Epidemiology and risk factors for idiopathic intracranial hypertension

Oral fluoroquinolones and risk of secondary pseudotumor cerebri syndrome: Nested case-control study

OBJECTIVE

To quantify the risk of secondary pseudotumor cerebri syndrome (PTCS) with fluoroquinolones.

METHODS

A case-control study of people 15-60 years of age from the LifeLink Database (QuintilesIMS, Parsippany, NJ) was conducted. Cases had the first ICD-9-CM code for benign intracranial hypertension (BIH) as well as having received a procedure code for an MRI or CT scan and a lumbar puncture within 15 days or 30 days of the BIH code. For each case, 10 controls were selected using density-based sampling. Current users of fluoroquinolones received a prescription within 15 days or 30 days of the date of the diagnosis. For the sensitivity analysis, risk periods for 30 and 60 days were also examined. Adjusted rate ratios (RRs) were computed from a conditional logistic regression model.

RESULTS

From a cohort of 6,110,723 people, there were 339 cases of PTCS and 3,390 corresponding controls. In the primary analysis, the adjusted RR for current users of fluoroquinolones for both the 15-day and 30-day definitions were 5.67 (95% confidence interval [CI] 2.72-11.83) and 4.15 (95% CI 2.29-7.50), respectively. The risk with tetracycline antibiotics was also increased, with RRs for 15 and 30 days of current use of 2.68 (0.89-8.11) and 3.64 (1.67-7.91), respectively.

CONCLUSION

Our study suggests an increase in the risk of PTCS with current users of fluoroquinolones. Although this adverse event is rare, patients who experience symptoms of raised intracranial pressure including headaches, tinnitus, and double vision while taking fluoroquinolones should seek medical attention.

An Estimation of the Risk of Pseudotumor Cerebri among Users of the Levonorgestrel Intrauterine Device

Because of a previous association of pseudotumor cerebri (PTC) with levonorgestrel, we wished to evaluate the use of levonorgestrel-eluting intrauterine devices ("levonorgestrel intrauterine systems", LNG-IUS) in our University of Utah and Rigshospitalet PTC patients. In our retrospective series, PTC prevalence was approximately 0.18% and 0.15% in the LNG-IUS population versus 0.02% and 0.04% in the non-LNG-IUS population (Utah and Rigshospitalet, respectively), with no significant differences in PTC signs and symptoms among the two groups. Our investigation suggests that women with an LNG-IUS may have increased risk of developing PTC but does not suggest an LNG-IUS can cause PTC.

Outcomes of endoscopic optic nerve decompression in patients with idiopathic intracranial hypertension

BACKGROUND

The conventional treatment for idiopathic intracranial hypertension involves weight loss, steroids, diuretics, and/or serial lumbar punctures; however, if the symptoms persist or worsen, surgical intervention is recommended. Surgical options include cerebrospinal fluid diversion procedures, such as ventriculoperitoneal and lumboperitoneal shunts, and optic nerve decompression with nerve sheath fenestration. The latter can be carried out using an endoscopic approach, but the outcomes of this technique have not been firmly established.

METHODS

This systematic review examined the outcomes of performing endoscopic optic nerve decompression (EOND) in patients with idiopathic intracranial hypertension (IIH). Six studies were included for a total of 34 patients.

RESULTS

The patients presented with visual field disturbances (32 of 32 [100%]), visual acuity disruptions (33 of 34 [97.1%]), papilledema (26 of 34 [76.5%]), and persistent headache (30 of 33 [90.1%]). The mean duration of symptoms ranged from 7 to 32 months. Overall, the patients showed post-EOND improvement in signs and symptoms associated with IIH, specifically visual field deficits (93.8%), visual acuity (85.3%), papilledema (81.4%), and headaches (81.8%). Interestingly, 11 cases showed postoperative improvement in their symptoms with bony decompression of the optic canal alone, without nerve sheath fenestration. There were no major adverse events or complications reported with this approach.

CONCLUSION

EOND appears to be a promising and safe surgical alternative for patients with IIH who fail to respond to medical treatment. Further studies are needed before we can attest to the clinical validity of this procedure.

Idiopathic Intracranial Hypertension in Monozygotic Female Twins: Intracranial Pressure Dynamics and Treatment Outcome

BACKGROUND

Familial cases of idiopathic intracranial hypertension (IIH) are exceedingly rare, and its occurrence in monozygotic twins has not been reported previously.

CASE DESCRIPTION

We report monozygotic female twins who developed IIH, one at age 25 years and the other at age 28 years. Continuous intracranial pressure (ICP) monitoring confirmed elevated ICP as measured initially by lumbar puncture. In both cases, successful treatment with resolution of papilledema and symptoms relief was achieved after ventriculoperitoneal shunting.

CONCLUSIONS

This report documents the first case of IIH in monozygotic twins and the associated changes in ICP dynamics. Interestingly, almost equivalent alterations in ICP dynamics were found in the 2 patients.

Re-evaluating the Incidence of Idiopathic Intracranial Hypertension in an Era of Increasing Obesity

PURPOSE

To re-evaluate the population-based incidence of idiopathic intracranial hypertension (IIH) and to determine if it mirrors the rise in obesity.

DESIGN

Retrospective, population-based cohort.

PARTICIPANTS

All residents of Olmsted County, Minnesota, diagnosed with IIH between January 1, 1990, and December 31, 2014.

METHODS

All cases of IIH were identified using the Rochester Epidemiology Project, which is a record-linkage system of medical records for all patient-physician encounters among Olmsted County, Minnesota, residents. All medical records were reviewed to confirm a diagnosis of IIH. The incidence rates of IIH were compared against the incidence of obesity in Minnesota over the same period.

MAIN OUTCOME MEASURES

Incidence of IIH, lumbar puncture opening pressures, and body mass index.

RESULTS

There were 63 new cases of IIH, yielding an overall age- and gender-adjusted annual incidence of 1.8 per 100 000 (95% confidence interval, 1.3-2.2) between 1990 and 2014. It increased from 1.0 per 100 000 (1990-2001) to 2.4 per 100 000 (2002-2014; P = 0.007). The incidence of IIH was 3.3 per 100 000 in women and 0.3 per 100 000 in men (P ≤ 0.001). In obese women 15 to 44 years of age, the incidence was 22.0 per 100 000 compared with 6.8 per 100 000 among all women in the same age group. A strong correlation was observed between IIH incidence rates and obesity rates in Minnesota (R² = 0.70, P = 0.008).

CONCLUSIONS

The incidence of IIH has increased since 1990, which is highly correlated with the rise in obesity during the same period.

Effectiveness and safety of nutritional supplements in the treatment of hereditary retinal dystrophies: a systematic review

The hereditary retinal dystrophies (HRDs) are a group of genetically determined disorders that result in loss of the visual function. There is a lack of standard pharmacological treatments or widely accepted nutritional recommendations. The objective of this review is to summarise the scientific evidence on the effectiveness and safety of nutritional supplements for the treatment of HRDs. We conducted a scientific literature search on Medline and PreMedline, EMBASE, SCI-EXPANDED, SSCI, and The Cochrane Library up to August 2014. Experimental, quasi-experimental and controlled observational studies were selected. Eight studies were ultimately included, seven on retinitis pigmentosa (RP) and one on Best disease. Vitamin A, vitamin E, docosahexaenoic acid (DHA), lutein and β-carotene were assessed. A 15 000 IU daily dose of vitamin A was reported to have shown a small protective effect on the progression of RP, as was the use of the carotenoids lutein and β-carotene. Different DHA doses has no effect on RP or Best disease. No supplement showed severe adverse effects in the selected studies although strong evidence of toxicity exists for high doses of vitamin A and β-carotene in certain populations. The selected studies concluded that there may be a small beneficial effect of vitamin A, lutein and β-carotene on the progression of RP. The limited evidence available indicates some well-designed additional studies on combined supplements strategies may achieve more robust conclusions. Moreover, the scarcity of evidence available on the treatment of HRD other than RP with nutritional supplements supports the need for further research efforts.

Neurological and Neuropsychiatric Adverse Effects of Dermatologic Medications

Severe, recalcitrant dermatologic conditions often require systemic treatment. Although efficacious, these medications have been associated with wide-ranging adverse reactions. Some are reversible, predictable, and either dose-dependent or treatment length-dependent, while others are unpredictable, irreversible, and potentially fatal. This review examines the neuropsychiatric adverse effects associated with US FDA-approved medications for treatment of the following dermatologic pathologies that typically require systemic therapy: autoimmune dermatoses, acne, psoriasis, and melanoma. A search of the literature was performed, with adverse effects ranging from mild headaches and neuropathy to severe encephalopathies. The medications associated with the most serious reactions were those used to treat psoriasis, especially the older non-biologic medications such as cyclosporine A and methotrexate. Given the importance of these systemic dermatologic therapies in treating severe, recalcitrant conditions, and the wide variety of potentially serious neuropsychiatric adverse effects of these medications, neurologists, psychiatrists, dermatologists, oncologists, and primary care providers must be aware of the potential for these neuropsychiatric adverse reactions to allow for appropriate counseling, management, and medication withdrawal.

Role of vitamin A metabolism in IIH: Results from the idiopathic intracranial hypertension treatment trial

INTRODUCTION

Vitamin A and its metabolites (called retinoids) have been thought to play a role in the development of idiopathic intracranial hypertension (IIH). The IIH Treatment Trial (IIHTT) showed the efficacy of acetazolamide (ACZ) in improving visual field function, papilledema grade, quality of life and cerebrospinal fluid (CSF) pressure. We postulated that IIH patients would demonstrate elevated measures of vitamin A metabolites in the serum and CSF.

METHODS

Comprehensive measures of serum vitamin A and its metabolites were obtained from 96 IIHTT subjects, randomly assigned to treatment with ACZ or placebo, and 25 controls with similar gender, age and body mass index (BMI). These included retinol, retinol binding protein, all-trans retinoic acid (ATRA), alpha- and beta-carotenes, and beta-cryptoxanthin. The IIHTT subjects also had CSF and serum vitamin A and metabolite measurements obtained at study entry and at six months.

RESULTS

At study entry, of the vitamin A metabolites only serum ATRA was significantly different in IIHTT subjects (median 4.33nM) and controls (median 5.04nM, p=0.02). The BMI of IIHTT subjects showed mild significant negative correlations with serum ATRA, alpha- and beta-carotene, and beta-cryptoxanthin. In contrast, the control subject BMI correlated only with serum ATRA. At six months, the serum retinol, alpha-carotene, beta-carotene, and CSF retinol were increased from baseline in the ACZ treated group, but only increases in alpha-carotene (p=0.02) and CSF ATRA (p=0.04) were significantly greater in the ACZ group compared with the placebo group. No other vitamin A measures were significantly altered over the six months in either treatment group. Weight loss correlated with only with the change in serum beta-carotene (r=-0.44, p=0.006) and the change in CSF retinol (r=-0.61, p=0.02).

CONCLUSION

Vitamin A toxicity is unlikely a contributory factor in the causation of IIH. Our findings differ from those of prior reports in part because of our use of more accurate quantitative methods and measuring vitamin A metabolites in both serum and CSF. ACZ may alter retinoid metabolism in IIH patients.

Translating the Low Translaminar Cribrosa Pressure Gradient Hypothesis into the Clinical Care of Glaucoma

Glaucoma is an optic neuropathy with multiple known risk factors, including age, race, family history, and intraocular pressure. Unfortunately, the only currently modifiable risk factor in treating the disease is intraocular pressure (IOP). Recent studies have investigated intracranial pressure (ICP) and the translaminar cribrosa pressure gradient as a potential explanation for glaucomatous optic nerve vulnerability across a range of IOP values. The difference between these two pressures across the lamina cribrosa may have an effect on the optic nerve, which could provide another modifiable parameter in the battle against glaucoma. In order for modification of the translaminar pressure gradient to be considered in the treatment of glaucoma, noninvasive methods to accurately measure ICP need to be developed. The translaminar pressure gradient could be therapeutically adjusted by either further lowering the IOP or raising the ICP when it is pathologically low, if possible.

Idiopathic intracranial hypertension occurred after spinal surgery: report of two rare cases and systematic review of the literature

BACKGROUND

Idiopathic intracranial hypertension (IIH) is a relatively rare syndrome of increased intracranial pressure of unknown etiology. It is characterized by cerebrospinal fluid (CSF) opening pressure more than 250 mmH₂O, with normal cranial imaging and CSF content. IIH occurred after spinal surgery is extremely rare.

METHODS

We present two IIH cases occurred after spinal surgery and conduct a systematic review of articles reporting IIH occurred after spinal surgery.

RESULTS

The first patient underwent a posterior decompression and fixation for cervical fractures. IIH symptoms appeared 3 days postoperatively and gradually resolved with appropriate medication. The second patient underwent posterior spinal fusion with segmental instrumentation for congenital scoliosis. IIH symptoms appeared 5 days postoperatively and the patient died due to the irreversible intracranial hypertension although underwent intensive care and treatment. The literature review revealed that there were only five cases of IIH occurred after spinal surgery reported till date.

CONCLUSIONS

IIH occurred after spinal surgery is relatively rare; the diagnosis is based upon exclusion of other diseases. IIH should be kept in mind in patients underwent spinal surgery as it could develop into irreversible intracranial hypertension.

Ophthalmic Disparities in Transgender Patients

Transgender individuals experience unique challenges with regards to discrimination and access to health care. Further, their unique health-care needs and challenges lead to greater rates of morbidity. This article seeks to review the unique biology of transgender patients and the effects of cross-sex hormone therapy on ophthalmic and non-ophthalmic pathology. Attention is given to topics in neuro-ophthalmology, oculoplastics, and retinal disease.

A case series of dural venous sinus stenting in idiopathic intracranial hypertension: association of outcomes with optical coherence tomography

Purpose/Aim: Pseudotumor cerebri or idiopathic intracranial hypertension (IIH) is characterized by increased intracranial pressure of unknown etiology. A subset of patients has shown benefit from endovascular dural venous sinus stenting (DVSS). We sought to identify a population of IIH patients who underwent DVSS to assess outcomes.

MATERIALS AND METHODS

A retrospective study was performed to identify IIH patients with dural sinus stenosis treated with DVSS. Outcome measures included dural sinus pressure gradients, peripapillary retinal nerve fiber layer (RNFL) thickness using optical coherence tomography and improvement in symptoms.

RESULTS

Seventeen patients underwent DVSS. Average pre- and post-intervention pressure gradients were 23.06 and 1.18 mmHg, respectively (p < 0.0001). Sixteen (94%) noted improvement in headache, fourteen (82%) had visual improvement and all (100%) patients had improved main symptom. Of 11 patients with optical coherence tomography, 8 showed decreased RNFL thickness and 3 remained stable; furthermore, these 11 patients had improved vision with improved papilledema in 8, lack of pre-existing papilledema in 2 and stable, mild edema in 1 patient.

CONCLUSIONS

Our series of patients with dural sinus stenosis demonstrated improvement in vision and reduction in RNFL thickness. DVSS appears to be a useful treatment for IIH patients with dural sinus stenosis.

Ultrasound evaluation of internal jugular valve incompetence (IJVI) in Egyptian patients with idiopathic intracranial hypertension (IIH)

BACKGROUND

Idiopathic intracranial hypertension (IIH) is a clinical syndrome with no identified causative factor. Internal jugular valve incompetence (IJVI) has been linked to many neurological disorders such as idiopathic intracranial hypertension (IIH), transient global amnesia and cough-induced headache. Intact valves prevent efficiently retrograde flow into the internal jugular vein.

AIM

The aim of this study is to evaluate the competence of the jugular vein valves and its relationship to age, BMI, opening CSF pressure and MRV findings in IIH patients.

SUBJECTS AND METHODS

Twenty-five Egyptian female patients diagnosed with IIH according to the modified Dandy criteria, and 24 female controls, matched for age and BMI, were included and examined using color-coded duplex for IJVI during the Valsalva maneuver. The patients underwent lumbar puncture to measure the opening pressure, MRV, ophthalmic examination and laboratory work-up.

RESULTS

There was no statistically significant difference in the proportion of IJVI among the patients and controls (P=0.7). There was a statistically significant increase in the opening pressure and proportion of MRV abnormalities in the patients with IJVI compared to the patients without IJVI (P=0.03 and 0.007, respectively), but there were no statistically significant difference with regard to age, BMI, grade of papilledema and perimetry findings.

CONCLUSION

This study showed that there is no relationship between IJVI and IIH; thus, IJVI would be a rather normal finding. Further studies are recommended to confirm or rule out a possible relationship.

Causes and Prognosis of Visual Acuity Loss at the Time of Initial Presentation in Idiopathic Intracranial Hypertension

PURPOSE

To determine the etiology and prognosis of visual acuity loss in idiopathic intracranial hypertension (IIH) at presentation and to provide objective measures to predict visual outcome.

METHODS

A retrospective review of 660 patients with IIH (2009-2013) identified 31 patients (4.7%) with 48 eyes having best-corrected visual acuity (BCVA) of 20/25 or worse on initial presentation. Fundus photography, optical coherence tomography (OCT) of the optic disc and macula, and perimetry were used to determine the causes and prognosis of vision loss. Segmentation of the macula OCT was performed using the Iowa Reference Algorithm to determine the retinal ganglion cell-inner plexiform layer complex (GCL-IPL) thickness.

RESULTS

Outer retinal changes alone caused decreased BCVA at initial presentation in 22 eyes (46%): subretinal fluid in 16, chorioretinal folds in 5, and peripapillary choroidal neovascularization in 1. The vision loss was reversible except for some eyes with chorioretinal folds. Optic neuropathy alone caused decreased BCVA in 10 eyes (21%) and coexisting outer retinal changes and optic neuropathy caused decreased BCVA in 16 eyes (33%). A GCL-IPL thickness less than or equal to 70 μm at initial presentation or progressive thinning of greater than or equal to 10 μm within 2 to 3 weeks compared with baseline correlated with poor visual outcome.

CONCLUSIONS

Visual acuity loss in IIH can be caused by both outer retinal changes and optic neuropathy. Vision loss from outer retinal changes is mostly reversible. The outcome of patients with coexisting outer retinal changes and optic neuropathy or optic neuropathy alone depends on the degree of optic neuropathy, which can be predicted by the GCL-IPL thickness.

Mercury poisoning as a cause of intracranial hypertension

Mercury poisoning is a rare but fatal toxicologic emergency. Neurologic manifestations involving the central nervous system are seen usually with chronic mercury intoxication. The most commonly seen complaints are headache, tremor, impaired cognitive skills, weakness, muscle atrophy, and paresthesia. Here, we present a male patient who was chronically exposed to elemental mercury and had papilledema and intracranial hypertension without parenchymal lesion in the central nervous system. A 12-year-old male patient was referred to our emergency room because of severe fatigue, generalized muscle pain and weakness, which was present for a month. Physical examination revealed painful extremities, decreased motor strength and the lack of deep tendon reflexes in lower extremities. He had mixed type polyneuropathy in his electromyography. Whole blood and 24-hour urinary mercury concentrations were high. A chelation therapy with succimer (dimercaptosuccinic acid) was started on the fourth day of his admission. On the seventh day of his admission, he developed headache and nausea, and bilateral papilledema and intracranial hypertension were detected on physical examination. Acetazolamide was started and after 1 month of treatment, the fundi examination was normal. The patient stayed in the hospital for 35 days and was then discharged with acetazolamide, vitamin B6, gabapentin, and followed as an outpatient. His clinical findings were relieving day by day. Although headache is the most common symptom in mercury poisoning, the clinician should evaluate the fundus in terms of intracranial hypertension.