Is cerebrospinal fluid shunting in idiopathic intracranial hypertension worthwhile? A 10-year review

Cephalalgia ◽  
2011 ◽  
Vol 31 (16) ◽  
pp. 1627-1633 ◽  
Author(s):  
Alexandra J Sinclair ◽  
Sarin Kuruvath ◽  
Diptasri Sen ◽  
Peter G Nightingale ◽  
Michael A Burdon ◽  
...  
Keyword(s):  
Cerebrospinal Fluid ◽  
Visual Acuity ◽  
Intracranial Hypertension ◽  
Idiopathic Intracranial Hypertension ◽  
Low Pressure ◽  
Shunt Revision ◽  
Common Symptom ◽  
Csf Diversion ◽  
Low Pressure Headache ◽  
Pressure Headache

Background: The role of cerebrospinal fluid (CSF) diversion in treating idiopathic intracranial hypertension (IIH) is disputed. Method: We conducted a 10-year, retrospective case note review to evaluate the effects of CSF diversion in IIH. Symptoms, signs and details of shunt type, complications and revisions were documented at baseline, 6, 12 and 24 months post-operatively. Results: Fifty-three IIH patients were shunted [predominantly lumboperitoneal (92%)]. The most common symptom pre-surgery was headache (96%). Post-operatively, significantly fewer patients experienced declining vision and visual acuity improved at 6 ( p = 0.001) and 12 months ( p = 0.016). Headache continued in 68% at 6 months, 77% at 12 months and 79% at 2 years post-operatively. Additionally, post-operative low-pressure headache occurred in 28%. Shunt revision occurred in 51% of patients, with 30% requiring multiple revisions. Conclusion: We conclude that CSF diversion reduces visual decline and improves visual acuity. Unfortunately, headache remained in the majority of patients and low-pressure headache frequently complicated surgery. Over half of the patients required shunt revision with the majority of these requiring multiple revisions. We suggest that CSF shunting should be conducted as a last resort in those with otherwise untreatable, rapidly declining vision. Alternative treatments, such as weight reduction, may be more effective with less associated morbidity.

Cerebrospinal fluid shunting protocol for idiopathic intracranial hypertension for an improved revision rate

2021 ◽  
pp. 1-6
Author(s):  
Luke Galloway ◽  
Kishan Karia ◽  
Anwen M. White ◽  
Marian E. Byrne ◽  
Alexandra J. Sinclair ◽  
...  
Keyword(s):  
Cerebrospinal Fluid ◽  
Intracranial Hypertension ◽  
Idiopathic Intracranial Hypertension ◽  
Revision Rate ◽  
Shunt Revision ◽  
Csf Shunt ◽  
Peritoneal Catheter ◽  
Vp Shunt ◽  
Primary Surgery ◽  
Csf Shunting

OBJECTIVE Cerebrospinal fluid (CSF) shunting in idiopathic intracranial hypertension (IIH) is associated with high complication rates, primarily because of the technical challenges that are related to small ventricles and a large body habitus. In this study, the authors report the benefits of a standardized protocol for CSF shunting in patients with IIH as relates to shunt revisions. METHODS This was a retrospective study of consecutive patients with IIH who had undergone primary insertion of a CSF shunt between January 2014 and December 2020 at the authors’ hospital. In July 2019, they implemented a surgical protocol for shunting in IIH. This protocol recommended IIH shunt insertion by neurosurgeons with expertise in CSF disorders, a frontal ventriculoperitoneal (VP) shunt with an adjustable gravitational valve and integrated intracranial pressure monitoring device, frameless stereotactic insertion of the ventricular catheter, and laparoscopic insertion of the peritoneal catheter. Thirty-day revision rates before and after implementation of the protocol were compared in order to assess the impact of standardizing shunting for IIH on shunt complications. RESULTS The 81 patients included in the study were predominantly female (93%), with a mean age of 31 years at primary surgery and mean body mass index (BMI) of 37 kg/m2. Forty-five patients underwent primary surgery prior to implementation of the protocol and 36 patients after. Overall, 12 (15%) of 81 patients needed CSF shunt revision in the first 30 days, 10 before and 2 after introduction of the protocol. This represented a significant reduction in the early revision rate from 22% to 6% after the protocol (p = 0.036). The most common cause of shunt revision for the whole cohort was migration or misplacement of the peritoneal catheter, occurring in 6 of the 12 patients. Patients with a higher BMI were significantly more likely to have a shunt revision within 30 days (p = 0.022). CONCLUSIONS The Birmingham standardized IIH shunt protocol resulted in a significant reduction in revisions within 30 days of primary shunt surgery in patients with IIH. The authors recommend standardization for shunting in IIH as a method for improving surgical outcomes. They support the notion of subspecialization for IIH shunts, the use of a frontal VP shunt with sophisticated technology, and laparoscopic insertion of the peritoneal end.

scholarly journals “Benign intracranial hypertension” is a misleading name for a more serious disease: analysis of the visual outcome in cases with idiopathic intracranial hypertension

2019 ◽  
Vol 34 (1) ◽  
Author(s):  
Ali R. Hamdan ◽  
Amr M. Tayel ◽  
Eslam El Sayed El Khateeb ◽  
Osama Elsoghiar
Keyword(s):  
Cerebrospinal Fluid ◽  
Visual Acuity ◽  
Magnetic Resonance ◽  
Visual Field ◽  
Intracranial Hypertension ◽  
Idiopathic Intracranial Hypertension ◽  
The Other ◽  
Benign Intracranial Hypertension ◽  
Fundus Examination ◽  
Opening Pressure

Abstract Objective Assessment of visual field outcomes following the medical or surgical management of increased intracranial pressure in patients with idiopathic intracranial hypertension. Patient and methods Thirty-two patients diagnosed with idiopathic intracranial hypertension who met all the modified Dandy criteria were included in this study. Magnetic resonance brain imaging with contrast and magnetic resonance venography were performed to exclude the presence of secondary causes of intracranial hypertension. Following normal neuroimaging, a lumbar puncture was performed for all patients with papilledema to measure the cerebrospinal fluid opening pressure. The assessment of visual function, including visual acuity, fundus examination (dilated fundus examination to confirm the presence and the grade of papilledema and to exclude the other ocular causes of optic disc swelling), and formal visual field assessment by perimetry when visual acuity was more than 1/60 were performed by the ophthalmologist before and after medical or surgical treatment. Results Thirty-two patients were included, the majority of whom were females of childbearing age (29/32; 90.6%). All patients complained of headache. Visual assessment revealed the presence of blurry vision in all patients. Papilledema with different grades was observed in 31/32 (96.9%) patients, while the other patient (3.1%) showed optic atrophy; 30/32 (93.8%) patients had visual acuity ˃ 1/60. The average visual field was − 18 dB ± 9.97 SD in the right eye and − 19.47 dB ± 5.43 SD in the left eye. Twenty-nine patients received medical treatment in the form of acetazolamide, which succeeded in controlling idiopathic intracranial hypertension in 24/29 (82.7%) patients, while a theco-peritoneal shunt was inserted in 8/32 (25%) patients. After management, statistically significant improvements in cerebrospinal fluid opening pressure, presenting manifestation, visual acuity, and field were noticed. Conclusions Permanent visual loss is the most feared complication of idiopathic intracranial hypertension; therefore, early diagnosis and multidisciplinary treatment are necessary to improve visual acuity and visual field.

scholarly journals Evaluation of cerebrospinal fluid flow dynamic changes in patients with idiopathic intracranial hypertension using phase contrast cine MR imaging

2020 ◽  
Vol 56 (1) ◽  
Author(s):  
Tamer Belal ◽  
Abd-Elhalim Al Tantawy ◽  
Fatema Mohamed Sherif ◽  
Alshaimaa Ramadan
Keyword(s):  
Cerebrospinal Fluid ◽  
Medical Treatment ◽  
Intracranial Hypertension ◽  
Idiopathic Intracranial Hypertension ◽  
Phase Contrast ◽  
Cine Mri ◽  
Mean Flow ◽  
Csf Flow ◽  
Flow Dynamic ◽  
Dynamic Changes

Abstract Background Idiopathic intracranial hypertension (IIH) mainly affects overweight women in the middle age period. The pathophysiology of IIH stays unclear, but suggested mechanisms include excess CSF production, reduced CSF absorption, increased brain water content, and increased cerebral venous pressure Objectives To assess the cerebrospinal fluid (CSF) flow dynamic changes in aqueduct of Sylvius in patients of idiopathic intracranial hypertension (IIH) with new MRI technique: phase contrast cine MRI (PCC-MRI). Methods Thirty patients diagnosed with idiopathic intracranial hypertension were divided into 3 groups according to treatment options (no treatment, medical treatment, and medical treatment with repeated lumbar tapping). CSF flow data were evaluated by phase contrast cine MRI. Results PCC-MRI parameters were significantly higher in group who was on medical treatment (group II) than other groups. The sensitivity of PCC MRI parameters ranged from 56.7 (stroke volume (SV) and mean flow (MF)) to 83.3% (peak systolic velocity (PSV)). A statistically significant difference was found for the mean flow value (p 0.039) between the control group and IIH patients. Conclusion The most specific CSF flowmetry parameter detected to help diagnosis of IIH is mean flow especially among early discovered patients. PCC MRI can be used as non-invasive technique for diagnosis of IIH and treatment follow-up.

Spontaneous Skull Base Cerebrospinal Fluid Leaks and Their Relationship to Idiopathic Intracranial Hypertension

2020 ◽  
Vol 35 (1) ◽  
pp. 36-43 ◽  
Author(s):  
Samuel Bidot ◽  
Joshua M. Levy ◽  
Amit M. Saindane ◽  
Kannan M. Narayana ◽  
Michael Dattilo ◽  
...  
Keyword(s):  
Cerebrospinal Fluid ◽  
Optic Nerve ◽  
Intracranial Hypertension ◽  
Skull Base ◽  
Optic Nerve Head ◽  
Idiopathic Intracranial Hypertension ◽  
Signs And Symptoms ◽  
Csf Leak ◽  
Imaging Evaluation ◽  
Cerebrospinal Fluid Leaks

Background The association between spontaneous skull base cerebrospinal fluid (CSF) leaks and idiopathic intracranial hypertension (IIH) has been suggested, but its significance remains unclear. Objective To estimate the prevalence of IIH in spontaneous skull base CSF leak patients. Methods Systematic collection of demographics, neuro-ophthalmic and magnetic resonance imaging evaluation of spontaneous skull base CSF leak patients seen pre- and post-leak repair in one neuro-ophthalmology service. Patients with preexisting IIH were diagnosed with definite IIH if adequate documentation was provided; otherwise, they were categorized with presumed IIH. Classic radiographic signs of intracranial hypertension and bilateral transverse venous sinus stenosis were recorded. Results Thirty six patients were included (age [interquartile range]: 50 [45;54] years; 94% women; body mass index: 36.8 [30.5;39.9] kg/m2), among whom six (16.7%, [95% confidence interval, CI]: [6.4;32.8]) had a preexisting diagnosis of definite or presumed IIH. Of the remaining 30 patients, four (13.3%, 95%CI: [3.8;30.7]) had optic nerve head changes suggesting previously undiagnosed IIH, while one was newly diagnosed with definite IIH at initial consultation. One out of 29 patients with normal findings of the optic nerve head at presentation developed new onset papilledema following surgery (3.4%, 95%CI: [0.1;17.8]) and was ultimately diagnosed with definite IIH. Overall, the prevalence of definite IIH was 19.4% (95%CI: [8.2;36.0]). Conclusion Striking demographic overlap exists between IIH patients and those with spontaneous CSF leak. Definite IIH was present in approximately 20% of our patients. However, its true prevalence is likely higher than identified by using classic criteria. We therefore hypothesize that an active CSF leak serves as an auto-diversion for CSF, thereby “treating” the intracranial hypertension and eliminating characteristic signs and symptoms at initial presentation.

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