Gastric Surgery for Pseudotumor Cerebri Associated With Severe Obesity

Abstract

ObjectiveTo study the efficacy of gastric surgery-induced weight loss for the treatment of pseudotumor cerebri (PTC). Summary Background DataPseudotumor cerebri (also called idiopathic intracranial hypertension), a known complication of severe obesity, is associated with severe headaches, pulsatile tinnitus, elevated cerebrospinal fluid (CSF) pressures, and normal brain imaging. The authors have found in previous clinical and animal studies that PTC in obese persons is probably secondary to a chronic increase in intraabdominal pressure leading to increased intrathoracic pressure. CSF-peritoneal shunts have a high failure rate, probably because they involve shunting from a highpressure system to another high-pressure zone. In an earlier study of gastric bypass surgery in eight patients, CSF pressure decreased from 353 Ϯ 35 to 168 Ϯ 12 mm H 2 O at 34 Ϯ 8 months after surgery, with resolution of headaches in all. MethodsTwenty-four severely obese women underwent bariatric surgery-23 gastric bypasses and one laparoscopic adjustable gastric banding-62 Ϯ 52 months ago for the control of severe obesity associated with PTC. CSF pressures were 324 Ϯ 83 mm H 2 O. Additional PTC central nervous system and cranial nerve problems included peripheral visual field loss, trigeminal neuralgia, recurrent Bell's palsy, and pulsatile tinnitus. Spontaneous CSF rhinorrhea occurred in one patient, and hemiplegia with homonymous hemianopsia developed as a complication of ventriculoperitoneal shunt placement in another. There were two occluded lumboperitoneal shunts and another functional but ineffective lumboperitoneal shunt. Additional obesity comorbidity in these patients included degenerative joint disease, gastroesophageal reflux disease, hypertension, urinary stress incontinence, sleep apnea, obesity hypoventilation, and type II diabetes mellitus. ResultsAt 1 year after bariatric surgery, 19 patients lost an average of 45 Ϯ 12 kg, which was 71 Ϯ 18% of their excess weight. Their body mass index and percentage of ideal body weight had fallen to 30 Ϯ 5 kg/m 2 and 133 Ϯ 22%, respectively. In four patients, less than 1 year had elapsed since surgery. Five patients were lost to follow-up. Surgically induced weight loss was associated with resolution of headache and pulsatile tinnitus in all but one patient within 4 months of the procedure. The cranial nerve dysfunctions resolved in all patients. The patient with CSF rhinorrhea had resolution within 4 weeks of gastric bypass. Of the 19 patients not lost to follow-up, 2 regained weight, with recurrence of headache and pulsatile tinnitus. Additional resolved associated comorbidities were 6/14 degenerative joint disease, 9/10 gastroesophageal reflux disorder, 2/6 hypertension, and all with sleep apnea, hypoventilation, type II diabetes mellitus, and urinary incontinence. ConclusionsBariatric surgery is the long-term procedure of choice for severely obese patients with PTC and is shown to have a much higher rate of success than CSF-peritoneal shunting reported in the literature, as well as ...

Pseudotumor Cerebri: Brief Review of Clinical Syndrome and Imaging Findings

“…Another case report demonstrated a reduction of dural venous sinus pressure in 2 patients following bariatric surgery. 46,47 Medications to treat and prevent recurrence of PTC typi- cally have activity against carbonic anhydrase, which has been found to decrease the rate of CSF production, and thus address 1 of the proposed mechanisms of PTC. 22 Acetazolamide is historically the most commonly used medication to treat PTC, but topiramate has been shown to have equal effect as a result of partial carbonic anhydraseϪinhibition activity augmented by beneficial analgesic action against headaches and weight loss as a fortuitous side effect.…”

Continuous negative abdominal pressure device to treat pseudotumor cerebri

“…Previous studies 1,14 have documented the ef®cacy of gastric surgery-induced weight loss for the treatment of PTC associated with severe obesity. Furthermore, additional obesity co-morbidity is often seen in these patients, including type II diabetes, obstructive sleep apnea, infertility, dysmenorrhea, stress over¯ow urinary incontinence, as well as the previously mentioned co-morbidities associated with an increased intra-abdominal pressure.…”

Silla turca vacía primaria: clínica, fisiopatología y tratamiento

“…De hecho, el tratamiento con azetazolamida no mejora el cuadro de HIC si no se acompaña de una dieta que consiga una pérdida de peso de al menos el 6% 51 . Sugerman y col 93 , sometieron a cirugía gástrica reductora a 24 mujeres con obesidad mórbida e HICI, consiguiendo la curación de la hipertensión intracraneal a los cuatro meses de la intervención en el 95,8% de ellas, así como de la única rinorrea de la serie.…”

“…Mas raramente se ha publicado algún caso con hidrocefalia, en que la diversión del lcr ha provocado neumoencéfalo 50 . En las personas obesas, se ha señalado como una posible causa del mal funcionamiento de la derivación, al aumento típico de presión intra-abdominal que tienen estos enfermos 93 . Tres de los siete pacientes a los que se les practicó, de manera no selectiva, una derivación de lcr en la serie publicada por García-Uría y col 37 , tuvieron recidiva de la rinorrea a largo plazo (0,8 años de promedio), lo que consideran como resultado muy pobre en comparación con los obtenidos cuando hacen un abordaje quirúrgico directo de la fístula.…”

“…En los pacientes con obesidad >35 Kg./m 2 y comorbilidad, entre la que se ha propuesto la HICI 93 o bien con >40 Kg/m 2 , está indicado la cirugía gástrica, ya que se ha demostrado que soluciona el problema de la hipertensión intracraneal a medio y largo plazo 93 . En este grupo de pacientes con obesidad mórbida, el adelgazamiento es muy difícil de conseguir con medidas convencionales, en especial cuando están bajo tratamiento con dexametasona.…”