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Idiopathic intracranial hypertension

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  • • increased intracranial pressure (ICP);• normal/small ventricles on neuro-imaging;• no evidence of intracranial mass;• normal CSF composition (a low CSF protein is acceptable).
  • Recommended treatment compared with shunting: shorter OT time and lower complications; ? Unilateral ONSF is adequate
  • Transcript

    • 1. EBS PresentationEffectiveness of optic nerve sheathfenestration in idiopathic intracranialhypertension Johnny Wong 14th July, 2011 Advanced Scholar: Prof Marcus Stoodley
    • 2. Introduction• “Benign intracranial hypertension”• “Idiopathic intracranial hypertension”• “Pseudotumour cerebri”• Symptoms: Headaches and visual blurring• Treatment options – Conservative: Weight loss, diet, diuretics, acetazolamide, corticosteroids, octreotide – Surgical procedures: Optic nerve sheath fenestration, CSF diversion – multiple lumbar punctures, LP or VP shunt, subtemporal decompressions – Venous stenting
    • 3. Clinical Questions:• Primary Question: What is the effectiveness of optic nerve sheath fenestration (ONSF) in patients with idiopathic intracranial hypertension?• Secondary Question: How does ONSF compare with other treatments for idiopathic intracranial hypertension?
    • 4. Search strategy• P = Idiopathic intracranial hypertension• I = Optic nerve fenestration• [C = Other surgical procedures (eg CSF shunting; sinus stenting) ]• O = Treatment outcomes• Cochrane, Ovid Medline, Scopus, Google Scholar• MeSH terms: “Pseudotumour cerebri” ; “ophthalmologic surgical procedures”
    • 5. Cochrane • Methods: – Searched for RCT only – 3 categories: Idiopathic patients with papilloedema; Idiopathic without papilloedema; IIH with underlying aetiology – 7 Interventions types • Results: – 85 studies relevant to IIH – 1 RCT found – poor randomisation (acetazolamide) • Recommendations: – Optic nerve fenestration or LP shunt for papilloedema – Further research required
    • 6. Ovid Medline 5 useful articles identified
    • 7. Ovid Medline 12 useful articles identified
    • 8. Scopus 10 additional useful articles
    • 9. Primary Question – Efficacy of ONSF• No RCT; Case series only;• 3 review articles found• Prevent visual deterioration; Improved VA, not HA (33-50% not relieved)• Review by Brazis et al(2008), Uretzky et al. (2009) – Papilloedema: 86-97% resolved or sig. improved – VA: 85-91% Improved or stabilised – VF: 48-95% improved; 25-38% stabilised
    • 10. Primary Question – Efficacy of ONSF – Bilateral VA improvement from unilateral ONSF – Better for acute papilloedema – 10-15% worsening vision – 4.5-45% complication rates – Long-term (5 years): • 36% improvement • 32% stabilisation • 33% later deterioration after initial improvement – Maintenance of vision • 66% @ 12 months; 55% @ 3y, 38% @ 5y, 16% @ 6y
    • 11. • Retrospective series of 32 patients, 51 eyes• 41% with PTC; 47% ONSF as primary procedure• 11/17 had second shunt procedure
    • 12. Case series• Retrospective case series; 10 patients with bilateral ONSF• All 10 patients improved in papilloedema and VA in short-term• Long-term: evaluation difficult due to concomittant treatment
    • 13. Case series: Alsuhaibani et al, 2011Effect of Optic Nerve Sheath Fenestration on Papilloedema of the operated and contralateral non-operated eyes in idiopathic intracranial hypertension• Retrospective series; 62 patients unilateral ONSF• Pre-op papilloedema scores: Ipsi & contral – 3 & 2• Post-op: 2 & 2 (2 wks); 1 & 1 (3 & 6 months); 0.5 & 1 (12 months)
    • 14. Secondary question: Comparison withother treatments• No RCT comparing surgical options or medical treatment• Case series and review articles• LPS – effective in treating symptoms, but high rates of revisions• VPS – difficult ventriculostomy with small ventricles
    • 15. LPS (Review articles – Brazis 2008) (Burgett 1997: 30 patients) – VA: 71% improvement of 2 lines; VF: stabilised in 62%; Symptom resolution: 82% – Mean no. of revisions: 4.2; – Revision rate: 55-63% (Eggenberger 1996: 27 patients) – 100% improvement – 56% revisions (3 requiring 35 revisions)
    • 16. LPS• 40 patients; VAD in 21 patients• 10 revision operations• 7 intractable headaches
    • 17. VPS (Review article – Brazis 2008) Bynke 2004: 17 patients – Symptom resolution: 100% – Mean FU: 6.5 years – Revision rate: 7/17 for 1 or 2 revisions Woodworth 2005: 21 patients – 100% initial improvement – Failure rates: 10% at 1 month, 20% at 2 months, 50% at 12 months, 60% at 24 months – Revisions for distal obstruction (67%) & overdrainage
    • 18. VPS• 8/9 improvement in HA; 12 revisions in 6 patients
    • 19. LPS vs VPS• 115 shunt operations in 42 patients (79 LPS, 36 VPS)• 95% improvement in headaches• 19% and 48% recurrent HA despite functioning shunt at 12 and 36 months respectively• 2.5 fold increased risk of revisions with LPS• 3 fold increased risk of distal obstruction with LPS.
    • 20. LPS vs VPS• Retrospective; 25 patients• 72% LPS – 11% failure rate, 60% revision• 28% VPS – 14% failure rate, 30% revision
    • 21. Conclusion• ONSF effective in short term for papilloedema and visual deterioration (85-94%); not HA.• Unilateral may be adequate;• Long-term recurrence• Efficacy similar to LP or VP shunts• RCTs required for best treatment for IIH

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