New developments in idiopathic intracranial hypertension

Treatment of pulsatile tinnitus caused by anomalies of the sigmoid sinus wall via combined internal and external sigmoid sinus wall reconstruction with 3D temporal bone CT guidance

PURPOSE

The present analysis aims to describe a surgical approach wherein pulsatile tinnitus (PT) arising due to sigmoid sinus wall anomalies (SSWA) can be treated via combination internal and external sigmoid sinus wall reconstruction. We further evaluated the utility of temporal bone 3D-CT imaging during both the pre- and post-operative assessments of all treated patients.

METHODS

Data pertaining to 11 patients that had undergone sigmoid sinus wall reconstruction were retrospectively analyzed. All of these patients underwent preoperative 3D-CT imaging assessment. These patients were additionally subjected to sigmoid sinus wall reconstruction via a combined internal and external layer approach. Postoperatively, all patients underwent a radiological assessment of auricular cartilage and autologous bone powered displacement. Patients were additionally asked about any subjective changes in PT or associated symptoms at follow-up time points.

RESULTS

SSWA in the 3D-CT imaging from these patients were all distinct. In 10/11 patients, PT fully resolved following reconstruction of the sinus wall. The remaining patients exhibited significant improvements in symptoms postoperatively, with PT fully resolving within a 1-month follow-up period. No patients suffered any major complications.

CONCLUSIONS

Temporal bone 3D-CT imaging allow for effective visualization of SSWA, enabling effective pre- and post-operative assessments of treated patients. A combined internal and external layer approach to sigmoid sinus wall reconstruction can be implemented safely and effectively, yielding high rates of satisfactory outcomes and achieving rigid reconstruction of this surface. As such, there is clear value in the consideration of this approach when treating individuals suffering from PT as a result of SSWA.

Undiagnosed papilledema in a morbidly obese patient population: a prospective study

BACKGROUND

Idiopathic intracranial hypertension (IIH) is a rare condition that can lead to significant morbidity from visual loss. The cause of IIH is unknown, but IIH is known to be associated with obesity. Obese patients may be at particularly high risk for suffering vision loss from IIH. The purpose of the present study is to determine the prevalence of undiagnosed or asymptomatic papilledema in a population of morbidly obese individuals and to determine if these patients should undergo routine screening for papilledema.

METHODS

Patients presenting to the UC Davis Bariatric Surgery Clinic between February 2008 and January 2011 who met the National Institutes of Health criteria for bariatric surgery were invited to participate in the study. Those patients who met the inclusion criteria and consented to the study were included. Participants were screened for IIH by nonmydriatic fundus photographs and by concerning symptoms prompting direct referral for neuro-ophthalmologic evaluation. Images were reviewed by a neuro-ophthalmologist, and patients with suspicious optic discs underwent neuro-ophthalmologic evaluation. Patients with findings consistent with IIH were sent for neurological evaluation.

RESULTS

A total of 606 patients with an average body mass index of 47 kg/m2 were included in the study. Seventeen of these patients had photographic optic disc findings or symptoms suspicious for IIH. Seven of these patients did not have disc edema on clinical examination. Six patients were not evaluated in the clinic. Four of the 17 patients had subtle optic disc edema confirmed by clinical evaluation and were referred for full neurological workup. These 4 patients had normal neuroimaging, 3 of whom underwent lumbar punctures with borderline high opening pressures. All 4 patients had unremarkable visual field examinations. Fundus abnormalities other than optic disc edema were discovered in 33 patients.

CONCLUSION

Our study suggests that in a morbidly obese patient population, papilledema with significant visual loss is rare. Routine screening with fundus photography of morbidly obese patients likely is not warranted.

Profiles of obesity, weight gain, and quality of life in idiopathic intracranial hypertension (pseudotumor cerebri)

PURPOSE

Obesity and weight gain are known risk factors for idiopathic intracranial hypertension (IIH; or pseudotumor cerebri). The authors examined profiles of body mass index (BMI) and patterns of weight gain associated with IIH. They also examined vision-specific health-related quality of life (HRQOL) in newly diagnosed IIH patients and explored the relative contribution of obesity and weight gain to overall HRQOL in this disorder.

DESIGN

Matched case-control study.

METHODS

Female patients with newly diagnosed IIH (n = 34) and other neuro-ophthalmologic disorders (n = 41) were enrolled in a case-control study to assess patterns of self-reported weight gain. The HRQOL was examined using the 25-Item National Eye Institute Visual Function Questionnaire (NEI-VFQ-25) and the SF-36 Health Survey (Physical Components Summary and Mental Components Summary [MCS]).

RESULTS

Higher BMIs were associated with greater risk of IIH (P = .003, logistic regression analysis adjusting for case-control matching), as were higher percentages of weight gain during the year before symptom onset (P = .004). Moderate weight gain (5% to 15%) was associated with a greater risk of IIH among both obese and nonobese patients. Obesity and weight gain influenced the relation between HRQOL and IIH only for subscale scores reflecting mental health (SF-36 MCS). The NEI-VFQ-25 and SF-36 subscale scores were lower in IIH compared with other neuro-ophthalmologic disorders and published norms.

CONCLUSIONS

Higher levels of weight gain and BMI are associated with greater risk of IIH. Even nonobese patients (BMI <30) are at greater risk for IIH in the setting of moderate weight gain. Vision-specific and overall HRQOL are affected to a greater extent in IIH than in other neuro-ophthalmologic disorders.

Evidence-based neuro-ophthalmology: advances in treatment

This review presents highlights and updates from of the most significant clinical trials in neuro-ophthalmology to date, the Optic Neuritis Treatment Trial, the Controlled High-Risk Avonex Multiple Sclerosis Prevention Study, and the Ischemic Optic Neuropathy Decompression Trial. The quality of evidence for treatment efficacy from these trials and other recent investigations of giant cell arteritis and idiopathic intracranial hypertension is classified herein according to published criteria based on sample size and study design.