Pseudotumor cerebri: brief review of clinical syndrome and imaging findings

Evaluation of postoperative intracranial pressure in patients with radiological diagnosis of idiopathic intracranial hypertension

OBJECTIVE

This study aimed to assess postoperative intracranial pressure in patients with clinical and/or radiological features of idiopathic intracranial hypertension (IIH) undergoing endoscopic endonasal surgery for primary cerebrospinal fluid (CSF) leak repair.

METHODS

Data was prospectively collected from 9 patients diagnosed with CSF nasal leaks who underwent corrective endonasal surgery between January 1, 2021, and October 31, 2022. Postoperative intracranial pressure was measured via lumbar puncture at least one month after surgery. Preoperative and postoperative MRI scans were compared to evaluate changes.

RESULTS

Postoperative lumbar puncture revealed elevated intracranial pressure in 67 % of patients, and 100 % showed persistent signs of intracranial hypertension on MRI.

CONCLUSION

Managing elevated intracranial pressure in patients with CSF nasal leaks should be prioritized alongside surgical correction. Consideration of permanent peritoneal shunt or pharmacological treatment may be necessary for patients with classic IIH phenotype. Longitudinal studies are essential for further understanding long-term outcomes.

The ligamentous cervical instability etiology of human disease from the forward head-facedown lifestyle: emphasis on obstruction of fluid flow into and out of the brain

Ligamentous cervical instability, especially ligamentous upper cervical instability, can be the missing structural cause and/or co-morbidity for many chronic disabling brain and systemic body symptoms and diagnoses. Due to the forward head-facedown lifestyle from excessive computer and cell phone usage, the posterior ligament complex of the cervical spine undergoes a slow stretch termed "creep" which can, over time, lead to cervical instability and a breakdown of the cervical curve. As this degenerative process continues, the cervical curve straightens and ultimately becomes kyphotic, a process called cervical dysstructure; simultaneously, the atlas (C1) moves forward, both of which can lead to encroachment of the structures in the carotid sheath, especially the internal jugular veins and vagus nerves. This obstruction of fluid flow can account for many brain diseases, and compression and stretch of the vagus nerve for body diseases, including dysautonomia. This article describes the consequences of impaired fluid flow into and out of the brain, especially venous flow through the internal jugular veins, leading to intracranial hypertension (formerly called pseudotumor cerebri). Cervical structural, internal jugular vein, and optic nerve sheath measurements are presented from a retrospective chart review of 227 consecutive patients with no obvious cause for 1 of 8 specific brain or mental health symptoms-anxiety, brain fog, concentration difficulty, depression/hopelessness, headaches, obsessive thoughts, panic attacks, and rumination on traumatic events. A case example is given to demonstrate how cervical structural treatments can open up internal jugular veins and improve a patient's chronic symptoms.

Sinus vein thrombosis conundrum: Persistent empty sella vs. flexible optic nerve sheath

INTRODUCTION

Our objective was to investigate the potential effect of thrombotic burden on pituitary gland height, bony sella and optic sheath width, taking into consideration the various venous sites and dominant drainage pattern.

PATIENTS AND METHODS

This retrospective cohort study followed patients diagnosed with cerebral sinus vein thrombosis in a single primary healthcare center between the years 2000 and 2022. Data was collected from both CT/V and MR/V scans available on the local PACS system. Dural sinuses were divided into main anatomical sites and scored for patent, partially or totally blocked lumen. Dominant drainage flow was noted for each patient. For most scans, pituitary mid height, maximal depth and AP width of the bony sella and dorsum sella to tuberculum sella distance were assessed. Optic sheath width was measured for both sides at the maximal retrobulbar diameter. Regression methods, including linear mixed models, and non-parametric tests were used to analyze the data.

RESULTS

90 patients (mean age, 44 years ±16.8, 54 women) were evaluated. Overall thrombus burden did not correlate with pituitary mid-height, however a relationship was observed between the change (from presentation) in the superficial thrombus score and the average width of the optic nerve sheath; the width of the optic sheath tended to decrease as thrombus burden improved and vice versa (p = 0.010).

CONCLUSIONS

Thrombus recanalization had a favorable effect on the optic nerve sheath diameter but did not appear to reverse the flattening of the pituitary gland, regardless of temporal improvement.

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).

Role of diffusion tensor imaging in the evaluation of white matter integrity in idiopathic intracranial hypertension

OBJECTIVES

To determine whether idiopathic intracranial hypertension (IIH) may affect white matter integrity and optic pathways by using diffusion tensor imaging (DTI) and to correlate the DTI metrics with intracranial pressure (ICP).

METHODS

This study is a retrospective case-control study. A total of 42 patients who underwent lumbar puncture and those with elevated ICP, meeting the diagnostic criteria for IIH, were included in the study. All patients had supportive magnetic resonance imaging findings for the diagnosis of IIH. The headache control group comprised 36 patients who presented to the Neurology Department with infrequent episodic tension-type headache, had a normal neurologic examination, and had clinical and radiological findings suggestive of normal ICP. For each patient with IIH, clinical findings and ophthalmological measurements were recorded. The apparent diffusion coefficient (ADC), fractional anisotropy (FA), axial diffusivity (AD), and radial diffusivity (RD) values were calculated using a region of interest-based method in different white matter tracts and optic pathways and compared.

RESULTS

A total of 42 patients diagnosed with IIH (three males, 39 females), with a mean (standard deviation [SD] age of 38.1 (8.9) years), and 36 headache controls (10 males, 26 females, mean [SD] age; 38.1 [9.4] years) were included in the study. The mean (SD) body mass index (BMI) of the patients with IIH was 25.2 (1.9) kg/m2, and the mean (SD) BMI of the headache controls was 23.3 (1.5) kg/m2 (p < 0.001). Decreased FA values and increased RD values in the cingulum were detected in patients with IIH compared to the headache controls (p = 0.003, Cohen's d = 0.681; p = 0.002 Cohen's d = -0.710). Decreased AD values in the left and right superior cerebellar peduncle and increased ADC values in the middle cerebellar peduncle were detected in patients with IIH compared to the headache controls (p < 0.001, Cohen's d = 0.961; p = 0.009, Cohen's d = 0.607; p = 0.015, Cohen's d = -0.564). Increased ADC and RD values and decreased FA values in optic nerve were detected in patients with IIH (p = 0.010, Cohen's d = -0.603; p = 0.004, Cohen's d = -0.676; p = 0.015 Cohen's d = 0.568). A positive correlation was found between the cerebrospinal fluid pressure and ADC values of the left and right superior and left inferior longitudinal fasciculus, genu of the corpus callosum, and right optic radiation (r = 0.43, p = 0.005; r = 0.31, p = 0.044; r = 0.39, p = 0.010; r = 0.35, p = 0.024; r = 0,41, p = 0.007). There was a positive correlation between the retinal nerve fiber layer thickness and the ADC values of the optic nerve (r = 0.32, p = 0.039).

CONCLUSIONS

Intracranial hypertension can be associated with deteriorated DTI values, which might be interpreted as a sign of impaired white matter microstructural integrity in many brain regions beyond the periventricular white matter. Pressure-induced edema and axonal degeneration may be the potential underlying mechanisms of this microstructural damage.

A narrative review of magnetic resonance imaging findings in pediatric idiopathic intracranial hypertension

Background and Aims

Idiopathic intracranial hypertension (IIH) is a rare neurological disorder in the pediatric population which is defined as an increase in intracranial pressure (ICP) without the presence of brain parenchymal lesions, hydrocephalus, or central nervous system infection. In this study, we have determined the magnetic resonance imaging (MRI) findings in IIH patients.

Methods

A comprehensive literature search was conducted using the electronic databases including Web of Sciences, Scopus, and Pubmed to identify suitable and relevant articles using keyword search methods. The search included keywords such as "idiopathic intracranial hypertension," "pseudotumor cerebri," "MRI," and "pediatrics." The search was limited to the available publications up to January 2024.

Results

MRI plays a crucial role in diagnosing IIH by excluding secondary causes and revealing neuroimaging findings associated with elevated ICP. Despite fewer studies in children compared to adults, MRI serves as a cornerstone in identifying traditional neuroradiological markers such as empty sella turcica, posterior globe flattening, optic nerve tortuosity, optic nerve sheath distension, and transverse venous sinus stenosis. Additional subtle markers include increased Meckel's cave length, cerebellar tonsillar herniation, and slit-like ventricles, although these are less reliable. Diffusion-weighted imaging does not typically show cerebral ADC value changes indicative of cerebral edema in pediatric IIH.

Conclusion

MRI findings provide valuable non-invasive diagnostic indicators that facilitate early detection, clinical management, and potential surgical intervention in pediatric IIH. The reliability of these MRI markers underscores their importance in clinical practice.

Transorbital B-mode ultrasound for the assessment of posterior globe flattening in idiopathic intracranial hypertension: a pilot study

BACKGROUND

Posterior globe flattening (PGF) is a specific neuroimaging sign in patients with idiopathic intracranial hypertension (IIH), but its detection is based on subjective qualitative neuroradiological assessment. This study sought to evaluate the utility of transorbital ultrasound to detect and quantify PGF in IIH patients using the Posterior Globe Angle (PGA).

METHODS

Consecutive IIH patients and healthy controls were enrolled in a prospective case-control study. Transorbital ultrasound was performed to assess the presence of PGF. For quantification of PGF, an angular measurement (PGA) was performed with the vertex centering the optic nerve at a predefined distance from the lamina cribrosa and angle legs tangentially aligned to the borders of the vitreous body. PGA measurements were compared between IIH patients and healthy controls. Additionally, the diagnostic accuracy of PGA measurements in detecting PGF was evaluated using ROC analysis.

RESULTS

Thirty-one IIH patients (37.3 ± 12.3 years, 29 female) and 28 controls (33.3 ± 11.8 years, 21 female) were compared. PGF was present in 39% of IIH patients and absent in the control group. PGA3mm measurements significantly differed between IIH and controls (116.5° ± 5.5 vs. 111.7° ± 2.9; p < 0.001). A PGA3mm cutoff of ≥ 118.5° distinguished IIH patients from controls with 100% specificity, while retaining a sensitivity of 37.5%.

CONCLUSIONS

Transorbital ultrasound may be applied to detect and quantify PGF in IIH patients. Prospective, multicenter studies with extended cohorts and blinded design are needed to validate these preliminary findings and confirm the diagnostic utility of transorbital ultrasound for the assessment of PGF in IIH.

Collapse or distention of the perioptic space in children - What does it mean to pediatric radiologists? Comprehensive review of perioptic space evaluation

The perioptic space comprises the subarachnoid space [SAS] of the optic nerve communicating with the SAS of the central nervous system. Pressure variations in the SAS of the central nervous system can be transmitted to the optic papilla through the perioptic space. Variations in the diameter of the perioptic space serve as an important indicator for select intracranial pathologies in the pediatric population. Though the perioptic space can be evaluated using various imaging modalities, MRI is considered highly effective due to its superior soft tissue resolution. With advancement in MR imaging techniques, high-resolution images of the orbits can provide improved visualization of the perioptic space. It is imperative for the pediatric radiologist to routinely assess the perioptic space on brain and orbit MR imaging, as it can prompt exploration for additional features associated with select intracranial pathologies, thus improving diagnostic accuracy. This article reviews basic anatomy of the perioptic space, current understanding of the CSF dynamics between the perioptic space and central nervous system SAS, various imaging modalities utilized in the assessment of the perioptic space, MRI sequences and the optimal parameters of specific sequences, normal appearance of the perioptic space on MR imaging, and various common pediatric pathologies which cause alteration in the perioptic space.

Arachnoid granulations in idiopathic intracranial hypertension: Do they have an influence?

OBJECTIVE

The aim of this study was to investigate whether the relative narrowing of the dural venous sinuses by arachnoid granulations (AGs) is more pronounced in patients with idiopathic intracranial hypertension (IIH) compared to healthy controls.

BACKGROUND

IIH is characterized by increased intracranial pressure, which is associated with symptoms such as headache and visual disturbances. The role of cerebral venous drainage obstruction in IIH is the subject of ongoing research.

MATERIALS AND METHODS

In this retrospective case-control study, 3D contrast-enhanced magnetic resonance images of a cohort of 43 patients with IIH were evaluated for (1) the number of AGs per venous sinus and (2) the diameters of the dural venous sinuses at the site of an AG and at standardized measurement points. In addition, the minimum width of the transverse/sigmoid sinus was measured. All data were compared to the same data from a cohort of 43 control participants.

RESULTS

Patients with IIH showed less relative sinus narrowing by AG compared to controls (median: 7%, interquartile range [IQR] 10% vs. 11%, IQR 9% in controls; p = 0.009). In patients with IIH, sinus diameter was larger at the site of an AG (70 ± 25 mm2) compared to its diameter at the standardized measurement point (48 ± 23 mm2; p = 0.010). In the superior sagittal sinus (SSS), patients with IIH had smaller AGs (median: 3 mm2, IQR 2 mm2 vs. 5 mm2, IQR 3 mm2 in controls; p = 0.023) while the respective sinus segment was larger (median: 69 mm2; IQR 21 mm2 vs. 52 mm2, IQR 26 mm2 in controls; p = 0.002). The right transverse sinus was narrower in patients with IIH (41 ± 21 mm vs. 57 ± 20 mm in controls; p < 0.001).

CONCLUSIONS

In contrast to our hypothesis, patients with IIH showed less pronounced relative sinus narrowing by AG compared to controls, especially within the SSS, where AGs were smaller and the corresponding sinus segment wider. Smaller AGs could result in lower cerebrospinal fluid resorption, favoring the development of IIH. Conversely, the smaller AGs could also be a consequence of IIH due to backpressure in the SSS because of the narrower transverse/sigmoid sinus, which widens the SSS and compresses the AG.

Atypical Presentation of Idiopathic Intracranial Hypertension: A Case Series and Literature Review

Idiopathic intracranial hypertension (IIH) is a condition in which intracranial pressure (ICP) increases without an apparent cause. Typically, patients present with headaches, dizziness, pulsatile tinnitus, visual disturbances, blurred vision, diplopia, photophobia, visual field defects, and papilledema on fundoscopy. The association between IIH, spontaneous cerebrospinal fluid (CSF) rhinorrhea, and arachnoid cysts has been discussed in the literature; however, there is no clear explanation for this association. We aimed to present a series of four patients with a confirmed diagnosis of IIH with atypical presentations, discuss the management of each case, and provide an explanation for this association to alert clinicians to the atypical presentation of IIH and facilitate early diagnosis and proper treatment of this condition by CSF diversion. This was a retrospective case series of all patients who were diagnosed with IIH and showed improvement after ventriculoperitoneal shunt insertion after failure of at least one operative intervention resulting from primary radiological and clinical findings in 2001 to 2022. Data on demographics, clinical presentation, radiological findings, surgical management, and diagnostic criteria for IIH were recorded. We identified four patients with a confirmed diagnosis of IIH who presented with atypical presentations as follows: intracranial arachnoid cyst, cervical spine arachnoid cyst, giant Virchow perivascular space, and spontaneous CSF (CSF) rhinorrhea. All patients responded to CSF diversion after failure of surgical treatment targeting the primary pathology. IIH should be suspected after the failure of primary surgical treatment in cases of spontaneous CSF rhinorrhea, spinal and cranial arachnoid cysts, and symptomatic ventriculoperitoneal shunt. Treatment in such situations should be directed toward IIH with CSF diversion.

Enhancing Diagnostic Accuracy Through Neuroimaging Revisions in Pediatric Pseudotumor Cerebri Syndrome: A Cross-Sectional Study

BACKGROUND

This cross-sectional study aimed to report all neuroimaging findings suggestive of raised intracranial pressure in children with pseudotumor cerebri syndrome (PTCS), before and after re-review by two neuroradiologists.

METHODS

We included 48 children aged <18 years diagnosed with PTCS between 2016 and 2021. Clinical and radiological data were obtained from their medical files. Two neuroradiologists independently re-reviewed all neuroimages, and the average of their assessments was compared with the initial neuroimaging reports; an additional review was done to analyze inter- and intraclass correlation.

RESULTS

The initial neuroimaging reports showed under-reporting of findings, with only 26 of 48 (54.1%) patients identified with abnormal reports. After revision, the proportion of the reported findings increased to 44 of 48 (91.6%). Distention of the perioptic space was the most commonly reported finding after revision (36.5 of 48; 76%). Flattening of the posterior globe and empty sella were initially under-reported but improved after revision. Moreover, several findings suggestive of increased intracranial pressure not mandated by Friedman criteria were identified, such as narrowing of the Meckel cave, posterior displacement of the pituitary stalk, and narrowing of the cavernous sinus. Analysis of associations between neuroimaging findings and demographic and clinical characteristics yielded no statistically significant results. The inter- and intraclass correlation results demonstrated a significant agreement between raters and within each rater's assessment (P < 0.05).

CONCLUSIONS

This study highlights the impact of image revision in enhancing PTCS diagnosis. Intra- and interclass correlations underscore the reliability of the review process, emphasizing the importance of meticulous image analysis in clinical practice.

Effectiveness and Safety of Ventriculoperitoneal Shunt Versus Lumboperitoneal Shunt for Idiopathic Intracranial Hypertension: A Systematic Review and Comparative Meta-Analysis

INTRODUCTION

Idiopathic Intracranial Hypertension (IIH) is a condition characterized by elevated intracranial pressure. Although several mechanisms have been proposed as underlying causes of IIH, no identifiable causative factor has been determined for this condition. Initial treatments focus on weight or CSF reduction, but severe cases may require surgery. This study compares outcomes in IIH patients treated with lumboperitoneal shunts (LPSs) versus ventriculoperitoneal shunts (VPSs).

METHODS

This systematic-review and meta-analysis follows Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines and includes studies about VPS and LPS patients, reporting one of the outcomes of interest. We conducted searches on PubMed, Embase, Web of Science, and Cochrane Library.

RESULTS

Our analysis involved twelve studies, comprising 5990 patients. The estimated odds ratio (OR) for visual improvement was 0.97 (95% CI 0.26-3.62; I2 = 0%) and for headache improvement was 0.40 (95% CI 0.20-0.81; I2 = 0%), favoring LPS over VPS. Shunt revision analysis revealed an OR of 1.53 (95% CI 0.97-2.41; I2 = 77%). The shunt complications showed an OR of 0.91 (95% CI 0.68-1.22; I2 = 0%). The sub-analyses for shunt failure uncovered an OR of 1.41 (95% CI 0.92-2.18; I2 = 25%) and for shunt infection events an OR of 0.94 (95% CI 0.50-1.75; I2 = 0%).

CONCLUSIONS

The interventions showed general equivalence in complications, shunt failure, and other outcomes, but LPS seems to hold an advantage in improving headaches. Substantial heterogeneity highlights the need for more conclusive evidence, emphasizing the crucial role for further studies. The findings underscore the importance of considering a tailored decision between VPS and LPS for the management of IIH patients.

Occipital emissary vein existence and its impact on the diagnosis of idiopathic intracranial hypertension in pediatric patients

PURPOSE

This study aimed to investigate the efficacy of occipital emissary vein (OEV) detection in the diagnosis of idiopathic intracranial hypertension (IHH) in the pediatric age group, and to compare the prevalence and luminal diameter of OEV in patients with IHH and in healthy control subjects.

METHODS

Conventional magnetic resonance imaging findings were assessed in the patients with IHH and in healthy control subjects who were under the age of 18, by two observers. The presence and luminal dimension of OEV and transverse sinus stenosis were also evaluated and compared between these two groups with magnetic resonance venography techniques.

RESULTS

The rate of OEV existence was 7 times higher in the IIH group compared to the control group based on the second observer outcome (p = 0.010, OR = 7.0), with a very good interobserver agreement (Ƙ = 0.85). The dimension of OEV ranged between 0.6 and 2.5 mm. There was no correlation found between the opening pressure and the dimension of OEV (p = 0.834).

CONCLUSION

In conclusion, OEV existence could be an additional radiological finding for diagnosing IHH among pediatric patients, alongside other conventional findings.

Pituitary Dysfunction in Idiopathic Intracranial Hypertension: An Analysis of 80 Patients

BACKGROUND

Empty sella is a commonly described imaging entity in patients with idiopathic intracranial hypertension (IIH). Though menstrual and hormonal disturbances have been associated with IIH, available literature lacks systematic analysis of pituitary hormonal disturbances in IIH. More so, the contribution of empty sella in causing pituitary hormonal abnormalities in patients of IIH has not been described. We carried out this study to systematically assess the pituitary hormonal abnormalities in patients with IIH and its relation to empty sella.

METHODS

Eighty treatment naïve patients of IIH were recruited as per a predefined criterion. Magnetic resonance imaging (MRI) brain with detailed sella imaging and pituitary hormonal profile were done in all patients.

RESULTS

Partial empty sella was seen in 55 patients (68.8%). Hormonal abnormalities were detected in 30 patients (37.5%), reduced cortisol levels in 20%, raised prolactin levels in 13.8%, low thyroid-stimulating hormone (TSH) levels in 3.8%, hypogonadism in 1.25%, and elevated levels of gonadotropins were found in 6.25% of participants. Hormonal disturbances were independent and were not associated with the presence of empty sella (p = 0.493).

CONCLUSION

Hormonal abnormalities were observed in 37.5% patients with IIH. These abnormalities did not correlate with the presence or absence of empty sella. Pituitary dysfunction appears to be subclinical in IIH and responds to intracranial pressure reduction, not requiring specific hormonal therapies.

Idiopathic intracranial hypertension in two twin sisters

Idiopathic intracranial hypertension (IIH) is a condition of unknown aetiology characterised by an increase in the intracranial pressure. Familial cases of IIH are rare and not well-understood. We present two monozygotic twins who developed IIH two years apart. The case involves two monozygotic female twins developing IIH in their 50s. They presented with a history of blurry vision and headaches. The diagnosis included the neurological, radiological and ophthalmological examination, excluding other causes. Both patients received treatment with acetazolamide, successfully resolving the papilloedema and restoring a normal visual field. This case highlights the occurrence of IIH among twins presenting at similar periods, emphasising the potential genetic influence. Clinicians should alert and educate the family regarding the risk factors and potential symptoms of this condition in the unlikely occurrence that other family members are affected.

MRI signs of intracranial hypertension in morbidly obese and normal-weight individuals

PURPOSE

Idiopathic intracranial hypertension (IIH) is associated with intracranial abnormalities, although not obligatory, which can be detected with cranial MRI. Obesity is an important risk factor for IIH and a pathogenetic link is suspected but the extent to which these MRI signs are already related to obesity has not yet been examined. We investigated whether IIH-MRI signs are present more often in obese individuals with a BMI > 30 kg/m² than in individuals of normal weight.

MATERIALS AND METHODS

Brain MRI of 32 obese and 53 normal-weight participants from the Food-Chain-Plus cohort were analyzed for three main signs of IIH: (I) stenosis of the transverse sinus, (II) increased width of the optic nerve sheath, and (III) reduction of pituitary height. In addition, a scoring system for the MRI signs was applied. Furthermore, tortuosity of the optic nerve and flattening of the posterior globe were considered as additional MRI signs.

RESULTS

Obese participants had a significantly higher MRI score (p < 0.001) than those in the normal-weight cohort, with significant differences in quantitative measurements of cerebral venous sinus stenosis (p < 0.001), widening of the optic nerve sheath (p < 0.05), and flattening of the pituitary gland (p < 0.05) also always being observed more frequently and in a more pronounced manner in the obese group. Furthermore, our findings correlated significantly with BMI and proportionately with hip and waist circumference.

CONCLUSION

Obese individuals show a significantly higher prevalence of cerebral MRI signs related to IIH. This supports the hypothesis that obesity is a risk factor for possible intracranial hypertension and reinforces the suspicion that obesity is involved in the pathomechanism of IIH.

KEY POINTS

· Obesity is associated with changes such as those seen in IIH.. · BMI, weight, and body measurements correlate with the expression of MRI signs of IIH.. · To prevent IIH symptoms in obesity, the pathomechanism must be further clarified..

Effectiveness of radiology modalities in diagnosing and characterizing brain disorders

OBJECTIVES

To observe the accuracy of Computed Tomography (CT) and Magnetic Resonance Imaging (MRI) scans in evaluating neurological disorders.

METHODS

This retrospective research used CT or MRI to diagnose and characterize brain disorders. Patients' records suffering from neurological disorders were considered eligible for inclusion, regardless of the time of appearance of symptoms, the severity of their symptoms, or their final clinical diagnosis. The exclusion criteria for this study involved patients who did not undergo either a CT or MRI scan. A chi-square test was performed to observe the association between the study variables. A total of 3155 cases were analyzed.

RESULTS

The most prevalent comorbid was dyslipidemia 670 (21.6%) followed by hypertension 548 (17.6%). Overall brain disorders were confirmed in 2426 (77%) patients. It was observed that half of the patients 1543 (48.9%) were diagnosed with stroke. It was found that the accuracy of CT and MRI was 78% and 74% respectively. The association of modalities, patient type, and gender with the confirmation of diseases was not found significant (p=>0.05).

CONCLUSION

Our study revealed that CT and MRI were accurate by more than 75% and no difference was between both techniques to detect neurological disorders.

Evaluation of Miethke M.scio Device Implantation for Intracranial Pressure Monitoring in Patients with Cerebrospinal Fluid Disorders

BACKGROUND

Patients with complex shunt-related problems and varying diagnoses of cerebrospinal fluid (CSF) disturbance can present with headache and clinical symptoms that may be difficult to relate to underdrainage or overdrainage. Telemetric intracranial pressure (ICP) monitoring may assist in evaluating individual patients and assessing shunt function and adjustment. We report a case series of patients receiving a Miethke M.scio sensor.

METHODS

Between June 2016 and August 2021, 14 patients older than 18 years with different diagnoses underwent ventriculoperitoneal shunt surgery and received a Miethke M.scio sensor.

RESULTS

Patients had idiopathic intracranial hypertension (n = 3), obstructive hydrocephalus caused by tumors (n = 4), and malformations (n = 5). Headaches (71%) and visual impairment (50%) were the most common symptoms before surgery and 65% of the symptoms were improved after surgery. In total, 25 measurements were made and 11 of these led to changes in the shunt settings. Postoperative measurements were taken in 8 patients and the most common indication of ICP measurement was headache and/or control of the shunt settings.

CONCLUSIONS

The Miethke M.scio is a safe and valuable device to use in shunt-treated patients, in particular those expected to need assessment of ICP monitoring postoperatively. Repeated ICP measurements can also assist in personalized adjustment of the shunt setting to optimize CSF flow in this diverse patient group. Future studies should include a standardized protocol with ICP measurements correlated to the symptoms and cause of CSF disturbances to provide better understanding of the dynamics of the ICP in each patient.

Long Term Effects of Metabolic and Bariatric Surgery on Idiopathic Intracranial Hypertension

BACKGROUND

Idiopathic Intracranial Hypertension (IIH) is a rare disorder, linked to severe obesity. The study aimed to evaluate long-term effects of metabolic and bariatric surgery (MBS) on IIH outcomes.

METHODS

Retrospective study of patients with IIH and severe obesity who underwent MBS. Data were retrieved from prospectively maintained databases of two bariatric surgeons.

RESULTS

Thirteen patients were included, of them 12 women. Median age was 36 (interquartile range;IQR 21,47) years and body mass index (BMI) was 40.4 (IQR 37.8,41.8) kg/m2. All patients had visual disturbances,12/13 had headaches, and 6/13 had tinnitus. The mean opening pressure on lumbar puncture was 45 cmH2O, and 11/13 patients had papilledema. Medications for IIH were consumed by 11/13 patients, and 2/13 patients had prior surgical intervention for IIH. MBS types included sleeve gastrectomy (n=7), adjustable gastric banding (n=2), roux-en-y gastric bypass (n=2), one anastomosis gastric bypass (n=1), duodenal switch (n=1). At a median follow-up of 10 years (IQR 8,13), the median BMI and total weight loss were 29.7 kg/m2 and 27%, respectively. Remission of symptoms was achieved in 9/13 patients.

CONCLUSIONS

MBS results in significant and sustainable weight loss, with subsequent resolution or improvement of IIH. It may be considered as a preventive measure for IIH in patients with severe obesity.

Enhancement of optic nerve sheath on MRI in idiopathic intracranial hypertension(IIH)

OBJECTIVE

Optic nerve sheath(ONS) enhancement in idiopathic intracranial hypertension (IIH) patients has been reported in recent years. In this retrospective observation, we analyzed the clinical characteristics of IIH patients with enhancement of ONS.

METHODS

Eighty-two patients with clinically diagnosed IIH from January 2017 to December 2019 were under observation. Then, based on the presence of contrast-enhancement (CE) in ONS on orbital magnetic resonance image (MRI), the IIH patients were divided into CE-ONS group and no-CE(NCE)-ONS group. Six months follow-up information was also included in the observation study. By comparing clinical data of the two groups of IIH patients, we tried to evaluate whether there is clinical heterogeneity in CE-ONS patients.

RESULT

12 patients were included in CE-ONS group, 10 females and 2 males. 70 patients were included in NCE-ONS group, 56 women and 14 men. We found that patients with CE-ONS had a longer course of disease (median disease duration before diagnosis, 5 months vs. 3months, P<0.01) and more likely had the sign of distension of the perioptic subarachnoid space (DPSS) (58.33 % vs. 24.29 %, P = 0.034). But no significant differences were found in demographic characteristics, clinical symptoms, degree of visual impairment, papilledema, opening pressure(OP) on lumbar puncture and clinical outcomes.

CONCLUSION

As a rare sign on MRI, ONS enhancement can occur in patients with IIH. IIH patients with CE-ONS may have a longer course of disease and more prone to DPSS, but there is no significant difference in clinical manifestations, OP, and clinical outcomes compared with IIH patients without CE-ONS.

Evaluation of peripheral and central olfactory regions by MRI in patients with idiopathic intracranial hypertension

OBJECTIVES

We investigated the peripheral and central smell regions in patients with idiopathic intracranial hypertension (IIH) by cranial MRI.

METHODS

In this retrospective study, cranial MRI images of 43 adult patients with IIH (Group 1) and 43 healthy adults without IIH (Group 2) were included. In both groups, peripheral [Olfactory bulb (OB) volume and Olfactory sulcus (OS) depth] and central smell regions (insular gyrus and corpus amygdala area, and thalamus volume) were measured in cranial MRI.

RESULTS

Bilateral OB volume and insular gyrus area, and right corpus amygdala and thalamus volumes of the IIH group were significantly lower than those of the control group (p < 0.05). In the IIH group, OB volume of the right side was significantly lower, and insular gyrus area of the right side was significantly higher than those of the left side (p < 0.05). In the IIH group, there were positive correlations between OB volumes; OS depths; insular gyrus areas; corpus amygdala areas; and thalamus volumes bilaterally (p < 0.05). In older patients, right OS depth and right corpus amygdala area decreased (p < 0.05).

CONCLUSION

In conclusion, IIH may be related to olfactory impairment. Cranial MRI images showed a decrease in peripheral (OB volume) and central (insular gyrus and corpus amygdala area and thalamus volume) smell regions. To prevent olfactory impairment in IIH patients, treatment should be done in IIH patients to decrease intracranial pressure. It is very important to prevent the circulation of CSF with increased pressure between the sheets of the olfactory nerve in IIH patients.

Editorial Comment: Estimation of venous sinus pressure drop in patients with idiopathic intracranial hypertension using 4D-flow MRI

KEY POINTS

• Work-energy equation using 4D-flow MRI is a promising technique for non-invasive estimation of trans-stenotic pressure drop in patients with idiopathic intracranial hypertension.• Additional research with larger and multicentric prospective cohorts is needed to validate the results, along with improvement of the segmentation process with automated techniques and shortening of scanning times to allow for practical clinical use.

Epilepsy with anterior temporal encephaloceles: Baseline characteristics, post-surgical outcomes, and comparison to mesial temporal sclerosis

OBJECTIVE

To review clinical and neuropsychological characteristics and natural history of a series of patients with temporal lobe epilepsy (TLE) and anterior temporal encephaloceles (ATE) and compare them to a similar series of TLE patients with mesial temporal sclerosis (MTS) to identify characteristics suggestive of ATE-related epilepsy.

METHODS

Patients with epilepsy and ATE were identified via clinic encounters and consensus epilepsy surgery conference at a Level 4 epilepsy center. The drug-resistant subset of these patients who underwent epilepsy surgery (twenty-two of thirty-five) were compared to age- and laterality-matched patients with MTS. Clinical, neuropsychological, electrophysiologic, and surgical data were abstracted through chart review.

RESULTS

In comparison with MTS, ATE patients were more often female, had significantly later onset of epilepsy, and did not have prior febrile seizures. In addition, ATE patients were more likely to have chronic headaches and other historical features consistent with idiopathic intracranial hypertension (IIH). Failure to identify ATE on initial imaging was common. Most patients had limited temporal cortical resections sparing mesial structures. Of the twenty ATE patients who had a long-term postsurgical follow-up, seventeen (85%) had International League Against Epilepsy (ILAE) Class 1 or 2 outcomes.

SIGNIFICANCE

A shorter duration of epilepsy, female gender, and lack of history of febrile seizures may suggest ATE as an etiology of refractory TLE in adults. Targeted encephalocele resections can result in seizure freedom, underscoring the importance of encephalocele identification.

The Link Between Empty Sella Syndrome, Fibromyalgia, and Chronic Fatigue Syndrome: The Role of Increased Cerebrospinal Fluid Pressure

The etiopathogenesis of fibromyalgia (FM) and chronic fatigue syndrome (CFS) is not yet elucidated. Hypothalamo-pituitary-adrenal (HPA) axis dysfunction is reflected in the hormonal disturbances found in FM and CFS. Some study groups have introduced a novel hypothesis that moderate or intermittent intracranial hypertension may be involved in the etiopathogenesis of FM and CFS. In these conditions, hormonal disturbances may be caused by the mechanical effect of increased cerebrospinal fluid pressure, which hampers blood flow in the pituitary gland. Severe intracranial pressure may compress the pituitary gland, resulting in primary empty sella (ES), potentially leading to pituitary hormone deficiencies. The aim of this narrative review was to explore whether similar hormonal changes and symptoms exist between primary ES and FM or CFS and to link them to cerebrospinal fluid pressure dysregulation. A thorough search of the PubMed and Web of Science databases and the reference lists of the included studies revealed that several clinical characteristics were more prevalent in primary ES, FM or CFS patients than in controls, including increased cerebrospinal fluid pressure, obesity, female sex, headaches and migraine, fatigue, visual disturbances (visual acuity and eye motility abnormalities), vestibulocochlear disturbances (vertigo and neurosensorial hearing loss), and bodily pain (radicular pain and small-fiber neuropathy). Furthermore, challenge tests of the pituitary gland showed similar abnormalities in all three conditions: blunted adrenocorticotropic hormone, cortisol, growth hormone, luteinizing hormone, and thyroid stimulating hormone responses and an increased prolactin response. The findings of this narrative review provide further support for the hypothesis that moderately or intermittently increased cerebrospinal fluid pressure is involved in the pathogenesis of FM and CFS and should stimulate further research into the etiopathogenesis of these conditions.

Long-term monitoring of children with Pseudo Tumor Cerebri Syndrome by transbulbar sonography

Determination of optic nerve sheath diameter (ONSD) with transbulbar sonography has become an easily accessible and time-effective tool in the assessment of increased intracranial pressure. The aim of our study was to evaluate the usefulness of transbulbar sonography in the initial diagnosis and in follow-up examinations of children and adolescents with the diagnosis of pseudotumor cerebri syndrome (PTCS). We retrospectively reviewed imaging results of 24 patients aged 0.75-17 years with PTCS. Serial transbulbar sonography examinations were performed between 2011 and 2021. Sonographic evaluation included the ONSD, papilledema and subarachnoid space. 240 sonographic measurements taken at 108 time points in 17 patients met the inclusion criteria. All patients underwent serial lumbar punctures and routine fundoscopy in close relation to transbulbar sonography. We found that ONSD values remained high in all patients. The longest follow-up period was dated 2498 days (6.84 years) after initial diagnosis. Papilledema resolved in close correlation to fundoscopy normalization. In 16/17 patients the subarachnoid space remained cystic in appearance. These findings were independent of clinical symptoms and lumbar puncture opening pressure. We conclude that transbulbar sonography is a useful diagnostic tool in the initial diagnostic workup of children with PTCS. On follow-up however ONSD values and the cystic transformation of the subarachnoid space remained pathologic in the majority of cases while papilledema resolved parallel to fundoscopy findings. Serial measurements of ONSD are therefore of limited value in the follow-up of patients with PTCS and cannot be considered a reliable tool in subsequent therapeutic decisions.

The Monro-Kellie Doctrine: A Review and Call for Revision

The Monro-Kellie doctrine is a well-accepted principle of intracranial hemodynamics. It has undergone few consequential revisions since it was established. Its principle is straightforward: The combined volume of neuronal tissue, blood, and CSF is constant. To maintain homeostatic intracranial pressure, any increase or decrease in one of these elements leads to a reciprocal and opposite change in the others. The Monro-Kellie doctrine assumes a rigid, unadaptable calvaria. Recent studies have disproven this assumption. The skull expands and grows in response to pathologic changes in intracranial pressure. In this review, we outline what is known about calvarial changes in the setting of pressure dysregulation and suggest a revision to the Monro-Kellie doctrine that includes an adaptable skull as a fourth component.

Management of a Growth Hormone-Secreting Pituitary Macroadenoma Associated With Idiopathic Intracranial Hypertension and an Empty Sella

Idiopathic intracranial hypertension (IIH) is a -condition associated with elevated intracranial pressure (ICP) and frequently presents with headaches, papilledema, and visual loss. Rarely, IIH has been reported in association with acromegaly. Although removal of the tumor may reverse this process, elevated ICP, especially in the setting of an otherwise empty sella, may result in a cerebrospinal fluid (CSF) leak that is exceedingly difficult to manage. We present the first case of a patient with a functional pituitary adenoma causing acromegaly associated with IIH and an otherwise empty sella and discuss our management paradigm for this rare condition.

Efficacy of Dural Sinus Quantitative Measurements in Idiopathic Intracranial Hypertension : A Practical Diagnostic Feature

BACKGROUND AND PURPOSE

This study aimed to investigate the potential contribution of quantitative measurements of dural venous sinuses to the diagnosis of idiopathic intracranial hypertension (IIH) and the relationship between IIH and dural venous sinus dimensions on 3D post-gadolinium T1-weighted magnetic resonance (MR) images.

MATERIAL AND METHODS

A total of 129 individuals (57 IIH patients and 72 controls) who complained of headache and underwent both magnetic resonance venography (MRV) and precontrast/postcontrast 3D T1-weighted MR imaging between 2018 and 2021 were included in this retrospective study. Dural venous sinus and jugular vein diameters were measured in all cases using post-gadolinium 3D T1 TFE images. The presence of transverse sinus (TS) hypoplasia and occipital sinus variation, the number and size of arachnoid granulations in the TS, and the presence of brain parenchymal herniation were also evaluated. Cut-off values that maximized accurate diagnosis of IIH were established on the receiver operating characteristic curve. The sensitivity and specificity of the diagnosis of IIH based on quantitative measurements of the dural sinus were calculated.

RESULTS

The ratios of the maximum to minimum TS diameters and the minimum TS diameters to minimum sigmoid sinus (SS) diameters were significantly higher in IIH patients than in the control group (p < 0.001). The diagnostic sensitivity and specificity values of TS_max/TS_min and TS_{min sum}/SS_{min sum} parameters for the detection of IIH were 84.2%, 84.7% and 83.3%, 84.2%, respectively.

CONCLUSION

Practical measurements from multiplanar T1 sequences can be useful for both quantitative assessment and overcoming misinterpretation due to anatomical variation.

Features of Idiopathic Intracranial Hypertension on MRI With MR Elastography: Prospective Comparison With Control Individuals and Assessment of Postintervention Changes

BACKGROUND. Understanding of dynamic changes of MRI findings in response to intracranial pressure (ICP) changes in idiopathic intracranial hypertension (IIH) is limited. Brain stiffness, as assessed by MR elastography (MRE), may reflect changes in ICP. OBJECTIVE. The purpose of this study was to compare pituitary height, ventricular size, and brain stiffness between patients with IIH and control individuals and to evaluate for changes in these findings in patients with IIH after interventions to reduce ICP. METHODS. This prospective study included 30 patients (28 women, two men; median age, 29.9 years) with IIH and papilledema and 21 control individuals (21 women, 0 men; median age, 29.1 years), recruited from January 2017 to July 2019. All participants underwent 3-T brain MRI with MRE; patients with IIH underwent additional MRI examinations with MRE after acute intervention (lumbar puncture with normal closing pressure; n = 11) and/or chronic intervention (medical management or venous sinus stenting with resolution or substantial reduction in papilledema; n = 12). Pituitary height was measured on sagittal MP-RAGE images. Ventricular volumes were estimated using unified segmentation, and postintervention changes were assessed by tensor-based morphometry. Stiffness pattern score and regional stiffness values were estimated from MRE. RESULTS. In patients with IIH, median pituitary height was smaller than in control individuals (3.1 vs 4.9 mm, p < .001) and was increased after chronic (4.0 mm, p = .05), but not acute (2.3 mm, p = .50), intervention. Ventricular volume was not different between patients with IIH and control individuals (p = .33) and did not change after acute (p = .83) or chronic (p = .97) intervention. In patients with IIH, median stiffness pattern score was greater than in control individuals (0.25 vs 0.15, p < .001) and decreased after chronic (0.23, p = .11) but not acute (0.25, p = .49) intervention. Median occipital lobe stiffness was 3.08 kPa in patients with IIH versus 2.94 kPa in control individuals (p = .07) and did not change after acute (3.24 kPa, p = .73) or chronic (3.10 kPa, p = .83) intervention. CONCLUSION. IIH is associated with a small pituitary and increased brain stiffness pattern score; both findings may respond to chronic interventions to lower ICP. CLINICAL IMPACT. The "partially empty sella" sign and brain stiffness pattern score may serve as dynamic markers of ICP in IIH.

Optic ataxia in a patient with HaNDL syndrome

We present a woman in her 40s who arrived at the emergency room with hypertension and optic ataxia. Her medical history is only relevant for obesity. Her lumbar puncture revealed high intracranial pressure and lymphocytic pleocytosis, and her neuroimaging tests, including angiography and venography, were normal. The patient improved after a cerebrospinal fluid drainage with a lumbar puncture, and her clinical manifestations resolved in parallel to the lymphocytic pleocytosis.The patient was diagnosed with a syndrome of transient headache and neurological deficits with cerebrospinal fluid lymphocytosis and fully recovered 21 days after her discharge.

Cerebrospinal Fluid Shunting for Idiopathic Intracranial Hypertension: A Systematic Review, Meta-Analysis, and Implications for a Modern Management Protocol

BACKGROUND

Cerebrospinal fluid (CSF) shunting is widely used in refractory idiopathic intracranial hypotension (IIH). Although multiple reviews have assessed its efficacy compared with other surgical treatments, there is no detailed analysis that evaluates the clinical outcomes after CSF shunting.

OBJECTIVE

To conduct a meta-analysis of the clinical impact of CSF shunting for refractory IIH and use this in conjunction with existing information on other treatment modalities to develop a modern management protocol.

METHODS

PubMed and Embase were systematically searched for studies describing CSF shunting for medically refractory IIH. Relevant information including study characteristics, patient demographics, clinical outcomes, periprocedural complications, and long-term outcomes were subjected to meta-analysis.

RESULTS

Fifteen studies published between 1988 and 2019 met our inclusion and exclusion criteria, providing 372 patients for analysis. The mean age was 31.2 years (range 0.5-71) with 83.6% being female. The average follow-up was 33.9 months (range 0-278 months). The overall rate of improvement in headache, papilledema, and visual impairment was 91% (95% CI 84%-97%), 96% (95% CI 85%-100%), and 85% (95% CI 72%-95%), respectively. Of 372 patients, 155 had 436 revisions; the overall revision rate was 42% (95% CI 26%-59%). There was no significant correlation between average follow-up duration and revision rates in studies ( P = .627). Periprocedural low-pressure headaches were noted in 74 patients (20%; 95% CI 11%-32%).

CONCLUSION

CSF shunting for IIH is associated with significant improvement in clinical symptoms. Shunting rarely causes periprocedural complications except overdrainage-related low-pressure headache. However, CSF shunting has a relatively high revision rate.

The Reliability of Venous Sinus Stenosis Using Non Contrast 3D MRV in Prediction of the Diagnosis of Idiopathic Intracranial Hypertension, A Case Control Study

Idiopathic intracranial hypertension, or shorty IIH, refers to a clinical syndrome in which there is elevated CSF pressure and papilledema in the lack of any focal neurological signs. It is largely a diagnosis of exclusion, but imaging workup is undertaken routinely in order to rule out other pathologies. In this study we tried to evaluate the prevalence of venous sinus abnormalities using the simpler and less invasive non contrast enhanced 3D TOF MRV in group of patients with IIH, using the combined stenosis score, and compare this score with a group of controls, to assess the accuracy of MRV alone as an individual test in predicting the diagnosis of IIH.

The study sample included 44 patients and 25 control subjects, following MRV analysis it was found that a combined severity score of cut of value of 4.5 for the combined conduit score (CCS) was associated with 79% sensitivity and 88.6 specificity for the diagnosis of IIH, and a cut off value of 5.5 for the adjusted score method gives a 83% sensitivity and 88.6 % specificity for the diagnosis.

MRV is a valuable in the diagnosis of IIH; non contrast 3D MRV is an efficient test and gives valuable diagnostic information.

A Systematic Review on Whether an Association Exists Between Adolescent Obesity and Idiopathic Intracranial Hypertension

Pseudotumor cerebri syndrome (PTCS)/idiopathic intracranial hypertension (IIH) is a clinical presentation appertaining to signs/symptoms of raised intracranial pressure, like headache and papilledema. It is an uncommon but clinically significant cause of morbidity such as permanent vision loss. It is crucial to understand if idiopathic intracranial hypertension (IIH) is on the rise in adolescents, it is probably due to the rising prevalence of obesity worldwide. Our study aimed to find an association between obesity and IIH in adolescents. We utilized Preferred Reporting Items for Systematic Review and Meta-Analysis 2020 (PRISMA) guidelines to run this systematic review. Many publications related to the topic in the discussion were scrutinized through a comprehensive database search. We filtered them down to a final count of 10 articles after utilizing our inclusion/exclusion criteria and assessing the quality of work. In these final papers, we identified several possibilities to explain the link between obesity and IIH in adolescents. Overweight and obese adolescents were found to have a significantly increased risk of IIH development, with a more severe clinical picture seen in morbidly obese female patients.

Comprehensive Management of Headache for the Otolaryngologist: A Summary

Otolaryngologists will frequently encounter patients with head and facial pain. The headache may be a primary disorder or a symptom of a secondary pathology. Understanding diagnostic criteria and the autonomic and otologic manifestations of primary headaches is imperative for accurate diagnosis and treatment. This article summarizes key points in the issue "Comprehensive Management of Headache for the Otolaryngologist" and can be used as a cursory reference.

Utility of Neuroimaging in the Management of Chronic and Acute Headache

Imaging plays an important role in identifying the cause of the much less common secondary headaches. Such headaches may be caused by a variety of pathologic conditions which can be categorized as intracranial and extracranial. Idiopathic intracranial hypertension imaging findings include "empty sella," orbital changes, and dural venous sinus narrowing. Intracranial hypotension (ICH) is frequently caused by CSF leaks. Imaging findings include loss of the CSF spaces, downward displacement of the brain, as well as dural thickening and enhancement. Severe cases of ICH may result in subdural hematomas. A variety of intracranial and skull base tumors may cause headaches due to dural involvement. Extracranial tumors and lesions that frequently present with headaches include a variety of sinonasal tumors as well as mucoceles. Neurovascular compression disorders causing headaches include trigeminal and glossopharyngeal neuralgia. Imaging findings include displacement and atrophy of the cranial nerve caused by an adjacent arterial or venous structure.

Headache and neuroimaging findings in conditions of cerebrospinal fluid (CSF) circulation disorders: in hydrocephalus, pseudotumor cerebri, and CSF hypotension syndrome

The authors wish in this narrative minireview show and comment on some neuroimaging findings encountered in patients with conditions of cerebrospinal fluid circulation disorders, such as in the hydrocephalus, pseudotumor cerebri, and CSF hypotension syndrome. The MRI of a young woman with a clinical diagnosis of post-dural puncture headache, performed on the fourth postpartum day after cesarean delivery, evolving with headache and diplopia, is shown. Non-contrast-enhanced sagittal T1 magnetic resonance imaging shows that the cerebellar tonsils are at the level of the foramen magnum, therefore still within normal limits, but, despite that, the opening of the cerebral aqueduct in the third ventricle is below the imaginary line connecting the anterior clinoid to the vein of Galen, therefore considered abnormally lower than the expected anatomical position. The axial T1-weighted images with post-contrast fat suppression also show impregnation and thickening of the dura mater. There is also mild engorgement of the cerebral venous sinuses, best demonstrated on T1 with post-contrast fat suppression, which is also identified on post-contrast magnetic resonance angiography, with no signs of venous thrombosis. We conclude that the diagnosis of a patient with intracranial hypotension syndrome can be suspected or confirmed with typical neuroimaging findings.

Papilledema: A Review of the Pathophysiology, Imaging Findings, and Mimics

Increased intracranial pressure is the most common cause of papilledema. Multiple etiologies such as cerebral edema, hydrocephalus, space occupying lesions, infection, and idiopathic intracranial hypertension among others should be considered. Imaging plays a critical role in the detection of pathologies that can cause papilledema. MRI with contrast and CE-MRV, in particular, are key for the diagnosis of idiopathic intracranial hypertension. This review will focus in common and infrequent causes of papilledema, the role of imaging in patients with papilledema as well as its potential mimickers.

The Association between Cerebrospinal Fluid Open Pressure and Body Mass Index in Idiopathic Intracranial Hypertension

BACKGROUND: Idiopathic intracranial hypertension (IIH) is strongly associated with obesity. However, the relationship between cerebrospinal fluid open pressure (CSFOP) and body mass index (BMI) is still controversial. AIM: The aim of this study is to assess the relationship between CSFOP and BMI in patients with IIH. METHODS: The measurement of CSFOP was done by Lumbar puncture manometry following a standardized procedure. Age and gender were registered and BMI was calculated for each patient. RESULTS: This study enrolled 104 patients with IIH, 96 females and eight males, with mean age was 31.88 ± 13.73 years. The mean CSFOP was 410.48 ± 129.98 mm H2O and the mean BMI was 33.97 ± 53 kg/m2. There was a significant positive relationship between the CSFOP and BMI (p = 0.0001) according to the Pearson correlation test. There was no relationship between the age (p = 0.06), gender (p = 0.16) and CSFOP of the patients. CONCLUSIONS: The CSFOP was positively correlated with high BMI of the patient. There was no relationship between patients demographic features and CSFOP.

Subacute Thyroiditis Presenting as Idiopathic Intracranial Hypertension

Background

Several case reports have illustrated a rare neurological manifestation, idiopathic intracranial hypertension (IIH), in patients with thyrotoxicosis. However, none were diagnosed with thyroiditis. We report the case of a patient with subacute thyroiditis who presented with severe intractable headache due to IIH. Case Presentation. A 36-year-old woman visited Lampang Hospital in February 2021 complaining of neck pain and progressive severe intractable headache. Her vital signs and neurological examination were normal. Thyroid examination revealed a single 1 cm right thyroid nodule. A computed tomography (CT) scan of her brain illustrated diffuse brain edema. However, CT angiography and venography of the brain did not show abnormalities. The opening pressure of the cerebrospinal fluid was elevated (27 cmH₂O). The free triiodothyronine level was 6.19 pg/mL, free thyroxine was 2.32 ng/dL, and thyroid-stimulating hormone was 0.0083 μIU/mL. Anti-Tg was positive at a low titer, but anti-TPO was negative. TRAb was also negative. Methimazole and acetazolamide were prescribed and monitored. The symptoms resolved completely within 2 weeks of onset. Thyroid hormones had returned to normal by 8 weeks.

Conclusion

This is the first case report of subacute thyroiditis presenting with IIH.

Is conventional brain MRI useful for the diagnosis of cluster headache in patients who meet ICHD-3 criteria? Experience in three hospitals in Spain

OBJECTIVE

To assess the frequency of symptomatic structural lesions and the diagnostic yield of conventional brain MRI in cluster headache (CH).

BACKGROUND

In contrast to migraine, brain MRI is recommended in patients with CH to exclude potential mimics. The prevalence of symptomatic CH is not known.

METHODS

We retrospectively analysed in detail the brain MRIs of patients diagnosed as CH in 3 Neurology Services in Spain and reviewed their clinical history. Clinical diagnoses were reassessed based on the ICHD-3 criteria.

RESULTS

We included 130 patients: 113 (86.9%) were male; mean age at diagnosis being 41.4 years (range 7-82). Forty-nine (37.7%) showed some abnormal MRI finding. Only in two cases potential symptomatic lesions were found: one trigeminal schwannoma and one craneopharyngioma, but both presented atypical features (facial hypoesthesia on examination and episodes of prolonged duration that had progressed to continuous refractory pain without specific pattern, respectively) and therefore did not fulfil the ICHD-3 CH criteria. The remaining abnormal MRI findings were: white matter lesions (24 patients; 18.4%), sinus inflammatory changes (13; 10.0%), small arachnoid cysts (5; 3.8%), empty sella turca (3; 2.3%), and other unspecific findings (8; 6.2%). All of them were not symptomatic based on neuroimaging characteristics, clinical course and response to treatment.

CONCLUSIONS

Brain MRI in patients who meet ICHD-3 CH criteria, with no atypical clinical features, does not show any clinically-relevant findings, suggesting that these criteria are highly predictive of its primary origin and that systematic MRI is not useful for the diagnosis of typical CH.

Secondary intracranial hypertension in aplastic anemia: A case report and review of current concepts

Intracranial hypertension (IH) when detected mandates prompt and appropriate therapy to avoid permanent visual impairment. We report a 7-year-old boy who presented to the emergency services with purpuric rashes and bruises. Peripheral blood smear and bone marrow aspiration confirmed the diagnosis of aplastic anemia. During admission, the child developed headache, nausea, vomiting, and diplopia. Ophthalmic examination revealed intermittent esotropia and bilateral papilledema. The findings on neuroimaging and lumbar puncture led to the diagnosis of secondary IH (SIH). The intracranial pressure normalized on treatment with oral acetazolamide, oral furosemide, and intravenous dexamethasone.

Pediatric Intracranial Hypertension: A Spotlight on Imaging, the Idiopathic Intracranial Hypertension Treatment Trial, and COVID-19 Associated Cases

Primary intracranial hypertension (PIH) is characterized by clinical signs of increased intracranial pressure, papilledema, elevated opening pressure, and absence of mass lesion, hydrocephalus, or meningeal enhancement on neuroimaging. Visual changes are a common presenting feature and if untreated there is risk of irreversible vision loss. There have been recent proposed changes to the criteria for PIH along with studies looking at the differences in imaging characteristics between adult and pediatric PIH. The presence of transverse sinus stenosis alone was highly sensitive and specific for pediatric PIH. The Idiopathic Intracranial Hypertension Treatment Trial was an adult, multicenter study that examined the use of acetazolamide and weight loss on the course of PIH. The study confirmed many previously held beliefs including the most common presenting symptom in PIH is headache. Most patients present with bilateral papilledema with 58.2% of patients having symmetric Frisen scale grading and within one grade in 92.8%. Although diplopia is a common reported symptom, very few have evidence of cranial nerve palsy. Male gender, high-grade papilledema, and decreased visual acuity at presentation are risk factors for treatment failure. Acetazolamide use is associated with mild metabolic acidosis. During acetazolamide treatment, monitoring for hypokalemia or aplastic anemia is not recommended. Monitoring transaminases in the titration phase of treatment should be considered due to a case of transaminitis and pancreatitis with elevated lipase. Newer case reports have also seen associations of secondary intracranial hypertension with concurrent COVID-19 infection and MIS-C.

Clinical features and the role of magnetic resonance imaging in pediatric patients with intracranial hypertension

Increased intracranial hypertension (IIH) is a defined clinical condition; however, an unsolved pathophysiologic background usually creates problems in its diagnosis and proper approach. The aim of this study was to emphasize the clinical conditions and brain magnetic resonce imaging (MRI) clues of pediatric patients, especially this clinical entity with high morbidity. Here, we review the etiology, clinical presentation, brain MRI findings, and prognosis of IIH in children. The symptoms' onset age ranged from 9 months to 16 years. Headache (81%), vomiting (37%), and diplopia (33.3%) were the most frequent symptoms. The most common etiologic factors were found to be obesity and dural venous sinus thrombosis. Cerebrospinal fluid (CSF) opening pressure had mean a mean value of 615.2 ± 248 mm H₂O. A significant relationship was found between visual field impairment and height of CSF pressure (p < 0.001). Optic nerve sheath enlargement (88.8%) and optic nerve tortuosity (85.1%) were found as the most common brain MRI findings. Slit-like ventricle (37%), venous sinus thrombosis (29.6%), posterior globe sclera flattening (29.6%), empty sella (25.9%), and intraocular protrusion of the optic nerve (14.8%) were the other findings. A significant relationship was found between CSF opening pressure and the presence of optic nerve tortuosity (p = 0.002), and distension of the optic nerve sheath (p = 0.006). All patients received acetazolamide, only one patient underwent lumboperitoneal shunt, and only one received steroids. In children, IIH can present with different etiologies and symptoms. Brain MRI provides crucial clues in diagnosis. Urgent diagnosis and treatment planning are required to protect vision functions.

Clinical and imaging features of idiopathic intracranial hypertension

OBJECTIVES

Idiopathic intracranial hypertension (IIH) is a syndrome that excludes secondary causes such as intracranial space-occupying lesion, hydrocephalus, cerebrovascular disease, and hypoxic ischemic encephalopathy. If not be treated promptly and effectively, IIH can cause severe, permanent vision disability and intractable, disabling headache. This study aims to explore the clinical and image features for IIH, to help clinicians to understand this disease, increase the diagnose rate, and improve the outcomes of patients.

METHODS

We retrospectively analyzed 15 cases of IIH that were admitted to Xiangya Hospital, Central South University, during January 2015 to September 2020. The diagnosis of IIH was based on the updated modified Dandy criteria. We analyzed clinical data of patients and did statistical analysis, including age, gender, height, weight, medical history, physical examination, auxiliary examination, treatment and outcome.

RESULTS

There were 10 females and 5 males. Female patients were 22 to 42 years old with median age of 39.5. Male patients were 27 to 52 years old with the median age of 44.0. The BMI was 24.14-34.17 (28.71±2.97) kg/m2. All patients had a BMI above the normal range (≥24 kg/m2), among them 10 cases (66.7%) were obese, and 5 cases (33.3%) were overweight. Eleven cases (73.3%) had headache, and 8 cases (53.3%) had persistent visual loss of different severity. Other symptoms included paroxysmal amaurosis (2 cases), tinnitus (3 cases), horizontal diplopia (2 cases), unilateral peripheral facial paralysis (2 cases), and unilateral blepharoptosis (1 case). Iron-deficiency anemia was found in 3 patients. One of them fully recovered from IIH after the correction of anemia. Other comorbidities included hypertension (8 cases) and polycystic ovarian syndrome (1 case). Fourteen patients assessed blood lipid profile, and all of them had abnormity. Nervous system signs included cervical rigidity (2 cases), limited abduction of eyeball (6 cases), peripheral facial paralysis (2 cases), and blepharoptosis (1 case). Cerebral spinal fluids of all patients had normal cell count, chemical component, Gram's stain, acid-fast stain, and India ink stain. Typical image signs suggesting that IIH could be seen in some patients, including empty sella (5 cases, 33.3%) or partially empty sella (4 cases, 26.7%), distension of perioptic subarachnoid space (3 cases, 20%), flattening of the posterior sclera (5 cases, 33.3%), intraocular protrusion of the optic papilla (7 cases, 46.7%), and enhancement of the optic papilla (2 cases, 13.3%). Ophthalmic exam showed all patients had bilateral papilledema. After diagnosed as IIH, all patients received individualized dehydration treatment to reduce the intracranial hypertension. Three patients received the ventriculo-peritoneal shunt operation. Most patients had good outcome after treatment. For 2 patients, visual impairment was poorly recovered.

CONCLUSIONS

IIH primarily affects women of childbearing age who are overweight. The major hazard of IIH is the severe and permanent visual loss. Typical image signs have high specificity in IIH diagnosis. Prompt diagnosis and effective treatment are significantly important to improve the outcomes of patients.

MR findings suggestive of idiopathic intracranial hypertension in 117 patients with spontaneous cerebrospinal fluid rhinorrhea

PURPOSE

The purpose of this study is to document the prevalence of MR findings suggestive of idiopathic intracranial hypertension (IIH) in patients undergoing endoscopic repair of spontaneous CSF rhinorrhea (SCSFR).

METHODS

In a retrospective study, MR images of 117 consecutive patients who had undergone endoscopic repair of SCSFR were evaluated for features suggestive of IIH (empty sella, widened optic nerve sheath, tortuous optic nerve, flattened posterior globe, and enlarged Meckel's cave). Pituitary height was used to diagnose partial and complete empty sella. MR images were independently evaluated by two of the authors without knowledge of the clinical findings. Consensus method was used to resolve differences between the two evaluators.

RESULTS

Empty or partially empty sella was diagnosed in the MR of 105 (89.7%) patients. In 38/105 (36.2%) patients with empty/partial empty sella, no additional MR findings were present. In 43/105 (41%) patients, one or more of the MR features with high specificity for diagnosis of IIH (flattened posterior globe and enlarged Meckel's cave) were seen. In the other 24 (22.9%) additional MR findings, less specific for IIH (widened optic nerve sheath, tortuous optic nerve) were noted. Papilledema was seen in 11 of 60 (18.3%) patients who underwent funduscopic examination. All patients with papilledema had empty/partial empty sella, and 9/11 (81.8%) had an additional MR finding suggestive of IIH.

CONCLUSION

The majority of patients with SCSFR have MR imaging features of IIH. These imaging features should be a major component of previously published modified diagnostic criteria for IIH in patients with SCSFR.

Evaluation of 2D FLAIR hyperintensity of the optic nerve and optic nerve head and visual parameters in idiopathic intracranial hypertension

BACKGROUND AND PURPOSE

T2/FLAIR hyperintensity of the optic nerve/optic nerve head has been described as a sensitive finding in idiopathic intracranial hypertension using post-contrast 3D-T2/FLAIR imaging. The purpose of this study is to assess whether hyperintensity on non-enhanced 2D-T2/FLAIR imaging occurs more likely in diseased patients than controls and to evaluate the relationship between FLAIR signal and visual parameters MATERIALS AND METHODS: A retrospective case-control study was performed of patients with idiopathic intracranial hypertension and controls who underwent orbital MRI. Three neuroradiologists reviewed the FLAIR images, subjectively evaluating for hyperintense signal within the optic nerves/optic nerve heads using a 5-point Likert Scale. Quantitative assessment of optic nerve signal using regions of interests was performed. Clinical parameters were extracted. The diagnostic performance was evaluated, and Spearman correlation calculated to assess the relationship between FLAIR signal and visual outcomes.

RESULTS

The sensitivity of abnormal FLAIR signal within the optic nerves and optic nerve heads in patients with idiopathic intracranial hypertension ranged from 25-54% and 4-29%, respectively, with specificities ranging from 67-92% and 83-100%. Quantitative assessment revealed a significant difference in CNR between cases and controls in the left posterior optic nerve (p=.002). A positive linear relationship existed between abnormal optic nerve head signal and papilledema grade (OD: p=.02, OS: p=.008) but not with other visual parameters.

CONCLUSION

T2/FLAIR hyperintensity in the optic nerve/optic nerve head may support the diagnosis of idiopathic intracranial hypertension but its absence should not dissuade it. If present, abnormal signal in the optic nerve head correlates with papilledema.

Sensitivity and specificity of neuroimaging signs in patients with idiopathic intracranial hypertension

BACKGROUND

The primary role of neuroimaging in idiopathic intracranial hypertension (IIH) is to exclude secondary causes of raised intracranial pressure. Recently, a few imaging markers have been described which may suggest diagnosis of IIH in atypical cases. We carried out this study to assess the prevalence and accuracy of these neuroimaging signs in predicting the diagnosis of IIH.

METHODS

Eighty treatment-naive patients with IIH and 30 controls were recruited as per a predefined criterion. Magnetic resonance imaging (MRI) brain with detailed sella imaging was done in all patients.

RESULTS

The most common abnormality noted was optic nerve tortuosity in 82.5% of patients, followed by posterior scleral flattening in 80%, perioptic subarachnoid space (SAS) dilatation in 73.8% and partial empty sella in 68.8% of patients. The presence of optic nerve tortuosity was the most sensitive sign on neuroimaging, though the highest specificity was seen for posterior scleral flattening and perioptic SAS dilatation. The presence of more than three neuroimaging features correlated with severity of vision loss.

CONCLUSION

In suggestive clinical scenarios, posterior scleral flattening, perioptic SAS dilatation and optic nerve tortuosity are highly sensitive and specific signs in IIH. This study also highlights the utility of MRI as a valuable tool for prognosis of visual outcome in patients with IIH.