Intracranial hypertension

Diagnosis and Treatment of Idiopathic Intracranial Hypertension (IIH) in Children and Adolescents

Authors: Victorio MC, Rothner AD.

Idiopathic intracranial hypertension (IIH) is characterized by symptoms and signs of elevated intracranial pressure, elevated cerebrospinal fluid (CSF) pressure, normal CSF content, and normal brain with normal or small ventricles on neuroimaging studies. IIH in children has a wide spectrum of clinical presentation. Diagnostic criteria with modifications to adapt to the variations in children are discussed. Diagnostic and therapeutic options are reviewed.

Paediatric idiopathic intracranial hypertension

Authors: Galveia JN, Mendonça AP, Costa JM.

Idiopathic intracranial hypertension (IIH) can occur in paediatric age with clinical characteristics that may differ from adult presentation. The authors present a case of an 11-year-old boy, presenting with severe holocranial headaches for the past 4 weeks. Best-corrected visual acuities (BCVA) were 20/200 bilaterally and the fundus examination showed marked bilateral optical disc and macular oedema. CT scan with contrast as well as MRI showed no space occupying lesions, normal permeability of the dural venous sinuses and a partially empty sella. Lumbar puncture revealed an opening pressure of 540 mm Hg, with clear cerebrospinal fluid, with normal biochemistry and cytology. The patient was treated medically and subsequently submitted to a ventriculoperitoneal shunting procedure. 3 months after surgery the symptoms got completely resolved and his BCVA were 20/20 bilaterally.

Reduced complexity of intracranial pressure observed in short time series of intracranial hypertension following traumatic brain injury in adults

Authors: Soehle M, Gies B, Smielewski P, Czosnyka M.

Physiological parameters, such as intracranial pressure (ICP), are regulated by interconnected feedback loops, resulting in a complex time course. According to the decomplexification theory, disease is characterised by a loss of feedback loops resulting in a reduced complexity of the time course of physiological parameters. We hypothesized that complexity of the ICP time series is decreased during periods of intracranial hypertension (IHT) following adult traumatic brain injury. In an observational retrospective cohort study, ICP was continuously monitored using intraparenchymally implanted probes and stored using ICM + -software. Periods of IHT (ICP > 25 mmHg for at least 1,024 s), were compared with preceding periods of intracranial normotension (ICP < 20 mmHg) and analysed at 1 s-intervals. ICP data (length = 1,024 s) were normalised (mean = 0, SD = 1) and complexity was estimated using the scaling exponent α (as derived from detrended fluctuation analysis), sample entropy (SampEn, m = 1, r = 0.2 × SD) and multiscale entropy. 344 episodes were analysed in 22 patients. During IHT (ICP = 31.7 ± 7.8 mmHg, mean ± SD), α was significantly elevated (α = 1.02 ± 0.22, p < 0.001) and SampEn significantly reduced (SampEn = 1.45 ± 0.46, p = 0.004) as compared to before IHT (ICP = 15.7 ± 3.2 mmHg, α = 0.81 ± 0.14, SampEn = 1.81 ± 0.24). In addition, MSE revealed a significantly (p < 0.05) decreased entropy at scaling factors ranging from 1 to 10. Both the increase in α as well as the decrease in SampEn and MSE indicate a loss of ICP complexity. Therefore following traumatic brain injury, periods of IHT seem to be characterised by a decreased complexity of the ICP waveform.

Reevaluation of presentation and course of idiopathic intracranial hypertension - a large cohort comprehensive study

Authors: Pollak L, Zohar E, Glovinsky Y, Huna-Baron R.

OBJECTIVES: We analyzed the clinical and ophthalmological findings in a large group of patients with idiopathic intracranial hypertension (IIH) trying to find factors that might influence the course of the disease.
MATERIALS AND METHODS: Medical records of patients with IIH were retrospectively reviewed. The patients included were women after menarche and men older than 18 years of age who were followed up for at least 1 year.
RESULTS: Eighty-two patients (89% women) with a mean age of 30.2 ± 12.0 years were included. The prevailing complaint was headache and transient visual obscurations followed by tinnitus and double vision. Eighty-two percent of patients were overweight at the time of diagnosis. Overweight patients had higher opening cerebrospinal fluid (CSF) pressure than patients with normal weight did. The grade of papilledema correlated with the CSF opening pressure. Inverse correlation was found between the depression of the visual field sensitivity and the grade of papilledema. The mean follow-up time was 61.3 ± 62.3 months. Eighty-four percent of the patients have improved while in 22% CSF diversion procedures or optic nerve decompression was required. The mean body mass index (BMI) at the end of follow-up decreased significantly. Sixty-seven percent of the patients suffered a recurrence of IIH. The number of recurrences inversely correlated with weight loss. Visual field defects on presentation were encountered more frequently in patients with recurrence. Women with recurrence had a history of more pregnancies.
CONCLUSIONS: Our results confirm the strong association between overweight and IIH. The recurrence rate seemed to be influenced by the obstetrical history and the severity of visual field defects at presentation. In contrast to some previous studies, we have found an interrelation between the CSF opening pressure, grade of papilledema and depression of the visual field sensitivity.

Clinical course of idiopathic intracranial hypertension with transverse sinus stenosis

Authors: Riggeal BD, Bruce BB, Saindane AM, Ridha MA, Kelly LP, Newman NJ, Biousse V.

OBJECTIVE: Transverse sinus stenosis (TSS) is common in idiopathic intracranial hypertension (IIH), but its effect on the course and outcome of IIH is unknown. We evaluated differences in TSS characteristics between patients with IIH with "good" vs "poor" clinical courses.
METHODS: All patients with IIH seen in our institution after September 2009 who underwent a high-quality standardized brain magnetic resonance venogram (MRV) were included. Patients were categorized as having a good or poor clinical course based on medical record review. The location and percent of each TSS were determined for each patient, and were correlated to the clinical outcome.
RESULTS: We included 51 patients. Forty-six patients had bilateral TSS. The median average percent stenosis was 56%. Seventy-one percent of patients had stenoses >50%. Thirty-five of the 51 patients (69%) had no final visual field loss. Eight patients (16%) had a clinical course classified as poor. There was no difference in the average percent stenosis between those with good clinical courses vs those with poor courses (62% vs 56%, p = 0.44). There was no difference in the percent stenosis based on the visual field grade (p = 0.38). CSF opening pressure was not associated with either location or degree of TSS.
CONCLUSION: TSS is common, if not universal, among patients with IIH, and is almost always bilateral. There is no correlation between the degree of TSS and the clinical course, including visual field loss, among patients with IIH, suggesting that clinical features, not the degree of TSS, should be used to determine management in IIH.

Idiopathic intracranial hypertension: A caesarean with epidural anaesthesia after bringing the cerebrospinal fluid pressure back to normal

Authors: Pérez Rodríguez M, de Carlos Errea J, Dorronsoro Auzmendi M, Batllori Gastón M.

Idiopathic intracranial hypertension is diagnosed by exclusion. Because of its uncertain physiopathology and infrequent occurrence, its anaesthetic management is not well defined. The patient in this case is a pregnant woman with this disease with no lumbar-peritoneal shunt who was referred for non-urgent caesarean section, consisting of CSF drainage and pressure normalisation before the administration of epidural anaesthesia. We believe this technique can de effective to achieve adequate blockage and increased patient comfort, as well as improving postoperative recovery.
 

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