Idiopathic intracranial hypertension: consensus guidelines on management

Drug-Induced Intracranial Hypertension: The Adverse Effects of Acne Medications and Topical Retinoids

BACKGROUND

Tetracyclines and vitamin A derivatives, major components in acne care and antiaging products, have been associated with the development of drug-induced intracranial hypertension (DIIH). Treatment practices and longitudinal visual outcomes have been highly understudied in DIIH. The purpose of this study was to provide management guidelines for DIIH and report visual outcomes of patients with DIIH.

METHODS

This was a single institute ophthalmology center case-control study where patients were seen between June 1, 2012, and September 1, 2023, in the United States. Patients with an International Classification of Disease (ICD) code for IIH and meeting the IIH diagnostic criteria who were taking a tetracycline or a vitamin A derivative during their diagnosis were included in this study. Patients were stratified into the following 3 categories: tetracyclines only, vitamin A derivatives only, or both, and compared with Kruskal-Wallis rank-sum tests. Poor visual outcomes were evaluated for and defined as a visual field mean deviation (peripheral visual measure) of -7 dB or greater. Individuals were followed for up to 1.5 years after diagnosis.

RESULTS

Among patients with IIH (n = 839), DIIH occurred in 8.10% of them (n = 68) with 83% taking the medication for acne. 88% of cases were female, and patients had a mean age of 24.96 years. DIIH medications were taken for an average length of 25.79 weeks before diagnosis of IIH. 20.5% of patients with DIIH were not treated with any IIH medication and were discontinued from the inducing drug. 3 patients had a poor visual outcome on follow-up with all of them taking a vitamin A derivative ( P < 0.05). Patients identified as having a poor visual outcome did not report discontinuing the DIIH drug ( P < 0.05).

CONCLUSIONS

We propose treatment guidelines highlighting that patients taking a DIIH medication who develop headaches or visual changes should be immediately referred to ophthalmology, removal of the offending agent, and close monitoring by ophthalmology for vision loss. Importantly, vitamin A DIIH may have more severe visual outcomes, but further research is needed to corroborate this finding.

Prediction of Poor Visual Outcomes at Idiopathic Intracranial Hypertension Diagnosis Using a Supervised Machine Learning Algorithm

BACKGROUND

Idiopathic intracranial hypertension (IIH) is a vision-threatening disorder mainly affecting women of a reproductive age. Prompt diagnosis and intervention are vital to prevent vision loss, but validated tools to predict visual outcomes are lacking. The purpose of this study was to create a machine learning algorithm predicting poor visual outcomes at the time that the diagnosis of IIH is established, and stratifying risk among those with and without poor visual acuity at presentation.

METHODS

Using electronic health records, a retrospective cohort study was conducted between June 1, 2012 and September 30, 2023. Any patient aged 0-70 years who was diagnosed with IIH and met the revised diagnostic criteria was included in the analysis. In total, 391 patients with IIH had final outcomes available and were included in this analysis. Final visual outcomes were reported between 3 months and 1 year after diagnosis. Poor visual outcomes served as the model outcome and was defined as a visual field mean deviation (VFMD) worse than -7 dB or a visual acuity of 20/80 or worse. Both logistic regression and decision trees were used to build predictive models. Models were evaluated using multiple parameters including accuracy, sensitivity, specificity, and area under the curve. The best performing models were validated using a k-fold cross-validation.

RESULTS

The decision tree models performed the best and 4 prognostic risk groups were created: critical, high, medium, and low. In the critical risk group, patients who had both high baseline VFMD (worse than -12.59 dB) and identified as non-White had a poor visual outcome risk of 92.6%. A baseline VFMD worse than -9.1 dB resulted in a critical risk of a poor visual outcome at 69.8%. Any patient with a baseline VFMD better than -3.39 dB had a risk of a poor visual outcome at 1.04%.

CONCLUSIONS

Our study provides clinicians with valuable prognostic markers to assist in identifying patients who are at critical risk for significant vision loss. Patients with a VFMD worse than -9.1 dB have a critical risk of a poor visual outcome, and this further increased if they identified as a minority patient.

Non-invasive assessment of intracranial compliance in idiopathic intracranial hypertension: an MRI-ICP study

BACKGROUND/OBJECTIVES

Idiopathic intracranial hypertension (IIH) is a disease which threatens vision and causes disabling headaches, affecting women of childbearing age with obesity. It is characterised by raised intracranial pressure (ICP), measured invasively either with lumbar punctures or intracranially-inserted monitors. There is an unmet clinical need to develop non-invasive means to assess ICP. This study aims to utilise the MRI-ICP imaging technique to measure intracranial compliance index and assess its suitability as surrogate biomarker of ICP.

SUBJECTS/METHODS

Nine IIH patients and ten age, sex, and body mass index matched healthy controls were recruited. All participants underwent lumbar puncture, visual assessments, detailed headache phenotyping, and MRI-ICP scans to calculate intracranial compliance index at baseline. Following treatment, patients were invited to attend a one-year visit when all assessments were repeated.

RESULTS

There was significant (p = 0.017) reduction in intracranial compliance index in IIH (mean = 1006.0 cc/mmHg/cm, SD = ± 384.6 cc/mmHg/cm) compared to controls (mean = 1493.0 cc/mmHg/cm, SD = ± 411.8 cc/mmHg/cm), inversely correlating with lumbar puncture opening pressure (r = -0.502, p = 0.029). A significant inverse correlation between compliance index and headache disability was also found (r = -0.458, p = 0.049) and a trend for an association between lower compliance index and increased frequency of headaches (r = -0.430, p = 0.066). This latter became significant (p = 0.018) after accounting for use of analgesics. Following successful treatment, compliance index was increased in all patients at one year (mean of differences = 380.7 cc/mmHg/cm, p = 0.031).

CONCLUSIONS

This is the first study to apply the MRI-ICP technique longitudinally in IIH. It illustrates reduced intracranial compliance index in IIH, correlating with opening pressure and headache disability and ameliorating with treatment.

Calcitonin gene-related peptide in newly diagnosed idiopathic intracranial hypertension: a prospective, cross-sectional, case-control study of cerebrospinal fluid and plasma

BACKGROUND

Calcitonin Gene-Related Peptide (CGRP) is involved in migraine pain signaling, and blockage hereof is effective in migraine treatment. Headache in idiopathic intracranial hypertension (IIH) is often migraine-like but the underlying mechanisms are not understood. We report levels of CGRP in plasma and cerebrospinal fluid (CSF) of patients with newly diagnosed IIH to elucidate CGRP involvement in the pathogenesis of headache in IIH.

METHOD

We consecutively enrolled patients suspected of having IIH in a prospective cohort at two Danish tertiary headache centers. Patients are confirmed to have IIH or disproven of it (non-IIH). We included non-IIH with primary headache disorders as headache controls to IIH cases. We also recruited sex-, age- and BMI-matched healthy controls (HC). All participants had CSF and blood drawn and CGRP was analyzed using a validated radioimmunoassay. CSF plasma-ratios were calculated. Between-group levels were compared with ANOVA or Kruskal-Walli's test. In sub-analyses we restricted comparison of HC to non-IIH/IIH with chronic migraine; we also compared IIH with versus without headache. We correlated CGRP to lumbar opening pressure (OP), and BMI, and assessed the correlation between CGRP in plasma and CSF. Generalized or linear regression was applied to adjust for confounding by BMI, age, and active smoking.

RESULTS

Comparing 97 patients with IIH, 52 non-IIH, and 37 HC, we found no between-group differences in CGRP levels in plasma (p = 0.78), CSF (p = 0.79), or in CSF:plasma-ratio (p = 0.13). Adjusting for BMI, age, and smoking yielded similar results. CGRP levels were neither associated with having a migraine phenotype or chronic headache, nor with having any headache versus no headache in IIH. CGRP in plasma correlated with CGRP in CSF (p < 0.0001). CGRP did not correlate with OP or BMI.

CONCLUSION

CGRP levels in plasma and CSF and their ratios were comparable in IIH, non-IIH patients with headache, and sex-, age-, and BMI-matched HC. CGRP in plasma correlated with CGRP in CSF. Due to methodology, we probably measured basal resting CGRP. The role of CGRP in IIH-headache needs further clarification. A headache preventive effect in IIH of anti-CGRP targeted therapy remains a relevant unexplored area.

Optical coherence tomography surpasses fundus imaging and intracranial pressure measurement in monitoring idiopathic intracranial hypertension

We aim to evaluate the retinal nerve fiber layer (RNFL) thickness measured with optical coherence tomography (OCT) in comparison with papilledema grade, and to assess the relationship between RNFL thickness, papilledema grade, and intracranial pressure (ICP) in idiopathic intracranial hypertension (IIH). Sixty-five patients with active IIH (AIIH) with papilledema, 39 with chronic IIH (CIIH) without papilledema and 80 healthy controls (HC) were examined with OCT and fundus imaging. RNFL thickness, papilledema grade and ICP level were assessed in 55 with AIIH and 26 with CIIH. RNFL thickness was significantly higher in AIIH compared to CIIH or HC. RNFL thickness correlated strongly with papilledema grade (coefficient 0.78, p < 0.01) and moderately with ICP (coefficient 0.569, p < 0.01). RNFL thickness was associated with papilledema progression (R2 = 0.656, p < 0.01): specifically, with increases of 9 µm from normal to mild grade (p > 0.05), 91 µm from normal to moderate (p < 0.01), and 214 µm from normal to severe (p < 0.01). ICP showed a weaker correlation with papilledema grades (R2 = 0.339, p < 0.05), with significant increase (8 cm H2O, p < 0.01) only from normal to severe papilledema. RNFL correlated strongly with papilledema grade and moderately with ICP levels. RNFL thickness increased proportionally per papilledema grade.

Clinical indications and patient outcomes of intracranial venous sinus stenting beyond overt idiopathic intracranial hypertension: a scoping review

BACKGROUND

Intracranial venous sinus stenting (VSS) was initially developed as an alternative approach to addressing venous outflow obstruction in the context of idiopathic intracranial hypertension (IIH). In recent years, the technique has been increasingly used for other conditions involving venous compromise beyond overt IIH. The aim of this study was to describe the nature and volume of literature considering clinical applications and efficacy of VSS.

METHODS

A scoping review was conducted using MEDLINE, EMBASE, Scopus, The Cochrane Library, and various grey literature sources. Articles published since the introduction of VSS in 2002 were included. Independent screening of articles occurred in two stages: title-and-abstract and full-text screening. Relevant data was extracted and evidence mapping with narrative synthesis followed.

RESULTS

The search strategy yielded 1814 articles, of which 165 were included in this review. A total of 27 additional clinical indications of VSS beyond overt IIH were identified, spanning a diverse range of neurological pathology. Most evidence came from case reports, with the United States being the commonest study origin. Focal stenotic lesions and stenting locations were distributed throughout the dural sinus anatomy. An outline of patient outcomes reported by VSS providers is presented, with pulsatile tinnitus and visual impairment showing the greatest likelihood of clinical resolution.

CONCLUSION

This scoping review demonstrates the wider clinical utility and therapeutic potential of VSS beyond overt IIH. We also highlight the need for further studies to assess efficacy for each respective indication and clinical standardisation of VSS practice.

Comparison of bariatric surgery and community weight management for idiopathic intracranial hypertension in a multicenter retrospective cohort study

Idiopathic Intracranial Hypertension (IIH) is a neurological disorder characterized by elevated intracranial pressure without definitive etiology, primarily affecting young, obese women. This study aimed to compare the efficacy of bariatric surgery versus conventional community weight management in treating IIH. We conducted a retrospective cohort study in IIH patients undergoing bariatric procedures versus conventional weight loss interventions. Propensity score matching was employed to balance study groups. Outcomes were assessed at 3, 6, 12, and 24 months, including papilledema, headache, visual symptoms, and therapeutic interventions. Bariatric surgery demonstrated superior outcomes compared to community weight management. Papilledema incidence was consistently lower in the bariatric group (RR = 0.591 at 24 months, p = 0.0001). Headache prevalence and visual symptoms were also reduced in the surgical group. Acetazolamide dose was lower in bariatric patients, starting at 12 and 24 months. Subgroup analysis of different bariatric procedures showed comparable efficacy. Body mass index reduction was significantly greater in the bariatric group throughout the follow-up period. This study provides evidence supporting the efficacy of bariatric surgery in managing IIH, with superior outcomes across multiple parameters compared to conventional weight management. The sustained improvements in papilledema, headache, and visual symptoms, coupled with for the reduction in pharmacological intervention dose, suggest that bariatric surgery may offer a more definitive solution for IIH patients with concurrent obesity. Further research is needed to develop evidence-based guidelines for patient selection and optimize post-operative care protocols.

Knowledge and diagnostic confidence of general practitioners in managing idiopathic intracranial hypertension: A nationwide survey from the Northern regions of Oman

BACKGROUND

Idiopathic intracranial hypertension (IIH) is a rare but potentially vision-threatening condition, often underrecognized in primary care settings. Timely diagnosis and effective management are critical to prevent complications, yet knowledge gaps among general practitioners (GPs) may hinder optimal care. This study assessed the knowledge and diagnostic confidence of GPs in Oman regarding IIH.

METHODS

A cross-sectional survey was conducted among 150 GPs in the Al Batinah region and Muscat. The survey evaluated familiarity with IIH, recognition of clinical symptoms, diagnostic practices, and confidence in managing the condition. Descriptive statistics, chi-square tests, and ordinal regression analyses were used to assess associations between knowledge levels, professional background, and confidence in IIH management.

RESULTS

While 95.3 % of respondents accurately defined IIH, only 20.7 % could identify its symptoms, and 11.3 % were aware of appropriate treatment options. Significant associations were found between higher knowledge scores and international medical training (p = 0.001), as well as internship location (p = 0.001). Confidence in diagnosing IIH was strongly associated with clinical exposure to IIH patients (p < 0.001).

CONCLUSIONS

The study highlights critical knowledge gaps and low diagnostic confidence among GPs in Oman regarding IIH, particularly in recognizing symptoms and management strategies. Findings suggest that international training and clinical exposure enhance IIH knowledge and confidence, underscoring the need for targeted educational interventions to improve diagnosis and patient outcomes.

Guidelines for Diagnosis and Management of Idiopathic Normal Pressure Hydrocephalus

In 1965, Hakim and Adams described 3 patients with normal pressure hydrocephalus who responded to treatment with a ventriculoatrial shunt. Afterward the adoption of shunt treatment without clear diagnostic criteria and surgical techniques resulted in poor outcomes with significant complications. The clinical practice guidelines for the diagnosis and treatment of idiopathic normal pressure hydrocephalus were first published by the Japanese Neurosurgical Society in 2004 and the international guidelines were published in 2005. Both guidelines led to diagnosis and treatment algorithms and significantly improved outcomes, along with decreased surgical risk. These guidelines should be reevaluated and updated on a regular basis.

Papilledema

OBJECTIVE

This article describes the recognition, investigation, and management of papilledema.

LATEST DEVELOPMENTS

Papilledema describes optic disc swelling (usually bilateral) arising from raised intracranial pressure. Due to the serious nature of papilledema, there is a fear of underdiagnosis and hence one of the major stumbling points is the correct identification of papilledema. While there has been a stepwise increase in the incidence and prevalence of idiopathic intracranial hypertension due to the worldwide epidemic of people living with obesity, secondary causes such as cerebral venous sinus thrombosis, intracranial masses, and infections must not be missed. Our ability to image the optic nerve has been greatly enhanced by the directed use of optical coherence tomography, with recent studies observing novel imaging findings that can help distinguish pseudopapilledema from papilledema. The structured investigation of papilledema is now routine and research into the management of CSF disorders is finding new avenues for targeted treatments.

ESSENTIAL POINTS

Confirmation of papilledema typically requires a thorough ocular examination including visual field testing. Ocular imaging such as color fundus photographs and optical coherence tomography are useful. Joint care between ophthalmologists and neurologists is key to treating the underlying condition and managing any visual dysfunction and headache.

Retinal findings in pediatric idiopathic intracranial hypertension

BACKGROUND

Pediatric and adult idiopathic intracranial hypertension (IIH) have distinct clinical features. Retinal manifestations associated with adult IIH are well known and can limit visual function; however, data detailing these manifestations in pediatric IIH are sparse. The purpose of this study was to identify the range and effects of retinal manifestations in pediatric IIH focusing on associated visual and structural outcomes.

METHODS

The medical records of IIH patients from an academic children's hospital between 1998 and 2022 were reviewed retrospectively. Patients meeting diagnostic criteria for IIH without other concomitant retinal disease of alternate etiology were included. We evaluated demographics, visual function, and structural correlates longitudinally, and discernible retinal pathology based on fundus photography and optical coherence tomography was recorded.

RESULTS

Of the 253 patients with IIH, 24 (9.5%) had retinal manifestations, including 20 (7.9%) with retinal folds, 15 (5.9%) with macular exudates, 11 (4.3%) with subretinal fluid and 1 (0.4%) with a choroidal neovascular membrane. Baseline (P < 0.001) and final (P = 0.013) visual acuities were significantly lower in patients with retinal findings than those without. Eight patients (33.3%) had persistent retinal damage after the resolution of optic nerve edema. The presence of optic nerve atrophy after treatment was significantly higher in patients with retinal findings than those without (P < 0.001).

CONCLUSIONS

In our study cohort, retinal pathology was seen in a minority of pediatric IIH patients and persisted in many cases following resolution of papilledema. Retinal pathology in pediatric IIH was associated with worse visual function and outcomes and likely reflects worse disease severity. The extent to which retinal disease in IIH might contribute to vision loss remains unclear.

Idiopathic Intracranial Hypertension with Papilledema

Idiopathic intracranial hypertension (IIH) is becoming an increasingly common health care concern as global obesity rates rise. Physicians need to be familiar with the salient clinical features of this condition to improve the quality of lives of patients, reduce related health care costs, and optimize visual outcomes. The focus of this review is IIH with papilledema, because the potential for vision loss is a dire concern that drives urgency in diagnosis and management. We will discuss potential pathogenic mechanisms, describe the expanding clinical spectrum, highlight emerging diagnostic biomarkers, and explore established and emerging treatment options for people with IIH.

A 15-year-old teenager with refractory intracranial hypertension due to scalp arteriovenous fistula: case report

BACKGROUND

Refractory intracranial hypertension is a condition characterized by persistently elevated intracranial pressure that does not respond to conventional treatments. Diagnosis and management typically involve a combination of medical and surgical interventions. However, identifying the potential etiology can be particularly difficult under certain conditions. The causes of refractory intracranial hypertension due to non-traumatic brain injury are often difficult to detect. Untreated or ineffectively treated refractory intracranial hypertension can result in severe symptoms and potential vision loss.

CASE PRESENTATION

We reported a 15-year-old teenager with no history of trauma who experienced intermittent headaches and projectile vomiting over a 30-day period, accompanied by intracranial pressure exceeding 28 cmH2O. Through clinical reasoning combined with auxiliary examinations, including angiography and ultrasonography, and confirmed by follow-ups after experimental therapy, a final diagnosis of scalp arteriovenous fistula was established.

CONCLUSIONS

This case highlights the importance of considering extracranial causes in cases of refractory intracranial hypertension and management strategy for patients with refractory intracranial hypertension.

Diagnostic process, misdiagnosis and bias in suspected idiopathic intracranial hypertension: a retrospective observational cohort study

Background

Misdiagnosis of idiopathic intracranial hypertension (IIH) is prevalent and potentially harmful. We evaluated the diagnostic process of IIH and the impact of implementing a National Guideline (NG) on IIH management to improve patient care.

Method

In this observational retrospective study, we retrieved data on diagnostic investigations, duration, errors and causes for suspecting IIH from patients referred to the Danish Headache Center by suspected new-onset IIH from January 2020 to September 2022. We compared outcomes by final diagnosis (true vs disproven IIH) and the period before and after implementation of the NG. Level of significance was Bonferroni adjusted to p<0.002.

Results

96 patients were referred. We confirmed IIH in 27 (28%) and disproved IIH in 69 (72%) whose final diagnoses were predominantly headache disorders (70%) and pseudo-papilloedema (12%). True IIH was discovered by optic disc oedema (n=25, none detected by neurologists); neuroimaging indicating elevated intracranial pressure (n=1) or a typical clinical phenotype (n=1) aided little but often elicited IIH suspicion suggesting anchoring bias with premature closure. Misdiagnosis affected 11% (n=11). Diagnostic workup was more comprehensive and faster in true IIH (p<0.001). Mismanagement dropped by implementation of the NG (from 44% to 20%, p=0.02).

Conclusion

Optic disc oedema is the most predictive determinant of true IIH; neuroimaging and phenotype alone have poor diagnostic value and introduce bias. Fundus exam is urgent and decisive in suspected IIH and should guide diagnostic strategy to mitigate unnecessary investigations and preserve vision. An NG reduced diagnostic errors and optimised the diagnostic process.

Effectiveness of Topiramate Versus Acetazolamide in the Management of Idiopathic Intracranial Hypertension: ASystematic Review and Meta-Analysis

Background and Objectives: Primary pseudotumor cerebri syndrome, another name for idiopathic intracranial hypertension (IIH), is a neurological condition marked by elevated intracranial pressure (ICP) that can result in papilledema without a known etiology. The purpose of this study is to compare the efficacy of topiramate and acetazolamide as medical treatments for IIH and to evaluate the long-term outcomes of both medications. Materials and Methods: This systematic review and meta-analysis followed the PRISMA guidelines and was approved by the International Prospective Register for Systematic Reviews (PROSPERO). This study included randomized clinical trials, retrospective and prospective cohort studies, and patients with idiopathic intracranial hypertension (IIH). Data extraction was performed using the Rayyan application, and the risk of bias was assessed using the Critical Appraisal Skills Program (CASP). Results: The findings revealed a statistically significant 67% increase in the likelihood of improvement at 6 months compared to the baseline with the administration of acetazolamide and topiramate. After six months of the drug administration, there was a 3.6 times decrease in visual obscuration compared to the baseline. A significant advantage of topiramate in IIH is the added benefit of weight loss, since obesity is a modifiable risk factor. However, acetazolamide remains the conventional treatment. Conclusions: This study found that acetazolamide and topiramate are both effective therapies for idiopathic intracranial hypertension (IIH), improving visual metrics and decreasing cerebrospinal fluid pressure. Topiramate aids in weight reduction, while acetazolamide is recommended for its ability to lower CSF pressure and alleviate visual changes. A combination treatment of topiramate and acetazolamide is recommended for better results.

Clinical outcomes after stenting treatment in patients with idiopathic intracranial hypertension and intrinsic versus extrinsic venous sinus stenosis

BACKGROUND

Endovascular stenting is a promising treatment for patients with idiopathic intracranial hypertension (IIH) and venous sinus stenosis (VSS). However, data on the impact of stenosis type on clinical outcomes of patients undergoing stenting treatment remain limited. This prospective cohort study aimed to compare post-stenting outcomes in patients with IIH and intrinsic versus extrinsic VSS.

METHODS

Patients with IIH and VSS undergoing stenting at a tertiary hospital in China were enrolled consecutively from 2017 to 2023. Based on digital subtraction angiography, high-resolution MRI, and intravascular ultrasound findings, patients were categorized into two groups: intrinsic or extrinsic stenosis. At 6 months post-stenting, clinical outcomes including cerebrospinal fluid (CSF) pressure, headache, visual impairment, and papilledema were recorded. Multivariable regression models were used to explore the relationship between stenosis type and clinical outcomes.

RESULTS

In total, 92 patients were included, 60 with intrinsic stenosis and 32 with extrinsic stenosis. At 6 months, the intrinsic group had lower CSF pressure (median 180 vs 210 mmH2O, β coefficient -31.8, 95% CI -54.0 to -9.6) and a higher rate of complete symptom resolution (81.7% vs 40.6%, OR 8.88, 95% CI 2.60 to 30.30) than the extrinsic group. Additionally, 36.8% (95% CI 10.5% to 77.2%) of the effect of stenosis type on complete symptom resolution at 6 months was mediated through reduction in CSF pressure.

CONCLUSION

This single-center study suggested that patients with IIH and intrinsic VSS had lower CSF pressure and better symptom recovery compared with those with extrinsic VSS at 6 months post-stenting. Further validation in other centers and populations is needed.

TRIAL REGISTRATION NUMBER

ChiCTR.org.cn, ChiCTR-ONN-17010421.

Contemporary Management of Cerebrospinal Fluid Rhinorrhoea: A Review of the Literature

Background/Objectives: Cerebrospinal fluid (CSF) rhinorrhoea carries a significant risk of life-threatening intracranial complications. This review provides a contemporary overview of current management strategies for CSF rhinorrhoea. Methods: We conducted a literature review, examining studies from Medline, Embase, and Google Scholar published within the last 20 years. This narrative synthesis summarises the current and future trends in the management of CSF rhinorrhoea. Results: The management of CSF leaks requires a multidisciplinary approach, encompassing a thorough clinical assessment, targeted diagnostic testing, and a spectrum of surgical and non-surgical interventions. Endoscopic techniques, particularly the use of vascularised flaps such as the nasoseptal flap, has become central to anterior skull base reconstruction. Numerous graft and flap choices provide tailored solutions based on defect size and CSF flow characteristics, with reported success rates exceeding 90%. Conclusions: Endoscopic repair of CSF rhinorrhoea continues to evolve, with modern techniques significantly enhancing success rates and reducing morbidity. Further understanding of underlying aetiologies, advances in technology, and refinement in surgical technique are areas for future innovation in CSF rhinorrhoea management.

A randomized sequential cross-over trial evaluating five purportedly ICP-lowering drugs in idiopathic intracranial hypertension

OBJECTIVE

To gain initial insight into the efficacy to lower intracranial pressure (ICP), side effects, and effects on cognition of five drugs commonly used to treat idiopathic intracranial hypertension (IIH).

BACKGROUND

Limited clinical data exist for the treatment for IIH. Impaired cognition is recognized in IIH and can be exacerbated by medications.

METHODS

This human experimental medicine study was a secondary analysis that focused on an unblinded randomized, sequential, cross-over extension of a previously completed randomized controlled trial. This study evaluated females with active IIH, recruited from University Hospital Birmingham, UK. Participants were treated, in randomized order, for 2 weeks with acetazolamide, amiloride, furosemide, spironolactone, and topiramate; assessment was at baseline and 2 weeks with a minimum 1-week drug washout between drugs. The primary outcome was change in ICP at 2 weeks post-drug administration. The cognitive evaluation was an exploratory study of the trial. ICP was recorded with telemetric, intraparenchymal ICP monitors (Raumedic, Hembrechts, Germany). Adverse events were recorded, and cognition was assessed utilizing the National Institutes of Health Toolbox Cognitive Battery.

RESULTS

Fourteen participants were recruited and evaluated by intention-to-treat analysis. Mean (standard deviation) body mass index was 37.3 (7.0) kg/m2 and ICP was 33.2 (7.1) cm cerebrospinal fluid (CSF) at baseline. ICP fell with four drugs (mean [standard error (SE)]), acetazolamide -3.3 (1.0) mmHg, p = 0.001, furosemide -3.0 (0.9) mmHg, p = 0.001, spironolactone -2.7 (0.9) mmHg, p = 0.003, and topiramate -2.3 (0.9) mmHg, p = 0.010. There was no significant difference between drugs. Side effects were common with acetazolamide (100%, 11/11) and topiramate (93%, 13/14). Baseline cognitive performance was impaired, T-score (mean [SE]) 37.2 (2.6). After treatment, there was a further significant reduction in the fluid cognition domain (ability to process and integrate) with acetazolamide (mean T-score [SE]), -5.0 (2.6), p = 0.057 and topiramate -4.1 (2.0), p = 0.061.

CONCLUSIONS

Acetazolamide, furosemide, spironolactone, and topiramate marginally reduced ICP. While their effects were not significant, this study was not powered to detect a difference between drugs. Participants reported significant side effects with acetazolamide and topiramate including cognitive decline. Cognitive measures were impaired by acetazolamide and topiramate. Therapeutics with greater efficacy and a favorable side effect profile are an unmet need in the treatment of IIH.

Comparing open and closed cell stents in idiopathic intracranial hypertension: A comprehensive meta-analysis of clinical outcomes

Background: Open cell stents (OC) and closed cell stents (CC) each offer unique advantages and potential drawbacks in the context of idiopathic intracranial hypertension (IIH) treatment. We aim to investigate the safety and efficacy of using OC and CC for IIH.Methods: We conducted a systematic review in PubMed, Embase, and Cochrane Library databases following the PRISMA guidelines. Eligible studies included ≥4 patients with IIH treated by OC or CC. Primary outcomes were headache, visual acuity, and papilledema status before and after the procedure. Additionally, failure rate, minor complications, major complications, and total complications were assessed. Pooled analysis of the OC group and CC group were done separately and then compared.Results: Twenty-four studies were included. Of these, 20 reported on OC and 6 reported on CC. Pooled analysis of failure rate was 8% (4%-12%) in OC and 5% (0%-11%) in CC. For headache improvement rate: 78% (70%-86%) in OC and 81% (66%-69%) in CC. For visual acuity improvement: 78% (65%-92%) in OC and 76% (29%-100%) in CC. For papilledema improvement: 88% (77%-98%) in OC and 82% (67%-98%) in CC. For minor complications: 0% (0%-1%) in OC and 0% (0%-2%) in CC. For major complications: 0% (0%-1%) in OC and 2% (0%-6%) in CC. Total complications: 0% (0%-1%) in OC and 2% (0%-6%) in CC.Conclusion: Low failure and complication rates were found in both OC and CC, with no significant difference between them in effectiveness. The CC showed a slight but significant increase in major and total complications compared to the OC. Additionally, a subtle yet significantly lower failure rate was identified in the CC.

Cerebrospinal Fluid Pressure Measurement and Infusion Studies Using Lumbar Puncture

Lumbar puncture provides an easy way of accessing the subarachnoid space. Measuring of the opening cerebrospinal fluid pressure is the most commonly used method of evaluating intracranial pressure but provides basic snapshot information only. Further insights into cerebrospinal fluid dynamics can be obtained through infusion studies, which rely on measurement of the degree of pressure change in response to addition of fluid volume into the subarachnoid space. The authors describe applications of these 2 techniques pertinent to a practicing neuroradiologist, who may be asked to assist with fluoroscopy-guided lumbar puncture in patients with increased body mass index or difficult spine anatomy.

Longitudinal visual outcomes in idiopathic intracranial hypertension: the role of early prognostic indicators and risk stratification in disease management

BACKGROUND

Idiopathic intracranial hypertension (IIH) is increasingly prevalent, yet longitudinal outcome data are scarce. This study aimed to characterise demographic and longitudinal clinical changes in a cohort of patients with IIH.

METHODS

Retrospective cohort analysis on adult patients diagnosed with IIH (Friedman criteria) enrolled in the neuro-ophthalmology database (NODE) across two tertiary centres. Baseline demographic data was obtained at first assessment, with clinical and paraclinical outcomes collected longitudinally. Multivariable statistical analysis identified factors associated with poorer visual outcomes.

RESULTS

A total of 221 patients were included. 91.8% were female (ratio 11:1). Mean age at presentation was 29.2 ± 8.1 years with mean body mass index (kg/m2) at diagnosis of 38.7 ± 9.4. Headache was the most common symptom. Papilloedema was found in 95.5% of patients at baseline. Mean CSF opening pressure was 32.67 ± 6.85cmCSF (range 25-76). Visual outcomes remained stable over time. Trajectory plots showed no deviations in visual acuity, while regression models found no associations with sex, site or age. A higher retinal nerve fibre layer thickness and greater baseline Frisen grade were associated with worse outcomes. Baseline papilloedema grade and CSF opening pressure emerged as early prognostic indicators, aiding risk stratification for those with a greater probability of persistent optic nerve abnormalities including higher retinal nerve fibre layer elevation and sustained atrophic changes over time.

CONCLUSIONS

This study offers insights into visual outcomes in IIH, emphasising the importance of early recognition, risk stratification, and intervention in those with a more severe clinical phenotype at presentation.

Antithrombin III deficiency and idiopathic intracranial hypertension: a case report

BACKGROUND

Idiopathic intracranial hypertension (IIH) is a condition where the pressure of the cerebrospinal fluid in the brain increases without a known cause. It typically affects adults but can also occur in adolescents and children, although it is less common. Numerous elements, including coagulopathy, have been documented in previous cases as potential etiological factors of IIH. Nonetheless, our objective was to present the insufficiency of a coagulation factor as an additional contributing factor to IIH, a notion that has not been previously reported.

CASE PRESENTATION

In this case, a 34-year-old West Asian female patient presented with a subacute generalized headache, bilateral blurred vision, and papilledema. The patient's brain magnetic resonance imaging showed flattening of the posterior globe and empty sella, but no other abnormalities were detected. The results of magnetic resonance venography and cerebrospinal fluid analysis were also normal, except for an opening cerebrospinal fluid pressure of 600 mm H2O during the lumbar puncture. Rheumatologic and endocrine disorders were ruled out on the basis of clinical assessment and laboratory tests. The patient was started on acetazolamide (1 g/day, increased to 2 g/day) and furosemide (20 mg/twice a day) and was encouraged to lose weight. These treatments led to some improvement for about 1 year, but her symptoms then worsened without an obvious cause. Given the prolonged duration of the disease and the lack of expected response to treatment, the patient was reevaluated for endocrinopathy and collagen vascular disease, which were negative. An additional workup revealed an antithrombin III (AT III) deficiency, for which the patient was prescribed acetylsalicylic acid (80 mg/day) in addition to the previous medications. As a result, the patient's papilledema, macular thickness, and nerve fiber layer edema decreased, as observed by fundoscopy and optical coherence tomography. Clinical examination and imaging also showed improvement in the patient's symptoms.

CONCLUSION

This case highlights the importance of considering coagulopathy in cases of IIH and suggests that antiplatelet therapy with acetylsalicylic acid may be beneficial for such patients.

Stenting versus medical treatment for idiopathic intracranial hypertension based on a propensity score matching method

Background

In recent years, stenting has been widely used to treat patients with idiopathic intracranial hypertension (IIH) and venous sinus stenosis (VSS); however, research comparing stenting and medical treatment (MT) remains scarce. This study aimed to evaluate the effectiveness of stenting and MT in treating patients with IIH and VSS.

Methods

In this single-center, retrospective, cohort study, the clinical data of patients diagnosed with IIH and VSS at The First Affiliated Hospital of Zhengzhou University from January 2018 to June 2023 were collected for analysis. Based on the treatment approaches, the patients were divided into the following two groups: the stenting group (Group S), and the MT group (Group M). The patients underwent 1:1 propensity score matching (PSM) to compare the improvement in papilledema Frisén grade, lumbar puncture opening pressure (LPOP), and clinical symptoms after treatment.

Results

In total, 128 participants were included in the study. The participants had an average age of 40.0±11.1 years (range, 18-61 years) and a body mass index (BMI) of 27.5±3.3 kg/m2 (range, 20.0-40.0 kg/m2), and 73.43% were female (68 in Group S and 60 in Group M). Compared with the patients in Group M, those in Group S had a longer median time from onset to treatment (2 vs. 1 month, P=0.026), a higher proportion of papilledema (85.3% vs. 68.3%, P=0.033), a higher median pretreatment stenosis rate (80% vs. 70%, P=0.005), and a larger median pretreatment trans-stenotic pressure gradient (15.5 vs. 11.0 mmHg, P=0.001), and a larger median pretreatment LPOP (391.1 vs. 350.5 mmH2O, P=0.006). Following 1:1 PSM, both groups comprised 28 patients each, and there were no statistically significant differences between the two groups in terms of the covariates (all P>0.05). Compared with the patients in Group M, those in Group S had a lower median papilledema Frisén grade (1 vs. 2, P=0.002) and average LPOP (213.0 vs. 259.8 mmHg, P=0.003) at discharge, and showed more pronounced symptom improvement at the time of discharge (P=0.019), and at 6 months (P=0.011) and 12 months (P<0.001) post-discharge.

Conclusions

The research indicated that stenting was quicker and more effective in alleviating papilledema, LPOP, and corresponding symptoms and signs than MT.

Increased Intracranial Pressure in Myelin-Oligodendrocyte Glycoprotein Antibody-Associated Disease

OBJECTIVES

To assess characteristics of increased intracranial pressure (ICP) in myelin oligodendrocyte glycoprotein antibody-associated disease (MOGAD).

METHODS

This is a multicenter retrospective review of 84 MOGAD cases at the University of Florida, Baylor College of Medicine, the University of California San Diego, and Providence Health and Services, Portland, Oregon, to identify cases with a documented increased opening pressure >25 cm H2O. A literature review was conducted to identify previously reported MOGAD cases with an opening pressure >25 cm H2O.

RESULTS

Of 28 MOGAD cases with available opening pressures, 6 (21.4%) patients (age: 5 to 36 y; 2/6 females) had documented increased ICP with an opening pressure of 26 to 46 cm H2O and optic nerve head edema on funduscopic examination. The increased ICP occurred in the setting of bilateral optic neuritis in all cases. In 5/6 patients, this was the initial presentation of the disorder. Anti-MOG titers were 1:40 (n = 1), 1:100 (n = 4), and 1:1000 (n = 1). In our literature review, we identified 13 additional MOGAD cases with ICP elevations in the setting of meningo-cortical presentations (n = 10), as well as bilateral optic neuritis (n = 3).

CONCLUSIONS

Increased ICP may occur in MOGAD and may be more common in patients with optic neuritis or meningoencephalitis.

Factors associated with vision loss in idiopathic intracranial hypertension patients with severe papilledema

BACKGROUND/OBJECTIVES

Our aim was to compare factors associated with poor versus good visual outcomes in idiopathic intracranial hypertension (IIH) patients with severe papilledema at initial presentation.

SUBJECTS/METHODS

Retrospective review of consecutive IIH patients (1/1/2013-6/10/2023) with severe papilledema (Frisén grade 4-5 and/or atrophy in at least one eye); Patients were divided into "poor visual outcome" (poor visual acuity and constricted visual field in at least one eye) and "good visual outcome" (good visual acuity and only mild visual field changes in both eyes) at >6 months for medically-treated patients and >3 months follow-up for surgically-treated patients.

RESULTS

We included 134 IIH patients with severe papilledema (70 had poor and 64 had good visual outcomes). No significant differences existed for age, gender, race, hypertension, haemoglobin, or cerebrospinal fluid opening pressure. The poor-outcome group had significantly greater BMI (mean 39.2 vs 35.1 kg/m2, p = 0.004), and worse initial HVF-MD (-20.04 vs -5.81 dB, p < 0.0001). Poor-outcome patients saw more prior health-care providers (4.7 vs 2.4, p < 0.0001), with delayed neuro-ophthalmology encounters (58.5 vs 15.2 weeks, p = 0.001). 41.4% of poor-outcome patients were initially seen in outside emergency departments (ED) (vs 14.1% of good-outcome patients, p = 0.0005), while only 27.1% were seen by eye-care providers (vs 53.1% of good-outcome patients, p = 0.0027). No poor-outcome patients initially consulted our institution's ED vs 7.8% of good-outcome patients.

CONCLUSIONS

Although patients with poor visual outcome did not seek medical care later than good outcome patients, they had delayed diagnosis/treatment because of prior outside ED visits and lack of prior eye-care provider evaluations, suggesting that early diagnosis and specialized management of papilledema is essential for patients with symptoms of intracranial hypertension.

Diagnosis and treatment of disorders of intracranial pressure: consensus statement of the Spanish Society of Neurology's Headache Study Group

Primary intracranial pressure disorders include idiopathic intracranial hypertension and spontaneous intracranial hypotension. Remarkable advances have been made in the diagnosis and treatment of these 2entities in recent years. Therefore, the Spanish Society of Neurology's Headache Study Group (GECSEN) deemed it necessary to prepare this consensus statement, including diagnostic and therapeutic algorithms to facilitate and improve the management of these disorders in clinical practice. This document was created by a committee of experts belonging to GECSEN, and is based on a systematic review of the literature, incorporating the experience of the participants, and establishes practical recommendations with levels of evidence and grades of recommendation.

The Impact of Idiopathic Intracranial Hypertension on Cardiovascular Disease Risk Among UK Women: An Obesity-Adjusted Analysis

Introduction

Idiopathic intracranial hypertension (IIH) is known to elevate cardiovascular disease (CVD) risk, but the extent to which obesity and IIH-specific factors contribute to this risk is not well understood. WE aim to separate the effects of obesity from IIH-specific factors on the risk of stroke and CVD, building on previous findings that indicate a two-fold increase in cardiovascular events in women with IIH compared to BMI-matched controls.

Methods

An obesity-adjusted risk analysis was conducted using Indirect Standardization based on data from a cohort study by Adderley et al., which included 2,760 women with IIH and 27,125 matched healthy controls from The Health Improvement Network (THIN). Advanced statistical models were employed to adjust for confounding effects of obesity and determine the risk contributions of IIH to ischemic stroke and CVD, independent of obesity. Four distinct models explored the interactions between IIH, obesity, and CVD risk.

Results

The analysis showed that IIH independently contributes to increased cardiovascular risk beyond obesity alone. Risk ratios for cardiovascular outcomes were significantly higher in IIH patients compared to controls within similar obesity categories. Notably, a synergistic effect was observed in obese IIH patients, with a composite CVD risk ratio of 6.19 (95% CI: 4.58-8.36, p<0.001) compared to non-obese controls.

Conclusions

This study underscores a significant, independent cardiovascular risk from IIH beyond obesity. The findings advocate for a shift in managing IIH to include comprehensive cardiovascular risk assessment and mitigation. Further research is required to understand the mechanisms and develop specific interventions for this group.

Safety and Efficacy of Metformin for Idiopathic Intracranial Hypertension. A U.S-Based Real-World Data Retrospective Multicenter Cohort Study

Introduction

Managing idiopathic intracranial hypertension (IIH) is challenging due to limited treatment options. This study evaluates metformin as a potential therapy for IIH, examining its impact on disease outcomes and safety.

Methods

We performed a retrospective cohort study using the TriNetX database, covering data from 2009 to August 2024. The study included IIH patients, excluding those with other causes of raised intracranial pressure or pre-existing diabetes. Propensity score matching adjusted for age, sex, race, ethnicity, Hemoglobin A1C, and baseline BMI at metformin initiation. We assessed outcomes up to 24 months.

Results

Initially, 1,268 patients received metformin and 49,262 served as controls, showing disparities in various parameters. After matching, both groups consisted of 1,267 patients each. Metformin users had significantly lower risks of papilledema, headache, and refractory IIH at all follow-ups (p<0.0001). They also had fewer spinal punctures and reduced acetazolamide use. BMI reductions were more significant in the metformin group from 6 months onward (p<0.0001), with benefits persisting regardless of BMI changes. Metformin's safety profile was comparable to the control group.

Conclusions

The study indicates metformin's potential as a disease-modifying treatment in IIH, with improvements across multiple outcomes independent of weight loss. This suggests complex mechanisms at play, supporting further research through prospective clinical trials to confirm metformin's role in IIH management and its mechanisms of action.

Idiopathic intracranial hypertension: Imaging and clinical fundamentals

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.

Spontaneous cerebrospinal fluid rhinorrhea as a primary presentation of idiopathic intracranial hypertension, management strategies, and clinical outcome

Background

Causes of cerebrospinal fluid (CSF) rhinorrhea could be divided into primary (spontaneous) and secondary (head trauma and iatrogenic). Idiopathic intracranial hypertension (IIH) has emerged as a cause for spontaneous CSF rhinorrhea but is still underestimated, may be overlooked and needs special consideration in management. The objective of this study is to demonstrate spontaneous CSF rhinorrhea as the primary presentation of IIH and explore the algorithm of management.

Methods

All patients with spontaneous (primary) CSF rhinorrhea were included with complete clinical and radiological assessment. We performed lumbar puncture and CSF pressure measurements in the lateral decubitus position for all included patients to detect those with intracranial hypertension. A pressure of 20 cmH2O in cases of CSF rhinorrhea is considered a cutoff for diagnosing raised intracranial pressure. When intracranial hypertension was diagnosed, patients were subjected immediately to lumboperitoneal shunt. If CSF leakage stopped after shunt insertion, we would not perform skull base repair, and the patient was sent for follow-up. However, if CSF leakage did not stop after shunt insertion despite normalization of intracranial tension or recurrence of CSF rhinorrhea despite shunt patency or there was intracranial pneumocephalus, skull base repair would be performed.

Results

During the period of the study, 293 cases of CSF rhinorrhea were seen. Only 42 (14.3%) patients were diagnosed with spontaneous CSF rhinorrhea, and the remaining were posttraumatic. Thirty-seven patients (88.1%) of 42 patients revealed high CSF pressure readings. All 37 patients received lumboperitoneal shunt followed by CSF rhinorrhea stoppage. Later, during follow-up, 7 patients developed recurrence of leakage; 3 of them revealed shunt obstruction, and rhinorrhea improved after shunt revision. The other 4 patients revealed patent shunt and needed skull base repair.

Conclusion

Spontaneous CSF rhinorrhea is considered secondary to IIH until proven otherwise. Initial placement of lumboperitoneal shunt may provide an effective alternative to skull base repair for the treatment of patients with IIH presenting with CSF rhinorrhea.

Idiopathic Intracranial Hypertension Is Associated With an Increased Risk of Hypertensive Pregnancy Disorders

BACKGROUND

Idiopathic intracranial hypertension (IIH) mainly occurs in women of a reproductive age who are overweight or obese. As pregnancy occurs in this age group, it is important to understand whether there are associations between IIH and pregnancy. The purpose of this study was to determine the incidence of IIH development during a pregnancy and whether IIH is associated with hypertensive disorders of pregnancy (HDP).

METHODS

In this retrospective cohort analysis, electronic health records from a tertiary care center were used to identify patients with IIH. Patients who had a diagnostic code for IIH or papilledema and were seen between June 1, 2012, and September 1, 2023, were included. After meeting the revised Dandy diagnostic criteria, patients were evaluated for a history of pregnancy before, during, or after their IIH diagnosis and hypertensive disorders including preeclampsia/eclampsia, HELLP (hemolysis, elevated liver enzymes, low platelet count) syndrome, and hypertension. Incidence and risk ratios (RR) were calculated comparing patients with IIH with controls without IIH. To corroborate these results while controlling for obesity and migraine, the TriNetX platform housing more than 100 million patients was used to design a case-control analysis evaluating the odds of an IIH patient having an HDP.

RESULTS

Two hundred ninety-two IIH patients with a prior pregnancy were identified of which 7% developed new onset IIH during pregnancy. Patients had increased risks of all HDP including eclampsia (RR: 12.92, 95% CI: 5.35, 31.22), preeclampsia (2.39, CI 1.84, 3.10), and HELLP syndrome (6.72, CI 2.16, 20.90) compared with controls. Patients with IIH also had higher risks of ectopic pregnancies and miscarriages (P < 0.05). When controlling for obesity and migraine, patients continued to have increased odds of all HDP and eclampsia (P < 0.05).

CONCLUSIONS

Patients with IIH had an increased risk of having an HDP, especially eclampsia and HELLP syndrome highlighting a need for increased clinical monitoring of these patients during pregnancy.

Idiopathic Intracranial Hypertension - How Can Orthoptists Help Improve Care?

Care for people with idiopathic intracranial hypertension (IIH) needs improving and I think orthoptists are in a perfect position to help. The problems with IIH care are multi-fold:  People with fulminant IIH are still losing sight due to delayed diagnosis or mismanagement.People with IIH often have a poor quality of life due to disabling chronic headaches and poor mental health.There is a lack of access to evidence-based weight-loss interventions and support.Weight stigma in healthcare remains pervasive and damaging and disproportionately impacts women.Functional vision loss and headaches in IIH can complicate the interpretation of visual function which can have implications for management.There is a lack of evidence to support treatment options. Below I will describe the issues in more detail and outline the ways in which we as orthoptists can help this patient group.

Idiopathic intracranial hypertension presenting as bilateral palpebral venous engorgement

Purpose

To report the case of a woman in her fifties whose presenting symptom of idiopathic intracranial hypertension was engorgement of the eyelid veins.

Observations

Bilateral engorged palpebral veins were visible through the skin. Dilated fundus examination revealed bilateral optic disc edema. Magnetic resonance imaging revealed bilateral posterior globe flattening and empty sella. Magnetic resonance venogram revealed unilateral transverse sinus stenosis. Lumbar puncture revealed elevated opening pressure. All other initial diagnostic tests were negative.

Conclusions and importance

Idiopathic intracranial hypertension (IIH) typically presents with headache, vision changes, and weight gain. Palpebral venous engorgement has to the authors' knowledge not been previously reported as a presenting sign of IIH. Physicians should recognize this finding and its potential association with elevated intracranial pressure.

Severe visual loss from concurrent fulminant idiopathic intracranial hypertension and malignant arterial hypertension: Prompt suspicion matters

Purpose

To report a case series of 4 patients with poor visual outcomes from concurrent fulminant idiopathic intracranial hypertension (IIH) and malignant arterial hypertension with bilateral optic disc edema. The diagnosis of fulminant IIH was delayed given the bilateral optic disc edema was attributed initially to hypertensive optic neuropathy.

Observation

All 4 patients (3 males, 3 African Americans, mean BMI 27.6 kg/m2 (range 19.5-36 kg/m2) presented to the emergency department with bilateral vision loss, optic disc edema, and blood pressure (BP) of greater than 180/120. The patients were treated initially to control BP and the optic disc edema was either attributed to the hypertension or the ophthalmic examination was not performed. The patients were subsequently diagnosed with IIH with Brain MRI, MR venogram, and lumber puncture (mean cerebrospinal fluid (CSF) opening pressure 42 cm, range 40-43 cm). The mean time from presentation to diagnosis of IIH was 3.2 months (range 1-6 months). The final visual acuity ranged from 20/400 to hand motions in the better eye and count fingers to hand motions in the worse eye despite bilateral optic nerve sheath fenestrations (3 patients), ventriculoperitoneal shunts (3 patients), and treatments with acetazolamide (3 patients) and furosemide (1 patient).

Conclusion

Our case series underscores the need to promptly include IIH in the differential diagnosis in patients with bilateral optic disc edema including patients with malignant hypertension, particularly in those experiencing progressive visual loss, regardless of gender or BMI. Prompt work-up with brain MRI with contrast and MR or CT venogram to detect neuroimaging signs of intracranial hypertension followed by a lumbar puncture with CSF opening pressure are essential to initiate rapid treatment of fulminant IIH to avoid poor outcome.

Orthostatic Hemifacial Spasm in Idiopathic Intracranial Hypertension

BACKGROUND

Among the symptoms seen in idiopathic intracranial hypertension (IIH), hemifacial spasm (HFS) is rare. Orthostatic-induced HFS preceding lumbar puncture (LP) is previously unreported. We treated two patients with unusual IIH presentations. This case series reviews the few reports of HFS in IIH and proposes a mechanism for spasm occurrence.

METHODS

Case 1: A woman in her mid-40s with previously controlled IIH developed daily headache, pulsatile tinnitus, right-sided trigeminal paresthesia, and right-sided HFS. The latter 2 symptoms occurred exclusively when moving from a sitting to a standing position. Imaging was unremarkable; opening pressure (OP) on LP was 46 cmH 2 O with normal cerebrospinal fluid (CSF) components. Case 2: A woman in her late 40s presented with severe daily headache, pulsatile tinnitus, and left-sided HFS following weight gain. Imaging was unremarkable; OP on LP was 32 cmH 2 O with normal CSF components.

RESULTS

HFS episodes persisted following LP in both patients. Increasing and initiating acetazolamide, respectively, resolved all symptoms.

CONCLUSIONS

Earlier suggested mechanisms of HFS are based on elevated intracranial pressure (ICP) shifting the facial nerve into proximity of a vascular structure. HFS appearing upon standing and continuing after LP, and thus a lower ICP, contradicts this. We propose a mechanism based on the degree of ICP change. This theory is grounded in the lack of intracranial compliance in IIH, wherein substantial pressure changes occur following small volume changes.

Elevated systemic venous pressures as a possible pathology in prepubertal pediatric idiopathic intracranial hypertension

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.

IIH, SIH and headache: Diagnosis and treatment update

Idiopathic intracranial hypertension (IIH) and spontaneous intracranial hypotension (SIH) are two major secondary headache disorders resulting from abnormal intracranial pressure (ICP). This short communication outlines the pathophysiology, diagnostic criteria, and management strategies for IIH and SIH. IIH predominantly affects obese women of childbearing age and presents with daily headaches, visual disturbances, and papilledema. It is characterized by elevated cerebrospinal fluid (CSF) pressure, with diagnosis supported by imaging and lumbar puncture. Treatment includes weight reduction, medications, and surgical interventions in refractory cases. SIH, conversely, is caused by spontaneous spinal CSF leaks and presents with acute orthostatic headaches. Diagnosis is supported by neuroimaging and lumbar puncture, revealing low CSF pressure. Treatment includes supported care, (targeted) epidural blood patch, with surgical repair considered in refractory cases. Advances in imaging and treatment have significantly improved outcomes for both conditions.

Effectiveness of optic nerve sheath fenestration in preserving vision in idiopathic intracranial hypertension: an updated meta-analysis and systematic review

BACKGROUND

This study aims to evaluate the effectiveness of Optic Nerve Sheath Fenestration (ONSF) in improving visual outcomes in patients with Idiopathic Intracranial Hypertension (IIH).

METHODS

A meta-analysis was conducted using data from 19 studies, totaling 1159 observations. The main assessed outcomes after ONSF surgery were: the improvement in visual acuity, the improvement in visual fields and reduction in papilledema. We performed separate analyses to distinguish between outcomes using different surgical approaches. Comprehensive literature searches were conducted in the Ovid MEDLINE(R) and SCOPUS databases, following PRISMA guidelines. Statistical analyses employed a Generalized Linear Mixed Model (GLMM) to integrate proportion data, with heterogeneity assessed via I-squared and H statistics. Publication bias was evaluated using funnel plots, Egger's test, and Peters' test.

RESULTS

The analysis revealed that ONSF significantly improved visual acuity in 41.09% of patients, and visual fields in 76.34% of cases. The transconjunctival approach demonstrated higher success rates for visual field improvement. A high improvement rate of 97% was observed in reducing optic disc swelling. Significant heterogeneity was noted, particularly in visual acuity (I2 = 92.1%) and visual field improvements (I2 = 73.8%), reflecting variability in surgical techniques and patient demographics. Publication bias assessments indicated no significant bias for visual acuity and visual field outcomes, although potential bias was detected for papilledema reduction.

CONCLUSIONS

This meta-analysis confirms that ONSF is effective in improving visual outcomes for IIH patients, especially when using the transconjunctival approach. Early surgical intervention is crucial for optimal results, principally in preventing advanced ischemic damage. Despite high success rates, observed heterogeneity highlights the need for standardized surgical techniques and further investigation into patient-specific factors influencing outcomes. Addressing potential publication bias and conducting more rigorous studies will enhance the reliability of future meta-analyses. Upcoming research in ONSF efficacy is needed to refine surgical practices and optimize patient care.

Disability and Patient-Reported Satisfaction in Women with Idiopathic Intracranial Hypertension: A Comparative Study of Venous Sinus Stenting and Medical Management

OBJECTIVE

Patients with chronic idiopathic intracranial hypertension (IIH) commonly experience a high level of disability and low satisfaction with medical treatment. We aim to evaluate long-term functional improvement and patient satisfaction in IIH patients with similar symptoms by comparing venous sinus stenting (VSS) to standard medical therapy.

METHODS

We conducted a cross-sectional questionnaire study of 111 IIH patients, comparing 37 adult female patients who underwent venous sinus stenting with 74 patients treated medically. Propensity score matching was used to balance age and presence of papilledema at presentation between groups. Headache-related disability was evaluated using the Migraine Disability Assessment Scale (MIDAS), while general function and treatment satisfaction were assessed using custom questionnaires. Electronic medical records and the results of imaging upon diagnosis were reviewed retrospectively.

RESULTS

The stented group reported significantly better outcomes in physical well-being (median 4.0 vs. 1.0, p < 0.001), task completion (4.0 vs. 1.0, p < 0.001), work/school persistence (5.0 vs. 1.0, p < 0.001), and mental well-being (4.0 vs. 1.0, p < 0.001). Additionally, the stented group had a lower proportion of patients with severe MIDAS (MIDAS > 4, 24.3% vs. 47.9%, p = 0.017). Logistic regression suggested venous stenting as a protective factor against severe MIDAS scores (OR = 0.174, p = 0.004).

CONCLUSION

Cerebral venous stenting in patients with IIH is associated with lower disability and higher patient satisfaction from medical treatment compared to those treated with medications only. These findings suggest that venous sinus stenting may be a valuable treatment option for selected IIH patients. However, larger prospective studies are needed to further validate our results.

A systematic review of surgical and interventional radiology procedures for pediatric idiopathic intracranial hypertension

Background

Idiopathic intracranial hypertension (IIH) is defined as elevated intracranial pressure and consequent symptoms (mainly headache and visual deterioration) occurring in the absence of secondary causes. Surgical and interventional radiology procedures should be considered for refractory IIH and mainly include cerebrospinal fluid (CSF) diversion techniques, optic nerve sheath fenestration (ONSF), and venous sinus stenting (VSS). Our study aims to review the current literature on the application of these techniques in clinical practice.

Methods

A systematic literature review on the surgical and interventional radiology treatment of IIH was conducted, focusing on ONSF, VSS, and CSF diversion techniques. According to PRISMA guidelines, all reports published in PubMed in the last 30 years (1993-2023) were considered, and among 722 papers, 48 were included in the present study, resulting in a total study population of 454 children or adolescents (11 months-17 years old).

Results

Among 454 patients, 193 underwent an invasive approach, divided into CSF diversion (115/193), ONSF (65/193), VSS (11/193), cranial subtemporal decompression (8/193), and internal cranial expansion (9/193). Sixteen of the 193 patients (8%) required reintervention due to relapsing symptoms or surgical complications, particularly those who underwent CSF diversion. Furthermore, 9/115 required shunt revision due to shunt obstruction or malfunction. We extracted data on the outcome of each procedure: of the 193 patients, 71 experienced a positive outcome with symptom resolution or improvement, while 27 demonstrated a negative outcome.

Discussion and conclusions

Severe and refractory cases of IIH are eligible for invasive treatments. CSF diversion is the most frequently used technique, despite its high failure risk and need for reintervention. ONSF has shown good results in terms of outcome and safety, particularly in children with visual symptoms. VSS is the most recent approach, indicated in children with stenosis of the venous sinus. In our study population, VSS demonstrated good results in terms of symptom resolution and need for reintervention, but its use remains limited to a few centers.

Systematic Review Registration

https://www.crd.york.ac.uk/, PROSPERO (CRD42024504244).

Safety and Efficacy of Metformin for Idiopathic Intracranial Hypertension. A U.S-Based Real-World Data Retrospective Multicenter Cohort Study

INTRODUCTION

Idiopathic intracranial hypertension (IIH) remains a challenging condition to manage, with limited therapeutic options. This study investigated the potential of metformin as a novel treatment for IIH, exploring its effects on disease outcomes and safety profile.

METHODS

We conducted a retrospective cohort study using the TriNetX database, analyzing data from 2009 to August 2024. Patients diagnosed with IIH were included, with exclusions for other causes of elevated intracranial pressure and pre-existing diabetes. Propensity score matching was employed to balance cohorts according to age, sex, race, ethnicity, Hemoglobin A1C, and baseline body mass index (BMI) at the time of metformin initiation. Outcomes were assessed at various follow-up points up to 24 months.

RESULTS

Our study initially comprised 1,268 patients in the metformin group and 49,262 in the control group, with notable disparities in several parameters. Post-matching, both cohorts were refined to 1,267 patients each after matching with metformin group. Metformin-treated patients showed significantly lower risks of papilledema, headache, and refractory IIH status at all follow-up points (p<0.0001). The metformin group also had reduced rates of therapeutic spinal punctures and acetazolamide continuation. BMI reductions were more pronounced in the metformin group, with significant differences observed from 6 months onward (p<0.0001). Notably, metformin's beneficial effects persisted independently of BMI changes. The safety profile of metformin was favorable, with no significant differences in adverse events compared to the control group which did not receive metformin during the study timeframe.

CONCLUSIONS

Our study provides evidence for metformin's potential as a disease-modifying therapeutic approach in IIH, demonstrating improvements across multiple outcomes. The benefits appear to extend beyond weight loss, suggesting complex mechanisms of action. These findings warrant further investigation through prospective clinical trials to establish metformin's role in IIH management and explore its underlying therapeutic mechanisms.

Venous Sinus Stenting for Idiopathic Intracranial Hypertension: A Report of Two Cases

Idiopathic intracranial hypertension (IIH) is characterized by an elevated intracranial pressure of unknown cause, which can lead to severe and sometimes irreversible visual impairment. Recently, venous sinus stenting (VSS) has emerged as an alternative treatment option for IIH. Here, we report two patients with IIH who successfully underwent VSS in the transverse sinus and displayed rapid improvement in visual symptoms. Two young women presented with progressive visual symptoms of papilledema. The cerebrospinal fluid (CSF) opening pressures were elevated higher than 40 cmH2O. Magnetic resonance venography demonstrated stenosis of the transverse sinuses. Intravascular ultrasonography demonstrated focal extrinsic narrowing of the sinuses. Dilatation of the stenotic sinuses using self-expanding open-cell stents resolved the trans-stenotic pressure gradients and lowered the CSF pressure. Visual symptoms and papilledema improved immediately after the procedures. VSS could be a useful treatment option for IIH with rapidly progressive visual impairment.

An interdisciplinary integrated specialized one-stop outpatient clinic for idiopathic intracranial hypertension-a comprehensive assessment of clinical outcome

BACKGROUND AND PURPOSE

Management of idiopathic intracranial hypertension (IIH) is complex requiring multiple specialized disciplines. In practice, this creates considerable organizational and communicational challenges for healthcare professionals and patients. Thus, an interdisciplinary integrated outpatient clinic for IIH (comprising neurology, neuroophthalmology, neuroradiology, neurosurgery and endocrinology) was established with central coordination and a one-stop concept. Here, the aim was to evaluate the effects of this one-stop concept on objective clinical outcome.

METHODS

In a retrospective cohort study, the one-stop era with integrated care (IC) (1 July 2021 to 31 December 2022) was compared to a reference group receiving standard care (SC) (1 July 2018 to 31 December 2019) regarding visual impairment/worsening and headache improvement/freedom 6 months after diagnosis. Multivariate binary logistic regression models were used to adjust for confounders.

RESULTS

Baseline characteristics of the IC group (n = 85) and SC group (n = 81) were comparable (female 90.6% vs. 90.1%; mean age 33.6 vs. 32.8 years; median body mass index 31.8 vs. 33.0; median cerebrospinal fluid opening pressure 32 vs. 34 cmH2O; at diagnosis, visual impairment was present in 71.8% vs. 69.1% and chronic headache in 55.3% vs. 56.8% in IC vs. SC). IC was associated with a higher likelihood of achieving both headache improvement (odds ratio [OR] 2.24, 95% confidence interval [CI] 1.52-4.33, p < 0.001) and headache freedom (OR 1.75, 95% CI 1.11-3.09, p = 0.031). Regarding the risk of visual impairment and visual worsening IC was superior numerically but not statistically significantly (OR 0.87, 95% CI 0.69-1.16, p = 0.231, and OR 0.67, 95% CI 0.41-1.25, p = 0.354).

CONCLUSIONS

Interdisciplinary integrated care of IIH is favourably associated with headache outcomes and potentially also visual outcomes.

Idiopathic intracranial hypertension secondary to Superior Sagittal Sinus Stenosis: a case report

INTRODUCTION

Idiopathic intracranial hypertension (IIH) is a disease characterized by elevated intracranial pressure (ICP) without established etiology. Venous sinus stenosis contributes to IIH; however, it is still uncertain whether the stenosis is a primary cause of IIH or a secondary result in response to elevated ICP. Transverse sinus stenosis is frequently identified in patients with IIH and it is suggestive of raised ICP. Here, we report a case of IIH caused by intrinsic superior sagittal sinus stenosis (SSS).

CASE PRESENTATION

A 43-year-old man suffered from IIH with headache, papilledema, and visual impairment. Angiography demonstrated isolated SSS stenosis with a pressure gradient of 30 mmHg. SSS stenosis was resistant to revascularization by stenting alone and intrastent balloon angioplasty was then performed to overcome such resistance. The rigidity of the vein wall suggests that the vein is not collapsed and the stenosis is intrinsic, secondary to idiopathic anatomical local changes. Post-procedure headache disappeared and visual acuity improved.

CONCLUSION

An isolated SSS stenosis could lead to intracranial hypertension and this condition should be taken into account in the diagnostic workup of IIH. By now, SSS stenosis is not mentioned in any current consensus guidelines or paper on the diagnostic workflow of intracranial hypertension.

Management of Idiopathic Intracranial Hypertension: A Case Report

ABSTRACT

BACKGROUND: Idiopathic intracranial hypertension (IIH) is a neurological disorder characterized by elevated intracranial pressure, affecting predominantly obese women of childbearing age. Early recognition and comprehensive management are vital for preventing severe complications, particularly vision loss. METHODS: This study reports a case of a 27-year-old woman who presented with chronic headaches and blurred vision. Notable findings included headaches that were intensified upon waking and exacerbated by activities that elevated intracranial pressure. The patient also reported nausea, vomiting, transient visual obscurations, and pulsatile tinnitus. After a clinical examination, she was given a diagnosis of IIH. RESULTS: The patient underwent a lumbar-peritoneal shunt procedure to alleviate her symptoms in conjunction with medication treatment. This case study highlights the importance of a multidisciplinary approach in diagnosing and treating IIH. In particular, weight management emerged as a crucial preventive measure against IIH recurrence. CONCLUSION: A multidisciplinary team strategy can enhance outcomes and quality of life, accentuating the need for continued research into IIH recurrence, treatments, and wider implications.

Idiopathic intracranial hypertension in Asians: a retrospective dual-center study

BACKGROUND

There have been limited data on idiopathic intracranial hypertension (IIH) in Asians and there remain uncertainties whether a cerebrospinal fluid (CSF) pressure of 250 mm CSF is an optimum diagnostic cutoff. The aims of the present study included (1) characterization of IIH patients in Taiwan, (2) comparisons among different diagnostic criteria for IIH, and (3) comparisons between patients with CSF pressures of > 250 and 200-250 mm CSF.

METHODS

This retrospective study involved IIH patients based on the modified Dandy criteria from two tertiary medical centers in Taiwan. Clinical manifestations were retrieved from electronic medical records, and findings on ophthalmologic examination and magnetic resonance images (MRIs) were reviewed.

RESULTS

A total of 102 patients (71 F/31 M, mean age 33.4 ± 12.2 years, mean CSF pressure 282.5 ± 74.5 mm CSF) were identified, including 46 (45.1%) with obesity (body-mass index ≥ 27.5), and 57 (62.6%) with papilledema. Overall, 80 (78.4%), 55 (53.9%), 51 (50.0%), and 58 (56.9%) patients met the Second and Third Edition of International Classification of Headache Disorders, Friedman, and Korsbæk criteria, respectively. Patients in the 200-250 mm CSF group (n = 40) were less likely to have papilledema (48.5% vs. 70.7%, p = 0.035), transient visual obscuration (12.5% vs. 33.9%, p = 0.005), and horizontal diplopia (10.0% vs. 30.6%, p = 0.006), and had fewer signs on MRIs (2.2 ± 1.3 vs. 2.8 ± 1.0, p = 0.021) when compared with those with CSF pressures > 250 mm CSF (n = 62). However, the percentages of patients with headache (95.0% vs. 87.1%, p = 0.109) at baseline, chronic migraine at six months (31.6% vs. 25.0%, p = 0.578), and visual field defect (86.7% vs. 90.3%, p = 0.709) were similar.

CONCLUSIONS

It was found that obesity and papilledema were less common in Asian IIH patients when compared with Caucasian patients. Although patients with CSF pressures of 200-250 mm CSF had a less severe phenotype, the risks of having headache or visual loss were comparable to those in the > 250 mm CSF group. It is possible that a diagnostic cutoff of > 200 mm CSF could be more suitable for Asians, although further studies are still needed.

An algorithm for the surgical approach to spontaneous temporal bone CSF leak

OBJECTIVE

To suggest a comprehensive algorithm for the surgical approach for correcting of sources of temporal bone CSF leaks.

METHODS

A case series for patients operated in a single academic tertiary referral center between 2011 and 4.2022. Included in the study were 46 patients, 5 of whom had a bilateral problem, resulting in 51 pathologic temporal bones. The presentation was an active CSF leak (38 patients) or bacterial otogenic meningitis (8 patients). Follow up ranged from 8 months to 5 years.

RESULTS

Of the 42 ears operated via the default middle fossa approach, 37 were successful (88 %) in controlling CSF leak. None had intracranial complications or sensorineural hearing loss. Location, number and size of the defects, hearing status, associated superior semicircular canal dehiscence, additional intra-temporal or intra-cranial pathologies may indicate a transmastoid approach. Of the six ears that had a canal wall up mastoidectomy as a primary procedure, one required revision due to ongoing CSF leak. Five revision cases and three primary cases were effectively sealed with a subtotal petrosectomy and obliteration. One was lost to follow-up. Hearing was reconstructed with bone-anchored hearing implants in 6 out of these 8 ears.

CONCLUSIONS

The middle fossa approach could be used as a default approach for sealing TD. There are a number of indications for transmastoid approaches in both primary and revision cases. Obliteration of the ear was used in all revision cases. The suggested algorithm can help in planning surgery for temporal bone CSF leaks or a history of otogenic meningitis.