Cerebrospinal Fluid Removal for Idiopathic Intracranial Hypertension: Less Cerebrospinal Fluid Is Best

Clinical and prognostic importance of craniospinal elastance and pressure volume index in pediatric pseudotumor cerebri syndrome

OBJECTIVE

The aim of the study was to determine the clinical and prognostic significance of craniospinal elastance (Ecs), pressure volume index (PVI), and cerebrospinal fluid (CSF) total protein data in terms of resolution of papilledema and improvement of headache in children with pseudotumor cerebri syndrome (PTCS).

METHODS

This is a retrospective observational study of 33 children with definitive PTCS. The relationships between lumbar puncture (LP) measurements, especially Ecs and PVI, and papilledema and headache resolution time were investigated.

RESULTS

In children with definite primary and secondary PTCS, higher opening pressure and decreased PVI were found to be associated with faster resolution of papilledema and faster improvement of headache (r = 0.904, P < 0.01; r = 0.894, P < 0.01 respectively). This effect was higher in children with secondary PTCS (P = 0.022). While papilledema resolution time and treatment time were statistically significantly higher in the secondary group (P = 0.035, P = 0.040), there was no significant difference between the two groups in terms of headache relief time (P = 0.051). Based on the primary and secondary groups, from the cut-off points determined, it was found that ≤ 41.60 ((AUC = 0.706, P = 0.0420), specificity 56%, sensitivity 86.7%) for opening pressure and ≤ 69.37 ((AUC = 0.702, P = 0.0448), specificity 48.2%, sensitivity 83.3%) for PVI were statistically significant. A very strong negative linear correlation was found between CSF total protein and lumbar puncture measurements and clinical outcomes (P < 0.001).

CONCLUSION

Ecs and PVI may be markers that can provide potentially important data on pediatric PTCS prognosis. CSF total protein may also provide clinical benefit.

A Unique Subset: Idiopathic Intracranial Hypertension Presenting as Spontaneous CSF Leak of the Anterior Skull Base

Introduction Spontaneous cerebrospinal fluid (CSF) leaks represent a unique clinical presentation of idiopathic intracranial hypertension (IIH), lacking classical features of IIH, including severe headaches, papilledema, and markedly elevated opening pressures.

Methods Following a single-institution retrospective review of patients undergoing spontaneous CSF leak repair, we performed a literature review of spontaneous CSF leak in patients previously undiagnosed with IIH, querying PubMed.

Results Our literature review yielded 26 studies, comprising 716 patients. Average age was 51 years with 80.8% female predominance, and average body mass index was 35.5. Presenting symptoms included headaches (32.5%), visual disturbances (4.2%), and a history of meningitis (15.3%). Papilledema occurred in 14.1%. An empty sella was present in 77.7%. Slit ventricles and venous sinus stenosis comprised 7.7 and 31.8%, respectively. CSF leak most commonly originated from the sphenoid sinus (41.1%), cribriform plate (25.4%), and ethmoid skull base (20.4%). Preoperative opening pressures were normal at 22.4 cm H2O and elevated postoperatively to 30.8 cm H2O. 19.1% of patients underwent shunt placement. CSF leak recurred after repair in 10.5% of patients, 78.6% involving the initial site. A total of 85.7% of these patients were managed with repeat surgical intervention, and 23.2% underwent a shunting procedure.

Conclusion Spontaneous CSF leaks represent a distinct variant of IIH, distinguished by decreased prevalence of headaches, lack of visual deficits, and normal opening pressures. Delayed measurement of opening pressure after leak repair may be helpful to diagnose IIH. Permanent CSF diversion may be indicated in patients exhibiting significantly elevated opening pressures postoperatively, refractory symptoms of IIH, or recurrent CSF leak.

Does post dural puncture headache exist in idiopathic intracranial hypertension? A pilot study

BACKGROUND/OBJECTIVE

Occurrence of post-dural puncture headache (PDPH) after diagnostic lumbar puncture (LP) for idiopathic intracranial hypertension (IIH) may seem very unlikely in clinical practice. Nevertheless, it has been suggested by several studies, mainly in sub-group analyses. We aimed to evaluate the prevalence of PDPH in an IIH population and determine any eventual predictive factors of PDPH occurrence.

METHODS

We conducted a retrospective multiple-center observational study. All newly diagnosed IIH patients who met the International Classification of Headache Disorders (ICHD-3) or the Dandy modified criteria were included from three different French hospitals. They all underwent LP following the same process with the same type of needle. We recorded PDPH occurring within five days after LP, as defined by ICHD-3 criteria.

RESULTS

Seventy-four IIH patients were recruited, of whom 23 (31%) presented with PDPH. Neither classical risk factors for PDPH such as body mass index, age or gender, nor cerebrospinal fluid opening pressure, or specific IIH features were associated with occurrence of PDPH.

CONCLUSION

PDPH can occur after LP in IIH patients. Clinicians should be aware of this possible event during the IIH diagnosis assessment and should not automatically reconsider IIH diagnosis. PDPH prevention using an atraumatic needle and dedicated PDPH treatment seem relevant in IIH patients.