5. CSF pressure elderly (n=40)
• Median pressure: 11.6
• Mean age: 70
• Median BMI:24.6
* Malm, Neurology 2011
6. CSF pressure children
• Median pressure: 18.6
• Mean age: 12
• Median BMI: 21
* Avery, Neurology 2011
7. Headache due to increased ICP
• What are the characteristics of the headache?
• When does ICP increase becomes painful?
• What is the origin of the headache?
• What are the treatment strategies?
14. IHCD-II classification
• 7.1.1 Headache attributed to idiopathic
intracranial hypertension (IIH)
• 7.1.2 Headache attributed to intracranial
hypertension secondary to metabolic, toxic or
hormonal causes
• 7.1.3 Headache attributed to intracranial
hypertension secondary to hydrocephalus
• Headache due to neoplasm, infection and
vascular disorders are coded elsewhere
15. Q: Brain tumor headache
• Which patient is more lickely to have pain?
16. Brain tumor headache
• 30-70% of brain tumor patients have headache
• Infratentorial or intraventricular more frequent
• Association with cerebral edema
• No relation to size of tumor
• Throbbing pain; mimicking migraine
• Progressive headache in weeks/months
• Relation with ICP?
â–« 25-35% have morning headaches
*Goffaux Neurosurgery 2010; * Pfund, Cephalalgia 1999
17. Headache in venous thrombosis
• Prevalence 0.6-7 per 100.000
• 70-80% of CVT patients have headache
• In 17% headache only symptom
• Headache is not related to location thrombus
• ±70% of CVT have ICP> 20cmH2O
• Relation ICP and headache unclear
*Biousse Neurology 1999; *Lin Ophtamlmology 2006; *Cumurciuc JNNP 2005
19. Modified Dandy criteria
• Symptoms of increased ICP
• No localizing findings in neurological exam
• Awake and alert patient
• Normal CT/MRI findings
• ICP of 250 mm H2O with normal CSF
• No other cause of increased ICP found
* Binder, Neurosurgery 2004
20. Headache characteristics in IIH
• Occuring in >90% of patients
• Generalized, moderate, pulsatile of pressing
• Worse in the morning
• Aggravation with coughing or straining
• Daily in 75%
• Decrease of pain with ICP normalization
* Dhungana, Acta Neurol Scand 2010; * Mathew, Neurology 1996
21. Origin of headache in IIH
• Little information…
• Meningen and meningeal bloodvessels are pain
sensitive
• Nociceptors are mechanosensitive
• Variation in nociceptor sensitivity in rats
â–« ICP of 20mmHg would activate <3% of receptors
â–« ICP of 40mmHg around 18%
â–« Thresholds might be lower due sensitisation
* Strassman, J Neurophysiol 2006
22. Pathogenesis of ICP increase in IIH
• Altered CSF dynamics; venous stenosis
• Obesity
• Other associated factors:
â–« Renal failure
â–« Systemic lupus erytematosus
â–« Drug induced (hypervitaminosis A, lithium etc)
* Dhungana, Acta Neurol Scand 2010
24. IIH and stenosis of transverse sinus
• MRV studies
• Higgins et al 2004:
â–« IIH patients n=20
â–« Controls n=40
â–« Bilateral stenosis in 13 patients and none in
controls
• Increase venous pressure prestenotic
*Higgins JNNP 2004; *Karahalios Neurology 1996
25. Stenting results in case series
• 9 case series from different countries
• Total 40 published cases
• Transverse sinus
• Outome:
â–« Around 45% asymptomatic
â–« 35% improvement of symptoms
â–« Rest no effect
• Complications such vessel perforation
*Arac Neurosurg focus 2009 (review),; *Bussiere , Am J. Neurorad 2010
26. Cause or consequence?
• Stenosis seems to bee associated with IIH
• Stenting of the stenotic segment might improve
symptoms
• Lowering ICP through medication also does
reverse the stenosis
29. BMI and ICP
• Study hannerz
â–« Randomly selected obese BMI 34-47 kg/m2
â–« 79% boven 20 cm H20
â–« 42% boven 25 cm H20
*Hannerz, Int J Obese Relat Metab Dis. 1995
31. Treatment of IIH
• Weight reduction
• Medication
• Invasive strategies
â–« Serial LP
â–« Surgery
32. Weight reduction
• No RCT
• Mainly retrospective case series
• One prospective cohort study with 3 month
baseline and measurement of ICP
â–« N=25
*Sinclair BMJ 2010
36. Q: Medication to treat IIH…
• Which would you prescribe and what dose?
â–« Azetazolamide
â–« Digoxin
â–« Furosemide
â–« Methylprednisone
â–« Octreotide
â–« Topiramate
37. Medication – quiz…
• Which would you prescribe and what dose?
â–« Azetazolamide: 500mg 2dd
â–« Digoxin: ? 1 study , serious side effect
â–« Furosemide: ? Sporadic case reports
â–« Methylprednisone ? Sporadic case reports
â–« Octreotide max 1mg/day, open label, n=26
â–« Topiramate max 100-150mg/day
*
38. Interventions
• Serial LP
• Optic nerve fenestration
• CSF shunting (LPD or VPD)
• For further details please read review
*Binder, Neurosurgery 2004
39. IIH and primary headache syndromes
• Clinical overlap with “CDH”
â–« 12 out of 85 patients had CSF pressure > 25
â–« No difference in headache symptoms
• Case control study IIH (n=25) vs “CDH” (n=60)
â–« No difference headache symptoms
â–« Tinnitis and obesity associated with IIH
• Rule out IIH in patients with frequent headache
*Mathew, Neurology 1996; * Wang, Neurology 1998
