ARRS 2022 Abstracts

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1127. Normalization of Intracranial Venous Pressures and Sinus Stenoses After Lumbar Puncture in Pseudotumor Cerebri Patients
Authors * Denotes Presenting Author
  1. Mason Brown *; Aurora St. Luke's Medical Center
  2. Thomas Wolfe; Aurora St. Luke's Medical Center
Objective:
The purpose of this case series is to present patients with medically refractory idiopathic intracranial hypertension (IIH), also known as pseudotumor cerebri; detail findings demonstrated on diagnostic cerebral angiography and manometry before and after high-volume lumbar puncture; and compare these outcomes to those of the current medical and surgical treatment options.

Materials and Methods:
Over 2 years and within a single academic institution, 3 patients (and 2 more potential patients for a total of 5) were evaluated by neuro-interventional surgery (NIS) for IIH. Prior to referral, each patient was formally evaluated by ophthalmology and clinically diagnosed. Patients expressed varying clinical symptoms that generally worsened over time and consisted of visual field deficits of peripheral vision loss, blurriness, and photophobia, waxing and waning papilledema, and intermittent/worsening migraines. Conservative and medical management included but was not limited to weight loss, rizatriptan, furosemide, acetazolamide, and therapeutic lumbar punctures. Radiologic workup involved MR venography (MRV) of the brain with/without contrast to evaluate for signs of intracranial hypotension. Upon neuro-interventional evaluation, patients underwent diagnostic cerebral angiography and manometry with recorded location pressures (mmHg) and pulsatility before and after intra-operative high-volume lumbar puncture. If patients met certain criteria both clinically and diagnostically, then the treatment option of ventriculoperitoneal shunt placement was offered. Standard clinical follow-up was scheduled, often times with post-operative shunt series, CT, and MRV imaging. However, some patients were lost to follow-up or did not require imaging due to symptom resolution.

Results:
Initial diagnostic imaging revealed signs of intracranial hypotension such as partially empty sella, ectatic optic nerve sheaths, and focal narrowing of sinus venous junctions. In conjunction with worsening clinical symptoms and unsuccessful conservative and medical management, patients underwent diagnostic cerebral angiography with pre- and post-lumbar puncture manometry. Pressure decreases were observed at stenotic sinus venous junctions corresponding to findings on MRV and initial angiography. Post-lumbar puncture angiography depicted decreases in stenosis at the corresponding locations as well. Patients subsequently underwent frontal ventriculoperitoneal shunt placement. All patients confirmed complete resolution of migraines and visual symptoms upon clinical follow-up.

Conclusion:
Aside from weight loss, there exists no formal consensus or guidelines regarding the management of IIH, and the efficacy of various medical and surgical treatment options has remained controversial. High-volume lumbar puncture in patients with IIH is an effective treatment option that results in resolution of intracranial hypertension and venous sinus stenoses. Although sinus stenting is currently more common, cerebrospinal fluid shunting may be a more viable option for treating the direct cause of an idiopathic disease.