Should Lumbar Puncture Be Required to Diagnose Every Patient With Idiopathic Intracranial Hypertension?

Moss, Heather E.; Margolin, Edward; Lee, Andrew G.; Stavern, Gregory P. Van

doi:10.1097/wno.0000000000001373

Cited by 8 publications

(4 citation statements)

References 29 publications

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“…The study was approved by the University of Toronto Health Sciences Research Ethics Board and adhered to the provisions of the Declaration of Helsinki. Patients were included if they (1a) met the modified Dandy criteria for the diagnosis of IIH or (1b) were in a typical IIH demographic and deferred lumbar puncture but met all of the other modified Dandy criteria and had mild papilledema and preserved visual function; 12,13 (2) were at least 18 years of age at presentation; (3) had at least 2 high-quality peripapillary OCT scans, defined as manufacturer signal strength of $5, between January 2012 and August 2022; and (4) had at least 1 eye with optic atrophy, defined as mean pRNFL thickness of #80 mm on high-quality OCT scans between at least 2 consecutive visits. 14 The exclusion criteria were (1) other ocular disease with the potential to cause acute optic disc swelling or visual loss and (2) systemic condition or medication associated with secondary intracranial hypertension.…”

Section: Methodsmentioning

confidence: 99%

Swelling of Atrophic Optic Discs in Idiopathic Intracranial Hypertension

Xie¹,

Donaldson²,

Margolin³

2023

Journal of Neuro-Ophthalmology

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Background: Monitoring patients with idiopathic intracranial hypertension (IIH) and optic atrophy may be difficult as papilledema may not be appreciable on ophthalmoscopy. This retrospective chart review evaluated whether papilledema recurrence can be detected in this population using optical coherence tomography (OCT). Methods: Serial clinical assessments, ophthalmoscopy, and peripapillary OCT were reviewed in a cohort of patients with IIH and optic atrophy. Atrophy was defined as moderate if average peripapillary retinal nerve fiber layer (pRNFL) thickness was ≤80 μm and severe if average pRNFL thickness was ≤60 μm on at least 2 consecutive high-quality OCT scans. Based on the upper tolerance limit of test–retest variability, mean pRNFL elevation of ≥6 μm with subsequent decrease to baseline thickness was considered papilledema. Results: In a cohort of 165 patients with IIH, 32 eyes of 20 patients and 22 eyes of 12 patients demonstrated moderate and severe optic atrophy, respectively. Over a median follow-up of 198.5 weeks (range, 14.0–428.9), 63.3% (19 of 30) of patients had at least 1 episode of relapse, and 50.0% (15 of 30) had at least 1 episode of papilledema. There was a total of 36 relapse episodes, of which 7 occurred in patients with clinical signs and symptoms but no OCT evidence of relapse, 12 occurred in patients with OCT changes but no clinical signs and symptoms of relapse, and 17 occurred in patients with both clinical and OCT evidence to support relapse. The median percent pRNFL increase in the latter 2 groups was 13.7% (range, 7.5–111.8), and 7 eyes (13.0%) of 5 patients (16.7%) showed thickening greater than 20.0% from baseline. The rate, magnitude, and concordance of pRNFL swelling were similar between moderately vs severely atrophic eyes. Conclusions: Papilledema recurrence can be detected in atrophic optic discs using OCT. All patients with atrophic IIH should be longitudinally monitored with pRNFL measurement. Concurrence of other relapse-suggestive features should prompt further evaluation.

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Section: Methodsmentioning

confidence: 99%

Swelling of Atrophic Optic Discs in Idiopathic Intracranial Hypertension

Xie¹,

Donaldson²,

Margolin³

2023

Journal of Neuro-Ophthalmology

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“…On the other hand, measurement of CSF opening pressure during lumbar puncture has been prone to errors. 45 Furthermore, lumbar puncture may not be always feasible in the acute setting and need to be postponed, until a fluoroscopy-guided lumber puncture can be scheduled. 46 In those clinical scenarios, TOS may prove a valuable tool in detecting and further stratifying patients with suspicion of IIH.…”

Section: Discussionmentioning

confidence: 99%

“…Although TOS can reliably predict elevated ICP, it cannot substitute lumbar puncture performance, in the context of CSF analysis. On the other hand, measurement of CSF opening pressure during lumbar puncture has been prone to errors 45 . Furthermore, lumbar puncture may not be always feasible in the acute setting and need to be postponed, until a fluoroscopy‐guided lumber puncture can be scheduled 46 .…”

Section: Discussionmentioning

confidence: 99%

Transorbital sonography in idiopathic intracranial hypertension: Single‐center study, systematic review and meta‐analysis

Bakola,

Palaiodimou,

Eleftheriou

et al. 2023

Journal of Neuroimaging

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Background and PurposeTransorbital sonography (TOS) provides a noninvasive tool to detect intracranial pressure by assessing optic nerve sheath diameter (ONSD) and optic disc elevation (ODE). The utility of TOS in the diagnosis of idiopathic intracranial hypertension (IIH) has been increasingly recognized.MethodsA single‐center case‐control study sought to compare TOS‐acquired ONSD and ODE among IIH‐cases versus patients with other neurological diseases (controls). Furthermore, a systematic review and meta‐analysis was conducted to present pooled mean differences and diagnostic measures of ONSD and ODE between IIH‐cases and controls.ResultsIn the single‐center study, consisting of 31 IIH‐cases and 34 sex‐ and age‐matched controls, ONSD values were higher among IIH‐cases than controls (p<.001), while ODE was more prevalent in cases (65% vs. 15%; p<.001). The receiver‐operating characteristic (ROC)‐curve analysis revealed that the optimal cutoff value of ONSD for predicting IIH was 5.15 mm, with an area under the curve (AUC) of 0.914 (95% confidence interval [CI]: 0.861‐0.967) and sensitivity and specificity values of 85% and 90%, respectively. In a meta‐analysis of 14 included studies with 415 IIH‐cases, ONSD and ODE values were higher in IIH‐cases than controls (mean difference in ONSD 1.20 mm; 95% CI: 0.96‐1.44 mm and in ODE 0.3 mm; 95% CI: 0.33‐0.67 mm). With regard to ONSD, pooled sensitivity, specificity, and diagnostic odds ratio were calculated at 85.5% (95% CI: 77.9‐90.8%), 90.7% (95% CI: 84.6‐94.5%), and 57.394 (95% CI: 24.597‐133.924), respectively. The AUC in summary ROC‐curve analysis was 0.878 (95% CI: 0.858‐0.899) with an optimal cutoff point of 5.0 mm.ConclusionsTOS has a high diagnostic utility for the noninvasive diagnosis of IIH and may deserve wider implementation in everyday clinical practice.

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“…Furthermore, new observations, such as the perivascular hyporeflective regions postulated to represent dilated glymphatic channels (3), offer even greater insights into the pathophysiology of papilledema. With our ability to detect elevated ICP with funduscopy, and now to follow it quantitatively with OCT, some have argued that lumbar puncture is not necessary to diagnose IIH (4) when the clinical picture is strongly suggestive of the diagnosis. Nevertheless, we would like to emphasize that the parameters on OCT cannot be used to determine an exact ICP nor the underlying etiology.…”

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confidence: 99%