Idiopathic intracranial hypertension surgery

Idiopathic intracranial hypertension surgery

Systematic reviews

Prospective studies on the surgical options for Idiopathic intracranial hypertension (IIH) are scant and no evidence-based guidelines for the surgical management of medically refractory IIH have been established. A search in Cochrane LibraryMEDLINE and EMBASE from 1 January 1985 to 19 April 2019 for controlled or observational studies on the surgical treatment of IIH (defined in accordance with the modified Dandy or the modified Friedman criteria) in adults yielded 109 admissible studies. Venous sinus stenting (VSS) improved papilledemavisual fields and headaches in 87.1%, 72.7%, and 72.1% of the patients respectively, with a 2.3% severe complication rate and 11.3% failure rate. Cerebrospinal fluid diversion techniques diminished papilledema, visual field deterioration, and headaches in 78.9%, 66.8%, and 69.8% of the cases and are associated with a 9.4 severe complication rate and a 43.4% failure rate. Optic nerve sheath fenestration ameliorated papilledema, visual field defects and headaches in 90.5, 65.2%, and 49.3% of patients. The severe complication rate was 2.2% and the failure rate was 9.4%. This is currently the largest systematic review for the available operative modalities for IIH. VSS provided the best results in headache resolution and visual outcomes, with low failure rates and a very favorable complication profile. In light of this, Venous sinus stenting ought to be regarded as the first-line surgical modality for the treatment of medically refractory IIH 1).

Indications

Idiopathic intracranial hypertension patients may require surgical management when maximal medical treatment has failed.

Controversy still exists about which is the preferred initial surgical treatment for IIH. Emerging procedures include venous sinus stenting in cases with venous sinus stenosis, and bariatric surgery for weight loss. Cranial (suboccipital or subtemporal) decompression was a more popular surgical procedure in the past, but can still have a role in selected cases with impaired cerebrospinal flow dynamics (e.g. Chiari malformation) or after multiple failed conventional surgical procedures 2).

Venous sinus stenting ought to be regarded as the first-line surgical modality for the treatment of medically refractory IIH 3).

The election will likely be based on local expertise until well designed, multicentered clinical trials clarify which intervention best suits a particular patient 4).

The visual outcomes of these procedures are favorable, though they tend to be associated with a high rate of complication and failure. Recent trials suggest that venous sinus stenting offers both comparable rates of efficacy – with improved papilledema in 97% of patients, resolved headache in 83%, and improved visual acuity in 78% – and improved safety and reliability relative to older surgical techniques.

Patients whose sight is threatened by medically refractory IIH must often consider invasive procedures to control their disease. Venous sinus stenting may offer equal efficacy and lower failure and complication rates than traditional surgical approaches such as optic nerve sheath fenestration and cerebrospinal fluid diversion.

Several surgical treatment modalities, including lumboperitoneal shunt or ventriculoperitoneal shunt surgery, subtemporal decompression, endovascular venous sinus stenting, optic nerve decompression (OND), were used in the management of idiopathic intracranial hypertension (IIH). Each surgical technique has different advantages and disadvantages. Endoscopic OND is rarely used in the management of IIH. There are only forteen reported cases 5).

Techniques

Cerebrospinal fluid diversion procedures

The most commonly performed surgical treatments for IIH are cerebrospinal fluid diversion procedures (e.g. ventriculo- and lumboperitoneal shunts).

Lumboperitoneal shunt

see Lumboperitoneal shunt for idiopathic intracranial hypertension

Ventriculoperitoneal shunt

see Ventriculoperitoneal shunt for pseudotumor cerebri

Transverse sinus stenting

see Transverse sinus stenting for idiopathic intracranial hypertension.

Optic nerve sheath fenestration

see Optic nerve sheath fenestration.

Subtemporal decompression

see Subtemporal decompression.

References

1) , 3)

Kalyvas A, Neromyliotis E, Koutsarnakis C, Komaitis S, Drosos E, Skandalakis GP, Pantazi M, Gobin YP, Stranjalis G, Patsalides A. A systematic review of surgical treatments of idiopathic intracranial hypertension (IIH). Neurosurg Rev. 2020 Apr 25. doi: 10.1007/s10143-020-01288-1. [Epub ahead of print] Review. PubMed PMID: 32335853.
2)

Spitze A, Malik A, Lee AG. Surgical and endovascular interventions in idiopathic intracranial hypertension. Curr Opin Neurol. 2014 Feb;27(1):69-74. doi: 10.1097/WCO.0000000000000049. PubMed PMID: 24296639.
4)

Uretsky S. Surgical interventions for idiopathic intracranial hypertension. Curr Opin Ophthalmol. 2009 Nov;20(6):451-5. doi: 10.1097/ICU.0b013e3283313c1c. Review. PubMed PMID: 19687737.
5)

Sencer A, Akcakaya MO, Basaran B, Yorukoglu AG, Aydoseli A, Aras Y, Sencan F, Satana B, Aslan I, Unal OF, Izgi N, Canbolat A. Unilateral endoscopic optic nerve decompression for idiopathic intracranial hypertension: a series of 10 patients. World Neurosurg. 2014 Nov;82(5):745-50. doi: 10.1016/j.wneu.2014.03.045. Epub 2014 Apr 2. PubMed PMID: 24704940.

Intracranial Meningioma Surgery Indications in Elderly

Intracranial Meningioma Surgery Indications in Elderly

Since the number of elderly people with intracranial meningiomas (IM) continues to rise, surgical treatment has increasingly become a considerable treatment option, even in very old (≥ 80 years old) meningioma patients. Since little is known about whether intracranial meningioma surgery in this age group is safe and justified, Rautalin et al. conducted a systematic review to summarize the results of surgical outcomes in very old meningioma patients. They performed a systematic literature search in PubmedCochrane Library, and Scopus databases. Primarily, they extracted 1-month and 1-year survival rates, and 1-year morbidity rates, as well as information about preoperative morbidity, operative complications, meningioma size, location, histology, and peritumoral edemaQuality of the included studies was evaluated by Cochrane Handbook for Systematic Reviews of Interventions and Critical Appraisal Skills Program. From the 1039 reviewed articles, seven retrospective studies fulfilled the eligibility criteria. Motor deficits (27-65%) and mental changes (51-59%) were the most common indications for surgery. One-month and 1-year mortality rates varied between 0-23.5% and 9.4-27.3%, respectively. Most of the operated IM patients (41.2-86.5%) improved their performance during postoperative follow-up. Impaired preoperative performance and comorbidities were most commonly related to higher postoperative mortality. None of the studies fulfilled the criteria of high quality. Based on the evidence currently available, surgical treatment of very old IM patients seems to improve the performance of highly selected individuals. Given the rapid increase of the aging population, more detailed retrospective studies, as well as prospective studies, are needed to prove the outcome benefits of surgery in this patient group 1).


The Japanese population features the highest rate of elderly individuals worldwide. Moreover, Japan has the highest number of computed tomography/magnetic resonance imaging devices in the world, which has led to an increase in the incidental detection of meningioma in healthy elderly patients. Many previous papers have discussed the risks and indications for surgery in this patient population, but available information remains insufficient, and the definition of “elderly” has not been standardized. This review tried to clarify the published evidence and challenges associated with elderly meningioma based on a search of the PubMed database using the terms “meningioma,” “elderly,” and “surgery” for English-language clinical studies and collected related papers published from 2000 to 2016. Twenty-four papers were reviewed and classified by definition of elderly age: over 60, 65, 70, and 80 years old. Six of seven papers that defined the elderly cutoff as over 65 years old were published after 2010, which suggested the consensus definition. Four preoperative grading scoring systems were described and associated with mortality. The 1-year and 5-year mortality rates ranged from 0% to 16.7% and from 7% to 27%, which were comparable with unselected cohorts. Review of risk factor analysis emphasized the importance of considering the preoperative status, presence of comorbidities, and optimum surgical timing during patient selection. Careful choice of patients can also lead to better quality of life. A prospective randomized study considering patient frailty should address the causes and prevention of complications 2).


The results of a study suggested that age should not be a limitation in surgical indications in patients older than 70 years old with intracranial meningioma. No statistical differences were found in functional status compared with conservative management or in surgical complications between younger and elderly patients 3).


A grading system, called the Clinical-Radiological Grading System (CRGS), was developed to standardize surgical indications in elderly patients harboring intracranial meningiomas. Patients with a score lower than 10 had a bad prognosis regardless of surgical treatment, those with a score between 10 and 12 had a prognosis positively influenced by surgery, and those with a score higher than 12 had a good prognosis regardless of surgical treatment. The authors performed a prospective cross-sectional study to validate further the use of the CRGS as a clinical tool to orientate surgical decision making in elderly patients and to explore prognostic factors of survival.

From 1990 to 2000 the authors consecutively recruited and surgically treated 90 patients 70 years of age or older with neuroimaging findings of intracranial meningiomas and a preoperative evaluation based on the CRGS. The surgical mortality rate, which covers deaths within 3 months after surgical intervention, was 7.8%, and the 1-year mortality rate was 15.6%. Female sex and a higher CRGS score were associated with a higher probability of survival. Among the different subset items of the CRGS score, no peritumoral edema for surgical survival and no concomitant diseases for 1-year survival provide the strongest predictive contribution, even if not at a statistically significant level.

The CRGS score is a useful and practical tool for the selection of elderly patients affected by intracranial meningiomas as surgical candidates. A CRGS score higher than 10 and female sex are good prognostic factors of survival. whereas age is not a contraindication to surgery 4).


For Buhl et al. age, in general, was not a contraindication for operation. In cases of incidental findings of small meningiomas, we recommend observation and MRI follow-up. Symptomatic meningiomas should be removed whenever there is an acceptable risk from an internal or anesthesiological point of view 5).


Few authors have reported on patients who have undergone surgery for intracranial meningiomas in their 9th decade of life, without providing indications regarding the surgical criteria and the prognostic factors. We report on a series of 17 patients who have received surgery for intracranial meningiomas in their 9th decade of life, with the goal of determining some surgical criteria for general physicians and neurosurgeons. Patients with severe systemic disease and definite functional limitations (American Society of Anesthesiology Class III) had major postoperative morbidity (P = 0.020) and mortality (P = 0.005), especially if they scored low (< 70) on the preoperative Karnofsky Rating Scale (P = 0.010). The risk of postoperative morbidity was higher when the maximum diameter of the tumor was > 5 cm (P = 0.031) 6).


Arienta et al. studied 46 cases of intracranial meningioma in patients over 70 years of age, 34 patients were operated on while 12 patients were not, although both groups were subjected to long term follow-up. The operative mortality rate was 12%, a rate which increased to 20% at 3 months follow-up. Various unfavourable prognostic factors were taken into consideration, the most significant of which were: poor overall clinical condition, peritumoral oedema, the presence of diabetes mellitus and the duration of surgery. A scored grading system was created to standardize surgical indications in elderly patients with cerebral meningioma. An analysis of the grading system, when applied to patients submitted to surgery, showed that the decreased patients within 3 months of surgery had a score which varied from 7 to 12, with a mean score of 10. The surviving patients had a score averaging from 10 to 16 with a mean of 13. The patients with the lowest scores (7-9) had a 100% mortality rate while those in the upper ranges (13-16) demonstrated a mortality rate of 0%. Among the conservatively treated patients the worst outcome was seen in patients with a grading equal to or less than 12 7).


Papo in 1983 stated that after 65, postoperative complications and mortality increased steeply: of the patients over 65 in whom the growth was excised 55% died. The radical surgery of intracranial meningiomas in geriatric patients over 65 still remains a tremendous challenge despite all the advances in operative technique, neuro anesthesia, and intensive care. On these grounds, in such patients surgical indications should be carefully evaluated 8).

References

1)

Rautalin I, Niemelä M, Korja M. Is surgery justified for 80-year-old or older intracranial meningioma patients? A systematic review. Neurosurg Rev. 2020 Apr 4. doi: 10.1007/s10143-020-01282-7. [Epub ahead of print] PubMed PMID: 32248508.
2)

Ikawa F, Kinoshita Y, Takeda M, Saito T, Yamaguchi S, Yamasaki F, Iida K, Sugiyama K, Arita K, Kurisu K. Review of Current Evidence Regarding Surgery in Elderly Patients with Meningioma. Neurol Med Chir (Tokyo). 2017 Oct 15;57(10):521-533. doi: 10.2176/nmc.ra.2017-0011. Epub 2017 Aug 15. Review. PubMed PMID: 28819091; PubMed Central PMCID: PMC5638779.
3)

Troya Castilla M, Chocrón Gonzalez Y, Márquez Rivas FJ. [Complications and outcomes in the elderly with intracranial meningioma]. Rev Esp Geriatr Gerontol. 2016 Mar-Apr;51(2):82-7. doi: 10.1016/j.regg.2015.06.004. Epub 2015 Jul 17. Spanish. PubMed PMID: 26195279.
4)

Caroli M, Locatelli M, Prada F, Beretta F, Martinelli-Boneschi F, Campanella R, Arienta C. Surgery for intracranial meningiomas in the elderly: a clinical-radiological grading system as a predictor of outcome. J Neurosurg. 2005 Feb;102(2):290-4. PubMed PMID: 15739557.
5)

Buhl R, Hasan A, Behnke A, Mehdorn HM. Results in the operative treatment of elderly patients with intracranial meningioma. Neurosurg Rev. 2000 Mar;23(1):25-9. PubMed PMID: 10809483.
6)

Mastronardi L, Ferrante L, Qasho R, Ferrari V, Tatarelli R, Fortuna A. Intracranial meningiomas in the 9th decade of life: a retrospective study of 17 surgical cases. Neurosurgery. 1995 Feb;36(2):270-4. PubMed PMID: 7731506.
7)

Arienta C, Caroli M, Crotti F, Villani R. Treatment of intracranial meningiomas in patients over 70 years old. Acta Neurochir (Wien). 1990;107(1-2):47-55. PubMed PMID: 2096608.
8)

Papo I. Intracranial meningiomas in the elderly in the CT scan era. Acta Neurochir (Wien). 1983;67(3-4):195-204. PubMed PMID: 6846076.

Intracranial arachnoid cyst clinical features

Intracranial arachnoid cyst clinical features

Most of the intracranial arachnoid cysts are asymptomatic and are detected as incidental findings on Computed Tomography or Magnetic Resonance Imaging of the head carried out for other reasons.

Those that become symptomatic usually do so in early childhood 1).

The presentation varies with the location of the cyst, and oftentimes appear mild considering the large size of some.

Typical presentations include:

1. symptoms of intracranial hypertension (elevated ICP): H/A, nausea/vomitinglethargy

2. seizures

3. sudden deterioration:

a) due to hemorrhage (into a cyst or subdural compartment): middle fossa cysts are notorious for hemorrhage due to tearing of bridging veins. Some sports organizations do not allow participation in contact sports for these patients

b) due to rupture of the cyst

4. as a focal protrusion of the skull

5. with focal signs/symptoms of a space-occupying lesion

6. incidental finding discovered during evaluation for an unrelated condition

7. suprasellar arachnoid cysts may additionally present with:

a) hydrocephalus (probably due to compression of the third ventricle)

b) endocrine symptoms: occurs in up to 60%. Includes precocious puberty

c) head bobbing (the so-called “bobble-head doll syndrome”): considered suggestive of suprasellar cysts, but occurs in as few as 10%

d) visual impairment.

Cognitive dysfunction

The patients with arachnoid cysts presented with cognitive dysfunction compared to the normal population which improved after surgical decompression. Arachnoid cysts should not be considered asymptomatic unless thoroughly evaluated with clinical and neuropsychological workup 2).

Epilepsy

Sudden deterioration

Due to hemorrhage into cyst or subdural hematoma.see Subdural hematoma and arachnoid cyst

Due to cyst rupture.

There are multiple case reports of arachnoid cysts becoming symptomatic with hemorrhagic complications following head trauma. In such cases, the bleeding is often confined to the side ipsilateral to the arachnoid cyst. Occurrence of contralateral subdural hematomas in patients with temporal fossa arachnoid cysts has rarely been observed and is reported less frequently in the medical literature 3).


Usually they remain stable in size and are asymptomatic, however, a few cysts contain remnants of the choroid plexus or arachnoid granulations leading to secretion of CSF resulting in an increase in size with time. These cases may present with features of compression of adjacent structures (Kallmann syndrome, precocious puberty, bitemporal hemianopia in suprasellar lesions, cranial nerve palsies etc.) and/or raised intracranial pressure due to their large size or hemorrhage. Spontaneous hemorrhage is supposed to be due to a minor trauma with rupture of intracystic or bridging vessels 4) 5).

References

1)

Harsh GR 4th, Edwards MS, Wilson CB. Intracranial arachnoid cysts in children. J Neurosurg. 1986 Jun;64(6):835-42. PubMed PMID: 3701434.
2)

Agopian-Dahlenmark L, Mathiesen T, Bergendal Å. Cognitive dysfunction and subjective symptoms in patients with arachnoid cyst before and after surgery. Acta Neurochir (Wien). 2020 Jan 20. doi: 10.1007/s00701-020-04225-9. [Epub ahead of print] Erratum in: Acta Neurochir (Wien). 2020 Jan 29;:. PubMed PMID: 31960141.
3)

Pillai P, Menon SK, Manjooran RP, Kariyattil R, Pillai AB, Panikar D. Temporal fossa arachnoid cyst presenting with bilateral subdural hematoma following trauma: two case reports. J Med Case Rep. 2009 Feb 9;3:53. doi: 10.1186/1752-1947-3-53. PubMed PMID: 19203370; PubMed Central PMCID: PMC2646743.
4)

Ide C, Coene BD, Gilliard C, et al. Hemorrhagic arachnoid cyst with third nerve paresis: CT and MR findings. Am J Neuroradiol. 1997;18:1407–10.
5)

Gunduz B, Yassa MIK, Ofluoglu E, et al. Two cases of arachnoid cyst complicated by spontaneous intracystic hemorrhage. Neurology India. 2010;58:312–15.
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