RESUMO
INTRODUCTION: Idiopathic Intracranial Hypertension (IIH) is a condition characterized by elevated intracranial pressure. Although several mechanisms have been proposed as underlying causes of IIH, no identifiable causative factor has been determined for this condition. Initial treatments focus on weight or CSF reduction, but severe cases may require surgery. This study compares outcomes in IIH patients treated with lumboperitoneal shunts (LPSs) versus ventriculoperitoneal shunts (VPSs). METHODS: This systematic-review and meta-analysis follows Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines and includes studies about VPS and LPS patients, reporting one of the outcomes of interest. We conducted searches on PubMed, Embase, Web of Science, and Cochrane Library. RESULTS: Our analysis involved twelve studies, comprising 5990 patients. The estimated odds ratio (OR) for visual improvement was 0.97 (95% CI 0.26-3.62; I2 = 0%) and for headache improvement was 0.40 (95% CI 0.20-0.81; I2 = 0%), favoring LPS over VPS. Shunt revision analysis revealed an OR of 1.53 (95% CI 0.97-2.41; I2 = 77%). The shunt complications showed an OR of 0.91 (95% CI 0.68-1.22; I2 = 0%). The sub-analyses for shunt failure uncovered an OR of 1.41 (95% CI 0.92-2.18; I2 = 25%) and for shunt infection events an OR of 0.94 (95% CI 0.50-1.75; I2 = 0%). CONCLUSIONS: The interventions showed general equivalence in complications, shunt failure, and other outcomes, but LPS seems to hold an advantage in improving headaches. Substantial heterogeneity highlights the need for more conclusive evidence, emphasizing the crucial role for further studies. The findings underscore the importance of considering a tailored decision between VPS and LPS for the management of IIH patients.
Assuntos
Pseudotumor Cerebral , Derivação Ventriculoperitoneal , Humanos , Derivação Ventriculoperitoneal/métodos , Pseudotumor Cerebral/cirurgia , Pseudotumor Cerebral/complicações , Resultado do Tratamento , Derivações do Líquido Cefalorraquidiano/métodos , Complicações Pós-Operatórias/epidemiologia , Complicações Pós-Operatórias/etiologiaRESUMO
BACKGROUND AND AIM: Shunt dysfunction is a common event, especially in children who have this intervention performed early in life. The consequences of chronic shunt overdrainage can be multiple since the cerebral hydrodynamics is altered. A thrombotic event with consequent symptoms of intracranial hypertension is discussed in this article. MATERIAL AND METHODS: We performed a detailed review of cerebral hydrodynamics and intracranial pressure compensation mechanisms and how this can alter cerebral venous circulation. Next, we report the case of a 4-year-old child with such a clinical presentation that was conducted by our team. RESULTS: A child with a history of hydrocephalus treated with a ventriculo-peritoneal (VP) shunt in his early childhood presented with symptoms of intracranial hypertension, initial computed tomography (CT) demonstrating reduced-sized ventricles. Complementary investigation showed bilateral papilledema, cranial suture closure, changes compatible with Chiari type I, and venous sinus thrombosis (transverse and sigmoid, bilaterally). The case was managed conservatively with full anticoagulation with enoxaparin. Four months after the onset of symptoms, there was an improvement in the clinical and imaging status. CONCLUSION: A condition of severe headache in a patient with an apparently functioning shunt and small ventricles on initial CT should open up a range of diagnostic possibilities, with pseudotumor cerebri syndrome and cerebral venous sinus thrombosis being suggested. The therapeutic approach in these cases must be individualized.
Assuntos
Hipertensão Intracraniana , Papiledema , Pseudotumor Cerebral , Trombose dos Seios Intracranianos , Pré-Escolar , Cavidades Cranianas/diagnóstico por imagem , Cavidades Cranianas/patologia , Humanos , Hipertensão Intracraniana/complicações , Papiledema/etiologia , Pseudotumor Cerebral/cirurgia , Trombose dos Seios Intracranianos/complicações , Trombose dos Seios Intracranianos/etiologiaRESUMO
CASE REPORT: A 26-year-old woman presented a superior sagittal and transverse sinus thrombosis with venous infarction. Anticoagulation was started. Six months later headache and visual impairment developed, and intracranial hypertension was diagnosed-secondary pseudotumor cerebri. It was managed with a lumbo-peritoneal shunt (LPS) resulting in a positive initial evolution with initial symptoms resolution, but headache and visual impairment eventually reappeared. Magnetic Resonance Imaging revealed a Pseudo-Chiari malformation, leading to lumbo-peritoneal shunt removal (Friedman et al. Neurology 81:1159-1165, 2013; Moncho et al. Rev Neurol 56(12):623-634, 2013). As symptoms reappeared, a short period of continuous transcranial Doppler neuromonitoring, including a change of head of bed elevation, was performed. A sudden decrease in cerebral blood flow velocity with a dramatic increase in pulsatility index developed when head of bed was moved from 45° to horizontal position. Transcranial Doppler changes were compatible with a plateau wave of intracranial hypertension. A ventricle-peritoneal shunt was inserted, which resulted in symptomatology, imaging, and digital campimetry improvement.
Assuntos
Malformação de Arnold-Chiari , Adulto , Feminino , Humanos , Hipertensão Intracraniana , Imageamento por Ressonância Magnética , Pseudotumor Cerebral/complicações , Pseudotumor Cerebral/diagnóstico por imagem , Pseudotumor Cerebral/cirurgia , Ultrassonografia Doppler TranscranianaRESUMO
Idiopathic intracranial hypertension (IIH) is a rare disease with an incidence rate of 0.5-2.0/100,000/year. Characteristic symptoms are headache and several degrees of visual impairment. Psychiatric symptoms in association with IIH are usually poorly described and underestimated. In this study, we evaluated IIH subjects to determine the association with psychiatric symptoms. We evaluated thirty consecutive patients with IIH submitted to neurosurgery from January 2017 to January 2020 in two Brazilian tertiary hospitals. They underwent clinical evaluation, obtaining medical history, comorbidities, body mass index (BMI-kg/m2), and applying Neuropsychiatric Inventory Questionnaire (NPI-Q). There were 28 females and 2 males. Ages ranged from 18 to 66 years old, with mean age of 37.97 ± 12.78. Twenty-five (83%) presented comorbidities, being obese and having arterial hypertension the most frequent. Body mass index ranged from 25 to 35 kg/m2 and mean value was 31 ± 3.42. After application of Neuropsychiatric Interview, 26 of 30 presented psychiatric symptoms (86%). Depression-anxiety syndromes were reported in 25 patients (83%). Nighttime disturbances were reported by 14 subjects (46%). Appetite and eating disorders were described by 23 (76%). Psychiatric symptoms in association with IIH are usually poorly described and underestimated. In our sample, twenty-six out of 30 (86%) reported psychiatric symptoms. We highlight the high prevalence of psychiatric symptoms among IIH patients and the need of managing these patients with a multidisciplinary team, including psychiatrists.
Assuntos
Transtornos Mentais/epidemiologia , Transtornos Mentais/psicologia , Procedimentos Neurocirúrgicos/tendências , Pseudotumor Cerebral/epidemiologia , Pseudotumor Cerebral/psicologia , Adolescente , Adulto , Idoso , Índice de Massa Corporal , Feminino , Cefaleia/epidemiologia , Cefaleia/psicologia , Cefaleia/cirurgia , Humanos , Masculino , Transtornos Mentais/cirurgia , Pessoa de Meia-Idade , Obesidade/epidemiologia , Obesidade/psicologia , Obesidade/cirurgia , Prevalência , Pseudotumor Cerebral/cirurgia , Adulto JovemRESUMO
INTRODUCTION: Cerebral hydrodynamics complications in shunted patients are due to the malfunction of the system. The objective of this retrospective, single-center, single-arm cohort study is to confirm the safety and performance of Sphera® Duo when used in adult patients suffering from hydrocephalus, pseudotumor cerebri or arachnoid cysts. METHODS: Data were generated by reviewing 112 adult patient's charts, who were submitted to a ventriculoperitoneal shunt surgery and followed for one year after surgery. RESULTS: The results show us that 76% of patients had their neurological symptoms improved and that the reoperation rate was 15% in the first year following surgery. DISCUSSION: Sphera Duo® shunt system is an applicable shunt option in routine neurosurgical management of hydrocephalus by several causes. It has presented good results while mitigating effects of overdrainage. Overdrainage is especially important in adults with non-hypertensive hydrocephalus and can cause functional shunt failure, which causes subnormal ICP (particularly in the upright position) and is associated with characteristic neurological symptoms, such as postural headache and nausea. CONCLUSION: Sphera Duo® shunt system is safe when used in adult patients suffering from hydrocephalus, pseudotumor cerebri or arachnoid cyst.
Assuntos
Cistos Aracnóideos/cirurgia , Hidrocefalia/cirurgia , Pseudotumor Cerebral/cirurgia , Derivação Ventriculoperitoneal/instrumentação , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Cistos Aracnóideos/fisiopatologia , Desenho de Equipamento , Feminino , Seguimentos , Humanos , Hidrocefalia/fisiopatologia , Hidrodinâmica , Pressão Intracraniana/fisiologia , Masculino , Pessoa de Meia-Idade , Pseudotumor Cerebral/fisiopatologia , Reoperação , Reprodutibilidade dos Testes , Estudos Retrospectivos , Fatores de Tempo , Resultado do Tratamento , Derivação Ventriculoperitoneal/métodos , Adulto JovemRESUMO
Abstract Introduction: Cerebral hydrodynamics complications in shunted patients are due to the malfunction of the system. The objective of this retrospective, single-center, single-arm cohort study is to confirm the safety and performance of Sphera® Duo when used in adult patients suffering from hydrocephalus, pseudotumor cerebri or arachnoid cysts. Methods: Data were generated by reviewing 112 adult patient's charts, who were submitted to a ventriculoperitoneal shunt surgery and followed for one year after surgery. Results: The results show us that 76% of patients had their neurological symptoms improved and that the reoperation rate was 15% in the first year following surgery. Discussion: Sphera Duo® shunt system is an applicable shunt option in routine neurosurgical management of hydrocephalus by several causes. It has presented good results while mitigating effects of overdrainage. Overdrainage is especially important in adults with non-hypertensive hydrocephalus and can cause functional shunt failure, which causes subnormal ICP (particularly in the upright position) and is associated with characteristic neurological symptoms, such as postural headache and nausea. Conclusion: Sphera Duo® shunt system is safe when used in adult patients suffering from hydrocephalus, pseudotumor cerebri or arachnoid cyst.
Resumo Introdução: As complicações da hidrodinâmica cerebral em pacientes com derivação ventriculoperitoneal são frequentemente relacionadas ao malfuncionamento do sistema. O objetivo deste estudo retrospectivo de coorte de centro único é avaliar a segurança e performance clínica do Sistema Sphera® Duo quando utilizado em adultos com hidrocefalia, pseudotumor cerebral ou cistos aracnoides. Métodos: Avaliamos os prontuários de 112 pacientes adultos submetidos a cirurgia de derivação ventriculoperitoneal e acompanhados por 1 ano após a cirurgia. Resultados: O resultado mostra que 76% dos pacientes melhoraram dos sintomas neurológicos e a taxa de reoperação foi de 15% no primeiro ano após a cirurgia. Discussão: O sistema de derivação Sphera Duo® é uma opção de shunt adequada a ser usada no tratamento neurocirúrgico da hidrocefalia por causas diversas. Ele demonstrou bons resultados clínicos enquanto reduziu riscos de hiperdrenagem. A hiperdrenagem é especialmente preocupante e mórbida em pacientes adultos com hidrocefalia não hipertensiva e pode levar a prejuízo clínico e disfunção da válvula, com sintomas de hipotensão craniana, como cefaléia ortostática e náuseas. Conclusão: O sistema de derivação Sphera Duo® é seguro para tratamento da hidrocefalia, pseudotumor cerebri ou cistos aracnóides em adultos.
Assuntos
Humanos , Masculino , Feminino , Adolescente , Adulto , Pessoa de Meia-Idade , Idoso , Idoso de 80 Anos ou mais , Adulto Jovem , Pseudotumor Cerebral/cirurgia , Cistos Aracnóideos/cirurgia , Derivação Ventriculoperitoneal/instrumentação , Hidrocefalia/cirurgia , Reoperação , Fatores de Tempo , Pseudotumor Cerebral/fisiopatologia , Pressão Intracraniana/fisiologia , Reprodutibilidade dos Testes , Estudos Retrospectivos , Seguimentos , Cistos Aracnóideos/fisiopatologia , Resultado do Tratamento , Derivação Ventriculoperitoneal/métodos , Desenho de Equipamento , Hidrodinâmica , Hidrocefalia/fisiopatologiaRESUMO
BACKGROUND: Primary idiopathic intracranial hypertension (PIIH) in children is rare and has a poorly understood pathophysiology. It is characterized by raised intracranial pressure (ICP) in the absence of an identified brain lesion. Diagnosis is usually confirmed by the measurement of a high cerebrospinal fluid (CSF) opening pressure and exclusion of secondary causes of intracranial hypertension. Refractory PIIH may lead to severe visual impairment. The purpose of this study was to evaluate a cranial morcellation decompression (CMD) technique as a new surgical alternative to stabilize intracranial pressure in PIIH. MATERIALS AND METHODS: A literature review was carried out, disclosing only 7 pediatric cases of PIIH treated with surgical skull expansion. In addition, we describe here one case of our own experience treated by CMD. CONCLUSIONS: CMD surgery is a safe and effective option to control refractory PIIH in selected patients.
Assuntos
Craniotomia/métodos , Descompressão Cirúrgica/métodos , Pseudotumor Cerebral/cirurgia , Criança , Feminino , HumanosRESUMO
ABSTRACT CONTEXT: Pseudotumor cerebri occurs when there is an increase in intracranial pressure without an underlying cause, usually leading to loss of vision. It is most commonly observed in obese women of child-bearing age. CASE REPORT: A 46-year-old woman presented at our service with idiopathic intracranial hypertension that had been diagnosed two years earlier, which had led to chronic refractory headache and an estimated 30% loss of visual acuity, associated with bilateral papilledema. She presented partial improvement of the headache with acetazolamide, but the visual loss persisted. Her intracranial pressure was 34 cmH2O. She presented a body mass index of 39.5 kg/m2, also associated with high blood pressure. Computed tomography of the cranium with endovenous contrast did not show any abnormalities. She underwent Roux-en-Y gastric bypass with uneventful postoperative evolution. One month following surgery, she presented a 24% excess weight loss. An ophthalmological examination revealed absence of visual loss and remission of the papilledema. There were no new episodes of headache following the surgery. There was also complete resolution of high blood pressure. The intracranial pressure decreased to 24 cmH2O, six months after the surgery. CONCLUSION: Although the condition is usually associated with obesity, there are few reports of bariatric surgery among individuals with pseudotumor cerebri. In cases studied previously, there was high prevalence of resolution or improvement of the disease following bariatric surgery. There is no consensus regarding which technique is preferable. Thus, further research is necessary in order to establish a specific algorithm.
RESUMO CONTEXTO: O pseudotumor cerebri ocorre quando há aumento na pressão intracraniana sem causa subjacente, comumente levando a perda visual. É mais comum em mulheres obesas em idade fértil. RELATO DE CASO: Mulher de 46 anos, foi admitida com hipertensão intracraniana idiopática diagnosticada há dois anos, que levou a cefaleia refratária crônica e perda estimada de 30% da acuidade visual, associada a papiledema bilateral. Apresentou melhora parcial da cefaleia com acetazolamida, mas a perda visual persistiu. A pressão intracraniana era de 34 cmH2O. Apresentava índice de massa corpórea de 39,5 kg/m2, associado a hipertensão arterial. Tomografia computadorizada com contraste endovenoso de crânio não apresentou anormalidades. Foi submetida ao bypass gástrico em Y de Roux, com evolução pósoperatória sem intercorrências. Um mês após a cirurgia, apresentou perda de peso em excesso de 24%. Um exame oftalmológico demonstrou ausência de perda visual e remissão do papiledema; não houve novos episódios de cefaleia após a cirurgia. Houve também resolução completa da hipertensão arterial. A pressão intracraniana caiu para 24 cmH2O após seis meses da cirurgia. CONCLUSÃO: Embora a condição seja usualmente associada à obesidade, há escassos relatos de cirurgia bariátrica em indivíduos com pseudotumor cerebri. Nos casos previamente estudados, há alta prevalência de resolução ou de melhora da doença após a cirurgia bariátrica. Não há consenso sobre qual é a técnica cirúrgica de escolha. Portanto, mais estudos são necessários para estabelecer um algoritmo específico.
Assuntos
Humanos , Feminino , Obesidade Mórbida/cirurgia , Obesidade Mórbida/complicações , Pseudotumor Cerebral/etiologia , Derivação Gástrica , Papiledema/etiologia , Hipertensão Intracraniana/etiologia , Pseudotumor Cerebral/cirurgia , Papiledema/cirurgia , Resultado do Tratamento , Hipertensão Intracraniana/cirurgiaRESUMO
CONTEXT: Pseudotumor cerebri occurs when there is an increase in intracranial pressure without an underlying cause, usually leading to loss of vision. It is most commonly observed in obese women of child-bearing age. CASE REPORT: A 46-year-old woman presented at our service with idiopathic intracranial hypertension that had been diagnosed two years earlier, which had led to chronic refractory headache and an estimated 30% loss of visual acuity, associated with bilateral papilledema. She presented partial improvement of the headache with acetazolamide, but the visual loss persisted. Her intracranial pressure was 34 cmH2O. She presented a body mass index of 39.5 kg/m2, also associated with high blood pressure. Computed tomography of the cranium with endovenous contrast did not show any abnormalities. She underwent Roux-en-Y gastric bypass with uneventful postoperative evolution. One month following surgery, she presented a 24% excess weight loss. An ophthalmological examination revealed absence of visual loss and remission of the papilledema. There were no new episodes of headache following the surgery. There was also complete resolution of high blood pressure. The intracranial pressure decreased to 24 cmH2O, six months after the surgery. CONCLUSION: Although the condition is usually associated with obesity, there are few reports of bariatric surgery among individuals with pseudotumor cerebri. In cases studied previously, there was high prevalence of resolution or improvement of the disease following bariatric surgery. There is no consensus regarding which technique is preferable. Thus, further research is necessary in order to establish a specific algorithm.
Assuntos
Derivação Gástrica , Hipertensão Intracraniana/etiologia , Obesidade Mórbida/complicações , Obesidade Mórbida/cirurgia , Papiledema/etiologia , Pseudotumor Cerebral/etiologia , Feminino , Humanos , Hipertensão Intracraniana/cirurgia , Pessoa de Meia-Idade , Papiledema/cirurgia , Pseudotumor Cerebral/cirurgia , Resultado do TratamentoRESUMO
BACKGROUND: The conventional treatment for idiopathic intracranial hypertension involves weight loss, steroids, diuretics, and/or serial lumbar punctures; however, if the symptoms persist or worsen, surgical intervention is recommended. Surgical options include cerebrospinal fluid diversion procedures, such as ventriculoperitoneal and lumboperitoneal shunts, and optic nerve decompression with nerve sheath fenestration. The latter can be carried out using an endoscopic approach, but the outcomes of this technique have not been firmly established. METHODS: This systematic review examined the outcomes of performing endoscopic optic nerve decompression (EOND) in patients with idiopathic intracranial hypertension (IIH). Six studies were included for a total of 34 patients. RESULTS: The patients presented with visual field disturbances (32 of 32 [100%]), visual acuity disruptions (33 of 34 [97.1%]), papilledema (26 of 34 [76.5%]), and persistent headache (30 of 33 [90.1%]). The mean duration of symptoms ranged from 7 to 32 months. Overall, the patients showed post-EOND improvement in signs and symptoms associated with IIH, specifically visual field deficits (93.8%), visual acuity (85.3%), papilledema (81.4%), and headaches (81.8%). Interestingly, 11 cases showed postoperative improvement in their symptoms with bony decompression of the optic canal alone, without nerve sheath fenestration. There were no major adverse events or complications reported with this approach. CONCLUSION: EOND appears to be a promising and safe surgical alternative for patients with IIH who fail to respond to medical treatment. Further studies are needed before we can attest to the clinical validity of this procedure.