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Headaches:Neuro-endovasculardiagnos4candtreatmentop4ons.
“PseudotumorCerebri”EdisonValle,M.D.
Disclosures
Introduc4on
• Pseudotumorcerebri:à1904àpa4entswithsignsandsymptomsofincreasedintracranialpressurebutnotumor.– DandyCriteria:normalbrainimaging(ventriculograms).
• Otherterms:meningi4sserosa,o44chydrocephalus,toxichydrocephalus,hypertensivemeningealhydrops,pseudoabscess,papilledemaofundeterminede4ology,andintracranialpressurewithoutbraintumor.
• 1955àbenignintracranialhypertensionà1969àIdiopathicintracranialhypertension(IIH)
GiridharanN,PatelSK,OjugbeliA,NouriA,ShiraniP,GrossmanAW,ChengJ,ZuccarelloM,Pres4giacomoJ,Understandingthecomplexpathophysiologyofidiopathicintracranialhypertensionandtheevolvingroleofvenoussinussten4ng:acomprehensivereviewoftheliterature.NeurosurgFocus45(1):E10,2018
• Recently:primaryintracranialhypertension(PIH)andsecondaryintracranialhypertension(SIH).
• IIHandPIHareuseindis4nctlyàisadiagnosisofexclusion.
Epidemiology
• Incidence0.5-2/100,000.• 25–36yearsofageinaverage.• Morecommoninwomen.• Obesityincreasesrisk20-fold.
Clinicalpresenta4on.
• GeneralizedHeadaches+visualchanges.– HA:pressure-like,severeuponawakening,accompaniedbynausea,photophobiaand/orphonophobia,neckpain,4nnitus.
– Transient/permanentvisionloss:doublevision,reduc4oninvisualacuity,VFdeficits.
• Signs:ElevatedICPàpapilledema.• DiagnosisisDxofexclusion.
Pathophysiology
• Specula4vereasons.• IncreasedCSFproduc4on,decreasedCSFabsorp4on,increasedvenoussinuspressure,obesity,changesinvitaminAmetabolism,hormonalinbalance.
GiridharanN,PatelSK,OjugbeliA,NouriA,ShiraniP,GrossmanAW,ChengJ,ZuccarelloM,Pres4giacomoJ,Understandingthecomplexpathophysiologyofidiopathicintracranialhypertensionandtheevolvingroleofvenoussinussten4ng:acomprehensivereviewoftheliterature.NeurosurgFocus45(1):E10,2018
Treatment• Firstline:medicaltherapyandweightloss.• Medicaltherapy:Carbonicanhydraseinhibitor(acetazolamide)à
classIBevidence.– Improvedvisualfields– Decreasedpapilledema– Improvedqualityoflife.– DecreasedCSFpressure.– Othermedica4ons:furosemide,topiramate.
• Acetazolamide:adverseevents:electrolytedisturbances,nephrolithiasis,paresthesias,dysgeusia,nausea/vomin4ng,diarrhea,fa4gue.
• Secondline(failedmedicaltherapy):CSFdiversion,op4cnervesheathfenestra4on,bariatricsurgery,VSSàthereisnoRTCforthisdata.
WallM:Idiopathicintracranialhypertension.NeurolClin28:593–617,2010WallM:Updateonidiopathicintracranialhypertension.NeurolClin35:45–57,2017
ONF
CSFdiversion
• 7.6%majorcomplica4ons.• 33%minorcomplica4on• Revisionrate43%.• 95%improvedHAby1month• HArecurrence:– 6months:63%– 1year:77%– 2years:79%.
SajSRSr,LeishangthemL,ChaudryMI:Meta-analysisofCSFdiversionproceduresandduralvenoussinussten4nginthesejngofmedicallyrefractoryidiopathicintracranialhypertension.AJNRAmJNeuroradiol36:1899–1904,2015
VSS
• 10-90%oftheIIH,dependingonseries.• 78%ofpa4entshadreliefinHA.• 86.5%hadimprovementonvision.• 94%resolu4onofpapilledema.• 93%improvementof4nnitus.• Complica4onrate5.4%.• Followupsà6%developadjacentstenosis.
KanagalingamS,SubramanianPS.UpdateonIdiopathicIntracranialHypertension.CurrTreatOp4onsNeurol(2018)20:24
VSS
• 78%con4nuetohaveHA• 33%con4nuevisualdisturbances.• 0%hadauditorybruitorpapilledema.• 6%hadnewonset4nnitus.• 89%hadimprovementofsymptoms.
CappuzzoJM,HessRM,MorrisonJF,DaviesJM,SnyderKV,LevyEI,SiddiquiAH.Transversevenoussten4ngforthetreatmentofidiopathicintracranialhypertension,orpeudotumorcerebri.NeurosurgFocus45(1):E11,2018
ShuntVSVSS
• Shun4ngàgoodshort-termsuccess(classIIA)àclosetohalfofpa4entshaverecurrenceofHAat36mo.
• CostofshuntismuchgreaterthanVSSà$15kVS13K.
• Alsodelayedcostàshuntrevisionmuchhigherratethansten4ng.àcostper100casesforshuntwasalmosttwicethecostforVSS.
AhmedRM,ZmudzkiF,ParkerGD,OwlerBK,HalmagyiGM:Transversesinussten4ngforpseudotumorcerebri:acostcomparisonwithCSFshun4ng.AJNRAmJNeuroradiol35:952–958,2014
KanagalingamS,SubramanianPS.UpdateonIdiopathicIntracranialHypertension.CurrTreatOp4onsNeurol(2018)20:24
Totopitoff…
• Reversiblesinusstenosis.– McGonigaletal.Neurology2004;62:514-515– Baryshniketal.Neurology2004;62:1444-1446– HigginsJNPetal.Neurology2004;62:1907-1908
Wherearewegoing?