngology, St. Marianna University School of Medicine, Kawasaki, JPN
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Banerjee M, Phuljhele S, Saxena R, Sharma P, Misra V, Vibha D, Pandit AK. Impact of weight reduction on structural and functional parameters of the optic nerve in idiopathic intracranial hypertension. Eur J Ophthalmol 2024; 34:1594-1599. [PMID: 38380874 DOI: 10.1177/11206721241232038] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/22/2024]
Abstract
PURPOSE To evaluate the effect of weight reduction on the structural and functional parameters of the optic nerve in established cases of papilledema in Idiopathic Intracranial Hypertension (IIH). METHODS A prospective observational study in early and established cases of papilledema in IIH presenting from December 2019 to February 2021. Functional parameters (visual acuity, contrast sensitivity, mean deviation, VER), structural parameters (RNFL, GCL-IPL, and optic disc height), and clinical grading of papilledema were measured at baseline and every 6 weeks for 6 months. All patients underwent medical (oral acetazolamide) and diet therapy. RESULTS Mean body mass index (BMI) at presentation was 26.32 ± 3.52 kg/m² and the mean change in BMI over 6 months was 1.27 ± 0.50 kg/m². 67% of eyes had papilledema of grades 2-3 at the presentation. At the end of 6 months, 75% of eyes had grade 1 papilledema while 13% showed complete resolution. A reduction of 5.32 ± 3.58 in mean deviation (r = 0.316; p-value 0.01) and gain in VER P100 amplitude of 4.2 ± 2.7 µV (r = 0.40; p-value 0.003) were noted over 6 months with reduction in BMI over 6 months. A statistically significant reduction in optic disc height (ODH) was noticed with BMI reduction over 6 months (p = 0.0007; r = 0.45).A reduction of 1.72 ± 0.90 kg/m² (equivalent to 6.53% weight loss) in BMI was associated with a four-grade change in clinical grading of papilledema. CONCLUSION Reduction in BMI had a significant impact on both structural and functional parameters of the optic nerve in IIH. The involvement of a well-certified dietician should be an integral part of treatment in IIH.
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Affiliation(s)
- Mousumi Banerjee
- Dr Rajendra Prasad Centre for Ophthalmic Sciences, AIIMS, New Delhi, India
| | - Swati Phuljhele
- Dr Rajendra Prasad Centre for Ophthalmic Sciences, AIIMS, New Delhi, India
| | - Rohit Saxena
- Dr Rajendra Prasad Centre for Ophthalmic Sciences, AIIMS, New Delhi, India
| | - Pradeep Sharma
- Dr Rajendra Prasad Centre for Ophthalmic Sciences, AIIMS, New Delhi, India
| | - Vasundhra Misra
- Dr Rajendra Prasad Centre for Ophthalmic Sciences, AIIMS, New Delhi, India
| | - Deepti Vibha
- Department of Neurology, AIIMS, New Delhi, India
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Zhou C, Zhou Y, Liu L, Jiang H, Wei H, Zhou C, Ji X. Progress and recognition of idiopathic intracranial hypertension: A narrative review. CNS Neurosci Ther 2024; 30:e14895. [PMID: 39097911 PMCID: PMC11298205 DOI: 10.1111/cns.14895] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2024] [Revised: 06/03/2024] [Accepted: 07/19/2024] [Indexed: 08/06/2024] Open
Abstract
BACKGROUND Idiopathic intracranial hypertension (IIH) mainly affects obese young women, causing elevated intracranial pressure, headaches, and papilledema, risking vision loss and severe headaches. Despite weight loss as the primary treatment, the underlying mechanisms remain unclear. Recent research explores novel therapeutic targets. AIMS This review aimed to provide a comprehensive understanding of IIH's pathophysiology and clinical features to inform pathogenesis and improve treatment strategies. METHODS Recent publications on IIH were searched and summarized using PubMed, Web of Science, and MEDLINE. RESULTS The review highlights potential pathomechanisms and therapeutic advances in IIH. CONCLUSION IIH incidence is rising, with growing evidence linking it to metabolic and hormonal disturbances. Early diagnosis and treatment remain challenging.
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Affiliation(s)
- Chenxia Zhou
- Department of NeurologyXuanwu Hospital, Capital Medical UniversityBeijingChina
- Neurology and Intracranial Hypertension and Cerebral Venous Disease CenterNational Health Commission of China, Xuanwu Hospital, Capital Medical UniversityBeijingChina
| | - Yifan Zhou
- Laboratory of Brain Disorders, Ministry of Science and Technology, Collaborative Innovation Center for Brain DisordersBeijing Institute of Brain Disorders, Beijing Advanced Innovation Center for Big Data‐based Precision Medicine, Capital Medical UniversityBeijingChina
| | - Lu Liu
- Department of NeurologyXuanwu Hospital, Capital Medical UniversityBeijingChina
- Neurology and Intracranial Hypertension and Cerebral Venous Disease CenterNational Health Commission of China, Xuanwu Hospital, Capital Medical UniversityBeijingChina
- Zhongguancun Xirui Institute of Precision Medicine for Heart and Brain TumorsBeijingChina
| | - Huimin Jiang
- Laboratory of Brain Disorders, Ministry of Science and Technology, Collaborative Innovation Center for Brain DisordersBeijing Institute of Brain Disorders, Beijing Advanced Innovation Center for Big Data‐based Precision Medicine, Capital Medical UniversityBeijingChina
| | - Huimin Wei
- Beijing Advanced Innovation Center for Big Data‐Based Precision MedicineSchool of Biological Science and Medical Engineering, Beihang UniversityBeijingChina
| | - Chen Zhou
- Neurology and Intracranial Hypertension and Cerebral Venous Disease CenterNational Health Commission of China, Xuanwu Hospital, Capital Medical UniversityBeijingChina
- Laboratory of Brain Disorders, Ministry of Science and Technology, Collaborative Innovation Center for Brain DisordersBeijing Institute of Brain Disorders, Beijing Advanced Innovation Center for Big Data‐based Precision Medicine, Capital Medical UniversityBeijingChina
| | - Xunming Ji
- Neurology and Intracranial Hypertension and Cerebral Venous Disease CenterNational Health Commission of China, Xuanwu Hospital, Capital Medical UniversityBeijingChina
- Laboratory of Brain Disorders, Ministry of Science and Technology, Collaborative Innovation Center for Brain DisordersBeijing Institute of Brain Disorders, Beijing Advanced Innovation Center for Big Data‐based Precision Medicine, Capital Medical UniversityBeijingChina
- Department of NeurosurgeryXuanwu Hospital, Capital Medical UniversityBeijingChina
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Colman BD, Boonstra F, Nguyen MN, Raviskanthan S, Sumithran P, White O, Hutton EJ, Fielding J, van der Walt A. Understanding the pathophysiology of idiopathic intracranial hypertension (IIH): a review of recent developments. J Neurol Neurosurg Psychiatry 2024; 95:375-383. [PMID: 37798095 DOI: 10.1136/jnnp-2023-332222] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/17/2023] [Accepted: 09/15/2023] [Indexed: 10/07/2023]
Abstract
Idiopathic intracranial hypertension (IIH) is a condition of significant morbidity and rising prevalence. It typically affects young people living with obesity, mostly women of reproductive age, and can present with headaches, visual abnormalities, tinnitus and cognitive dysfunction. Raised intracranial pressure without a secondary identified cause remains a key diagnostic feature of this condition, however, the underlying pathophysiological mechanisms that drive this increase are poorly understood. Previous theories have focused on cerebrospinal fluid (CSF) hypersecretion or impaired reabsorption, however, the recent characterisation of the glymphatic system in many other neurological conditions necessitates a re-evaluation of these hypotheses. Further, the impact of metabolic dysfunction and hormonal dysregulation in this population group must also be considered. Given the emerging evidence, it is likely that IIH is triggered by the interaction of multiple aetiological factors that ultimately results in the disruption of CSF dynamics. This review aims to provide a comprehensive update on the current theories regarding the pathogenesis of IIH.
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Affiliation(s)
- Blake D Colman
- Department of Neuroscience, Monash University Faculty of Medicine Nursing and Health Sciences, Clayton, Victoria, Australia
- Department of Neurology, Alfred Hospital, Melbourne, Victoria, Australia
| | - Frederique Boonstra
- Department of Neuroscience, Monash University Faculty of Medicine Nursing and Health Sciences, Clayton, Victoria, Australia
| | - Minh Nl Nguyen
- Department of Neuroscience, Monash University Faculty of Medicine Nursing and Health Sciences, Clayton, Victoria, Australia
- Department of Neurology, Alfred Hospital, Melbourne, Victoria, Australia
| | | | - Priya Sumithran
- Department of Surgery, Monash University Faculty of Medicine Nursing and Health Sciences, Clayton, Victoria, Australia
- Department of Endocrinology, Alfred Hospital, Melbourne, Victoria, Australia
| | - Owen White
- Department of Neurology, Alfred Hospital, Melbourne, Victoria, Australia
- Department of Neuroscience, Monash University Central Clinical School, Clayton, Victoria, Australia
| | - Elspeth J Hutton
- Department of Neuroscience, Monash University Faculty of Medicine Nursing and Health Sciences, Clayton, Victoria, Australia
- Department of Neurology, Alfred Hospital, Melbourne, Victoria, Australia
| | - Joanne Fielding
- Department of Neuroscience, Monash University Faculty of Medicine Nursing and Health Sciences, Clayton, Victoria, Australia
| | - Anneke van der Walt
- Department of Neuroscience, Monash University Faculty of Medicine Nursing and Health Sciences, Clayton, Victoria, Australia
- Department of Neurology, Alfred Hospital, Melbourne, Victoria, Australia
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Benchetrit L, Shave S, Garcia A, Chung JJ, Suresh K, Lee DJ. Predictors of non-primary auditory and vestibular symptom persistence following surgical repair of superior canal dehiscence syndrome. Front Neurol 2024; 15:1336627. [PMID: 38469592 PMCID: PMC10925929 DOI: 10.3389/fneur.2024.1336627] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2023] [Accepted: 02/06/2024] [Indexed: 03/13/2024] Open
Abstract
Objective Patients with superior canal dehiscence syndrome (SCDS) can present with a plethora of auditory and/or vestibular symptoms associated with a bony defect of the superior semicircular canal. While surgical repair is a reasonable option for patients with significant localizing symptoms, the degree of clinical improvement will vary among patients and poses challenges in outcome prediction. This study aims to assess the relationship between preoperative and postoperative symptoms and identify predictors of symptom persistence following repair. Study design Retrospective chart review. Setting Tertiary neurotology single-institution care center. Main outcome measures The primary outcome was to determine the proportion of resolved and persistent primary (most bothersome) and non-primary audiologic and vestibular symptoms following SCD repair. Secondary outcomes included comparison of patient, operative and radiologic characteristics between patients with resolved vs. persistent symptoms. Standardized patient questionnaires including 11 auditory and 8 vestibular symptoms were administered to patients at their preoperative and follow-up visits. Patient pre- vs. postoperative survey results, demographic and clinical characteristics, operative characteristics, audiometric data and cervical vestibular evoked myogenic potential (cVEMP) thresholds were compared via univariate χ2 and multivariate binary logistic regression analyses between those patients reporting full postoperative resolution of symptoms and persistence of one or more symptoms. Radiologic computed tomography (CT) measurements of superior canal dehiscence (SCD) defect size, location, and laterality were also compared between these two groups. Results Of 126 patients (132 ears) included in our study, 119 patients (90.2%) reported postoperative resolution (n = 82, 62.1%) or improvement (n = 37, 28.0%) of primary (most bothersome) symptoms, while 13 patients (9.8%) reported persistence of primary symptoms. The median (interquartile range) and range between surgery and questionnaire completion were 9 (4-28), 1-124 months, respectively. Analyzing all symptoms (primary and non-primary) 69 (52.3%) and 68 (51.1%) patients reported complete postoperative auditory and vestibular symptom resolution, respectively. The most likely persistent symptoms included imbalance (33/65/67, 50.8%), positional dizziness (7/20, 35.0%) and oscillopsia (44/15, 26.7%). Factors associated with persistent auditory symptoms included history of seizures (0% vs. 7.6%, p = 0.023), auditory chief complaint (50.0% vs. 70.5%), higher PTA (mean 19.6 vs. 25.1 dB, p = 0.043) and higher cervical vestibular evoked myogenic potential (cVEMP) thresholds at 1000 Hz (mean 66.5 vs. 71.4, p = 0.033). A migraine diagnosis (14.0% vs. 41.9% p < 0.010), bilateral radiologic SCD (17.5% vs. 38.1%, p = 0.034) and revision cases (0.0% vs. 14.0%, p = 0.002) were associated with persistent vestibular symptoms. Neither SCD defect size nor location were significantly associated with symptom persistence (P > 0.05). Conclusions Surgical repair for SCDS offers meaningful reduction in the majority of auditory and vestibular symptoms. However, the persistence of certain, mostly non-primary, symptoms and the identification of potential associated factors including migraines, PTA thresholds, cVEMP threshold, bilateral SCD, and revision cases emphasize the importance of individualized patient counseling and management strategies.
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Affiliation(s)
- Liliya Benchetrit
- Department of Otolaryngology-Head and Neck Surgery, Massachusetts Eye and Ear and Harvard Medical School, Boston, MA, United States
- Department of Otolaryngology-Head, and Neck Surgery, Boston University, Boston, MA, United States
| | - Samantha Shave
- Department of Otolaryngology-Head and Neck Surgery, Massachusetts Eye and Ear and Harvard Medical School, Boston, MA, United States
- Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ, United States
| | - Alejandro Garcia
- Department of Otolaryngology-Head and Neck Surgery, Massachusetts Eye and Ear and Harvard Medical School, Boston, MA, United States
- Department of Otolaryngology-Head, and Neck Surgery, University of Iowa, Iowa City, IA, United States
| | - Janice J Chung
- Department of Otolaryngology-Head and Neck Surgery, Massachusetts Eye and Ear and Harvard Medical School, Boston, MA, United States
| | - Krish Suresh
- Department of Otolaryngology-Head and Neck Surgery, Massachusetts Eye and Ear and Harvard Medical School, Boston, MA, United States
| | - Daniel J Lee
- Department of Otolaryngology-Head and Neck Surgery, Massachusetts Eye and Ear and Harvard Medical School, Boston, MA, United States
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Schmill LPA, Peters S, Juhász J, Jansen O, Laudes M, Aludin S. MRI signs of intracranial hypertension in morbidly obese and normal-weight individuals. ROFO-FORTSCHR RONTG 2024; 196:176-185. [PMID: 37963551 DOI: 10.1055/a-2114-1919] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2023]
Abstract
PURPOSE Idiopathic intracranial hypertension (IIH) is associated with intracranial abnormalities, although not obligatory, which can be detected with cranial MRI. Obesity is an important risk factor for IIH and a pathogenetic link is suspected but the extent to which these MRI signs are already related to obesity has not yet been examined. We investigated whether IIH-MRI signs are present more often in obese individuals with a BMI > 30 kg/m² than in individuals of normal weight. MATERIALS AND METHODS Brain MRI of 32 obese and 53 normal-weight participants from the Food-Chain-Plus cohort were analyzed for three main signs of IIH: (I) stenosis of the transverse sinus, (II) increased width of the optic nerve sheath, and (III) reduction of pituitary height. In addition, a scoring system for the MRI signs was applied. Furthermore, tortuosity of the optic nerve and flattening of the posterior globe were considered as additional MRI signs. RESULTS Obese participants had a significantly higher MRI score (p < 0.001) than those in the normal-weight cohort, with significant differences in quantitative measurements of cerebral venous sinus stenosis (p < 0.001), widening of the optic nerve sheath (p < 0.05), and flattening of the pituitary gland (p < 0.05) also always being observed more frequently and in a more pronounced manner in the obese group. Furthermore, our findings correlated significantly with BMI and proportionately with hip and waist circumference. CONCLUSION Obese individuals show a significantly higher prevalence of cerebral MRI signs related to IIH. This supports the hypothesis that obesity is a risk factor for possible intracranial hypertension and reinforces the suspicion that obesity is involved in the pathomechanism of IIH. KEY POINTS · Obesity is associated with changes such as those seen in IIH.. · BMI, weight, and body measurements correlate with the expression of MRI signs of IIH.. · To prevent IIH symptoms in obesity, the pathomechanism must be further clarified..
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Affiliation(s)
| | - Sönke Peters
- Clinic for Radiology and Neuroradiology, University Hospital Schleswig-Holstein - Campus Kiel, Germany
| | - Julia Juhász
- Clinic for Radiology and Neuroradiology, University Hospital Schleswig-Holstein - Campus Kiel, Germany
| | - Olav Jansen
- Clinic for Radiology and Neuroradiology, University Hospital Schleswig-Holstein - Campus Kiel, Germany
| | - Matthias Laudes
- Institute of Diabetes and Clinical Metabolic Research; Division of Endocrinology, Diabetes and Clinical Nutrition, Department of Medicine 1, University Hospital Schleswig-Holstein - Campus Kiel, Germany
| | - Schekeb Aludin
- Clinic for Radiology and Neuroradiology, University Hospital Schleswig-Holstein - Campus Kiel, Germany
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Pandit AK, Misra S, Sengupta S, Chakraborty R, Singh P, Singh GP, Phuljhele S, Srivastava AK, Vibha D, Garg A, Shankar V, Mohania D, Shukla G, Prasad K. Cerebrospinal fluid proteins in idiopathic intracranial hypertension: An exploratory SWATH proteomics analysis. Proteomics Clin Appl 2024; 18:e2300021. [PMID: 37551060 DOI: 10.1002/prca.202300021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2023] [Revised: 07/17/2023] [Accepted: 07/27/2023] [Indexed: 08/09/2023]
Abstract
PURPOSE The pathogenesis of idiopathic intracranial hypertension (IIH) is currently poorly understood. This exploratory study aimed to identify potential cerebrospinal fluid (CSF) biomarkers in IIH cases compared to controls using SWATH-MS proteomics approach. EXPERIMENTAL DESIGN CSF samples were collected prospectively from IIH cases and control subjects which were subjected to SWATH-MS based untargeted proteomics. Proteins with fold change > 1.5 or < 0.67 and p-value < 0.05 were considered significantly differentially expressed. Data are available via ProteomeXchange with identifier PXD027751. Statistical analysis was conducted in R version 3.6.2. RESULTS We included CSF samples from 33 subjects, consisting of 13 IIH cases and 20 controls. A total of 262 proteins were identified in Proteinpilot search. Through SWATH analysis, we quantified 232 proteins. We observed 37 differentially expressed proteins between the two groups with 24 upregulated and 13 downregulated proteins. There were two differential proteins among overweight versus non-overweight IIH cases. Network for 23 proteins was highly connected in the interaction analysis. CONCLUSIONS AND CLINICAL RELEVANCE Neurosecretory, neuroendocrine, and inflammatory proteins were predominantly involved in causing IIH. This exploratory study served as a platform to identify 37 differentially expressed proteins in IIH and also showed significant differences between overweight and non-overweight IIH patients.
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Affiliation(s)
- Awadh Kishor Pandit
- Department of Neurology, All India Institute of Medical Sciences, New Delhi, India
| | - Shubham Misra
- Department of Neurology, All India Institute of Medical Sciences, New Delhi, India
- Department of Neurology, Yale University, New Haven, USA
| | - Shantanu Sengupta
- CSIR-Institute of Genomics and Integrative Biology, New Delhi, India
| | - Rahul Chakraborty
- CSIR-Institute of Genomics and Integrative Biology, New Delhi, India
| | - Praveen Singh
- CSIR-Institute of Genomics and Integrative Biology, New Delhi, India
| | - Gyaninder Pal Singh
- Department of Neuroanesthesiology and Critical Care, All India Institute of Medical Sciences, New Delhi, India
| | - Swati Phuljhele
- Department of Ophthalmology, Dr R.P. Centre, All India Institute of Medical Sciences, New Delhi, India
| | - Achal K Srivastava
- Department of Neurology, All India Institute of Medical Sciences, New Delhi, India
| | - Deepti Vibha
- Department of Neurology, All India Institute of Medical Sciences, New Delhi, India
| | - Ajay Garg
- Department of Neuroradiology, All India Institute of Medical Sciences, New Delhi, India
| | - Vivek Shankar
- Department of Orthopedics, All India Institute of Medical Sciences, New Delhi, India
| | - Dheeraj Mohania
- Dr R.P. Centre, All India Institute of Medical Sciences, New Delhi, India
| | - Garima Shukla
- Department of Neurology (Epilepsy & Sleep Medicine), Department of Medicine, Queen's University, Kingston, Canada
| | - Kameshwar Prasad
- Department of Neurology, All India Institute of Medical Sciences, New Delhi, India
- Department of Neurology, Rajendra Institute of Medical Sciences, Ranchi, India
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15
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Huda F, Abdelmonem A, Dehghani Firouzabadi F, Srinivas Dola VN, Sheikhy A, Taheri MR. The role of arachnoid granulations in idiopathic intracranial hypertension. Neuroradiol J 2023; 36:651-656. [PMID: 37102274 PMCID: PMC10649532 DOI: 10.1177/19714009231173109] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/28/2023] Open
Abstract
OBJECTIVES Idiopathic intracranial hypertension (IIH) is a disease defined by elevated intracranial pressure (ICP) without an established etiology. Arachnoid granulations (AG) are conduits for CSF resorption from the subarachnoid space to the venous system. AG have been implicated to play a central role in maintaining CSF homeostasis. We tested the hypothesis that patients with fewer visible AG on MRI are more likely to present with IIH. METHODS In this institutional review board (Institutional Review Board)-approved retrospective chart review study, 65 patients with a clinical diagnosis of idiopathic intracranial hypertension were compared to 144 control patients who met inclusion/exclusion criteria. Patients' signs and symptoms pertaining to IIH were obtained through the electronic medical record Brain MR images were reviewed for the number and distribution of AGs indenting the dural venous sinuses. The presence of imaging and clinical findings associated with long standing increased ICP was noted. Propensity score method (with inverse probability weighting technique) was used to compare case and control groups. RESULTS In the control group, the number of AG indenting the dural venous sinuses on MRI (NAG) was lower in women compared to men when matched for age (20-45 yo) and BMI (>30 kg/m2). The NAG was lower in 20-45 yo females in the IIH group as compared to the 20-45 yo females in the control group. This statistically significant difference persists when controlled for BMI. In contrast, the NAG in >45 yo females in the IIH group trended higher compared to the >45 yo females in the control group. CONCLUSION Our results suggest that alterations in arachnoid granulations could play a role in the development of IIH.
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Affiliation(s)
- Fahimul Huda
- Department of Radiology, The George Washington University Hospital, Washington, DC, USA
| | - Ahmed Abdelmonem
- Department of Radiology, The George Washington University Hospital, Washington, DC, USA
| | | | | | - Ali Sheikhy
- Tehran University of Medical Sciences Non-Communicable Disease Research Center, Tehran, Iran
| | - M Reza Taheri
- Department of Radiology, The George Washington University Hospital, Washington, DC, USA
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16
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Christopher KL, Patnaik JL, Lynch AM, Grove N. Investigation into the relationship between body mass index and cataract surgery characteristics and complications. Clin Exp Ophthalmol 2023; 51:742-745. [PMID: 37406642 DOI: 10.1111/ceo.14273] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2023] [Accepted: 06/24/2023] [Indexed: 07/07/2023]
Affiliation(s)
- Karen L Christopher
- Department of Ophthalmology, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Jennifer L Patnaik
- Department of Ophthalmology, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Anne M Lynch
- Department of Ophthalmology, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Nathan Grove
- Department of Ophthalmology, University of Colorado School of Medicine, Aurora, Colorado, USA
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17
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Bateman GA. A scoping review of the discrepancies in the measurement of cerebral blood flow in idiopathic intracranial hypertension: oligemia, euvolemia or hyperemia? Fluids Barriers CNS 2023; 20:63. [PMID: 37612708 PMCID: PMC10463926 DOI: 10.1186/s12987-023-00465-w] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2023] [Accepted: 08/18/2023] [Indexed: 08/25/2023] Open
Abstract
BACKGROUND The literature regarding the global cerebral blood flow (CBF) in idiopathic intracranial hypertension (IIH) is divergent leading to skepticism about the significance of blood flow to the disease's underlying pathophysiology. METHODS The purpose of the current paper is to perform a PRISMA scoping review of the literature describing the CBF in IIH. The review investigated the PUBMED and Scopus data bases looking at case mix, technique and the methodologies employed by the studies selected. DISCUSSION Many studies indicate that the flow in IIH is normal but others show the flow to be altered. These later studies show a range of flows from a reduction of 20% to an increase of 50% compared to control values. Obesity is a common finding in IIH and is known to reduce CBF, anemia occurs in approximately 20% of IIH patients and is a potent cause of an increased CBF. Thus, variations in case mix may have a significant effect on the final outcome in those studies which are underpowered. The varying techniques which have been used to estimate CBF have differing strengths and weaknesses which may also have a bearing on the outcome. Some papers have significant confounding methodological issues. CONCLUSIONS This review suggests each of the variables investigated are responsible for the divergent CBF findings in IIH.
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Affiliation(s)
- Grant A Bateman
- Department of Medical Imaging, John Hunter Hospital, Locked Bag 1, Newcastle Region Mail Center, Newcastle, NSW, 2310, Australia.
- Newcastle University Faculty of Health, Callaghan Campus, Newcastle, NSW, Australia.
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18
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Durrant FG, Warner BK, Nguyen SA, Sturm JJ, Meyer TA. Elevated Body Mass Index Associated with Cerebrospinal Fluid Leak after Lateral Skull Base Surgery: A Systematic Review and Meta-analysis. Otol Neurotol 2023:00129492-990000000-00322. [PMID: 37400139 DOI: 10.1097/mao.0000000000003914] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/05/2023]
Abstract
OBJECTIVE To determine if body mass index (BMI) increases the risk of cerebrospinal fluid (CSF) leak after lateral skull base surgery. DATA SOURCES CINAHL, PubMed, and Scopus were searched from January 2010 to September 2022 for articles published in English. STUDY SELECTION Articles that reported BMI or obesity with and without CSF leaks after lateral skull base surgery were included. DATA EXTRACTION Two reviewers (F.G.D. and B.K.W.) independently performed study screening, data extraction, and risk of bias assessment. DATA SYNTHESIS A total of 11 studies and 9,132 patients met inclusion criteria. Meta-analysis of mean difference (MD), odds ratio (OR), proportions, and risk ratio (RR) were calculated using RevMan 5.4 and MedCalc 20.110. BMI for patients with CSF leak after lateral skull base surgery (29.39 kg/m2, 95% confidence interval [CI] = 27.75 to 31.04) was significantly greater than BMI for patients without CSF leak after lateral skull base surgery (27.09 kg/m2, 95% CI = 26.16 to 28.01) with an MD of 2.21 kg/m2 (95% CI = 1.09 to 3.34, p = 0.0001). The proportion of patients with BMI ≥ 30 kg/m2 that had a CSF leak was 12.7%, and the proportion of patients with BMI < 30 kg/m2 (control) that had a CSF leak was 7.9%. The OR for CSF leak after lateral skull base surgery in patients with BMI ≥ 30 kg/m2 was 1.94 (95% CI = 1.40 to 2.68, p < 0.0001), and the RR was 1.82 (95% CI = 1.36 to 2.43, p < 0.0001). CONCLUSION Elevated BMI increases the risk of CSF leak after lateral skull base surgery. LEVEL OF EVIDENCE IIa.
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Affiliation(s)
- Frederick G Durrant
- Department of Otolaryngology-Head and Neck Surgery, Medical University of South Carolina, Charleston, South Carolina
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19
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Wardman JH, Jensen MN, Andreassen SN, Styrishave B, Wilhjelm JE, Sinclair AJ, MacAulay N. Modelling idiopathic intracranial hypertension in rats: contributions of high fat diet and testosterone to intracranial pressure and cerebrospinal fluid production. Fluids Barriers CNS 2023; 20:44. [PMID: 37328884 DOI: 10.1186/s12987-023-00436-1] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2023] [Accepted: 04/29/2023] [Indexed: 06/18/2023] Open
Abstract
BACKGROUND Idiopathic intracranial hypertension (IIH) is a condition characterized by increased intracranial pressure (ICP), impaired vision, and headache. Most cases of IIH occur in obese women of childbearing age, though age, BMI, and female sex do not encompass all aspects of IIH pathophysiology. Systemic metabolic dysregulation has been identified in IIH with a profile of androgen excess. However, the mechanistic coupling between obesity/hormonal perturbations and cerebrospinal fluid dynamics remains unresolved. METHODS Female Wistar rats were either fed a high fat diet (HFD) for 21 weeks or exposed to adjuvant testosterone treatment for 28 days to recapitulate IIH causal drivers. Cerebrospinal fluid (CSF) and blood testosterone levels were determined with mass spectrometry, ICP and CSF dynamics with in vivo experimentation, and the choroid plexus function revealed with transcriptomics and ex vivo isotope-based flux assays. RESULTS HFD-fed rats presented with increased ICP (65%), which was accompanied by increased CSF outflow resistance (50%) without altered CSF secretion rate or choroid plexus gene expression. Chronic adjuvant testosterone treatment of lean rats caused elevated ICP (55%) and CSF secretion rate (85%), in association with increased activity of the choroid plexus Na+,K+,2Cl- cotransporter, NKCC1. CONCLUSIONS HFD-induced ICP elevation in experimental rats occurred with decreased CSF drainage capacity. Adjuvant testosterone, mimicking the androgen excess observed in female IIH patients, elevated the CSF secretion rate and thus ICP. Obesity-induced androgen dysregulation may thus contribute to the disease mechanism of IIH.
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Affiliation(s)
- Jonathan H Wardman
- Department of Neuroscience, Faculty of Health and Medical Sciences, University of Copenhagen, Blegdamsvej 3, 2200, Copenhagen N, Denmark
| | - Mette N Jensen
- Department of Neuroscience, Faculty of Health and Medical Sciences, University of Copenhagen, Blegdamsvej 3, 2200, Copenhagen N, Denmark
| | - Søren N Andreassen
- Department of Neuroscience, Faculty of Health and Medical Sciences, University of Copenhagen, Blegdamsvej 3, 2200, Copenhagen N, Denmark
| | - Bjarne Styrishave
- Department of Pharmacy, University of Copenhagen, Copenhagen, Denmark
| | - Jens E Wilhjelm
- Department of Health Technology, The Technical University of Denmark, Kgs. Lyngby, Denmark
| | - Alexandra J Sinclair
- Institute of Metabolism and Systems Research, University of Birmingham, Birmingham, UK
| | - Nanna MacAulay
- Department of Neuroscience, Faculty of Health and Medical Sciences, University of Copenhagen, Blegdamsvej 3, 2200, Copenhagen N, Denmark.
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Ghanem OM, Ghazi R, Abdul Razzak F, Bazerbachi F, Ravi K, Khaitan L, Kothari SN, Abu Dayyeh BK. Turnkey algorithmic approach for the evaluation of gastroesophageal reflux disease after bariatric surgery. Gastroenterol Rep (Oxf) 2023; 11:goad028. [PMID: 37304555 PMCID: PMC10256627 DOI: 10.1093/gastro/goad028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/22/2022] [Revised: 12/12/2022] [Accepted: 02/01/2023] [Indexed: 06/13/2023] Open
Abstract
Bariatric surgeries are often complicated by de-novo gastroesophageal reflux disease (GERD) or worsening of pre-existing GERD. The growing rates of obesity and bariatric surgeries worldwide are paralleled by an increase in the number of patients requiring post-surgical GERD evaluation. However, there is currently no standardized approach for the assessment of GERD in these patients. In this review, we delineate the relationship between GERD and the most common bariatric surgeries: sleeve gastrectomy (SG) and Roux-en-Y gastric bypass (RYGB), with a focus on pathophysiology, objective assessment, and underlying anatomical and motility disturbances. We suggest a stepwise algorithm to help diagnose GERD after SG and RYGB, determine the underlying cause, and guide the management and treatment.
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Affiliation(s)
- Omar M Ghanem
- Department of Surgery, Mayo Clinic, Rochester, MN, USA
| | - Rabih Ghazi
- Department of Medicine, Mayo Clinic, Rochester, MN, USA
| | | | - Fateh Bazerbachi
- CentraCare, Interventional Endoscopy Program, St Cloud Hospital, St Cloud, MN, USA
| | - Karthik Ravi
- Department of Medicine, Mayo Clinic, Rochester, MN, USA
| | - Leena Khaitan
- Department of Surgery, Case Western Reserve University, Cleveland, OH, USA
| | | | - Barham K Abu Dayyeh
- Corresponding author. Division of Gastroenterology, Mayo Clinic, 200 First Street SW, Rochester, MN 55905, USA. Tel: +1-507-284-2511; Fax: +1-507-284-0538;
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21
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Fargen KM, Coffman S, Torosian T, Brinjikji W, Nye BL, Hui F. "Idiopathic" intracranial hypertension: An update from neurointerventional research for clinicians. Cephalalgia 2023; 43:3331024231161323. [PMID: 36924237 DOI: 10.1177/03331024231161323] [Citation(s) in RCA: 21] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/18/2023]
Abstract
BACKGROUND The recognition of venous sinus stenosis as a contributing factor in the majority of patients with idiopathic intracranial hypertension coupled with increasing cerebral venography and venous sinus stenting experience have dramatically improved our understanding of the pathophysiologic mechanisms driving this disease. There is now a dense, growing body of research in the neurointerventional literature detailing anatomical and physiological mechanisms of disease which has not been widely disseminated among clinicians. METHODS A literature search was conducted, covering the most recent neurointerventional literature on idiopathic intracranial hypertension, the pathophysiology of idiopathic intracranial hypertension, and management strategies (including venous sinus stenting), and subsequently summarized to provide a comprehensive review of the most recently published studies on idiopathic intracranial hypertension pathophysiology and management. CONCLUSION Recent studies in the neurointerventional literature have greatly improved our understanding of the pathophysiologic mechanisms causing idiopathic intracranial hypertension and its associated conditions. The ability to make individualized, patient-specific treatment approaches has been made possible by advances in our understanding of how venous sinus stenosis and cerebral venous hypertension fundamentally contribute to idiopathic intracranial hypertension.
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Affiliation(s)
- Kyle M Fargen
- Neurological Surgery, Atrium Health Wake Forest Baptist, Winston-Salem, NC, USA
| | - Stephanie Coffman
- Neurological Surgery, Atrium Health Wake Forest Baptist, Winston-Salem, NC, USA
| | - Taron Torosian
- Neurological Surgery, Atrium Health Wake Forest Baptist, Winston-Salem, NC, USA
| | | | - Barbara L Nye
- Neurology, Atrium Health Wake Forest Baptist, Winston-Salem, NC, USA
| | - Ferdinand Hui
- Interventional Radiology, John Hopkins Hospital, Baltimore, MD, USA
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22
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Neuroimaging in the diagnosis and treatment of intracranial pressure disorders. Neurol Sci 2023; 44:845-858. [PMID: 36333629 DOI: 10.1007/s10072-022-06478-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2022] [Accepted: 10/22/2022] [Indexed: 11/06/2022]
Abstract
OBJECTIVE 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. METHODS 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. RESULTS 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. CONCLUSIONS 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.
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23
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Hermes SM, Bharadwaj M, Miller NR, Waslo C, Husain FA, Wolfe BM, Tanne E. Long-Term Outcomes of Bariatric Surgery in Idiopathic Intracranial Hypertension Patients. Neurologist 2023; 28:87-93. [PMID: 35593904 DOI: 10.1097/nrl.0000000000000446] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
BACKGROUND Idiopathic intracranial hypertension (IIH), a rare neurological disorder, has limited effective long-term treatments. Bariatric surgery has shown short-term promise as a management strategy, but long-term efficacy has not been evaluated. We investigated IIH-related outcomes 4 to 16 years postsurgery. MATERIALS AND METHODS This cross-sectional retrospective cohort study included Intracranial Hypertension Registry (IHR) participants with existing medical records that completed a bariatric surgery questionnaire at least 4 years postsurgery. Two physicians independently evaluated the IIH disease course at bariatric surgery and at the time of the questionnaire using detailed medical records. Determinations of improvements were based on within-participant comparisons between the 2 time points. IIH-related outcomes were then combined with bariatric surgery information and outcomes to assess the relationship between weight loss and alterations in IIH. RESULTS Among participants that underwent bariatric surgery and met study criteria (n=30) the median body mass index (BMI) at the time of surgery was 45.0 [interquartile range (IQR): 39.8-47.0], dropped to a postsurgical nadir of 27.3 (IQR: 22.8-33.1), and rose to 33.4 (IQR: 29.9-41.7) at the time of the questionnaire. Improvements in the IIH disease course at time of the questionnaire occurred in 37% of participants. However, there was a notable association between durable weight loss and IIH improvement as 90% (9 of 10) of participants that attained and maintained a BMI of 30 or below displayed improvement. CONCLUSIONS Attaining and maintaining a BMI of 30 or below was associated with long-term improvement in the IIH disease course, including improved disease management and amelioration of signs and symptoms of participants of the IHR.
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Affiliation(s)
- Sam M Hermes
- Intracranial Hypertension Registry, Casey Eye Institute
| | | | - Nick R Miller
- Intracranial Hypertension Registry, Casey Eye Institute
| | - Carin Waslo
- Intracranial Hypertension Registry, Casey Eye Institute
| | - Farah A Husain
- Division of Bariatric Surgery, School of Medicine, Oregon Health and Science University, Portland, OR
| | - Bruce M Wolfe
- Division of Bariatric Surgery, School of Medicine, Oregon Health and Science University, Portland, OR
| | - Emanuel Tanne
- Intracranial Hypertension Registry, Casey Eye Institute
- Intracranial Hypertension Research Foundation, Vancouver, WA
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Chidambaram R, Hendriks T, Phung S, Kuthubutheen J. Symptoms Underestimate the Presence of Obstructive Sleep Apnea in Patients with Spontaneous Cerebrospinal Fluid Leaks of the Temporal Bone. Otol Neurotol 2022; 43:e1194-e1199. [PMID: 36351231 DOI: 10.1097/mao.0000000000003736] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
OBJECTIVE To determine the severity of symptoms and degree of obstructive sleep apnea (OSA) in patients with spontaneous cerebrospinal fluid (sCSF) leaks of the temporal bone given the known association between sCSF leaks and OSA. STUDY DESIGN Retrospective case review. SETTING Ambulatory clinics in tertiary referral centers. PATIENTS Polysomnogram testing in 34 consecutive patients who had been diagnosed with sCSF leaks of the temporal bone was examined. Diagnosis of sCSF leak was defined as biochemically confirmed CSF from middle ear fluid with no other obvious source. INTERVENTION Diagnostic. MAIN OUTCOMES MEASURES Patient characteristics (age, sex, body mass index, Epworth Sleepiness Scale score, presence of hypoxia, overnight change in blood pressure, and apnea hypopnea index [AHI]) were recorded. Diagnosis of OSA was defined as mild when AHI ≥5 and <15/h, moderate when AHI ≥15 and <30/h, and severe when AHI ≥30/h. RESULTS Of the 34 patients, 28 (82%) had a confirmed diagnosis of OSA. There was a male predisposition in those with OSA, and 17 of 28 (61%) were male. A majority were overweight, and the mean body mass index was 30.1 (SD, 4.8; range, 23.2-40) kg/m2. The mean severity of OSA was moderate, and the mean AHI was 28.7 (SD, 21.9; range, 5.4-92.8). Of the 28 patients, 13 with OSA (46%) had Epworth Sleepiness Scale scores higher than 8, suggesting that many were asymptomatic for excessive daytime sleepiness at the time of presentation. CONCLUSION OSA is highly prevalent among patients with sCSF leaks of the temporal bone. Patients with sCSF leaks irrespective of symptoms of OSA should undergo formal polysomnogram testing.
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Affiliation(s)
- Rama Chidambaram
- Department of Otolaryngology and Head and Neck Surgery, Sir Charles Gairdner Hospital, Nedlands
| | | | - Scott Phung
- Department of Pulmonary Physiology and Sleep Medicine, Sir Charles Gairdner Hospital, Nedlands
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Kaufman AC, Cooperman S, Ali NES, Alyono JC. Matched Cohort Study of Radiographic Superior Semicircular Canal Dehiscence and Tegmen Dehiscence and Obstructive Sleep Apnea. Otol Neurotol 2022; 43:1222-1226. [PMID: 36214499 DOI: 10.1097/mao.0000000000003712] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To report the frequency of radiographic superior semicircular canal dehiscence (SSCD) and tegmen dehiscence in patients with and without obstructive sleep apnea (OSA). STUDY DESIGN Retrospective matched cohort study. SETTING Tertiary care center. PATIENTS Adults with OSA and fine-cut computed tomographic scans including the temporal bone were matched to patients without OSA by age, sex, and type of computed tomography (protocol, scanner type, slice thickness). Ears with otologic surgery or temporal bone tumors were excluded. MAIN OUTCOME MEASURES Prevalence of SSCD and tegmen dehiscence assessed by two independent reviewers. RESULTS The average body mass index of the OSA patients was 29.2 kg/m 2 with an average apnea-hypopnea index of 36.8. The control group had an average body mass index of 26.2 kg/m 2 . Of the 352 temporal bones, 34 (9.7%) had SSCD in the OSA cohort versus 37 (10.5%) in the control group ( p > 0.05). Seven OSA patients (25.6% of those with SSCD) had bilateral SSCD versus 8 controls (27.6% of those with SSCD; p > 0.05). The majority (87.3%) of dehiscences involved the temporal lobe, with the remaining involving the superior petrosal sinus or both. Of the 352 OSA ears, 90 (25.6%) had a tegmen dehiscence versus 95 (27.0%) in the control group ( p > 0.05). Neither group had a laterality preference for SSCD or tegmen dehiscence. CONCLUSION The prevalence of radiographic SSCD and tegmen dehiscences in OSA patients does not significantly differ from age- and sex-matched controls. This is in contrast to a previous case-control study finding patients with symptomatic SSCD to have higher rates of OSA. This may suggest that the effect size of OSA on SSCD prevalence may be limited despite OSA being a risk factor for elevated intracranial pressure.
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Affiliation(s)
- Adam C Kaufman
- Department of Otolaryngology, Head and Neck Surgery, Stanford University, Palo Alto, California
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Muacevic A, Adler JR, Alhassan B, Ali B. Idiopathic Intracranial Hypertension in a Morbidly Obese Young Female Managed With Bariatric Surgery. Cureus 2022; 14:e32868. [PMID: 36578846 PMCID: PMC9784589 DOI: 10.7759/cureus.32868] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/23/2022] [Indexed: 12/24/2022] Open
Abstract
Idiopathic intracranial hypertension (IIH) is a disorder of unknown etiology characterized by raised intracranial pressure (ICP) and papilledema, also known as pseudotumor cerebri. Morbid obesity mainly affects women of childbearing age, which makes it a consistent risk factor for the development of IIH in these individuals. Consequently, the higher the body mass index (BMI) the higher the risk of IIH. We report a case of a 30- year-old female with symptomatic idiopathic IIH and malfunctioning ventriculoperitoneal (VP) shunt, associated with obesity, who underwent a bariatric sleeve gastrectomy, which led to weight loss and a significant improvement in her IIH. Our objective is to better understand the efficacy of bariatric surgery as a treatment for IIH.
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Velusamy A, Anand A, Hameed N. CT Cisternogram Findings in Idiopathic Cerebrospinal Fluid Leaks with Emphasis on Long Term Management. Indian J Otolaryngol Head Neck Surg 2022; 74:1605-1611. [PMID: 36452803 PMCID: PMC9702258 DOI: 10.1007/s12070-021-02766-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2021] [Accepted: 07/11/2021] [Indexed: 11/28/2022] Open
Abstract
To study the various computed tomography (CT) cisternogram findings in idiopathic cerebrospinal fluid (CSF) leaks and the long term treatment modalities after surgical repair of idiopathic CSF leaks. This was a descriptive study conducted among 25 patients in MCV memorial ENT trust hospital, Pollachi between May 2014 and May 2020 amongst patients who underwent CT cisternogram for unilateral or bilateral spontaneous rhinorrhea with or without associated headache, visual disturbances and papilloedema diagnosed to be idiopathic CSF leak by investigations. These patients then underwent CSF leak repair and postoperatively were managed with weight reduction, low salt diet and diuretic therapy. Post surgery these patients were followed up for a period of 12 months and were evaluated on the basis of presence or absence of headache, rhinorrhea and papilloedema at the end of 1st month, 3rd month, 6th month and 1 year and data was collected. CT cisternogram findings were evaluated by proportion method and evaluation of long term management was done using proportion and repeated measures ANOVA for all patients. Evidence of the presence of previously mentioned CT cisternogram or contrast MRI findings at the end of 1 year of post-surgical treatment was recorded where patients were willing for the same. CT Cisternography was done for all patients and 72% patients had empty sella appearance while 28% had partially empty sella. Other findings included perioptic filling, optic blunting and arachnoid pits which were found in 11(44%), 8(32%) and 12(48%) of patients respectively. Only 3(12%) out of 25 patients had an encephalocoele. The commonest site of leak in CT cisternography was the cribriform plate (52%) followed by lateral recess of sphenoid (48%). None of the patients had multiple sites of leak in CT cisternography. On follow up post surgery maximum resolution of symptoms was found at the end of 12 months where 23 out of 25 patients improved. In our study, out of 25 only 5 patients agreed to undergo post diuretic therapy MRI scan out of which 2 patients had partially empty sella and 3 had normal sella indicating resolution of BIH. CT cisternography is an important investigation which aids in the diagnosis of CSF rhinorrhea due to idiopathic intracranial hypertension (IIH). The medical management of IIH post surgery such as weight reduction, salt restriction and diuretic therapy is also crucial to prevent recurrence of symptoms.
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Salih M, Enriquez-Marulanda A, Khorasanizadeh M, Moore J, Prabhu VC, Ogilvy CS. Cerebrospinal Fluid Shunting for Idiopathic Intracranial Hypertension: A Systematic Review, Meta-Analysis, and Implications for a Modern Management Protocol. Neurosurgery 2022; 91:529-540. [PMID: 35916578 DOI: 10.1227/neu.0000000000002086] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2021] [Accepted: 05/25/2022] [Indexed: 02/04/2023] Open
Abstract
BACKGROUND Cerebrospinal fluid (CSF) shunting is widely used in refractory idiopathic intracranial hypotension (IIH). Although multiple reviews have assessed its efficacy compared with other surgical treatments, there is no detailed analysis that evaluates the clinical outcomes after CSF shunting. OBJECTIVE To conduct a meta-analysis of the clinical impact of CSF shunting for refractory IIH and use this in conjunction with existing information on other treatment modalities to develop a modern management protocol. METHODS PubMed and Embase were systematically searched for studies describing CSF shunting for medically refractory IIH. Relevant information including study characteristics, patient demographics, clinical outcomes, periprocedural complications, and long-term outcomes were subjected to meta-analysis. RESULTS Fifteen studies published between 1988 and 2019 met our inclusion and exclusion criteria, providing 372 patients for analysis. The mean age was 31.2 years (range 0.5-71) with 83.6% being female. The average follow-up was 33.9 months (range 0-278 months). The overall rate of improvement in headache, papilledema, and visual impairment was 91% (95% CI 84%-97%), 96% (95% CI 85%-100%), and 85% (95% CI 72%-95%), respectively. Of 372 patients, 155 had 436 revisions; the overall revision rate was 42% (95% CI 26%-59%). There was no significant correlation between average follow-up duration and revision rates in studies ( P = .627). Periprocedural low-pressure headaches were noted in 74 patients (20%; 95% CI 11%-32%). CONCLUSION CSF shunting for IIH is associated with significant improvement in clinical symptoms. Shunting rarely causes periprocedural complications except overdrainage-related low-pressure headache. However, CSF shunting has a relatively high revision rate.
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Affiliation(s)
- Mira Salih
- Neurosurgical Service, Harvard Medical School, Beth Israel Deaconess Medical Center Brain Aneurysm Institute, Boston, Massachusetts, USA
| | - Alejandro Enriquez-Marulanda
- Neurosurgical Service, Harvard Medical School, Beth Israel Deaconess Medical Center Brain Aneurysm Institute, Boston, Massachusetts, USA
| | - MirHojjat Khorasanizadeh
- Neurosurgical Service, Harvard Medical School, Beth Israel Deaconess Medical Center Brain Aneurysm Institute, Boston, Massachusetts, USA
| | - Justin Moore
- Neurosurgical Service, Harvard Medical School, Beth Israel Deaconess Medical Center Brain Aneurysm Institute, Boston, Massachusetts, USA
| | - Vikram C Prabhu
- Department of Neurological Surgery, Loyola University Medical Center/Stritch School of Medicine, Maywood, Illinois, USA
| | - Christopher S Ogilvy
- Neurosurgical Service, Harvard Medical School, Beth Israel Deaconess Medical Center Brain Aneurysm Institute, Boston, Massachusetts, USA
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Sarrami AH, Bass DI, Rutman AM, Alexander MD, Aksakal M, Zhu C, Levitt MR, Mossa-Basha M. Idiopathic intracranial hypertension imaging approaches and the implications in patient management. Br J Radiol 2022; 95:20220136. [PMID: 35522777 PMCID: PMC10162046 DOI: 10.1259/bjr.20220136] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2022] [Revised: 04/05/2022] [Accepted: 04/27/2022] [Indexed: 11/05/2022] Open
Abstract
Idiopathic intracranial hypertension (IIH) represents a clinical disease entity without a clear etiology, that if left untreated, can result in severe outcomes, including permanent vision loss. For this reason, early diagnosis and treatment is necessary. Historically, the role of cross-sectional imaging has been to rule out secondary or emergent causes of increased intracranial pressure, including tumor, infection, hydrocephalus, or venous thrombosis. MRI and MRV, however, can serve as valuable imaging tools to not only rule out causes for secondary intracranial hypertension but can also detect indirect signs of IIH resultant from increased intracranial pressure, and demonstrate potentially treatable sinus venous stenosis. Digital subtraction venographic imaging also plays a central role in both diagnosis and treatment, providing enhanced anatomic delineation and temporal flow evaluation, quantitative assessment of the pressure gradient across a venous stenosis, treatment guidance, and immediate opportunity for endovascular therapy. In this review, we discuss the multiple modalities for imaging IIH, their limitations, and their contributions to the management of IIH.
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Affiliation(s)
- Amir Hossein Sarrami
- Department of Radiology, Stanford University School of Medicine, Palo Alto, CA, United States
| | - David I. Bass
- Department of Radiology, Stanford University School of Medicine, Palo Alto, CA, United States
| | | | - Matthew D Alexander
- Department of Radiology, University of Utah, Salt Lake City, Utah, United States
| | - Mehmet Aksakal
- Department of Radiology, University of Washington, Seattle, United States
| | - Chengcheng Zhu
- Department of Radiology, University of Washington, Seattle, United States
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30
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Michael AP, Elbuluk O, Tsiouris AJ, Tabaee A, Kacker A, Anand VK, Schwartz TH. The critical importance of a vascularized flap in preventing recurrence after endoscopic repair of spontaneous cerebrospinal fluid leaks and meningoencephaloceles. J Neurosurg 2022; 137:79-86. [PMID: 34767535 DOI: 10.3171/2021.7.jns211427] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2021] [Accepted: 07/22/2021] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Spontaneous CSF leaks into the anterior skull base nasal sinuses are often associated with meningoencephaloceles and occur in patients with idiopathic intracranial hypertension (IIH). Endonasal endoscopic repair has become the primary method of choice for repair. The authors sought to evaluate the success rate of endoscopic closure and to identify predictive factors for CSF leak recurrence. METHODS A consecutive series of endonasally repaired anterior skull base meningoencephaloceles was drawn from a prospectively acquired database. Lumbar punctures were not performed as part of a treatment algorithm. All patients had at least 5 months of follow-up. Chart review and phone calls were used to determine the timing and predictors of recurrence. Demographic information and details of operative technique were correlated with recurrence. Two independent radiologists reviewed all preoperative imaging to identify radiographic markers of IIH, as well as the location and size of the meningoencephalocele. RESULTS From a total of 54 patients there were 5 with recurrences (9.3%), but of the 39 patients in whom a vascularized nasoseptal (n = 31) or turbinate (n = 8) flap was used there were no recurrences (p = 0.0009). The mean time to recurrence was 24.8 months (range 9-38 months). There was a trend to higher BMI in patients whose leak recurred (mean [± SD] 36.6 ± 8.6) compared with those whose leak did not recur (31.8 ± 7.4; p = 0.182). Although the lateral recess of the sphenoid sinus was the most common site of meningoencephalocele, the fovea ethmoidalis was the most common site in recurrent cases (80%; p = 0.013). However, a vascularized flap was used in significantly more patients with sphenoid (78.3%) defects than in patients with fovea ethmoidalis (28.6%) defects (Fisher's exact test, p = 0.005). Radiographic signs of IIH were equally present in all patients whose leak recurred (75%) compared with patients whose leak did not recur (63.3%); however, an enlarged Meckel cave was present in 100% (2/2) of patients whose leaks recurred compared with 13.3% (4/30) of patients whose leaks did not recur (p = 0.03). The average meningoencephalocele diameter tended to be larger (1.73 ± 1.3 cm) in patients with recurrence compared to those without recurrence (1.2 ± 0.66 cm; p = 0.22). A ventriculoperitoneal shunt was already in place in 3 patients, placed perioperatively in 5, and placed at recurrence in 2, none of whose leaks recurred. CONCLUSIONS Recurrence after endonasal repair of spontaneous CSF leaks from meningoencephaloceles can be dramatically reduced with the use of a vascularized flap. Although failures of endonasal repair tend to occur in patients who have higher BMI, larger brain herniations, and no CSF diversion, the lack of vascularized flap was the single most important risk factor predictive of failure.
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Affiliation(s)
| | | | | | | | | | | | - Theodore H Schwartz
- Departments of1Neurological Surgery
- 3Otolaryngology, and
- 4Neuroscience, Weill Cornell Medical College, NewYork-Presbyterian Hospital, New York, New York
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31
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A perspective on spaceflight associated neuro-ocular syndrome causation secondary to elevated venous sinus pressure. NPJ Microgravity 2022; 8:3. [PMID: 35169156 PMCID: PMC8847421 DOI: 10.1038/s41526-022-00188-6] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2021] [Accepted: 01/21/2022] [Indexed: 11/17/2022] Open
Abstract
Spaceflight associated neuro-ocular syndrome (SANS) alters the vision of astronauts during long-duration spaceflights. There is controversy regarding SANS being similar to patients with idiopathic intracranial hypertension (IIH). IIH has been shown to be due to an elevation in venous sinus pressure. The literature suggests an increase in jugular vein pressure secondary to a headward shift of fluid occurs in SANS but this may not be enough to significantly alter the intracranial pressure (ICP). The literature regarding cardiac output and cerebral blood flow (CBF) in long-duration spaceflight is contradictory, however, more recent data suggests increased flow. Recent modelling has shown that an increase in CBF can significantly increase sinus pressure. The purpose of the present paper is to review the SANS vascular dynamics literature and through mathematical modelling suggest the possible underlying cause of SANS as an elevation in venous sinus pressure, secondary to the redistribution of fluids towards the head, together with a significant increase in pressure drop across the venous system related to the CBF.
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Arun A, Amans MR, Higgins N, Brinjikji W, Sattur M, Satti SR, Nakaji P, Luciano M, Huisman TAGM, Moghekar A, Pereira VM, Meng R, Fargen K, Hui FK. A proposed framework for cerebral venous congestion. Neuroradiol J 2022; 35:94-111. [PMID: 34224274 PMCID: PMC8826290 DOI: 10.1177/19714009211029261] [Citation(s) in RCA: 26] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023] Open
Abstract
BACKGROUND While venous congestion in the peripheral vasculature has been described and accepted, intracranial venous congestion remains poorly understood. The characteristics, pathophysiology, and management of cerebral venous stasis, venous hypertension and venous congestion remain controversial, and a unifying conceptual schema is absent. The cerebral venous and lymphatic systems are part of a complex and dynamic interaction between the intracranial compartments, with interplay between the parenchyma, veins, arteries, cerebrospinal fluid, and recently characterized lymphatic-like systems in the brain. Each component contributes towards intracranial pressure, occupying space within the fixed calvarial volume. This article proposes a framework to consider conditions resulting in brain and neck venous congestion, and seeks to expedite further study of cerebral venous diagnoses, mechanisms, symptomatology, and treatments. METHODS A multi-institution retrospective review was performed to identify unique patient cases, complemented with a published case series to assess a spectrum of disease states with components of venous congestion affecting the brain. These diseases were organized according to anatomical location and purported mechanisms. Outcomes of treatments were also analyzed. Illustrative cases were identified in the venous treatment databases of the authors. CONCLUSION This framework is the first clinically structured description of venous pathologies resulting in intracranial venous and cerebrospinal fluid hypertension. Our proposed system highlights unique clinical symptoms and features critical for appropriate diagnostic work-up and potential treatment. This novel schema allows clinicians effectively to approach cases of intracranial hypertension secondary to venous etiologies, and furthermore provides a framework by which researchers can better understand this developing area of cerebrovascular disease.
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Affiliation(s)
- Anirudh Arun
- Department of Radiology and
Radiological Science, Johns Hopkins University School of Medicine, USA
| | - Matthew R Amans
- Department of Radiology and
Biomedical Imaging, University of California San Francisco, USA
| | | | | | - Mithun Sattur
- Department of Neurosurgery, Medical
University of South Carolina, USA
| | - Sudhakar R Satti
- Department of Neurointerventional
Surgery, ChristianaCare Christiana Hospital, USA
| | - Peter Nakaji
- Department of Neurosurgery, Banner
University Medical Center, USA
| | - Mark Luciano
- Department of Neurosurgery, Johns
Hopkins University School of Medicine, USA
| | | | - Abhay Moghekar
- Department of Neurology, Johns
Hopkins University School of Medicine, USA
| | - Vitor M Pereira
- Department of Medical Imaging,
Toronto Western Hospital, Canada
| | - Ran Meng
- Department of Neurology, Xuanwu
Hospital, China
| | - Kyle Fargen
- Department of Neurosurgery, Wake
Forest School of Medicine, USA
| | - Ferdinand K Hui
- Department of Radiology and
Radiological Science, Johns Hopkins University School of Medicine, USA
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Guarnizo A, Albreiki D, Cruz JP, Létourneau-Guillon L, Iancu D, Torres C. Papilledema: A Review of the Pathophysiology, Imaging Findings, and Mimics. Can Assoc Radiol J 2022; 73:557-567. [PMID: 35044276 DOI: 10.1177/08465371211061660] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Increased intracranial pressure is the most common cause of papilledema. Multiple etiologies such as cerebral edema, hydrocephalus, space occupying lesions, infection, and idiopathic intracranial hypertension among others should be considered. Imaging plays a critical role in the detection of pathologies that can cause papilledema. MRI with contrast and CE-MRV, in particular, are key for the diagnosis of idiopathic intracranial hypertension. This review will focus in common and infrequent causes of papilledema, the role of imaging in patients with papilledema as well as its potential mimickers.
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Affiliation(s)
- Angela Guarnizo
- Division of Neuroradiology, Department of Radiology, 58629Fundación Santa Fe de Bogotá, Bogotá, Colombia
| | - Danah Albreiki
- Department of ophthalmology, The Ottawa Hospital Civic and General Campus, 27337University of Ottawa, Ottawa, ON, Canada
| | - Juan Pablo Cruz
- Division of Neuroradiology, Department of Radiology, 28033Pontificia Universidad Católica de Chile, Santiago, Chile
| | | | - Dana Iancu
- Division of Interventional Neuroradiology, Department of Radiology, 5622University of Montreal, Montreal, QC, Canada
| | - Carlos Torres
- Division of Neuroradiology, Department of Radiology, The Ottawa Hospital Civic and General Campus, 6363University of Ottawa, Ottawa, ON, Canada
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Bray DP, Bouobda G, Laxpati NG, Gary MF. Spontaneous resolution of cervicothoracic spinal cord syrinx after significant weight loss. J Neurol Neurosurg Psychiatry 2021; 92:1346-1347. [PMID: 34261751 DOI: 10.1136/jnnp-2020-325720] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/23/2020] [Accepted: 06/20/2021] [Indexed: 11/04/2022]
Affiliation(s)
| | | | - Nealen G Laxpati
- Department of Neurosurgery, Emory University, Atlanta, Georgia, USA
| | - Matthew F Gary
- Department of Neurosurgery, Emory University, Atlanta, Georgia, USA
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Soffer JM, Dowd RS, Sillman J, Heilman C. Diagnosis and operative repair strategy of an underlying tegmen defect presenting with spontaneous otogenic pneumocephalus after Valsalva maneuver. INTERDISCIPLINARY NEUROSURGERY 2021. [DOI: 10.1016/j.inat.2021.101129] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
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Mahendran V, Ricart P, Levine F, White E, Abolghasemi-Malekabadi K, Williams M, Wadley MS, Perry A, Robinson SJ. Bariatric Surgery as a Viable Treatment for Idiopathic Intracranial Hypertension: a Case Series and Review of Literature. Obes Surg 2021; 31:4386-4391. [PMID: 34322839 PMCID: PMC8318322 DOI: 10.1007/s11695-021-05587-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2021] [Revised: 06/26/2021] [Accepted: 07/09/2021] [Indexed: 12/24/2022]
Abstract
Purpose Idiopathic intracranial hypertension is a significant cause of preventable blindness. Patients suffer from debilitating headaches, pulsatile tinnitus, nausea, vomiting, photophobia and radicular pain. At this rate, treatment cost will increase to 462.7 million pounds sterling annually by 2030. Weight loss is the only proven disease-modifying therapy for reversal of idiopathic intracranial hypertension. Bariatric surgery leads to superlative weight loss and reversal of related comorbidities. The case series and literature review aim to raise awareness of bariatric surgery as a safe and effective treatment modality for idiopathic intracranial hypertension. Material and Methods The literature review comprises three systematic analysis and one randomised control trial which were identified after a PubMed search. In the case series, we have included four patients with a preoperative diagnosis of long-standing idiopathic intracranial hypertension. They were referred to our department for bariatric surgery by the neuro-ophthalmologist between January and December 2018. They were followed up for 2 years after bariatric surgery. Results All four patients were women with a mean age of 34 years. Mean body mass index reduced from 47.3 kg/m2 before surgery to 30 kg/m2 at the end of 2 years after surgery. They showed significant improvement or resolution in their symptoms related to idiopathic intracranial hypertension, and none of them required further cerebrospinal fluid pressure reducing procedures. Conclusion Bariatric surgery is a safe and effective method of treating idiopathic intracranial hypertension. It is superior compared to medical management and cerebrospinal fluid pressure reducing procedures which have high rates of recurrence.
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Affiliation(s)
- Vimaladhithan Mahendran
- Worcestershire Acute Hospitals NHS Trust, Charles Hastings Way, Worcester, Worcestershire, WR5 1DD, UK.
| | - Pol Ricart
- Worcestershire Acute Hospitals NHS Trust, Charles Hastings Way, Worcester, Worcestershire, WR5 1DD, UK
| | - Fridi Levine
- Worcestershire Acute Hospitals NHS Trust, Charles Hastings Way, Worcester, Worcestershire, WR5 1DD, UK
| | - Emma White
- Worcestershire Acute Hospitals NHS Trust, Charles Hastings Way, Worcester, Worcestershire, WR5 1DD, UK
| | | | - Madeleine Williams
- Worcestershire Acute Hospitals NHS Trust, Charles Hastings Way, Worcester, Worcestershire, WR5 1DD, UK
| | - Martin S Wadley
- Worcestershire Acute Hospitals NHS Trust, Charles Hastings Way, Worcester, Worcestershire, WR5 1DD, UK
| | - Anthony Perry
- Worcestershire Acute Hospitals NHS Trust, Charles Hastings Way, Worcester, Worcestershire, WR5 1DD, UK
| | - Steven John Robinson
- Worcestershire Acute Hospitals NHS Trust, Charles Hastings Way, Worcester, Worcestershire, WR5 1DD, UK
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Himes BT, Bhargav AG, Brown DA, Kaufmann TJ, Bancos I, Van Gompel JJ. Does pituitary compression/empty sella syndrome contribute to MRI-negative Cushing's disease? A single-institution experience. Neurosurg Focus 2021; 48:E3. [PMID: 32480375 DOI: 10.3171/2020.3.focus2084] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2020] [Accepted: 03/03/2020] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Cushing's disease arises from functioning adrenocorticotropic hormone (ACTH)-secreting pituitary adenomas. These tumors can be very small and evade detection by MRI. Empty sella syndrome is a phenomenon by which an arachnoid outpouching of CSF into the sella leads to compression of the pituitary, likely due to intracranial hypertension (a common issue in Cushing's disease), further leading to difficulty in visualizing the pituitary gland that may contribute to difficulty in finding a tumor on MRI, so-called MRI-negative Cushing's disease. The authors sought to examine the association between empty sella syndrome and MRI-negative Cushing's disease. METHODS A single-institution database of Cushing's disease cases from 2000 to 2017 was reviewed, and 197 cases were included in the analysis. One hundred eighty patients had a tissue diagnosis of Cushing's disease and 17 had remission with surgery, but no definitive tissue diagnosis was obtained. Macroadenomas (tumors > 1 cm) were excluded. The degree of empty sella syndrome was graded on the degree of CSF visualized in the sella on midline sagittal T1-weighted MRI. RESULTS Of the 197 cases identified, 40 (20%) presented with MRI-negative disease, and empty sella syndrome was present in 49 cases (25%). MRI-negative disease was found in 18 (37%) of 49 empty sella cases versus 22 (15%) of 148 cases without empty sella syndrome present. Empty sella syndrome was significantly associated with MRI-negative disease (OR 3.32, 95% CI 1.61-6.74, p = 0.0018). Decreased thickness of the pituitary gland was also associated with MRI-negative disease (mean thickness 5.6 vs 6.8 mm, p = 0.0002). CONCLUSIONS Empty sella syndrome is associated with an increased rate of MRI-negative Cushing's disease. Pituitary compression causing a relative reduction in the volume of the pituitary for imaging is a plausible cause for not detecting the tumor mass with MRI.
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Affiliation(s)
| | - Adip G Bhargav
- 2Mayo Clinic Alix School of Medicine, Rochester, Minnesota
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Montano N, Signorelli F, Giordano M, D'Onofrio FG, Izzo A, D'Ercole M, Ioannoni E, Pennisi G, Caricato A, Pallini R, Olivi A. Factors associated with cerebrospinal fluid leak after a retrosigmoid approach for cerebellopontine angle surgery. Surg Neurol Int 2021; 12:258. [PMID: 34221589 PMCID: PMC8247722 DOI: 10.25259/sni_42_2021] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2021] [Accepted: 05/20/2021] [Indexed: 11/04/2022] Open
Abstract
Background The retrosigmoid approach represents a crucial surgical route to address different lesions in the cerebellopontine angle but cerebrospinal fluid (CSF) leak still remains the most frequent complication after this approach. Here, we analyzed the impact of different factors in CSF leak development after a retrosigmoid approach. Identifying risk factors related to a specific approach may help the surgeon to tailor the perioperative management and to appropriately counsel patients regarding their risk profile. Methods We retrospectively reviewed the clinical, surgical, and outcome data of 103 consecutive patients (M/F, 47/56; mean follow-up 35.6 ± 23.9 months) who underwent a retrosigmoid approach for different cerebellopontine angle pathologies and studied the impact of different factors on the occurrence of a CSF leak to univariate and multivariate analysis. Results Seventy-nine patients (76.7%) were operated for tumors growing in the cerebellopontine angle. Twenty-four patients (23.2%) underwent microvascular decompression to treat a drug-resistant trigeminal neuralgia. Sixteen patients (15.5%) developed CSF leak in the postoperative course of which six underwent surgical revision. Performing a craniectomy as surgical procedure (P = 0.0450) and performing a reopening procedure (second surgery; P = 0.0079) were significantly associated to a higher risk of developing CSF leak. Moreover, performing a reopening procedure emerged as an independent factor for CSF developing on multivariate analysis (P = 0.0156). Conclusion Patients submitted to craniectomy and patients who underwent a second surgery showed an higher CSF leak rate. Ongoing improvement of biomaterial technology may help neurosurgeons to prevent this potentially life-threatening complication.
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Affiliation(s)
- Nicola Montano
- Department of Neurosurgery, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | - Francesco Signorelli
- Department of Neurosurgery, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | - Martina Giordano
- Department of Neurosurgery, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | | | - Alessandro Izzo
- Department of Neurosurgery, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | - Manuela D'Ercole
- Department of Neurosurgery, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | - Eleonora Ioannoni
- Neurosurgical Intensive Care Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | - Giovanni Pennisi
- Department of Neurosurgery, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | - Anselmo Caricato
- Neurosurgical Intensive Care Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | - Roberto Pallini
- Department of Neurosurgery, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | - Alessandro Olivi
- Department of Neurosurgery, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
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Abstract
OBJECTIVE Spontaneous cerebrospinal fluid (CSF) leaks are thought to arise due to elevated intracranial pressure which is distributed across the skull base, potentially predisposing the development of multifocal CSF leaks. The aims of this study are to evaluate the characteristics of this population at presentation and surgical outcomes. STUDY DESIGN Retrospective case series. SETTING Tertiary referral center. PATIENTS Patients 18 years or older with spontaneous CSF leak diagnosis were eligible for study inclusion. Multifocal spontaneous CSF leak was defined as leaks originating from more than one skull base defect at anatomically distinct subsites. INTERVENTION None. MAIN OUTCOME MEASURE Clinical presentation and surgical outcome. RESULTS Two hundred ninety-three patients with diagnosis of spontaneous CSF leak were identified. Of these, 11 (3.8%) were characterized as having multifocal spontaneous CSF leaks. Mean body mass index was significantly higher in multifocal CSF leak patients (31.5 ± 8.5 vs 46.2 ± 9.9, p < 0.0001). There was also higher prevalence of women (100% vs 63.8%, p = 0.012) and African-Americans (63.6% vs 23.4%, p = 0.003). The overall success rate of CSF leak repair was 95%. Fifty percent of patients developed headaches or blurry vision after surgical repair, and two patients required ventriculoperitoneal shunting. CONCLUSIONS Multifocal spontaneous CSF leaks are rare and occurred in 3.8% of patients with spontaneous CSF. These patients were morbidly obese and more likely to be female and African American. Surgical repair conferred excellent outcomes. However, these patients have high risk of developing symptoms suggestive of elevated intracranial pressure postoperatively and should be counseled accordingly.
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Hendriks T, Bala A, Kuthubutheen J. Spontaneous cerebrospinal fluid leaks of the temporal bone - clinical features and management outcomes. Auris Nasus Larynx 2021; 49:26-33. [PMID: 33832812 DOI: 10.1016/j.anl.2021.03.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2020] [Revised: 03/10/2021] [Accepted: 03/23/2021] [Indexed: 10/21/2022]
Abstract
OBJECTIVE METHODS: A retrospective cohort study over seven-years from 2013 to 2020 was conducted at five tertiary referral centres. Patients identified with biochemically confirmed spontaneous cerebrospinal fluid leaks of the temporal bone manifesting as middle ear fluid with no other obvious cause were included. Demographics (age, gender, body-mass-index), symptomatology, past medical history, examination, investigation (biochemical and radiological), management and outcomes were recorded. RESULTS 90 adult patients with spontaneous cerebrospinal fluid otorrhoea were identified. Right sided leaks were most common (58%), and a majority of the cohort overweight (mean body-mass-index = 29.2 kg/m2). Unilateral hearing loss was the commonest presenting symptom (81%). Two patients presented to hospital with meningitis presumed secondary to spontaneous cerebrospinal fluid otorrhoea. Over half (54%) of patients were observed who tended to be older (mean age of 71 years vs 62 years) whilst the remainder underwent surgical repair with middle-fossa craniotomy the most common approach (87%). Eight patients managed surgically had recurrent leaks (21%). CONCLUSIONS This is one of the largest cohorts of spontaneous cerebrospinal fluid otorrhoea reported in the literature and reiterates the importance for clinicians to have a high index of suspicion for this condition in patients presenting with a unilateral middle ear effusion, especially in those who are overweight. Surgical intervention carries a risk of recurrence and further studies are needed to determine the risk of intra-cranial infection in order to guide management.
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Affiliation(s)
- Thomas Hendriks
- Department of Ear, Nose and Throat Surgery, Fiona Stanley Hospital, 11 Robin Warren Drive, Murdoch, WA 6150, Australia; Department of Ear, Nose and Throat Surgery, Royal Perth Hospital, Perth, WA 6000, Australia; Department of Otolaryngology and Head and Neck Surgery, Sir Charles Gairdner Hospital, Nedlands, WA 6009, Australia.
| | - Arul Bala
- Department of Neurosurgery, Sir Charles Gairdner Hospital, Nedlands, WA 6009, Australia
| | - Jafri Kuthubutheen
- Department of Ear, Nose and Throat Surgery, Fiona Stanley Hospital, 11 Robin Warren Drive, Murdoch, WA 6150, Australia; Department of Ear, Nose and Throat Surgery, Royal Perth Hospital, Perth, WA 6000, Australia; Department of Otolaryngology and Head and Neck Surgery, Sir Charles Gairdner Hospital, Nedlands, WA 6009, Australia; Western ENT, South Perth Hospital, Como, WA 6151, Australia
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Primary empty sella: The risk factors and associations with the cerebral small vessel diseases-An observational study. Clin Neurol Neurosurg 2021; 203:106586. [PMID: 33730618 DOI: 10.1016/j.clineuro.2021.106586] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2020] [Revised: 02/11/2021] [Accepted: 02/27/2021] [Indexed: 11/20/2022]
Abstract
OBJECTIVE To investigate the risk factors of primary empty sella (PES) and its associations with cerebral small vessel diseases (CSVD). METHODS A total of 132 consecutive patients were recruited from Department of Neurology, The Second Affiliated Hospital of Chongqing Medical University from December 2018 to January 2020, including 69 cases of PES, and age, gender-matched 63 subjects without PES. Demographics and clinical characteristics were recorded. Enlarged perivascular spaces (PVS) and white matter hyperintensities (WMH), which are image markers for CSVD, were assessed. Univariate logistic regression models and multivariate logistic regression models were performed to predict the independent risk factors of PES. RESULTS There was a significant difference in baseline characteristics in terms of hypertension (p < 0.001) and pregnancy (p = 0.019) between PES and the control group; among markers of CSVD, whole WMH (p = 0.030) and periventricular hyperintensities (PVH) (p = 0.027) were significantly different; however, no significant differences concerning deep WMH, total PVS, basilar ganglia-PVS and centrum semiovale-PVS (p > 0.05). After adjusting relevant potential confounders, multivariate logistic regression revealed hypertension (OR=3.158, 95 %CI: 1.452∼6.865, p = 0.004) and pregnancy (OR=2.236, 95 %CI: 1.036-4.826, p = 0.040) were independent risk factors for PES. CONCLUSION Hypertension and pregnancy are independent risk factors of PES. There is a possible correlation between PES and WMH, especially PVH, however, further studies are required to confirm these findings.
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Arnaout MM, Hanz SZ, Heier LA, Schwartz TH. Prevalence and Outcome of Anterior and Middle Cranial Fossae Encephaloceles without Cerebrospinal Fluid Leak or Meningitis. World Neurosurg 2021; 149:e828-e835. [PMID: 33529766 DOI: 10.1016/j.wneu.2021.01.088] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2020] [Revised: 01/18/2021] [Accepted: 01/19/2021] [Indexed: 11/17/2022]
Abstract
BACKGROUND With advances in imaging techniques, encephaloceles, meningoceles, and meningoencephaloceles are occasionally discovered incidentally. These can be located in anterior cranial fossa (ACF), mostly protruding into sphenoid and ethmoid sinuses, or middle cranial fossa (MCF), protruding into the temporal bone. We reviewed a large series of cranial computed tomography and magnetic resonance imaging scans to identify the prevalence of asymptomatic encephaloceles, meningoceles, and meningoencephaloceles and describe their outcome. METHODS We retrospectively reviewed a database of all magnetic resonance imaging and computed tomography scans done at Weill Cornell Medicine for any reason between 2003 and 2018. Encephaloceles, meningoceles, or meningoencephaloceles were confirmed on 72 scans. Of these, chart reviews were performed to identify incidentally discovered cases with symptoms other than cerebrospinal fluid leak, and chart reviews and phone calls were conducted to determine patient demographics, treatment, and outcome. RESULTS There were 18 incidental cases for a prevalence of 0.0074%, of which 6 were located in ACF, and 12 were located in MCF. The mean age for ACF cases was 39 ± 15.9 years and for MCF cases was 49.5 ± 19.8 years. There were no leaks in any cases after the encephaloceles were discovered. Eleven of 12 (91.6%) MCF cases were treated conservatively, while 3 of 6 (50%; P = 0.083) ACF cases were treated surgically. CONCLUSIONS This study showed that encephaloceles, meningoceles, and meningoencephaloceles without cerebrospinal fluid leak or meningitis in MCF were more often conservatively managed with observation only, whereas these entities in ACF were often repaired prophylactically. Incidentally discovered encephaloceles have a relatively benign natural history and do not precipitously leak.
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Affiliation(s)
- Mohamed M Arnaout
- Department of Neurosurgery, Faculty of Medicine, Zagazig University, Sharqia, Egypt; Department of Neurological Surgery, Weill Cornell Medical College, NewYork-Presbyterian Hospital, New York, New York, USA.
| | - Samuel Z Hanz
- Department of Neurological Surgery, Weill Cornell Medical College, NewYork-Presbyterian Hospital, New York, New York, USA; Department of Radiology, Weill Cornell Medical College, NewYork-Presbyterian Hospital, New York, New York, USA; Boston University School of Medicine, Boston, Massachusetts, USA
| | - Linda A Heier
- Department of Radiology, Weill Cornell Medical College, NewYork-Presbyterian Hospital, New York, New York, USA
| | - Theodore H Schwartz
- Department of Neurological Surgery, Weill Cornell Medical College, NewYork-Presbyterian Hospital, New York, New York, USA; Department of Otolaryngology, Weill Cornell Medical College, NewYork-Presbyterian Hospital, New York, New York, USA; Department of Neuroscience, Weill Cornell Medical College, NewYork-Presbyterian Hospital, New York, New York, USA
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Chiloiro S, Giampietro A, Bianchi A, De Marinis L. Empty sella syndrome: Multiple endocrine disorders. HANDBOOK OF CLINICAL NEUROLOGY 2021; 181:29-40. [PMID: 34238465 DOI: 10.1016/b978-0-12-820683-6.00003-8] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
Empty sella is a pituitary disorder characterized by the herniation of the subarachnoid space within the sella turcica. This is often associated with a variable degree of flattening of the pituitary gland. Empty sella has to be distinguished in primary and secondary forms. Primary empty sella (PES) excludes any history of previous pituitary pathologies such as previous surgical, pharmacologic, or radiotherapy treatment of the sellar region. PES is considered an idiopathic disease and may be associated with idiopathic intracranial hypertension. Secondary empty sella, however, may occur after the treatment of pituitary tumors through neurosurgery or drugs or radiotherapy, after spontaneous necrosis (ischemia or hemorrhage) of chiefly adenomas, after pituitary infectious processes, pituitary autoimmune diseases, or brain trauma. Empty sella, in the majority of cases, is only a neuroradiological finding, without any clinical implication. However, empty sella syndrome is defined in the presence of pituitary hormonal dysfunction (more frequently hypopituitarism) and/or neurological symptoms due to the possible coexisting of idiopathic intracranial hypertension. Empty sella syndrome represents a peculiar clinical entity, characterized by heterogeneity both in clinical manifestations and in hormonal alterations, sometimes reaching severe extremes. For a proper diagnosis, management, and follow-up of empty sella syndrome, a multidisciplinary approach with the integration of endocrine, neurological, and ophthalmological experts is strongly advocated.
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Affiliation(s)
- Sabrina Chiloiro
- Pituitary Unit, Fondazione Policlinico Universitario A. Gemelli IRCCS, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Antonella Giampietro
- Pituitary Unit, Fondazione Policlinico Universitario A. Gemelli IRCCS, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Antonio Bianchi
- Pituitary Unit, Fondazione Policlinico Universitario A. Gemelli IRCCS, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Laura De Marinis
- Pituitary Unit, Fondazione Policlinico Universitario A. Gemelli IRCCS, Università Cattolica del Sacro Cuore, Rome, Italy.
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Sathaporntheera P, Saetia K. Risk factors associated with CSF leakage and complications after retrosigmoid surgery. INTERDISCIPLINARY NEUROSURGERY 2020. [DOI: 10.1016/j.inat.2020.100865] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
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Bateman GA, Subramanian GM, Yap SL, Bateman AR. The incidence of obesity, venous sinus stenosis and cerebral hyperaemia in children referred for MRI to rule out idiopathic intracranial hypertension at a tertiary referral hospital: a 10 year review. Fluids Barriers CNS 2020; 17:59. [PMID: 32993698 PMCID: PMC7526159 DOI: 10.1186/s12987-020-00221-4] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2020] [Accepted: 09/22/2020] [Indexed: 12/22/2022] Open
Abstract
BACKGROUND Children referred to a tertiary hospital for the indication, "rule out idiopathic intracranial hypertension (IIH)" may have an increased risk of raised venous sinus pressure. An increase in sinus pressure could be due to obesity, venous outflow stenosis or cerebral hyperemia. The purpose of this paper is to define the incidence of each of these variables in these children. METHODS Following a data base review, 42 children between the ages of 3 and 15 years were found to have been referred over a 10 year period. The body mass index was assessed. The cross sectional areas and circumferences of the venous sinuses were measured at 4 levels to calculate the hydraulic and effective diameters. The arterial inflow, sagittal and straight sinus outflows were measured. Automatic cerebral volumetry allowed the brain volume and cerebral blood flow (CBF) to be calculated. The optic nerve sheath diameter was used as a surrogate marker of raised intracranial pressure (ICP). The sagittal sinus percentage venous return was used as a surrogate marker of elevated venous pressure. Age and sex matched control groups were used for comparison. RESULTS Compared to controls, the obesity rates were not significantly different in this cohort. Compared to controls, those at risk for IIH had a 17% reduction in transverse sinus and 14% reduction in sigmoid sinus effective cross sectional area (p = 0.005 and 0.0009). Compared to controls, the patients at risk for IIH had an arterial inflow increased by 34% (p < 0.0001) with a 9% larger brain volume (p = 0.02) giving an increase in CBF of 22% (p = 0.005). The sagittal and straight sinus venous return were reduced by 11% and 4% respectively (p < 0.0001 and 0.0009) suggesting raised venous sinus pressure. Forty five percent of the patients were classified as hyperemic and these had optic nerve sheath diameters 17% larger than controls (p < 0.0002) suggesting raised ICP. CONCLUSION In children with the chronic headache/ IIH spectrum, the highest associations were with cerebral hyperemia and mild venous sinus stenosis. Obesity was not significantly different in this cohort. There is evidence to suggest hyperemia increases the venous sinus pressure and ICP.
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Affiliation(s)
- Grant Alexander Bateman
- Department of Medical Imaging, John Hunter Hospital, Newcastle Region Mail Center, Locked Bag 1, Newcastle, NSW, 2310, Australia.
- Newcastle University Faculty of Health, Callaghan Campus, Newcastle, NSW, Australia.
| | | | - Swee Leong Yap
- Department of Medical Imaging, John Hunter Hospital, Newcastle Region Mail Center, Locked Bag 1, Newcastle, NSW, 2310, Australia
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Um S, Koleilat A, Dutson E, Mehran A. Laparoscopic Vertical Sleeve Gastrectomy for the Treatment of Pseudotumor Cerebri. Am Surg 2020. [DOI: 10.1177/000313481307900204] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Affiliation(s)
- Scott Um
- Department of Surgery University of California–Los Angeles Los Angeles, California
| | - Alaa Koleilat
- Department of Surgery University of California–Los Angeles Los Angeles, California
| | - Erik Dutson
- Department of Surgery University of California–Los Angeles Los Angeles, California
| | - Amir Mehran
- Department of Surgery University of California–Los Angeles Los Angeles, California
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Takahashi K, Seki Y, Kasama K, Amiki M, Baba S, Ito M, Tanaka T, Kanehira E. Prevalence of reflux esophagitis in obese Japanese undergoing bariatric surgery. JGH OPEN 2020; 4:519-524. [PMID: 32514464 PMCID: PMC7273729 DOI: 10.1002/jgh3.12293] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/24/2019] [Revised: 11/20/2019] [Accepted: 12/01/2019] [Indexed: 12/22/2022]
Abstract
Background Currently, the data on the relationship between obesity and gastroesophageal reflux disease (GERD) in Asian populations are scarce. Methods The aim of this study is to investigate the prevalence of reflux esophagitis (RE) among obese Japanese patients in each body mass index (BMI) range group. In addition, we aim to investigate the risk factors for RE in obese Japanese patients. The present retrospective cohort study included 674 obese Japanese patients who underwent bariatric surgery between January 2003 and April 2016. The patients were stratified into five groups based on BMI range. Results The mean BMI was 42.7 ± 9.24 kg/m2. The prevalence of RE among each of the groups was as follows: Group 1 (BMI 30–34.9) = 20.7%; Group 2 (BMI 35–39.9) = 24.0%; Group 3 (BMI 40–44.9) = 25.2%; Group 4 (BMI 45–49.9) = 26.7%; and Group 5 (BMI ≥50) = 24.8%. Overall, the prevalence of RE was 24.2% in our study. Furthermore, no significant difference in BMI was noted between the RE and non‐RE groups (43.4 ± 9.3 kg/m2 and 42.5 ± 10.2 kg/m2, respectively; p = 0.24). According to the multivariate logistic regression model, gender, Helicobacter pylori infection status, GERD‐related symptoms, and hiatal hernia were significantly correlated with RE. Conclusion Our study shows that the prevalence of RE in severely obese Japanese patients was significantly higher than the average prevalence of RE in Japan. However, the prevalence of RE did not increase with BMI in our cohort.
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Affiliation(s)
| | - Yosuke Seki
- Weight Loss and Metabolic Surgery Center Yotsuya Medical Cube Tokyo Japan
| | - Kazunori Kasama
- Weight Loss and Metabolic Surgery Center Yotsuya Medical Cube Tokyo Japan
| | - Manabu Amiki
- Weight Loss and Metabolic Surgery Center Yotsuya Medical Cube Tokyo Japan
| | - Satoshi Baba
- Department of Gastroenterology Yotsuya Medical Cube Tokyo Japan
| | - Masayoshi Ito
- Department of Gastroenterology Yotsuya Medical Cube Tokyo Japan
| | - Tatsuro Tanaka
- Department of Gastroenterology Yotsuya Medical Cube Tokyo Japan
| | - Eiji Kanehira
- Department of Surgery Medical Topia Soka Saitama Japan
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Togha M, Martami F, Rahmanzadeh R, Ghorbani Z, Refaeian F, Behbahani S, Panahi P, Moghadam NB, Nafissi S, Shahbazi M. The role of opening CSF pressure in response to treatment for idiopathic intracranial hypertension (IIH). J Clin Neurosci 2020; 76:171-176. [PMID: 32331944 DOI: 10.1016/j.jocn.2020.04.066] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2020] [Accepted: 04/12/2020] [Indexed: 10/24/2022]
Abstract
The aim of the current study was to assess the risk factors, clinical symptoms and Cerebrospinal fluid (CSF) pressure of idiopathic intracranial hypertension (IIH) with emphasis on determining the risk factors which involved in poor response to treatment. We retrospectively included 202 patients who were diagnosed with IIH. Disease severity was classified according to prescribed therapeutic option into 4 groups: acetazolamide (group 1), Acetazolamide plus topiramate or Lasix (group 2), repeated LP (group 3) and surgical intervention (group 4). Being in the higher group was considered as a higher severity of disease and poor response to treatment. Among the evaluated features of IIH, the strongest association were observed between opening CSF pressure and disease severity. So that, the highest CSF pressure was observed in patients who underwent surgery, which represent the highest severity of disease (group 4) and poor response to therapy (mean ± SD: 43.9 ± 21.1 cm H2O). Headache was the most prevalent symptom of IIH in our series which was significantly higher among acetazolamide group. Blurred vision was the second most common symptoms which, unlike the headache was more reported in surgery group. Our results suggested that higher CSF pressure could be the risk factors of poor response to therapy, which may raise need for more intensive treatment. Furthermore, suffering of headache without blurred vision can consider as a prognostic factor for mild severity and good response to treatment.
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Affiliation(s)
- Mansoureh Togha
- Tehran University of Medical Sciences, Headache Department, Iranian Center of Neurological Research, Tehran, Iran.
| | - Fahimeh Martami
- Tehran University of Medical Sciences, Headache Department, Iranian Center of Neurological Research, Tehran, Iran
| | - Reza Rahmanzadeh
- Tehran University of Medical Sciences, Headache Department, Iranian Center of Neurological Research, Tehran, Iran
| | - Zeinab Ghorbani
- Guilan University of Medical Sciences, Department of Cardiology, Heshmat Hospital, Cardiovascular Disease Research Center, Rasht, Iran
| | - Farshid Refaeian
- Tehran University of Medical Sciences, Headache Department, Iranian Center of Neurological Research, Tehran, Iran
| | - Shirin Behbahani
- Tehran University of Medical Sciences, Headache Department, Iranian Center of Neurological Research, Tehran, Iran
| | - Parsa Panahi
- Tehran University of Medical Sciences, Headache Department, Iranian Center of Neurological Research, Tehran, Iran
| | - Nahid Beladi Moghadam
- Shahid Beheshti University of Medical Sciences, Department of Neurology, Imam Hossein Hospital, Tehran, Iran
| | - Shahriar Nafissi
- Tehran University of Medical Sciences, Headache Department, Iranian Center of Neurological Research, Tehran, Iran
| | - Mojtaba Shahbazi
- Tehran University of Medical Sciences, Headache Department, Iranian Center of Neurological Research, Tehran, Iran
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49
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An update on idiopathic intracranial hypertension in adults: a look at pathophysiology, diagnostic approach and management. J Neurol 2020; 268:3249-3268. [PMID: 32462350 DOI: 10.1007/s00415-020-09943-9] [Citation(s) in RCA: 36] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2020] [Revised: 05/18/2020] [Accepted: 05/20/2020] [Indexed: 02/06/2023]
Abstract
Idiopathic intracranial hypertension is a neurological syndrome determined by a rise in intracranial pressure without a detectable cause. Course and prognosis may be changeable, requiring a multidisciplinary approach for its diagnosis and management. Although its precise pathogenesis is still unknown, many studies have been carried out to define the possible causal and associated factors, such as retinoids, steroid hormones, body mass index and recent weight gains, cytokines and adipokines levels. The clinical presentation can be variable including chronic headache, disturbance of vision, diplopia and tinnitus. Even if papilloedema is considered the most specific sign, it could not be observed in more than 5% of patients during the evaluation of the fundus oculi. Neuroradiological signs acquire greater importance in patients who do not present papilloedema and may suggest the diagnosis of idiopathic intracranial hypertension. Other assessments can be useful in the diagnostic process, such as optical coherence tomography, visual evoked potentials, ocular ultrasonography and fundus fluorescein angiography and autofluorescence. Nonetheless, cerebrospinal fluid pressure measurement is required to establish a definite diagnosis. Management may be different, since surgical procedures or lumbar punctures are often required when symptoms develop rapidly leading to a loss of visual function. Apart from these cases, patients can be treated with a pharmacological approach and low-calorie diet, but they also need to be monitored over time since relapses years later are not uncommon.
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Kalyvas A, Neromyliotis E, Koutsarnakis C, Komaitis S, Drosos E, Skandalakis GP, Pantazi M, Gobin YP, Stranjalis G, Patsalides A. A systematic review of surgical treatments of idiopathic intracranial hypertension (IIH). Neurosurg Rev 2020; 44:773-792. [PMID: 32335853 DOI: 10.1007/s10143-020-01288-1] [Citation(s) in RCA: 80] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2019] [Revised: 03/10/2020] [Accepted: 03/17/2020] [Indexed: 01/28/2023]
Abstract
Idiopathic intracranial hypertension denotes raised intracranial pressure in the absence of an identifiable cause and presents with symptoms relating to elevated ICP, namely headaches and visual deterioration. Treatment of IIH aims at reducing intracranial pressure, relieving headache and salvaging patients' vision. Surgical interventions are recommended for medically refractory IIH and include CSF diversion techniques, optic nerve sheath fenestration, bariatric surgery and venous sinus stenting. Prospective studies on the surgical options for IIH are scant and no evidence-based guidelines for the surgical management of medically refractory IIH have been established. A search in Cochrane Library, MEDLINE and EMBASE from 1 January 1985 to 19 April 2019 for controlled or observational studies on the surgical treatment of IIH (defined in accordance with the modified Dandy or the modified Friedman criteria) in adults yielded 109 admissible studies. VSS improved papilledema, visual fields and headaches in 87.1%, 72.7% and 72.1% of the patients respectively, with a 2.3% severe complication rate and 11.3% failure rate. CSF diversion techniques diminished papilledema, visual field deterioration and headaches in 78.9%, 66.8% and 69.8% of the cases and are associated with a 9.4 severe complication rate and a 43.4% failure rate. ONSF ameliorated papilledema, visual field defects and headaches in 90.5, 65.2% and 49.3% of patients. Severe complication rate was 2.2% and failure rate was 9.4%. This is currently the largest systematic review for the available operative modalities for IIH. VSS provided the best results in headache resolution and visual outcomes, with low failure rates and a very favourable complication profile. In light of this, VSS ought to be regarded as the first-line surgical modality for the treatment of medically refractory IIH.
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Affiliation(s)
- Aristotelis Kalyvas
- Division of Neurosurgery, Toronto Western Hospital/University Health Network, University of Toronto, Toronto, ON, Canada. .,Department of Neurosurgery, Evangelismos Hospital, National and Kapodistrian University of Athens, Athens, Greece.
| | - Eleftherios Neromyliotis
- Department of Neurosurgery, Evangelismos Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Christos Koutsarnakis
- Department of Neurosurgery, Evangelismos Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Spyridon Komaitis
- Department of Neurosurgery, Evangelismos Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Evangelos Drosos
- Department of Neurosurgery, Evangelismos Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Georgios P Skandalakis
- Department of Anatomy, Medical School, National and Kapodistrian University of Athens, Athens, Greece
| | - Mantha Pantazi
- Department of Pediatrics, Hatzikosta General Hospital, Ioannina, Greece
| | - Y Pierre Gobin
- Department of Neurological Surgery, New York Presbyterian Hospital/Weill Cornell Medical Center, New York, NY, USA
| | - George Stranjalis
- Department of Neurosurgery, Evangelismos Hospital, National and Kapodistrian University of Athens, Athens, Greece.,Hellenic Center for Neurosurgical Research, "Petros Kokkalis", Athens, Greece
| | - A Patsalides
- Department of Neurological Surgery, New York Presbyterian Hospital/Weill Cornell Medical Center, New York, NY, USA
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