Ideopatische intracraniële hypertensie - Dr. E. Tack
1. D R . E . TA C K
IDIOPATHISCHE INTRACRANIËLE
HYPERTENSIE
AZ Nikolaas
2017
2. IDIOPATHISCHE INTRACRANIËLE
HYPERTENSIE
Syndroom met intracraniële overdruk, papiloedeem, ventrikels met
normaal volume, normale samenstelling van het CSF, zonder focale
neurologische tekens, noch aanwijzingen voor een RIP, een infectieus
proces, of obstructie van de liquor flow.
pseudotumor cerebri syndrome, benign intracranial
hypertension, pseudotumor cerebri
3. IDIOPATHISCHE INTRACRANIËLE
HYPERTENSIE
Incidentie:
- 0,9 per 100000
- 1,6 per 100000 vrouwen
- 3,3 per 100000 vrouwen tussen 15-44 jaar
- 7,9 per 100000 vrouwen met overgewicht*
- 20 per 100000 vrouwen tussen 15-44 jaar met overgewicht
Gender: 1/8 : M/V bij volwassenen;
F=M bij kinderen en adolescenten
* Vnl recente snelle G-toename als uitlokkende factor
4. SYMPTOMEN
- hoofdpijn (meest frequent, 68 - 98%) (minder bij kinderen)
Dagelijks, diffuus, constant
Ernstig bij > 90%
Migraineus > TTH
Vnl ‘s morgens, bij ontwaken
Neemt toe bij hoofdbewegingen, hoesten, inspanning, Valsalva
Reageert op analgetica (itt TTH)
- visuele stoornissen (57 - 72%)
Gezichtsverlies (30%)of wazig zicht, transiënte visusstoornissen (na Valsalva), diplopie
(38%), fotopsie, fotofobie
- Tinnitus / pulsatiele intracraniële geluiden (60%)
- Retrobulbaire pijn bij oogbewegen (22%)
- Uitval craniële zenuwen: nVI; olfactorius, nIII, nIV, nV, nVII, nVIII
- andere: tot 33%: pijn thv de nek en schouders, radiculaire pijn, nausea, …
5. VISUSVERLIES
meest gevreesde complicatie
- bij 4 - 31% indien niet behandeld
- Meestal bilateraal, soms zeer asymmetrisch of unilateraal
- risicofactoren:
• Hoge CSF druk
• Hoge BMI
• Arteriële hypertensie
• Man
• Hooggradig papiloedeem bij het begin
• Ras: afro: x4, minder bij etnische chinezen
6. Friedman DI, Liu GT, Digre KB. Revised diagnostic criteria for the pseudotumor cerebri syndrome in adults and children.
Neurology 2013;81:1159–1165. MODIFIED DANDY CRITERIA
10. PATHOGENESE
• secundaire toename van intracraniële veneuze druk door obesitas
• verminderde outflow CSF door de arachnoidale granulaties
• outflow resistentie thv CSF lymfe drainage sites
• toename abdominale, pleurale, en cardiale vulling
• veranderde natrium en water retentie mechanismen
• CO² retentie oa. door slaapapnee
• abnormaal vitamine A metabolisme
• veneuze stenose of obstructie - bilaterale sinus transversus stenosis
(BTSS) (50 - 93%)
• unilaterale stenose van de sinus transversus wordt gezien bij 30% van ptn met
normale CSF openingsdruk
• Bilaterale stenose: 1,8 % van ptn met normale CSF openingsdruk
11. BTSS: ROL?
Transverse sinus (TS) stenoses, as revealed by MR venography, persist in patients with idiopathic
intracranial hypertension after normalization of CSF pressure, suggesting the lack of a direct
relationship between the caliber of TS and CSF pressure.
MR venography of the transverse sinuses (TSs)
in a patient with idiopathic intracranial
hypertension at baseline condition (raised CSF
opening pressure) (A and C) and post treatment
(normal CSF opening pressure) (B and D),
showing stenosis in the midlateral portion of
both TSs (arrow). Axial view (A and B) and
coronal view (C and D) are shown.
Bono F, et al. Transverse sinus stenoses persist after
normalization of the CSF pressure in IIH. Neurology
2005;65:1090–1093
Bono F, et al. Cerebral MR venography of transverse
sinuses in subjects with normal CSF pressure.
Neurology 2003;61:1267–1270
15. IDIOPATHISCHE INTRACRANIËLE HYPERTENSIE
ZONDER PAPILOEDEEM - IIHWOP
- associatie met CDH
Chronische migraine (6,7%)
Chronisch TTH (9,1%)
- 60 - 70% van de BTSS hebben IIHWOP
F. Bono et al. Neurology 2006;67:419-423
26. Overdiagnosis of idiopathic intracranial hypertension
Adeniyi Fisayo, ea
Neurology January 26, 2016 vol. 86 no. 4 341-350
- 165 ptn referred either with a preexisting diagnosis of IIH or to rule out IIH
- 86/165 patients (52.1%) with a preexisting diagnosis of IIH, 34/86 (39.5%) did
not have IIH.
The most common diagnostic error was inaccurate ophthalmoscopic
examination in headache patients.
Of 34 patients misdiagnosed as having IIH
- 27 (27/34 [79.4%]; 27/86 [31.4%]) had at least one lumbar puncture
- 29 (29/34 [85.3%]; 29/86 [33.7%]) had a brain MRI
- 8 (8/34 [23.5%]; 8/86 [9.3%]) had a magnetic resonance/CT venogram
- 26 had received medical treatment
- 1 had a lumbar drain
- 4 were referred for surgery.
28. Examples of the most common types
of IIHTT baseline visual field
abnormalities.
The most common type of IIHTT
baseline hemifield abnormality was a
localized nerve fiber bundle-like
defect. Localized inferior hemifield
loss was more common than superior
hemifield loss. Quality control and
within- and between-reader
agreement were excellent for the
IIHTT
Invest Ophthalmol Vis Sci, 2014 May; 55(5): 3200–
3207.
Baseline Visual Field Findings in the Idiopathic
Intracranial Hypertension Treatment Trial (IIHTT)
John L. Keltner ea
OPHTALMOLOGIE
30. INVESTIGATIE
• PBO, ureum, elektrolyten, Ca, TSH, ANF, AFL-al,
fibrinogeen, factor V Leiden, ACE, Fe
• VEP: geen bijkomend nut
31. PROGNOSE
Niet goed gekend
Soms beperkt in tijd met spontane recuperatie in de
daaropvolgende weken
Meestal spontane recuperatie na 6 tot 18 maand
Recidieven
Bij sommigen echter chronisch …
33. BEHANDELING
Lumbale puncties
• Te overwegen als hoofdpijn blijft na de 1ste LP; 3 à 4
gedurende de 1ste 2 à 3 weken
• Nadien geen effect meer?
• Ev. bij hoofdpijn-opstoot: druk verlagen tot 120 - 175 mm H²O
• Repetitieve puncties kunnen liquorlek veroorzaken
• Nadeel: low-pressure hoofdpijn met visuele symptomen …
34. BEHANDELING: DIEET
Low energy diet and intracranial pressure in
women with idiopathic intracranial
hypertension: prospective cohort study
Sinclair ea, BMJ 2010; 340: c2701
- Prospective cohort study - 2010:
• 25 women with body mass index (BMI) >25
• active idiopathic intracranial hypertension chronic
(over 3 months)
• papilloedema
• intracranial pressure >25 cm H2O)
• low energy diet for 3 months
- significantly reduced intracranial pressure
compared with pressure measured in the 3
months before the diet
- improved symptoms
- reduced papilloedema.
These reductions persisted for 3 months after they
stopped the diet.
35. BEHANDELING: MEDICATIE
- Acetazolamide: reductie van CSF productie
- Topiramaat: reductie van CSF productie, gewichtsverlies
- Indomethacine: reductie bloed flow
- Corticosteroïden: “nood-behandeling” voor dreigend
visueel verlies;
Controversiëel:
• ICP kan terug stijgen na onttrekking
• bijwerkingen bij langduriger gebruik (vochtretentie, gewichtstoename)
37. BEHANDELING: MEDICATIE
Acetazolamide
Effect of Acetazolamide on Visual Function in Patients With Idiopathic
Intracranial Hypertension and Mild Visual Loss
The Idiopathic Intracranial Hypertension Treatment Trial
JAMA. 2014 Apr 23-30; 311(16): 1641–1651.
In patients with IIH and mild visual loss, the use of acetazolamide with a low-
sodium weight-reduction diet compared with diet alone resulted in modest
improvement in visual field function. The clinical importance of this
improvement remains to be determined.
41. DRAINAGE CSF (LUMBOPERITONEALE
OF VENTRICULOPERITONEALE SHUNT
Lumboperitoneale shunt: standaard therapie met snelle
reductie ICP
- complicaties: low pressure hoofdpijn bij 21%
- falen bij 55% na 1 jaar
• Voorkeur voor ventriculoperitoneale of ventriculoatriale
shunting?
42. LUMBOPERITONEALE OF
VENTRICULOPERITONEALE SHUNT?
ventriculoperitoneale of
ventriculoatriale shunting:
Voordelen:
Monitoring dmv een extracraniële
subcutane comprimeerbare structuur,
en een éénwegsklep (voor de
intracraniële-abdominale flow).
Obstructie van de drain kan worden
gecontroleerd.
43. VENTRICULOPERITONEALE SHUNT
Nadelen:
• Ventrikels zijn klein en plaatsen van de drain is moeilijk
zonder radiografische controle - stereotactisch
• significant risico op complicaties:
• Infectie
• Stroke
• Epilepsie
• shunt failure
44. LUMBOPERITONEALE OF
VENTRICULOPERITONEALE SHUNT
Sinclair et al - Cephalalgia. 2011:
Is cerebrospinal fluid shunting in idiopathic intracranial hypertension
worthwhile? A 10-year review.
• 53 ptn (LP shunt in 92%)
• verbeterde visus
• verbeterde hoofdpijn bij 68% na 6 maand, 79% na 2 jaar
• 68% behouden hoofdpijn
• 28% low-pressure hoofdpijn
• Shunt revisies bij 51% meestal meerdere
• Te reserveren indien snel verslechterende visus, ondanks adequate
conservatieve behandeling
• Geen eerste keuze : gewichtsverlies is minstens even effectief en met
minder morbiditeit
45. OPTISCHE ZENUW DEFENESTRATIE
- aanbrengen van insnijdingen of een
rechthoekige patch in de dura rond de opticus,
net achter de globus
- derivatie van CSF naar het orbitale vet, waar
resorptie naar de veneuze circulatie
- vermindering papiloedeem, recuperatie van
de functie
- vermindering van hoofdpijn bij sommige
46. OPTISCHE ZENUW DEFENESTRATIE
- ICP blijft verhoogd
- lokale filtering als een veiligheidsklep voor de opticus
- unilateraal ingrijpen kan occasioneel voldoende zijn voor bilaterale vermindering
van papiloedeem; indien niet: bilateraal ingrijpen
Complicaties:
• Diplopie
• letsel aan de opticus
• Vasculaire occlusie
• Tonische pupil
• bloeding en infectie
• Bij 1/3 terug vermindering van de visus na 3 à 5 jaar
• progressie met visusverlies bij 12,8%
• Spoor & McHenry (1993): long-term succes rate = 16%
50. ENDOVASCULAIRE STENT VENEUZE
SINUS
Over periode 2002-2016: verschillende studies van kleine reeksen:
Rationale: bij TSS met significant drukgradiënt verlaagt stenting de
cerebrale veneuze druk, verbetert de CSF resorptie in het veneus
systeem, met verlagen vd intracraniële (CSF) druk, met verbetering van
de symptomen van IIH en vermindering van het papiloedeem.
Geen grote prospectieve studies; geen safety studies
Sommigen toch nood aan CSF drainage
Geen vergelijkende studies ivm “optic nerve sheath fenestration” en
“cerebrospinal fluid diversion”
BTSS: primair of secundair in relatie tot de gestegen CSF druk?
51. ENDOVASCULAIRE STENT VENEUZE SINUS
Transverse Sinus Stenting for Idiopathic Intracranial Hypertension: A
Review of 52 Patients and of Model Predictions
R.M. Ahmed, ea - AJNR 2011 32: 1408-1414
• Previous Treatment: acetazolamide, weight loss, 4 patients w/ bilateral
sequential optic nerve sheath fenestration , 1 w/ ventricular drain, 3 w/
lumbar drain (2 nonfunctioning), 1 bilateral subtemporal decompression
• MR imaging of the brain and cerebral MRV: if TSS on MRV ->
• Retrograde cerebral venography and manometry:
• type of stenosis present (intrinsic or extrinsic or both) was assessed,
• transverse sinus stenosis on 1 side with a normal transverse sinus on the other
side with normal venous pressures was considered to be a normal variation, and
these patients were excluded.
• 52/80 : pressure gradient of >8 mm Hg (an arbitrary cutoff)
53. ENDOVASCULAIRE STENT VENEUZE
SINUS
Venous Sinus Stenting for Idiopathic Intracranial Hypertension Refractory to
Medical Therapy (VSSIIH)
Verified November 2016 by Weill Medical College of Cornell University
Estimated Study Completion Date: June 2019
https://clinicaltrials.gov/ct2/show/NCT01407809
Stenting of Venous Sinus Stenosis for Medically Refractory Idiopathic
Intracranial Hypertension
Verified July 2015 by Ottawa Hospital Research Institute
Estimated Study Completion Date: July 2017
https://clinicaltrials.gov/ct2/show/NCT02143258
54. CONCLUSIE: IDEOPATISCHE
INTRACRANIËLE HYPERTENSIE
• De openingsdruk van > 25 cm H²O blijft een arbritaire waarde en de
meting hangt af van de kwaliteit van de LP
• Een aantal ptn met migraine hebben een BTSS en IIHWOP
• De pathogenese blijft onbekend, maar er zijn aanwijzingen dat een
combinatie van BTSS en hoge BMI een rol spelen
• De rol van endovasculaire veneuze stenting in de behandeling is nog
geen uitgemaakte zaak
• Chirurgie is niet superieur tov. conservatieve therapie, en heeft een
hoge ratio van falen en complicaties
Editor's Notes
Olfactory dysfunction in patients with idiopathic intracranial hypertension - Hagen Kunte,ea - Neurology July 23, 2013 vol. 81 no. 4 379-382 : study provides new evidence that olfaction is impaired in patients with IIH, especially in those who have been newly diagnosed or who have experienced a recent clinical deterioration.
J Neurol Neurosurg Psychiatry. 2014 Sep;85(9):959-64. Marked olfactory impairment in idiopathic intracranial hypertension. Bershad EM1,
Risk factors for poor visual outcome in patients with idiopathic intracranial hypertension
Michael Wall, ea
Neurology September 1, 2015 vol. 85 no. 9 799-805
Idiopathic intracranial hypertension in men
B. B. Bruce, ea
Neurology January 27, 2009 vol. 72 no. 4 304-309
Racial differences in idiopathic intracranial hypertension
B. B. Bruce,ea
Neurology March 11, 2008 vol. 70 no. 11 861-867
CSF opening pressure in children with optic nerve head edema
R.A. Avery, ea
Neurology May 10, 2011 vol. 76 no. 19 1658-1661
Clinical Reasoning: A 20-year-old man with headache and double vision
Khaled Moussawi, ea
Neurology October 11, 2016 vol. 87 no. 15 e162-e167
--------------------
Pract Neurol doi:10.1136/practneurol-2014-000821
A practical approach to, diagnosis, assessment and management of idiopathic intracranial hypertension
Susan P Mollan1, Keira A Markey2, James D Benzimra1, Andrew Jacks1, Tim D Matthews1, Michael A Burdon1, Alex J Sinclair
Figure. CSF pressure in subjects with normal MR venography (MRV) categorized according to body mass index (<25 nonoverweight; 25 to 29.9 overweight; ≥30 obese). All subjects had CSF pressure lower than 200 mm H2O. The CSF pressure was not different among the three groups (p = 0.062).
BMI < 25 = nonoverweight; BMI 25 to 29.9 = overweight; and BMI ≥ 30 = obese
Figure 2. CSF opening pressure (cm CSF) according to body mass index (BMI, kg/m2) for 242 neurology outpatients, with a fitted linear regression line using BMI as the dependent variable (dashed line, r 2 = 0.19). Kendall tau b = 0.32, 95% CI 0.25 to 0.39 (significant). Some points overlap for patients with the same BMI and CSF opening pressure.
Clinical Reasoning: A 20-year-old man with headache and double vision
Khaled Moussawi, ea
Neurology October 11, 2016 vol. 87 no. 15 e162-e167
--------------------
Pract Neurol doi:10.1136/practneurol-2014-000821
A practical approach to, diagnosis, assessment and management of idiopathic intracranial hypertension
Susan P Mollan1, Keira A Markey2, James D Benzimra1, Andrew Jacks1, Tim D Matthews1, Michael A Burdon1, Alex J Sinclair
unilateral TSS was observed in 30% of 111 subjects with normal CSF pressure, whereas bilateral TSS occurred in only 1.8% of individuals.
bilateral TSS is one of the factors contributing to IIH.
both clinical course and CSF pressure should determine the management of patients with IIH in clinical practice.
Reformatting and measurement of the degree of transverse sinus stenosis
The entire course of the transverse sinus in a single axial magnetic resonance venography image (A) is difficult to visualize, but with curved reformatting (B), the entire course of the transverse sinus is apparent. The percent stenosis was calculated by dividing the width of stenosis (C) by the width of the adjacent normal-appearing transverse sinus (D), yielding the percent stenosis.
Distribution of the average percent stenosis
The average percent stenosis ranged from 19% to 96% with a median of 56% (interquartile range 49%–65%). Seventy-one percent of patients had 50% or greater average percent stenosis.
Linear regression of average percent transverse sinus stenosis by CSF opening pressure
There was no relationship between the two (slope: −0.0027 percent stenosis/cm H2O, p = 0.28).
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.
Figure 1. MR venography of the transverse sinuses (TS) in a patient with migraine without aura and raised CSF opening pressure, showing stenosis in the midlateral portion of both TSs (arrow). (A) Axial view; (B) coronal view.
Migraine: criteria established by the IHS
CSF opening pressure in children with optic nerve head edema
R.A. Avery, ea
Neurology May 10, 2011 vol. 76 no. 19 1658-1661
MRI include posterior sclera flattening (43%-80%), distended perioptic subarachnoid space (45%-67%), postcontrast enhancement of the prelaminar optic nerve (7%-50%), empty sella (25%-80%), intraocular protrusion of the prelaminar optic nerve (3%-30%), vertical tortuosity of the orbital optic nerve (40%), tonsillar ectopia, narrowing of the Meckel cave and cavernous sinuses, meningoceles, widening of the foramen ovale, and slitlike ventricles
Figure MRI features of idiopathic intracranial hypertension (A, B) Sagittal T2 MRI (1.5 Tesla) showing partially empty sella turcica and buckling of optic nerves. (C) Coronal T2 images showing dilated perioptic CSF spaces. (D) Axial fluid-attenuated inversion recovery images showing buckling of bilateral optic nerves and flattening of the posterior aspect of the optic globe.
MR images from the case of a 9-year-old male patient with IIH without papilledema. A, Transverse T2-weighted image (4000/96/2 [TR/TE/excitations]), obtained at admission, shows small cortical veins and superior sagittal, straight, transverse and sigmoid sinuses but no intracranial mass lesion, ventricular dilation, or sinus thrombosis.B, Sagittal fat-saturated T2-weighted image (4000/100/2) of the right optic nerve, obtained at admission, shows flattening of the posterior sclera, vertical tortuosity and elongation of the nerve, and distension of the perioptic subarachnoid space.C, Sagittal T1-weighted image (500/9/2), obtained at admission, shows a partially empty sella.D, Transverse T2-weighted image, obtained 4 months after admission and after three lumbar punctures and improvement of the clinical symptomatology, reveals a decrease in the subarachnoid space and normalization of the sizes of the cortical veins and superior sagittal, straight, transverse, and sigmoid sinuses.E, Sagittal fat-saturated T2-weighted image of the right optic nerve, obtained 4 months after admission and after three lumbar punctures and improvement of the clinical symptomatology, shows a normally round orbit and a normally straight nerve.F, Sagittal T1-weighted image, obtained 4 months after admission and after three lumbar punctures and improvement of the clinical symptomatology, shows that the previously compressed pituitary gland had reexpanded to fill the sella turcica.
(A) MRI T1-weighted sagittal image showing a partially empty sella. (B) MRI T2-weighted coronal imaging showing increased fluid in the optic nerve sheath complex bilaterally. (C) MRI T1-weighted axial image showing flattening of the posterior globes, and dilated optic nerve sheaths in patient with raised intracranial pressure.
MRI and CT cisternogram (A) Coronal T2 MRI shows bilateral meningoencephaloceles with herniating of temporal lobe and surrounding CSF on the left (arrowhead). (B) CT cisternogram shows intrathecal contrast extending through a punctate osseous defect in the lateral aspect of the left sphenoid sinus consistent with site of CSF leak (arrow).
Single colour fundus photographs of patients with disc swelling secondary to raised intracranial pressure (papilloedema). (A) Mild papilloedema with burring and elevation of nasal disc margin (arrow). (B) Moderate papilloedema with obscuration of vessels by oedematous nerve fibre layer. (C, D, E) Severe papilloedema with cotton wool spots, nerve fibre layer haemorrhage (arrows C and D) and venous engorgement and tortuosity (arrow E). (F) Papilloedema with secondary optic atrophy. Note, as atrophy progresses, fewer nerve fibres can swell.
Diagnostic errors in idiopathic intracranial hypertension (IIH)
Overdiagnosis of idiopathic intracranial hypertension
Adeniyi Fisayo, ea
Neurology January 26, 2016 vol. 86 no. 4 341-350
Single colour fundus photographs of pseudopapilloedema in patients initially thought to have IIH. (A) Elevated, lumpy disc with anomalous vascular pattern including trifurcation of central retinal artery (arrow) seen in optic nerve drusen. (B) Small disc height (arrow) leads to a crowded appearance of the optic nerve without a physiological cup. (C and D) High magnification photographs of right and left eyes of a patient with anomalous discs which show the indistinct nasal disc margin (arrow C) and absent physiological cup (arrow D).
loss of visual field (typically in the inferotemporal region), decreased visual acuity, and dysfunction of color vision.
Fundus fluorescein angiography of the left eye with papilloedema. A rapid series of fundus photographs follow the intravenous injection of a fluorescent contrast agent. In true disc swelling, the frames (A–E) show progressively increased intensity and area of fluorescence at the disc. This shows fluorescein leakage from the oedematous disc.
Long-term follow-up of idiopathic intracranial hypertension
V. A. Shah, ea
Neurology February 19, 2008 vol. 70 no. 8 634-640
Idiopathic intracranial hypertension is a chronic condition that may worsen after a period of stability, warranting long-term follow-up.
Bariatric surgery as a possible risk factor for spontaneous intracranial hypotension
Wouter I. Schievink,ea
Neurology November 11, 2014 vol. 83 no. 20 1819-1822
Low energy diet and intracranial pressure in women with idiopathic intracranial hypertension: prospective cohort study
BMJ 2010;341:c2701
Alexandra J Sinclair ea
Adjusted Mean Change in Perimetric Mean Deviation (PMD) Over Time by Treatment Group - Perimetric mean deviation is a measure of global visual field loss (mean deviation from age-corrected normal values), with a range of 2 to −32 dB
Numbers of patients reflect those contributing PMD data in each group at each time point. The adjusted means were obtained from an analysis of covariance model that included center, baseline papilledema grade (study eye), and baseline PMD as covariates. Missing data were accommodated with multiple imputation. Bars around the adjusted group means indicate 95% CIs. Adjusted group means for each treatment group are slightly offset around each visit to avoid overlap.
Mediation of acetazolamide's effect on quality of life Standardized coefficients of key symptoms and signs potentially affected by acetazolamide. In all cases, the net effect of acetazolamide (Net Rx) is positive (green), despite negative (red) direct effects (Direct Rx) that would generally be expected from the side effects of acetazolamide. BMI = body mass index; HIT-6 = 6-item Headache Impact Test; MCS = Mental Component Summary; NEI-VFQ-25 = 25-item National Eye Institute Visual Function Questionnaire; PCS = Physical Component Summary; PMD = perimetric mean deviation, best eye; TVO = transient visual obscurations; VA = visual acuity, worst eye.
Quality of life at 6 months in the Idiopathic Intracranial Hypertension Treatment Trial
Beau B. Bruce, ea
NORDIC Idiopathic Intracranial Hypertension Study Group
Neurology November 1, 2016 vol. 87 no. 18 1871-1877
http://www.neurology.org/content/87/18/1871.short?sid=44aeeeeb-ff9f-450a-9381-9dc471018027
Endovascular treatment of idiopathic intracranial hypertension - Clinical and radiologic outcome of 10 consecutive patients
A. Donnet, ea
Neurology February 19, 2008 vol. 70 no. 8 641-647
http://emedicine.medscape.com/article/1214410-treatment#d9
Endovascular treatment of idiopathic intracranial hypertension - Clinical and radiologic outcome of 10 consecutive patients
A. Donnet, ea
Neurology February 19, 2008 vol. 70 no. 8 641-647
http://emedicine.medscape.com/article/1214410-treatment#d9
Endovascular treatment of idiopathic intracranial hypertension - Clinical and radiologic outcome of 10 consecutive patients
A. Donnet, ea
Neurology February 19, 2008 vol. 70 no. 8 641-647
http://emedicine.medscape.com/article/1214410-treatment#d9
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.
Is cerebrospinal fluid shunting in idiopathic intracranial hypertension worthwhile? A 10-year review.
Cephalalgia. 2011; 31(16):1627-33 (ISSN: 1468-2982)
Sinclair AJ; Kuruvath S; Sen D; Nightingale PG; Burdon MA; Flint G
https://clinicaltrials.gov/ct2/show/NCT02143258
Figure 1 Magnetic resonance venography showing a bilateral venous sinus stenosis predominating on the left side
Figure 2 Direct retrograde cerebral venography (A) Anteroposterior cerebral angiography at the late venous phase showing a right lateral sinus stenosis (double arrows). (B) Anteroposterior subtracted venogram showing the site of stenosis via a direct retrograde cerebral venography (DRCV) in the same patient. (C) Stent deployment and balloon angioplasty (double arrows) during a DRCV procedure. (D) Anteroposterior subtracted venogram showing the stent after deployment with normal flow through the lateral sinus (double arrows). Pressure gradient is no longer detected by manometry.
Figure 3 Multidetector row three-dimensional CT angioscan showing the patency of the stent and the cortical drainage of veins through the stent wall
A, Example of a stenosis due to extrinsic compression (long narrowed segment, arrow).
B, Example of an intrinsic stenosis caused by a large arachnoid granulation (arrow).
C, Example of an intrinsic stenosis caused by a septal band (arrow).