Idiopathic Intracranial Hypertension Treatment & Management
- Author: Mark S Gans, MD; Chief Editor: Andrew G Lee, MD more...
The treatment goal for patients with idiopathic intracranial hypertension (IIH) is to preserve optic nerve function while managing increased intracranial pressure (ICP). Medical management is multifaceted. Optic nerve function should be carefully monitored with an assessment of visual acuity, color vision, optic nerve head appearance, and perimetry. Weight control is recommended for obese patients. Exogenous agents related to increased ICP should be discontinued.
Patients without visual loss most often are treated with a carbonic anhydrase inhibitor (eg, acetazolamide) to lower the ICP. While, historically, this has been the mainstay of treatment, it has now been corroborated with an NIH-funded study (Idiopathic Intracranial Hypertension Treatment Trial). In patients with severe symptoms, early visual field loss, or poor response to standard medical therapy, some clinicians utilize a short course of high-dose oral corticosteroids to temporarily postpone the need for surgical intervention.
When new visual field loss is documented, medical management should be coupled with plans for emergency surgical intervention if the visual function continues to deteriorate or does not improve immediately with corticosteroid treatment.
Visual loss in one or both of the eyes can evolve rapidly despite the best efforts to arrest the process. In this author’s experience, IIH has been a frequent cause of litigation. Almost uniformly, cases center on the delay of maximum medical and surgical management for patients who present with rapidly declining vision.
The exact time window within which vision loss can be reversed after symptomatic decline is not known. Opinions among experts in the field vary as to how rapidly and aggressively any given patient should have been treated. As a rule, it is better to err on the side of rapid intervention (ie, within hours to days) in such patients. This is a dramatic opportunity to save vision that can be easily lost. A major medicolegal pitfall is created when poor outcome is coupled with the perception of delayed treatment.
One of the standard teachings regarding this condition has been that pregnancy exacerbates or triggers the onset of symptomatic IIH. At present, however, there is little statistical evidence of a causal association between pregnancy and IIH, beyond the fact that pregnancy is common in the age group and gender that is predominantly affected by IIH.[61, 62]
Acetazolamide and furosemide
In a 2014 NIH-funded study of 165 patients with IIH and mild vision loss (the Idiopathic Intracranial Hypertension Treatment Trial), researchers found that acetazolamide treatment for six months in conjunction with a low-sodium weight-reduction diet modestly improved vision, reduced intracranial pressure, improved quality of life, and reduced papilledema. Average improvement in perimetric mean deviation (PMD) was 1.43 dB with acetazolamide and 0.71 dB with placebo. Data show that the effect of the drug was independent of weight loss.[63, 64]
Acetazolamide appears to be the most effective agent for lowering ICP. Most patients experience adequate relief of symptoms (typically, headache) with this first-line agent. The brand-name formulation Diamox appears to be better tolerated than generic acetazolamide is.
The initial dosage should be 0.5-1 g/day. Although many physicians start patients on 250 mg twice daily, others consider this dosage too low. A 500-mg oral dose of Diamox Sequels twice daily is preferred; however, some insurers only cover an oral dose of 250 mg 4 times per day. Most patients respond to a dosage of 1-2 g/day. This can be increased to 3-4 g/day, but most patients cannot tolerate the adverse effects (eg, extremity paresthesias, fatigue, metallic taste from carbonated beverages, and decreased libido) that occur at this high dosage.[2, 4]
In the event of intolerance to acetazolamide, furosemide may be used as a replacement diuretic in this group. Unfortunately, it does not appear to be as effective as acetazolamide.
For patients with stable visual function but inadequate headache relief with first-line pressure-lowering drugs, primary headache prophylaxis should be considered. Patients with IIH may experience headaches that have many of the features of migraine. These headaches can often be controlled with amitriptyline, propranolol, or other commonly prescribed migraine prophylaxis agents. Topiramate is also an excellent choice, in that one of its side effects is weight loss (a common association in IIH), which can help put the disease in remission.
Corticosteroids are effective in lowering ICP in patients whose IIH has an inflammatory etiology. In addition, they may be used as a supplement to acetazolamide to hasten recovery in patients who present with severe papilledema. Because of their significant adverse effects, corticosteroids should not be considered as a long-term solution for IIH patients. In addition, a rebound in the ICP may occur during the tapering of the corticosteroid dosage.
Patients experiencing a progressive loss of visual field in one or both of the eyes should immediately be placed on high-dose (60-100 mg/day) oral prednisone (or an equivalent corticosteroid regimen). Digoxin and furosemide have been advocated by some investigators, but these are on the same level of effectiveness as acetazolamide and are not appropriate as sole therapy for patients who are losing vision.
If a moderately severe new visual field loss is detected on a routine office visit, and the patient is not experiencing progressive symptoms, outpatient management can continue. However, visual fields should be measured every few days or at 1- to 2-week intervals, depending on the magnitude and progression of the defect. If the visual field continues to worsen on corticosteroid treatment, the patient should be admitted for immediate surgical management.
If the patient presents with symptomatic deterioration of vision, and the examination documents worsening of visual field despite adequate standard medical therapy, the patient should be started immediately on corticosteroids, as previously outlined. The patient also should be admitted to the hospital for consideration of emergency surgical decompression. Visual field examination should be performed daily, and surgical decompression should be carried out if no improvement or further worsening is noted in the subsequent 24-48 hours.
Optic Nerve Sheath Fenestration, CSF Diversion, and Venous Sinus Stenting
Patients with IIH should be closely monitored while on medical treatment. The frequency of visits is determined by the initial state of the patient’s visual function and the response to medical treatment. Despite close follow-up care and maximum medical treatment, some patients experience deterioration of their visual function. In this situation, surgical intervention may be considered. Such intervention most often takes 1 of the following 2 general approaches:
Optic nerve sheath fenestration (decompression)
Cerebrospinal fluid (CSF) diversion (ie, via a lumboperitoneal or ventriculoperitoneal shunt)
However, intracranial venous sinus stenting has also been investigated (see below). Treatment of IIH with repeated lumbar punctures is considered to be of historic interest only.
Optic nerve sheath fenestration
The ophthalmic surgical approach to managing patients with progressive vision loss and papilledema involves cutting slits or rectangular patches in the dura surrounding the optic nerve immediately behind the globe. This allows direct egress of CSF into the orbital fat, where it is absorbed into the venous circulation.
Optic nerve sheath fenestration has been demonstrated to reverse optic nerve edema and to bring about some recovery of optic nerve function. In addition, it may decrease headache in many patients. The approach to the optic nerve may be from either the medial or the lateral aspect of the orbit; each approach has its benefits and drawbacks.
Although ICP typically remains elevated in these patients postoperatively, the local filtering effect of the fenestration acts as a safety valve and keeps the pressure from being transmitted to the optic nerve. Despite the general lack of an ICP-lowering effect, unilateral surgery occasionally has a bilateral curative effect on the papilledema. However, if this is not the case, the opposite nerve must undergo the same procedure.
Complications related to optic nerve sheath fenestration include the following:
Optic nerve injury
Hemorrhage and infection (risks inherent to intraconal surgery)
Unfortunately, the procedure may not have lasting benefits. In most cases, visual function stabilizes or improves after optic nerve sheath decompression in the short run, but in at least one third of cases, secondary visual decline may occur within 3-5 years and may necessitate repeat surgery or an alternative treatment; Spoor and McHenry found the long-term success rate of this operation to be only 16%.
A study of optic nerve sheath fenestration performed in 41 eyes from 21 patients with vision loss from either IIH or intracranial hypertension from cerebral venous thrombosis found best-corrected visual acuity and visual field to be stabilized or improved in 32 of 34 eyes (94%) over a 3-month follow-up interval. Transient benign complications were apparent in 4 eyes. Only marginal improvement was shown in 4 eyes with no light perception vision; these were not analyzed with the remainder of the group.
CSF diversion procedures
CSF diversion procedures are highly effective in lowering ICP. In some facilities, they remain the procedures of choice for treating IIH patients who do not respond to maximum medical treatment.[4, 6, 66] Shunts are also indicated for patients with intractable headaches, patients in regions where there is no access to a surgeon comfortable with optic nerve sheath fenestration, and patients in whom optic nerve sheath fenestration has failed.
Lumboperitoneal shunting is the traditional method for providing prompt reduction of ICP in patients with IIH. However, this procedure has a high 1-year failure rate. Some neurosurgeons currently prefer ventriculoperitoneal or ventriculoatrial shunting to lumboperitoneal shunting.
The main reason why these neurosurgeons prefer ventricular shunts is that such shunts can be monitored for function by using an extracranial subcutaneous compressible bulb and a 1-way valve (permitting intracranial-to-abdominal flow) in series with the intracranial and abdominal ends of the shunt. The bulb will resist digital compression if the distal (abdominal or atrial) end is obstructed. It will collapse under digital pressure but will fail to reinflate if the intracranial end is obstructed.
Many neurosurgeons have been reluctant to place ventricular shunts in patients with IIH because the ventricles are small and difficult to cannulate without radiographic guidance. In addition, there is a significant risk of complications (eg, infection, stroke, seizures, and shunt failure). However, Woodworth et al reported that with a frameless stereotactic approach, they were able to place ventricular shunts in a single pass in all patients, even into slit ventricles, with good long-term viability.
Sinclair et al found that although CSF diversion minimizes visual decline and improves visual acuity, 68% of patients continued to have headaches and 28% had low-pressure headaches that complicated surgery. Shunt revision was required for 51% of patients, with most requiring multiple revisions. For those with otherwise untreatable rapidly declining vision, CSF diversion shunting should be conducted as a last resort. Other treatments, such as weight reduction, may be more effective and may have less associated morbidity.
Intracranial venous sinus stenting
Following up on the work of Farb et al, Bussière et al studied 13 patients with IIH that was refractory to medical management who were found to have stenosis of one or both of the transverse dural sinuses on time-of-flight magnetic resonance (MR) venography. Of these, 10 also had increased pressure gradient across the stenotic dural venous sinus (>10 mm Hg), and these underwent stent placement without significant complications.
All 10 of the patients experienced complete resolution or significant improvement of their headaches, and 8 experienced complete or near-complete resolution of papilledema. The authors suggested only that a randomized, controlled study of transverse dural venous sinus stenting in the management of IIH was needed to establish the safety and efficacy of the procedure in this setting.
Arac et al reported 1 case of endovascular stenting for IIH and reviewed the same published series that Bussière et al did, arriving at essentially the same conclusions. They also discussed Bateman’s proposed mathematical model of the relations among intracranial arterial inflow, CSF pressure, and venous outflow (see Pathophysiology).
Comparison of visual outcomes
In a meta-analysis of the existing literature comparing visual outcomes after optic nerve sheath decompression, ventriculoperitoneal and lumboperitoneal shunting, and intracranial venous sinus stenting, Feldon reported the following findings :
252 optic nerve sheath decompressions – Visual defects were improved or resolved in 80%
31 ventriculoperitoneal (VP) shunt placements – Visual defects were improved or resolved in 38.7%
44 lumboperitoneal (LP) shunt placements – Visual defects were improved or resolved in 44.6%
17 intracranial venous sinus stent placements – Visual defects were improved or resolved in 47%
Visual worsening was rare for all procedures. The author concluded that visual outcome was best documented for optic nerve sheath fenestration, which appeared to be the best surgical procedure for vision loss in IIH.
In a review of the literature on bariatric surgery for obese patients with IIH, Fridley et al found a total of 62 patients, of whom 52 (92%) experienced resolution of the presenting symptoms. Of 35 patients who underwent postoperative funduscopy, 34 had resolution of papilledema. Of 12 patients who underwent pre- and postoperative visual field examinations, 11 showed resolution of visual field defects.
Among 13 patients in whom CSF pressures were measured pre- and postoperatively, there was an average postoperative decrease of 254 mm water. The authors called for prospective controlled studies to confirm the effectiveness of this surgical approach for IIH patients in long-term follow-up.
Admission for pain management
Even for initial diagnosis, most patients do not require inpatient care, because lumbar puncture is usually performed in the ambulatory care setting. An occasional patient may develop an intractable low-tension headache after lumbar puncture and may require a short hospital stay for intravenous (IV) hydration and analgesic management. A blood patch (by an anesthesiologist) is sometimes indicated if the post–lumbar puncture headache does not subside spontaneously within a few days.
Admission for surgical management of increased ICP
Patients who complain of progressive visual loss (typically, constriction of peripheral vision or dimming of vision in one or both of the eyes) and have documented new visual field loss may respond to high-dose corticosteroid therapy; they should be admitted to the hospital and should undergo daily monitoring of visual function.
If the visual field worsens or does not recover promptly (ie, within 24-48 hours) with corticosteroid therapy, then emergency CSF shunting (lumboperitoneal, ventriculoperitoneal, or ventriculoatrial) or optic nerve sheath fenestration should be carried out.
If any delay in implementing surgical decompression of the failing optic nerve is anticipated, the patient should be moved to the intensive care unit (ICU) or a stepdown unit for lumbar CSF drainage until the definitive procedure can be performed. Another short-term treatment option is IV mannitol, but definitive pressure-lowering surgery must still be done within 2-3 days.
A very small number of patients with normal visual fields may require surgical relief of CSF pressure because of intractable headache. Optic nerve sheath fenestration does not provide reliable CSF pressure normalization or headache relief; thus, these patients will require a shunting procedure. Because patients with IIH frequently have other types of headaches, the decision to choose ventriculoperitoneal shunting over optic nerve sheath fenestration should not be made on the basis of headache alone.
Diet and Activity
Most patients with this disorder are females who are overweight. Weight loss is a cornerstone in the long-term management of these patients. As little as a 5-10% weight loss has been demonstrated to yield a reduction in ICP with accompanying resolution of papilledema.[49, 48, 2] Unfortunately, weight reduction generally proves to be a difficult task for these patients. To formalize the process of weight reduction, referral to a dietitian is appropriate.
On initial diagnosis, a weight-reduction diet should be strongly recommended to all patients with IIH. Often, a formal weight-loss program is required. No activity restriction is required in managing IIH. In fact, exercise programs are strongly recommended in conjunction with the weight-reduction diet.
Diagnosis and long-term management of patients with IIH requires the performance of lumbar puncture, which is typically performed by neurologists or internists, and careful monitoring of visual status (in particular, peripheral visual field and fundus photography). Vision examination and fundus photography are the domain of ophthalmologists, and neuro-ophthalmologists are especially expert in examining visual fields. A team approach is therefore needed for most, if not all, patients.
Neurosurgical consultation is required for ventriculoperitoneal shunting when patients are losing visual field and medical management does not arrest or reverse the process promptly (ie, within hours to days). Consultation with an orbital plastic surgeon is required for optic nerve sheath fenestration for the same clinical indications.
The frequency of the follow-up visits is determined by a number of factors, to include the following:
Initial visual function of the patient
Underlying disease causing increased ICP
Perceived compliance of the patient with medical therapy
Once the initial diagnosis has been established, investigations have been performed, and therapy has been initiated, the patient can be observed every 3-4 weeks.
If, however, the patient presents with a significant visual function deficit or marked papilledema, daily monitoring for 1 week is appropriate until some improvement and subsequent stability in visual function can be demonstrated. The clinician should be prepared to titrate the patient’s treatment to the status of visual function and should not hesitate to refer the patient for surgical treatment (optic nerve sheath fenestration or CSF diversion) visual function does not stabilize.
During follow-up visits, the best-corrected visual acuity for distant and near vision, color vision (with pseudoisochromatic plates), static perimetry, and optic nerve appearance (including the status of spontaneous venous pulsations) should be recorded. Patients who do not perform well on static perimetry testing may be better followed with kinetic perimetry testing.
Spontaneous pulsation of large retinal veins generally indicates a normal ICP. If the patient continues to remark on the persistence of a significant headache despite the presence of spontaneous venous pulsations, a source other than IIH for the headache should be considered.
When a patient appears to have stabilized with respect to visual function and treatment, the frequency of follow-up visits can be extended to once every 2-4 months.
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