THE RELATIONSHIP BETWEEN CEREBROSPINAL FLUID PRESSURE AND ATHEROGENIC INDEX OF PLASMA IN IDIOPATIC INTRACRANIAL HYPERTENSION PATIENTS

Background: Idiopathic intracranial hypertension (IIH) is a disease thought to be associated with obesity and rapid weight gain. There is no objective parameter with practical use in its follow-up and treatment other than optical coherence tomography. Objective: The aim of our study is to investigate the relationship between atherogenic index of plasma (AIP) and cerebrospinal fluid (CSF) pressure. Methods: Serum vitamin B12, vitamin D, homocysteine, folic acid, triglyceride (TG), high density lipoprotein cholesterol (HDL-C) levels, CSF pressure, CSF microprotein levels were recorded from the file data of patients diagnosed with IIH. AIP was calculated by dividing the TG level logarithmically by HDL-C. Height (kg) and weight (kg) data of the patients were used to calculate the body mass index (BMI). Results: File data of 64 patients were examined. 8 patients with secondary intracranial hypertension were excluded from the study. 80.36% of the patients were overweight, 16.07% were obese, 3.57% were with normal weight. There was no significant correlation between vitamin B12, vitamin D, homocysteine, HDL-C and CSF microprotein levels and CSF pressure level in patients with a diagnosis of IIH. There was a negative correlation between folic acid level and CSF pressure level, and a positive correlation between BMI, TG, AIP and CSF pressure level. Conclusion: Using folic acid supplements and drugs that reduce TG levels can contribute positively to the course of the disease.

Digital manometry to measure cerebrospinal fluid pressure during lumbar puncture

Rationale and Objectives Accurate cerebrospinal fluid (CSF) pressure measurements are critical for diagnosis and treatment of pathologic processes involving the central nervous system. Measuring opening CSF pressure using an analog device takes several minutes, which can be burdensome in a busy practice. The purpose of this study was to compare accuracy of a digital pressure measurement device with analog manometry, the reference gold standard. Secondary purpose included an assessment of possible time savings. Materials and Methods This study was a retrospective, cross-sectional investigation of 71 patients who underwent image-guided lumbar puncture (LP) with opening CSF pressure measurement at a single institution from June 2019 to September 2019. Exclusion criteria were examinations without complete data for both the digital and analog measurements or without recorded needle gauge. All included LPs and CSF pressures were measured with the patient in the left lateral decubitus position, legs extended. Acquired data included (1) digital and analog CSF pressures and (2) time required to measure CSF pressure. Results A total of 56 procedures were analyzed in 55 patients. There was no significant difference in mean CSF pressures between devices: 22.5 cm H2O digitally vs 23.1 analog ( p = .7). Use of the digital manometer resulted in a time savings of 6 min (438 s analog vs 78 s digital, p < .001). Conclusion Cerebrospinal fluid pressure measurements obtained with digital manometry demonstrate comparable accuracy to the reference standard of analog manometry, with an average time savings of approximately 6 min per case.

Optical Coherence Tomography to Monitor Rebound Intracranial Hypertension with Increased Papilledema after Lumbar Puncture

Objective: We report that lumbar puncture (LP) with removal of cerebrospinal fluid (CSF) induced rebound intracranial hypertension with increased papilledema as monitored by optical coherence tomography (OCT). Background: Severe papilledema causes visual field loss and central vision damage if untreated. Fundoscopy is a key to diagnose papilledema, but is not sensitive enough to monitor therapeutic effects. Methods: OCT was applied to follow a 24-year-old woman with headache, visual dysfunction, severe bilateral papilledema, and elevated CSF opening pressure. She was first treated with serial LP, which led to symptom deterioration, increased CSF pressure, and increased the retinal nerve fiber layer (RNFL) thickness. She was then successfully treated with acetazolamide and furosemide. Results: OCT showed reduction of RNFL thickness directly after LP with CSF removal, accompanied with reduced CSF pressure. Increased RNFL thickness accompanied with worsened headache, visual dysfunction, and increased CSF pressure was observed on the next day after LP. Less than 24 h after start of medication, the symptoms had reversed and RNFL thickness was reduced. The patient was symptom-free 2 weeks after starting on medical treatment. Papilledema had vanished on fundoscopy 6 weeks after the therapy, and RNFL thickness was normalized at 3 months of follow-up. Conclusion: This case provides evidence that OCT is an objective and sensitive tool to monitor papilledema and its response to therapy, and thereby important to help in correct clinical decision-making.

Symptomatic interdural cerebrospinal fluid collections after surgery for idiopathic spinal cord herniation: illustrative case

BACKGROUND Idiopathic spinal cord herniation (ISCH) is very rare. Some reports have described postoperative ventral cerebrospinal fluid (CSF) collections in patients with ISCH; however, such collections are asymptomatic in most patients, and there is no consensus regarding whether they are part of the natural history or a complication. OBSERVATIONS A 30-year-old man with ISCH underwent direct closure of a duplicated dura mater. Eight months postoperatively, he developed reworsening of right lower limb paresis and new severe right arm pain and paresis. Three-dimensional magnetic resonance imaging revealed ventral CSF collections, which the authors judged as the responsible lesions. The authors initially considered these collections to be present in the epidural space, extradurally compressing the dural sac and resulting in myelopathy. An epidural blood patch failed; however, a CSF drainage test resulted in dramatic improvement. The authors therefore determined that the CSF collections were located in the interdural space, not the epidural space. A lumboperitoneal (LP) shunt was performed to reduce the CSF pressure. The patient’s symptoms improved immediately postoperatively. He had developed no recurrence of symptoms 6 months after surgery. LESSONS Ventral interdural CSF collections after ISCH surgery can cause reworsening of myelopathy and may be cured by a LP shunt to control CSF pressure.

Pediatric Idiopathic Intracranial Hypertension Post-measles Vaccine: A Case Report

Idiopathic intracranial hypertension is characterized by an increase in intracranial pressure with no significant structural cause. The diagnostic criteria include general signs and symptoms of generalized increased intracranial pressure or papilledema, increased Cerebrospinal Fluid (CSF) pressure (>250 mm H2 O), and normal brain imaging. It usually occurs in adults but rarely can be seen in children. We report a 7-year-old child with a manifestation of increased intracranial tension after the measles vaccine, associated with bilateral sixth nerve palsy and bilateral facial palsy with lower motor neuron features. Normal magnetic resonance imaging and CSF results were normal, except for an increase in CSF pressure. The symptoms began to be resolved after lumbar puncture with the complete resolution of symptoms after one and half months. We add also acetazolamide at the proper dose to reduce intracranial pressure from the first day of diagnosis.

1338 Bariatric Surgery as a Viable Treatment for Idiopathic Intracranial Hypertension: A Case Series

Introduction Idiopathic Intracranial Hypertension (IIH) is a significant cause of preventable blindness. Patients also suffer from debilitating headaches, pulsatile tinnitus, nausea, vomiting, photophobia, and radicular pain. If IIH continues to rise as predicted, treatment cost will increase to 462.7 million GBP annually by 2030. Weight loss is the only proven disease-modifying therapy for reversal of IIH. Bariatric surgery is an attractive treatment option due to superlative weight loss and reversal of related comorbidities. The case series aims to raise awareness of bariatric surgery as a safe and effective treatment modality for IIH. Method The case series consists of a retrospective analysis of four patients with a pre-operative diagnosis of IIH. They were referred to our department for bariatric surgery between January to December 2018. They were followed up for a total of two years. Results In our case series, all four patients were females with a mean age of 34 years. Mean BMI reduced from 47.3 kg/m2 before surgery to 30 kg/m2 with an EWL of 76.4% at the end of two years after surgery. They all showed significant improvement or resolution in their symptoms related to IIH, and none of them required further CSF pressure reducing procedures afterwards. Conclusions Bariatric surgery is a safe and effective method of treating IIH. It is superior compared to medical management and CSF pressure reducing procedures which have high rates of recurrence.

Cerebrospinal fluid dynamics in idiopathic intracranial hypertension: a literature review and validation of contemporary findings

Background Idiopathic intracranial hypertension (IIH) is a rare disease of unknown aetiology related possibly to disturbed cerebrospinal fluid (CSF) dynamics and characterised by elevated intracranial pressure (ICP) causing optic nerve atrophy if not timely treated. We studied CSF dynamics of the IIH patients based on the available literature and our well-defined cohort. Method A literature review was performed from PubMed between 1980 and 2020 in compliance with the PRISMA guideline. Our study includes 59 patients with clinical, demographical, neuro-ophthalmological, radiological, outcome data, and lumbar CSF pressure measurements for suspicion of IIH; 39 patients had verified IIH while 20 patients did not according to Friedman’s criteria, hence referred to as symptomatic controls. Results The literature review yielded 19 suitable studies; 452 IIH patients and 264 controls had undergone intraventricular or lumbar CSF pressure measurements. In our study, the mean CSF pressure, pulse amplitudes, power of respiratory waves (RESP), and the pressure constant (P0) were higher in IIH than symptomatic controls (p < 0.01). The mean CSF pressure was higher in IIH patients with psychiatric comorbidity than without (p < 0.05). In IIH patients without acetazolamide treatment, the RAP index and power of slow waves were also higher (p < 0.05). IIH patients with excess CSF around the optic nerves had lower relative pulse pressure coefficient (RPPC) and RESP than those without (p < 0.05). Conclusions Our literature review revealed increased CSF pressure, resistance to CSF outflow and sagittal sinus pressure (SSP) as key findings in IIH. Our study confirmed significantly higher lumbar CSF pressure and increased CSF pressure waves and RAP index in IIH when excluding patients with acetazolamide treatment. In overall, the findings reflect decreased craniospinal compliance and potentially depleted cerebral autoregulation resulting from the increased CSF pressure in IIH. The increased slow waves in patients without acetazolamide may indicate issues in autoregulation, while increased P0 could reflect the increased SSP.

Successful management of spontaneous intracranial hypotension with epidural blood patch

Spontaneous intracranial hypotension (SIH) is characterised by postural headache and a cerebrospinal fluid (CSF) pressure of ≤6 cmH20 measured with the patient in the lateral decubitus position. Other symptoms include tinnitus, altered hearing, diplopia, photophobia, nausea and neck stiffness, and must not have occurred within a month of dural puncture. Symptoms typically remit after normalisation of CSF pressure or successful sealing of the CSF leak. An epidural blood patch (EBP) is a treatment option in those who have not responded to bed rest, fluids, non-steroidal anti-inflammatories or caffeine. We present a case of SIH successfully treated with both conservative measures and EBP. We compare our case with similar cases in the literature and summarise what is known about EBP for SIH to help clinicians take a more informed approach to managing such patients.