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1.
World Neurosurg ; 184: 372-386, 2024 Apr.
Article En | MEDLINE | ID: mdl-38590071

Although numerous case series and meta-analyses have shown the efficacy of venous sinus stenting (VSS) in the treatment of idiopathic intracranial hypertension and idiopathic intracranial hypertension-associated pulsatile tinnitus, there remain numerous challenges to be resolved. There is no widespread agreement on candidacy; pressure gradient and failed medical treatment are common indications, but not all clinicians require medical refractoriness as a criterion. Venous manometry, venography, and cerebral angiography are essential tools for patient assessment, but again disagreements exist regarding the best, or most appropriate, diagnostic imaging choice. Challenges with the VSS technique also exist, such as stent choice and deployment. There are considerations regarding postprocedural balloon angioplasty and pharmacologic treatment, but there is insufficient evidence to formalize postoperative decision making. Although complications of VSS are relatively rare, they include in-stent stenosis, hemorrhage, and subdural hematoma, and the learning curve for VSS presents specific challenges in navigating venous anatomy, emphasizing the need for wider availability of high-quality training. Recurrence of symptoms, particularly stent-adjacent stenosis, poses challenges, and although restenting and cerebrospinal fluid-diverting procedures are options, there is a need for clearer criteria for retreatment strategies. Despite these challenges, when comparing VSS with traditional cerebrospinal fluid-diverting procedures, VSS emerges as a favorable option, with strong clinical outcomes, lower complication rates, and cost-effectiveness. Further research is necessary to refine techniques and indications and address specific aspects of VSS to overcome these challenges.


Intracranial Hypertension , Pseudotumor Cerebri , Tinnitus , Humans , Pseudotumor Cerebri/complications , Pseudotumor Cerebri/diagnostic imaging , Pseudotumor Cerebri/surgery , Tinnitus/etiology , Tinnitus/surgery , Constriction, Pathologic/diagnostic imaging , Constriction, Pathologic/surgery , Constriction, Pathologic/complications , Cranial Sinuses/diagnostic imaging , Cranial Sinuses/surgery , Stents/adverse effects , Intracranial Hypertension/surgery , Intracranial Hypertension/complications , Treatment Outcome , Retrospective Studies
2.
World Neurosurg ; 184: 361-371, 2024 Apr.
Article En | MEDLINE | ID: mdl-38590070

Venous sinus stenosis has garnered increasing academic attention as a potential etiology of idiopathic intracranial hypertension (IIH) and pulsatile tinnitus (PT). The complex anatomy of the cerebral venous sinuses and veins plays a crucial role in the pathophysiology of these conditions. Venous sinus stenosis, often found in the superior sagittal or transverse sinus, can lead to elevated intracranial pressure (ICP) and characteristic IIH symptoms. Stenosis, variations in dural venous anatomy, and flow dominance patterns contribute to aberrant flow and subsequent PT. Accurate imaging plays a vital role in diagnosis, and magnetic resonance (MR) venography is particularly useful for detecting stenosis. Management strategies for IIH and PT focus on treating the underlying disease, weight management, medical interventions, and, in severe cases, surgical or endovascular procedures. Recently, venous sinus stenting has gained interest as a minimally invasive treatment option for IIH and PT. Stenting addresses venous sinus stenosis, breaking the feedback loop between elevated ICP and stenosis, thus reducing ICP and promoting cerebrospinal fluid outflow. The correction and resolution of flow aberrances can also mitigate or resolve PT symptoms. While venous sinus stenting remains an emerging field, initial results are promising. Further research is needed to refine patient selection criteria and evaluate the long-term efficacy of stenting as compared to traditional treatments.


Intracranial Hypertension , Pseudotumor Cerebri , Tinnitus , Humans , Pseudotumor Cerebri/complications , Pseudotumor Cerebri/diagnosis , Pseudotumor Cerebri/surgery , Tinnitus/diagnosis , Tinnitus/etiology , Tinnitus/therapy , Constriction, Pathologic/complications , Constriction, Pathologic/diagnostic imaging , Constriction, Pathologic/surgery , Intracranial Hypertension/complications , Intracranial Hypertension/diagnosis , Cranial Sinuses/diagnostic imaging , Cranial Sinuses/surgery , Stents/adverse effects
3.
Neurol Clin ; 42(2): 433-471, 2024 May.
Article En | MEDLINE | ID: mdl-38575259

Pseudotumor cerebri syndrome is a syndrome of increased cerebrospinal fluid pressure without ventriculomegaly, mass lesion, or meningeal abnormality. It is either primary (idiopathic intracranial hypertension, IIH) or secondary. A secondary cause is unlikely when adhering to the diagnostic criteria. Permanent visual loss occurs if undetected or untreated, and the associated headaches may be debilitating. Fulminant disease may result in blindness despite aggressive treatment. This study addresses the diagnosis and management of IIH including new insights into the pathobiology of IIH, updates in therapeutics and causes of overdiagnosis.


Intracranial Hypertension , Papilledema , Pseudotumor Cerebri , Humans , Pseudotumor Cerebri/diagnosis , Pseudotumor Cerebri/etiology , Pseudotumor Cerebri/therapy , Intracranial Hypertension/complications , Headache/diagnosis , Headache/etiology , Headache/therapy , Vision Disorders/therapy , Syndrome , Papilledema/complications , Papilledema/diagnosis
4.
Neurol Clin ; 42(2): 507-520, 2024 May.
Article En | MEDLINE | ID: mdl-38575263

Headache affects around half of patients in the acute phase of COVID-19 and generally occurs at the beginning of the symptomatic phase, has an insidious onset, and is bilateral, and of moderate to severe intensity. COVID-19 may also present complications that cause acute and persistent headaches, such as cerebrovascular diseases, rhinosinusitis, meningitis, and intracranial hypertension. In 10% to 20% of patients with COVID-19, headache may persist beyond the acute phase. In general, the headache improves over time. To date, there are no clinical trials that have assessed the treatment of persistent post-COVID-19 headache.


COVID-19 , Intracranial Hypertension , Rhinosinusitis , Humans , COVID-19/complications , Headache/etiology , Intracranial Hypertension/complications
5.
Neuroradiology ; 66(5): 817-824, 2024 May.
Article En | MEDLINE | ID: mdl-38429544

INTRODUCTION: Symptomatic intracranial hypertension (IH) due to venous outflow obstruction secondary to dural venous sinus (DVS) tumoral invasion affects up to 3% of intracranial meningioma patients. The literature regarding endovascular therapies of such patients is limited to a few case reports and a recent single-centre case series. PURPOSE: We describe our single-centre experience of endovascular therapy in patients with clinically symptomatic IH secondary to DVS meningioma invasion. METHODS: We performed a retrospective review of clinical and radiological data of all patients with refractory IH and meningiomas invading the DVS who were referred for possible DVS venoplasty and stenting. Seven endovascular procedures in six female patients were done. Presumed secondarily induced lateral transverse sinus stenosis was also stented in four patients as part of the primary intervention. RESULTS: All patients experienced complete symptomatic resolution at 6-month follow-up. Five patients had no symptom recurrence over a mean follow-up period of 3.5 years. One patient with multiple meningiomas developed recurrent IH 2 years following stenting secondary to in-stent tumour re-invasion. This was re-stented with consequent 6 months post-retreatment symptomatic relief at the time of writing. No procedure-related complications occurred. CONCLUSION: In the setting of DVS stenosis secondary to meningioma invasion, endovascular therapy is a safe and successful therapeutic option with promising mid-term results. The procedure should be considered in cases where complete surgical tumour resection is unlikely or carries a significant risk. If present, secondarily induced stenoses at the lateral ends of the transverse sinuses should also be considered for treatment.


Intracranial Hypertension , Meningeal Neoplasms , Meningioma , Pseudotumor Cerebri , Humans , Female , Meningioma/complications , Meningioma/diagnostic imaging , Meningioma/surgery , Constriction, Pathologic/surgery , Constriction, Pathologic/complications , Cranial Sinuses/diagnostic imaging , Cranial Sinuses/surgery , Intracranial Hypertension/complications , Stents/adverse effects , Retrospective Studies , Meningeal Neoplasms/complications , Meningeal Neoplasms/diagnostic imaging , Meningeal Neoplasms/surgery , Treatment Outcome , Pseudotumor Cerebri/complications
6.
BMJ Case Rep ; 17(3)2024 Mar 15.
Article En | MEDLINE | ID: mdl-38490699

Spontaneous intracranial hypotension (SIH) is a condition characterised by postural headaches due to low cerebrospinal fluid (CSF) pressure, often stemming from CSF leakage. Diagnosis poses a significant challenge, and the therapeutic approach encompasses both conservative measures and operative interventions, such as the epidural blood patch (EBP). However, EBP carries the potential risk of inducing rebound intracranial hypertension (RIH), subsequently leading to high-pressure headaches. We present a case wherein RIH following EBP was effectively managed through the implementation of an external ventricular drain (EVD) aimed at reducing CSF pressure. The patient improved significantly, underscoring the potential utility, if not necessity, of EVD in carefully selected cases, highlighting the imperative for further research to enhance the management of SIH and optimise EBP-related complications.


Intracranial Hypertension , Intracranial Hypotension , Humans , Cerebrospinal Fluid Leak/therapy , Cerebrospinal Fluid Leak/complications , Intracranial Hypotension/therapy , Intracranial Hypotension/complications , Blood Patch, Epidural , Headache/therapy , Drainage , Intracranial Hypertension/therapy , Intracranial Hypertension/complications
7.
Cephalalgia ; 44(3): 3331024241237237, 2024 Mar.
Article En | MEDLINE | ID: mdl-38459955

BACKGROUND: Idiopathic intracranial hypertension (IIH) occurs more frequently in obese females of childbearing age. A link between eating disorders and poor outcome has been suggested but remains unproven. METHODS: This prospective field study at two tertiary headache centers included patients with clinically suspected IIH after standardized diagnostic work-up. Eating disorders were evaluated using validated questionnaires (EDQs). Primary outcome was the impact of eating disorders on IIH severity and outcome, secondary outcome was the prevalence and type of eating disorders in IIH compared to controls. RESULTS: We screened 326 patients; 143 patients replied to the EDQs and were classified as 'IIH' or 'non-IIH' patients. The demographic profile of EDQ-respondents and non-respondents was similar. Presence of an eating disorder did not impact IIH severity (lumbar puncture opening pressure (p = 0.63), perimetric mean deviation (p = 0.18), papilledema (Frisén grad 1-3; p = 0.53)) nor IIH outcome (optic nerve atrophy (p = 0.6), impaired visual fields (p = 0.18)). Moreover, we found no differences in the prevalence and type of eating disorders when comparing IIH with non-IIH patients (p = 0.09). CONCLUSION: Eating disorders did not affect IIH severity or outcome. We found the same prevalence and distribution pattern of eating disorders in IIH and non-IIH patients advocating against a direct link between IIH and eating disorders.


Feeding and Eating Disorders , Intracranial Hypertension , Papilledema , Pseudotumor Cerebri , Female , Humans , Pseudotumor Cerebri/complications , Pseudotumor Cerebri/epidemiology , Pseudotumor Cerebri/diagnosis , Papilledema/diagnosis , Visual Fields , Obesity/complications , Feeding and Eating Disorders/epidemiology , Feeding and Eating Disorders/complications , Intracranial Hypertension/complications
8.
Neurologist ; 29(3): 166-169, 2024 May 01.
Article En | MEDLINE | ID: mdl-38372201

INTRODUCTION: We present the case of a gentleman who developed rapidly progressive vision loss, ophthalmo-paresis, and flaccid quadriparesis in the context of severe intracranial hypertension. We reviewed the available cases in the literature to increase awareness of this rare clinical entity.Case Report:A 36-year-old man developed rapidly progressive vision loss, ophthalmo-paresis, and flaccid quadriparesis. He had an extensive workup, only notable for severe intracranial hypertension, >55 cm of H 2 O. No inflammatory features were present, and the patient responded to CSF diversion. Few similar cases are available in the literature, but all show markedly elevated intracranial pressure associated with extensive neuroaxis dysfunction. Similarly, these patients improved with CSF diversion but did not appear to respond to immune-based therapies. CONCLUSIONS: We term this extensive neuroaxis dysfunction intracranial hypertension associated with poly-cranio-radicular-neuropathy (IHP) and distinguish it from similar immune-mediated clinical presentations. Clinicians should be aware of the different etiologies of this potentially devastating clinical presentation to inform appropriate and timely treatment.


Intracranial Hypertension , Humans , Male , Adult , Intracranial Hypertension/complications , Intracranial Hypertension/diagnosis , Intracranial Hypertension/etiology , Polyradiculoneuropathy/diagnosis , Polyradiculoneuropathy/complications
9.
Neurol Neurochir Pol ; 58(1): 31-37, 2024.
Article En | MEDLINE | ID: mdl-38393958

INTRODUCTION: Spontaneous CSF leak is a known complication of idiopathic intracranial hypertension (IIH). Patients with CSF rhinorrhea present a unique challenge within the IIH population, as the occurrence of a leak can mask the typical IIH symptoms and signs, complicating the diagnosis. Treatment of leaks in this population can also be challenging, with the risk of rhinorrhea recurrence if intracranial hypertension is not adequately treated. OBJECTIVE: The aim of this narrative review was to examine current literature on the association between spontaneous CSF rhinorrhea leaks and IIH, focusing on key clinical features, diagnostic approaches, management strategies, and outcomes. MATERIAL AND METHODS: A literature search was executed using the PubMed and Scopus databases. The search was confined to articles published between January 1985 and August 2023; extracted data was then analysed to form the foundation of the narrative review. RESULTS: This search yielded 26 articles, comprising 943 patients. Average age was 46.8 ± 6.5 years, and average body mass index was 35.8 ± 4.8. Most of the patients were female (74.33%). Presenting symptoms were rhinorrhea, headaches and meningitis. The most common imaging findings were empty sella and encephalocele. The standard treatment approach was endoscopic endonasal approach for correction of CSF rhinorrhea leak, and shunt placement was also performed in 128 (13%) patients. Recurrences were observed in 10% of cases. CONCLUSIONS: The complex relationship between spontaneous CSF leaks and IIH is a challenge that benefits from multidisciplinary evaluation and management for successful treatment. Treatments such as endoscopic repair, acetazolamide, and VP/ /LP shunts reduce complications and recurrence. Personalised plans addressing elevated intracranial pressure are crucial for successful outcomes.


Cerebrospinal Fluid Rhinorrhea , Intracranial Hypertension , Pseudotumor Cerebri , Humans , Female , Adult , Middle Aged , Male , Pseudotumor Cerebri/complications , Pseudotumor Cerebri/diagnosis , Pseudotumor Cerebri/therapy , Cerebrospinal Fluid Rhinorrhea/diagnostic imaging , Cerebrospinal Fluid Rhinorrhea/etiology , Cerebrospinal Fluid Rhinorrhea/surgery , Intracranial Hypertension/complications , Intracranial Hypertension/therapy , Acetazolamide , Endoscopy/adverse effects , Cerebrospinal Fluid Leak/complications , Retrospective Studies
10.
AJNR Am J Neuroradiol ; 45(2): 149-154, 2024 Feb 07.
Article En | MEDLINE | ID: mdl-38238097

BACKGROUND AND PURPOSE: The pathophysiology underlying idiopathic intracranial hypertension (IIH) remains incompletely understood. While one theory postulates impaired cerebral glymphatic clearance in IIH, there is a paucity of methods to quantify glymphatic activity in human brains. The purpose of this study was to use advanced diffusion-weighed imaging to evaluate the glymphatic clearance of IIH patients and how it may relate to clinical severity. MATERIALS AND METHODS: DWI was used to separately evaluate the diffusivity along the cerebral perivascular spaces and lateral association and projection fibers, with the degree of diffusivity used as a surrogate for glymphatic function (diffusion tensor image analysis along the perivascular space. Patients with IIH were compared with normal controls. Glymphatic clearance was correlated with several clinical metrics, including lumbar puncture opening pressure and Frisen papilledema grade (low grade: 0-2; high grade: 3-5). RESULTS: In total, 99 patients with IIH were identified and compared with 6 healthy controls. Overall, patients with IIH had significantly lower glymphatic clearance based on DWI-derived diffusivity compared with controls (P = .005). Additionally, in patients with IIH, there was a significant association between declining glymphatic clearance and increasing Frisen papilledema grade (P = .046) but no correlation between opening pressure and glymphatic clearance (P = .27). Furthermore, healthy controls had significantly higher glymphatic clearance compared with patients with IIH and low-grade papilledema (P = .015) and high-grade papilledema (P = .002). Lastly, patients with IIH and high-grade papilledema had lower glymphatic clearance compared with patients with IIH and low-grade papilledema (P = .005). CONCLUSIONS: Patients with IIH possess impaired glymphatic clearance, which is directly related to the extent of clinical severity. The DWI-derived parameters can be used for clinical diagnosis or to assess response to treatment.


Glymphatic System , Intracranial Hypertension , Papilledema , Pseudotumor Cerebri , Humans , Pseudotumor Cerebri/complications , Pseudotumor Cerebri/diagnostic imaging , Diffusion Magnetic Resonance Imaging , Glymphatic System/diagnostic imaging , Brain/diagnostic imaging , Intracranial Hypertension/complications
11.
Zhonghua Yi Xue Za Zhi ; 104(1): 31-37, 2024 Jan 02.
Article Zh | MEDLINE | ID: mdl-38178765

Objective: To investigate the etiology composition and clinical characteristics of bilateral optic disc swelling(ODS). Methods: The medical records of all newly diagnosed bilateral ODS patients admitted to the neurology ward of Beijing Tongren Hospital from January 2017 to June 2021 were retrospectively searched to classify the etiology, obtain demographic and clinical information, and compare the differences in clinical characteristics. Results: A total of 131 patients with bilateral ODS were included, including 56 males and 75 females, aged 15-73 (39±14) years. The most common cause of the bilateral ODS was increased intracranial pressure (ICP)(56/131, 42.7%), followed by optic neuritis (ON)(40/131, 30.5%). Other causes included vascular optic neuropathy (13/131, 9.9%), pseudopilledema (9/131, 6.9%); uveitis (6/131, 4.6%), toxic optic neuropathy (3/131, 2.3%) and unknown causes (4/131, 3.1%). Idiopathic intracranial hypertension (IIH) (43/56, 76.8%) was the most common etiology for papilledema. In the comparison of the two main causes of intracranial hypertension and the clinical characteristics of ON in ODS, there was no statistically significant difference in the incidence of age, gender, complaints of ocular pain or headache, and hemorrhage of optic disc(P>0.05). Visual acuity abnormalities and low vision were more common in ON group than the increased ICP group[36/40(90%) vs 33/56(58.9%), P=0.001; 35/80(43.8%) vs 22/112(19.6%), P<0.001], while severe papilledema was more common in increased ICP group[38/112(33.9%)vs 9/80(11.3%), P<0.001]. Conclusions: The most common cause for bilateral ODS is increased ICP, but it can also be triggered by a variety of other causes. Optic neuritis(ON) is the most important differentiating disease in the study of Chinese patients.


Intracranial Hypertension , Optic Disk , Optic Neuritis , Papilledema , Pseudotumor Cerebri , Male , Female , Humans , Papilledema/diagnosis , Papilledema/etiology , Retrospective Studies , Optic Neuritis/complications , Intracranial Hypertension/complications , Pseudotumor Cerebri/complications
13.
Childs Nerv Syst ; 40(3): 655-663, 2024 Mar.
Article En | MEDLINE | ID: mdl-37962632

PURPOSE: To compare transorbital point-of-care ultrasound techniques -optic nerve sheath diameter (US-ONSD) and optic disc elevation (US-ODE)- with fundoscopic papilledema to detect potentially raised intracranial pressure (ICP) with treatment indication in children. METHODS: In a prospective study, 72 symptomatic children were included, 50 with later proven disease associated with raised ICP (e.g. pseudotumour cerebri, brain tumour, hydrocephalus) and 22 with pathology excluded. Bilateral US-ONSD and US-ODE were quantified by US using a 12-MHz-linear-array transducer. This was compared to fundoscopic optic disc findings (existence of papilledema) and, in 28 cases, invasively measured ICP values. RESULTS: The sensitivity and specificity of a cut-off value of US-ONSD (5.73 mm) to detect treatment indication for diseases associated with increased ICP was 92% and 86.4%, respectively, compared to US-ODE (0.43 mm) with sensitivity: 72%, specificity: 77.3%. Fundoscopic papilledema had a sensitivity of 46% and a specificity of 100% in this context. Repeatability and observer-reliability of US-ODE examination was eminent (Cronbach's α = 0.978-0.989). Papilledema was detected fundoscopically only when US-ODE was > 0.67 mm; a US-ODE > 0.43 mm had a positive predictive value of 90% for potentially increased ICP. CONCLUSION: In our cohort, transorbital point-of-care US-ONSD and US-ODE detected potentially elevated ICP requiring treatment in children more reliably than fundoscopy. US-ONSD and US-ODE indicated the decrease in ICP after treatment earlier and more reliably than fundoscopy. The established cut-off values for US-ONSD and US-ODE and a newly developed US-based grading of ODE can be used as an ideal first-line screening tool to detect or exclude conditions with potentially elevated ICP in children.


Intracranial Hypertension , Papilledema , Child , Humans , Papilledema/complications , Papilledema/diagnostic imaging , Prospective Studies , Point-of-Care Systems , Reproducibility of Results , Intracranial Pressure/physiology , Optic Nerve/diagnostic imaging , Optic Nerve/pathology , Intracranial Hypertension/complications , Intracranial Hypertension/diagnostic imaging , Ultrasonography/methods
14.
Rofo ; 196(2): 176-185, 2024 Feb.
Article En | MEDLINE | ID: mdl-37963551

PURPOSE: Idiopathic intracranial hypertension (IIH) is associated with intracranial abnormalities, although not obligatory, which can be detected with cranial MRI. Obesity is an important risk factor for IIH and a pathogenetic link is suspected but the extent to which these MRI signs are already related to obesity has not yet been examined. We investigated whether IIH-MRI signs are present more often in obese individuals with a BMI > 30 kg/m² than in individuals of normal weight. MATERIALS AND METHODS: Brain MRI of 32 obese and 53 normal-weight participants from the Food-Chain-Plus cohort were analyzed for three main signs of IIH: (I) stenosis of the transverse sinus, (II) increased width of the optic nerve sheath, and (III) reduction of pituitary height. In addition, a scoring system for the MRI signs was applied. Furthermore, tortuosity of the optic nerve and flattening of the posterior globe were considered as additional MRI signs. RESULTS: Obese participants had a significantly higher MRI score (p < 0.001) than those in the normal-weight cohort, with significant differences in quantitative measurements of cerebral venous sinus stenosis (p < 0.001), widening of the optic nerve sheath (p < 0.05), and flattening of the pituitary gland (p < 0.05) also always being observed more frequently and in a more pronounced manner in the obese group. Furthermore, our findings correlated significantly with BMI and proportionately with hip and waist circumference. CONCLUSION: Obese individuals show a significantly higher prevalence of cerebral MRI signs related to IIH. This supports the hypothesis that obesity is a risk factor for possible intracranial hypertension and reinforces the suspicion that obesity is involved in the pathomechanism of IIH. KEY POINTS: · Obesity is associated with changes such as those seen in IIH.. · BMI, weight, and body measurements correlate with the expression of MRI signs of IIH.. · To prevent IIH symptoms in obesity, the pathomechanism must be further clarified..


Intracranial Hypertension , Obesity, Morbid , Pseudotumor Cerebri , Humans , Constriction, Pathologic/complications , Obesity, Morbid/complications , Obesity, Morbid/diagnostic imaging , Intracranial Hypertension/diagnostic imaging , Intracranial Hypertension/complications , Pseudotumor Cerebri/diagnostic imaging , Pseudotumor Cerebri/complications , Magnetic Resonance Imaging
15.
Neurocrit Care ; 40(2): 769-784, 2024 Apr.
Article En | MEDLINE | ID: mdl-37380894

Acute traumatic brain injury (TBI) is a major cause of mortality and disability worldwide. Intracranial pressure (ICP)-lowering is a critical management priority in patients with moderate to severe acute TBI. We aimed to evaluate the clinical efficacy and safety of hypertonic saline (HTS) versus other ICP-lowering agents in patients with TBI. We conducted a systematic search from 2000 onward for randomized controlled trials (RCTs) comparing HTS vs. other ICP-lowering agents in patients with TBI of all ages. The primary outcome was the Glasgow Outcome Scale (GOS) score at 6 months (PROSPERO CRD42022324370). Ten RCTs (760 patients) were included. Six RCTs were included in the quantitative analysis. There was no evidence of an effect of HTS on the GOS score (favorable vs. unfavorable) compared with other agents (risk ratio [RR] 0.82, 95% confidence interval [CI] 0.48-1.40; n = 406; 2 RCTs). There was no evidence of an effect of HTS on all-cause mortality (RR 0.96, 95% CI 0.60-1.55; n = 486; 5 RCTs) or total length of stay (RR 2.36, 95% CI - 0.53 to 5.25; n = 89; 3 RCTs). HTS was associated with adverse hypernatremia compared with other agents (RR 2.13, 95% CI 1.09-4.17; n = 386; 2 RCTs). The point estimate favored a reduction in uncontrolled ICP with HTS, but this was not statistically significant (RR 0.52, 95% CI 0.26-1.04; n = 423; 3 RCTs). Most included RCTs were at unclear or high risk of bias because of lack of blinding, incomplete outcome data, and selective reporting. We found no evidence of an effect of HTS on clinically important outcomes and that HTS is associated with adverse hypernatremia. The included evidence was of low to very low certainty, but ongoing RCTs may help to the reduce this uncertainty. In addition, heterogeneity in GOS score reporting reflects the need for a standardized TBI core outcome set.


Brain Injuries, Traumatic , Brain Injuries , Hypernatremia , Intracranial Hypertension , Humans , Intracranial Pressure , Intracranial Hypertension/etiology , Intracranial Hypertension/complications , Brain Injuries, Traumatic/drug therapy , Brain Injuries, Traumatic/complications , Brain Injuries/complications , Saline Solution, Hypertonic/therapeutic use , Saline Solution, Hypertonic/pharmacology
16.
Eye (Lond) ; 38(2): 274-278, 2024 02.
Article En | MEDLINE | ID: mdl-37491440

OBJECTIVE: To describe the clinical characteristics, outcomes, and management of a large cohort of patients with concomitant malignant arterial hypertension and intracranial hypertension. METHODS: Design: Retrospective case series. SUBJECTS: Patients aged ≥ 18 years with bilateral optic disc oedema (ODE), malignant arterial hypertension and intracranial hypertension at five academic institutions. Patient demographics, clinical characteristics, diagnostic studies, and management were collected. RESULTS: Nineteen patients (58% female, 63% Black) were included. Median age was 35 years; body mass index (BMI) was 30 kg/m2. Fourteen (74%) patients had pre-existing hypertension. The most common presenting symptom was blurred vision (89%). Median blood pressure (BP) was 220 mmHg systolic (IQR 199-231.5 mmHg) and 130 mmHg diastolic (IQR 116-136 mmHg) mmHg), and median lumbar puncture opening pressure was 36.5 cmH2O. All patients received treatment for arterial hypertension. Seventeen (89%) patients received medical treatment for raised intracranial pressure, while six (30%) patients underwent a surgical intervention. There was significant improvement in ODE, peripapillary retinal nerve fibre layer thickness, and visual field in the worst eye (p < 0.05). Considering the worst eye, 9 (47%) presented with acuity ≥ 20/25, while 5 (26%) presented with ≤ 20/200. Overall, 7 patients maintained ≥ 20/25 acuity or better, 6 demonstrated improvement, and 5 demonstrated worsening. CONCLUSIONS: Papilloedema and malignant arterial hypertension can occur simultaneously with potentially greater risk for severe visual loss. Clinicians should consider a workup for papilloedema among patients with significantly elevated blood pressure and bilateral optic disc oedema.


Hypertension, Malignant , Hypertension , Intracranial Hypertension , Papilledema , Pseudotumor Cerebri , Humans , Female , Adult , Male , Papilledema/diagnosis , Papilledema/etiology , Retrospective Studies , Intracranial Hypertension/complications , Intracranial Hypertension/diagnosis , Hypertension/complications , Hypertension, Malignant/complications , Hypertension, Malignant/diagnosis , Vision Disorders/diagnosis , Vision Disorders/etiology , Pseudotumor Cerebri/complications , Intracranial Pressure/physiology
17.
Childs Nerv Syst ; 40(1): 145-152, 2024 Jan.
Article En | MEDLINE | ID: mdl-37493721

PURPOSE: Craniosynostosis can lead to symptoms resulting from cranial compliance (CC) changes and intracranial hypertension (ICH), which may cause cognitive and visual impairment. Non-invasive methods have emerged, including a new device that captures and processes the intracranial pressure waveform (ICPw) by the skull's oscillation. The present study evaluates ICPw obtained non-invasively (NIICPw) in patients with craniosynostosis. METHODS: This prospective, cross-sectional, and descriptive study was conducted at a single center. Patients diagnosed with craniosynostosis and who provided informed consent were included. A US Food and Drug Administration-approved mechanical extensometer device (Brain4Care Corp.) was used to obtain a NIICPw. An ophthalmologist did a point-of-care retinography to check the optic nerve papilla. The P2/P1 ratio and the morphology of the NIICPw were analyzed, as well as the retinography. RESULTS: Thirty-five patients were evaluated, and 42 registers were obtained because seven were assessed before and after the surgery. The two patients who presented papilledema had low CC (NIICPw shape Class 3 or 4). There was a significant association between NIICPw and papilledema. CONCLUSION: The ratio P2/P1 and the NIICPw morphology provided by a non-invasive monitor are related to CC changes before papilledema occurs. This is especially useful in patients with craniosynostosis because invasive ICP monitoring is not always feasible. Further studies are warranted to establish the clinical utility of NIICPw in patients with craniosynostosis.


Craniosynostoses , Intracranial Hypertension , Papilledema , Humans , Intracranial Pressure/physiology , Papilledema/etiology , Cross-Sectional Studies , Prospective Studies , Craniosynostoses/complications , Craniosynostoses/surgery , Intracranial Hypertension/etiology , Intracranial Hypertension/complications
18.
Childs Nerv Syst ; 40(2): 463-469, 2024 Feb.
Article En | MEDLINE | ID: mdl-37665341

PURPOSE: Papilloedema is recognised as an indicator of raised intracranial pressure, although there is a paucity of literature describing the utility of fundoscopy in screening for raised ICP in children with craniofacial synostosis, particularly young children. We sought to investigate the association of optic disc morphology with ICP in children, and to define the sensitivity and specificity of papilloedema as a clinical indicator of raised ICP and determine if age, or underlying conditions impact the findings. METHOD: Retrospective analysis of all patients undergoing ICP monitoring at a designated paediatric neurosurgical and craniofacial unit in the United Kingdom between October 2009 and October 2018. The fundoscopy findings and ICP monitoring data were analysed for 31 children with craniosynostosis and 29 children without craniosynostosis. RESULTS: All children who had papilloedema had raised ICP confirmed with monitoring. Across the 60-patient cohort, confirmed papilloedema on fundoscopy had Positive Predictive Value (PPV) of 1.00, Negative Predictive Value (NPV) of 0.64 with sensitivity 48% and specificity 100% for the presence of raised ICP (p = < 0.0001). In the craniosynostosis group, PPV was 1.00, NPV was 0.39, sensitivity 48% and specificity 100% (p = < 0.03). There is no correlation between severity of optic disc swelling using Frisen grading and elevation of ICP. Age did not affect the presence of papilloedema in those with raised ICP. CONCLUSION: The presence of papilloedema is a strong indicator of raised ICP in a child, regardless of underlying aetiology. Detailed fundoscopy can prevent the need for further investigations including imaging-related radiation and invasive CSF pressure monitoring.


Craniosynostoses , Intracranial Hypertension , Papilledema , Child , Humans , Child, Preschool , Papilledema/etiology , Papilledema/complications , Intracranial Pressure , Retrospective Studies , Intracranial Hypertension/etiology , Intracranial Hypertension/complications , Craniosynostoses/complications , Craniosynostoses/surgery
20.
World Neurosurg ; 183: e250-e260, 2024 Mar.
Article En | MEDLINE | ID: mdl-38104933

OBJECTIVE: Almost two thirds of the world's aneurysmal subarachnoid hemorrhage (aSAH) are in low- and middle-income countries. Herein, we aimed to evaluate the impact of complications on the outcome of aSAH in a middle-income country. METHODS: Baseline data (age, sex, World Federation of Neurosurgical Society, time ictus-treatment, treatment modality) and medical and neurologic complications from a cohort in Brazil (2016-2019) were evaluated: delayed cerebral ischemia; hydrocephalus; meningitis; seizures; intracranial hypertension; infections (pneumonia, bloodstream, urinary tract infection infection of undetermined source); sodium disturbances; acute kidney injury; and cardiac and pulmonary complications. The primary outcome was the modified Rankin scale (mRS) at hospital discharge. Univariate and multivariate models were employed. RESULTS: From 212 patients (71.7% female, age 52.7 ± 12.8), 92% developed at least 1 complication (any infection-43.9%, hydrocephalus-34.4%, intracranial hypertension-33%, infection of undetermined source-20.8%, hypernatremia-20.8%, hyponatremia-19.8%, delayed cerebral ischemia-related infarction-18.7%, pneumonia-18.4%, acute kidney injury-16.5%, and seizures-11.8%). In unadjusted analysis, all but hyponatremia and urinary tract infection were associated with mRS 3-6 at discharge; however, complications explained only 12% of the variation in functional outcome (mRS). Most patients were treated by clipping (66.5%), and 15.6% (33 patients) did not receive a definitive treatment. The median time ictus-admission and ictus-treatment were 5 and 9 days, respectively. CONCLUSIONS: While medical and neurologic complications are a recognized opportunity to improve aSAH care, low- and middle-income countries comprise 70% of the world population and still encounter difficulties concerning early definitive aneurysm treatment, rebleeding, and human and material resources.


Acute Kidney Injury , Brain Ischemia , Hydrocephalus , Hyponatremia , Intracranial Hypertension , Pneumonia , Stroke , Subarachnoid Hemorrhage , Urinary Tract Infections , Humans , Female , Adult , Middle Aged , Aged , Male , Subarachnoid Hemorrhage/complications , Subarachnoid Hemorrhage/surgery , Hyponatremia/complications , Stroke/complications , Seizures/etiology , Seizures/complications , Brain Ischemia/etiology , Hydrocephalus/surgery , Hydrocephalus/complications , Cerebral Infarction/complications , Intracranial Hypertension/complications , Acute Kidney Injury/complications , Pneumonia/etiology , Pneumonia/complications , Urinary Tract Infections/complications , Treatment Outcome , Retrospective Studies
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