Case Report
Patient-Controlled Intracranial Pressure for Managing Idiopathic Intracranial Hypertension Melissa C. Werndle1
Elizabeth Newling-Ward2
Marios C. Papadopoulos1
1 Department of Neurosurgery, St. George’s University of London,
London, United Kingdom 2 St. Mary’s University College, Twickenham, School of Sport, Health and Applied Science, London, United Kingdom
Address for correspondence Marios C. Papadopoulos, MD FRCS(SN), Department of Neurosurgery, St. George’s Hospital, Atkinson Morley Wing Blackshaw Road, London SW17 0QT, United Kingdom (e-mail: [email protected]).
J Neurol Surg A 2015;76:76–78.
Abstract Keywords
► benign intracranial hypertension ► decompressive craniectomy ► ventriculoperitoneal shunt
Idiopathic intracranial hypertension is a difficult condition to manage. We present a novel treatment that substantially improved the headaches and reduced admissions and shunt revision surgery in a patient. We inserted a ventriculoperitoneal shunt, performed subtemporal craniectomies, and instructed our patient to apply different sized headbands to allow her to anticipate and control her own intracranial pressure: a tight headband for low-pressure headaches; no band for high-pressure headaches. Magnetic resonance imaging and intracranial pressure monitoring revealed this was not a placebo effect.
Introduction Idiopathic intracranial hypertension (IIH) is a poorly understood condition that primarily affects overweight young women.1 If untreated, the elevated intracranial pressure (ICP) damages the optic discs causing visual impairment. Some patients respond to acetazolamide that reduces the formation of cerebrospinal fluid (CSF), but most have CSF diversion by lumboperitoneal or ventriculoperitoneal (VP) shunt. Lumboperitoneal shunts often migrate or block.2 VP shunts are awkward to insert into the small lateral ventricles and often poorly control the elevated ICP because the slit ventricles intermittently cause shunt blockage.3 IIH patients typically have many shunt revisions. Programmable shunts were introduced to address these issues. Theoretical advantages include easily adjustable drainage thresholds to allow for differences between patients. Currently there is no good evidence in favor of programmable versus fixed pressure valves for hydrocephalus in general.4 Some neurosurgeons advocate subtemporal craniectomies. These eliminate the risk of visual loss, resolve the slit ventricle syndrome (thus allowing previously obstructed shunts to work), and decrease the number of hospital admissions.5 However, the craniectomies cause low-ICP headaches
received May 25, 2013 accepted after revision January 16, 2014 published online May 12, 2014
that can be disabling. Programmable gravitational shunts, which have a higher valve opening pressure in the upright compared with the supine position, might reduce low-ICP headaches, but they have not been evaluated in IIH. An emerging treatment option is venous stenting, from the observation of transverse sinus stenosis in IIH patients.6 A systematic review showed symptomatic improvement after sagittal sinus stenting, but with only short-term follow up and significant complications of restenosis, vessel perforation, stent migration, and hemorrhage from anticoagulation. More than 90% of patients with IIH who undergo bariatric surgery have symptom resolution.7 This is only suitable in very obese patients, whose vision is not at immediate risk because the weight loss occurs over time. In the National Health Service, eligibility for bariatric surgery requires a body mass index > 35, and, even then, waiting lists are long. Therefore, IIH remains a major management problem. We present a simple way of managing IIH that allowed our patient to anticipate and control her own ICP.
Case Report A 28-year-old woman attended outpatients with headaches and blurred vision. She was known to have IIH and had
© 2015 Georg Thieme Verlag KG Stuttgart · New York
DOI http://dx.doi.org/ 10.1055/s-0034-1373662. ISSN 2193-6315.
This document was downloaded for personal use only. Unauthorized distribution is strictly prohibited.
76
Patient-Controlled Intracranial Pressure for IIH
77
to 10/10 in severity, but afterward the headaches occurred once or twice a day with maximum 5/10 severity. During her last admission, we investigated whether the headband controls the headache by compressing the brain and altering the ICP. By MR imaging, applying a tight headband caused the brain surface to become concave at the craniectomy sites (►Fig. 1B), indicating brain compression. We monitored ICP for 24 hours by inserting a Codman pressure probe into the right frontal lobe. The data indicate that applying the headband raises ICP by 5 to 8 mm Hg when lying or sitting (►Fig. 1C).
Discussion In our patient, subtemporal craniectomies and headbanding improved the headaches and resulted in no further emergency scans or admissions. This is unlikely to be placebo because MR imaging revealed a change in brain shape, and ICP monitoring revealed a consistent increase in ICP with the headbanding. The concept of headbanding to reduce disabling orthostatic headaches of intracranial hypotension is simple. We suggest that a tight headband compresses each temporal lobe by 3 mm, which causes a sufficient rise in ICP over the threshold to ameliorate low-pressure symptoms. Headbanding might also treat headaches through mechanisms not studied here, such as cushioning high-amplitude ICP waves. Theoretical adverse effects of headbanding include reduced brain microcirculation venous congestion, and epilepsy. We detected no complications of headbanding in our patient to date, and an MR brain after 5 months of using the headbands revealed no evidence of injury at the craniectomy sites (►Fig. 2). There is a paucity of literature addressing any adverse effects of brain compression through cranial defects in general, with only theoretical complications and one case
Fig. 1 Headbanding for idiopathic intracranial hypertension. (A) The patient wearing a headband she designed herself. (B) Magnetic resonance scans without () versus with (þ) headband while lying flat. Brain surface contour at craniectomy site outlined. (C) Intracranial pressure (ICP) measurements without () versus with (þ) headband. Top section shows representative ICP traces; bottom section shows data summary when lying flat and sitting up. Each dot represents ICP averaged over 10 minutes; lines show means. p < 0.05. Journal of Neurological Surgery—Part A
Vol. 76
No. A1/2015
This document was downloaded for personal use only. Unauthorized distribution is strictly prohibited.
previously been treated with acetazolamide and multiple shunt revisions elsewhere. On examination, she had reduced visual acuities and bilateral papilledema. In addition, there was an exposed shunt reservoir that eroded through the scalp. We changed her shunt system as an emergency. Over the next year, she was seen five times with headaches and had five scans with one shunt revision including insertion of a programmable shunt valve. A year after her first outpatient visit she developed slit ventricle syndrome with intermittently high ICP, reduced visual acuities (6/36 left, 6/9 right), and papilledema. Intracranial magnetic resonance (MR) venogram was normal. We treated this with subtemporal craniectomies. Her visual acuities improved to 6/6 left and 6/6 right and the papilledema resolved, but she developed low-ICP headaches for which she was seen in outpatients once, and admitted once, and which were uncontrolled by reprogramming the shunt valve. We decided to use a novel approach to manage these headaches by instructing her to wear headbands of different diameters. Such headbands are made of elastic material and are easily obtainable from clothing shops. If she had a severe low-ICP headache, she wore a tight headband, for milder lowICP headache a looser headband, and for high-ICP headaches no headband. With time she learned to anticipate the headache, and she would apply the appropriate headband before the onset. For example, she applied a tight headband before sitting up from lying flat. She made her own headbands using different designs to match her clothes (►Fig. 1A). It has been 10 months since the craniectomies and use of headbands. The ability to anticipate and control her own ICP has reduced her headaches substantially. In the 4 years before the craniectomies and headbanding, she had 22 events (shunt revisions, inpatient admissions, emergency outpatient visits) versus no events in the 10 months after. Before the craniectomies and headbanding the headaches were constant and up
Werndle et al.
Patient-Controlled Intracranial Pressure for IIH
Werndle et al. positive psychological effect that distracts from the negative effect of the headache. We conclude that headbanding might be rarely indicated in patients with IIH who have intractable headaches despite VP shunting and subtemporal craniectomies.
References 1 Wall M. Idiopathic intracranial hypertension: mechanisms of
2 3 4
5
Fig. 2 Magnetic resonance (MR) imaging of the craniectomy sites. MR fluid-attenuated inversion recovery sequence axial cut through the subtemporal craniectomies (outlined) does not show any evidence of cortical damage after 5 months of headbanding.
report of trauma following a fall.8,9 Therefore, headbanding is likely to be safe. The main advantage of headbanding is that it allows patients to anticipate and control their ICP, thereby taking charge of their symptoms. This is analogous to patientcontrolled analgesia for pain management. The headband is also a fashion accessory; spending time to choose the color and pattern of the headband to match clothes may create a
Journal of Neurological Surgery—Part A
Vol. 76
No. A1/2015
6
7
8
9
visual loss and disease management. Semin Neurol 2000;20(1): 89–95 Garton HJ. Cerebrospinal fluid diversion procedures. J Neuroophthalmol 2004;24(2):146–155 Rekate HL. Shunt-related headaches: the slit ventricle syndromes. Childs Nerv Syst 2008;24(4):423–430 Ringel F, Schramm J, Meyer B. Comparison of programmable shunt valves vs standard valves for communicating hydrocephalus of adults: a retrospective analysis of 407 patients. Surg Neurol 2005; 63(1):36–41; discussion 41 Buxton N, Punt J. Subtemporal decompression: the treatment of noncompliant ventricle syndrome. Neurosurgery 1999;44(3): 513–518; discussion 518–519 Arac A, Lee M, Steinberg GK, Marcellus M, Marks MP. Efficacy of endovascular stenting in dural venous sinus stenosis for the treatment of idiopathic intracranial hypertension. Neurosurg Focus 2009;27(5):E14 Fridley J, Foroozan R, Sherman V, Brandt ML, Yoshor D. Bariatric surgery for the treatment of idiopathic intracranial hypertension. J Neurosurg 2011;114(1):34–39 Boström S, Bobinski L, Zsigmond P, Theodorsson A. Improved brain protection at decompressive craniectomy—a new method using Palacos R-40 (methylmethacrylate). Acta Neurochir (Wien) 2005; 147(3):279–281; discussion 281 Honeybul S. Decompressive craniectomy: a new complication. J Clin Neurosci 2009;16(5):727–729
This document was downloaded for personal use only. Unauthorized distribution is strictly prohibited.
78
Copyright of Journal of Neurological Surgery. Part A. Central European Neurosurgery is the property of Georg Thieme Verlag Stuttgart and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
Patient-Controlled Intracranial Pressure for Managing Idiopathic Intracranial Hypertension Melissa C. Werndle1
Elizabeth Newling-Ward2
Marios C. Papadopoulos1
1 Department of Neurosurgery, St. George’s University of London,
London, United Kingdom 2 St. Mary’s University College, Twickenham, School of Sport, Health and Applied Science, London, United Kingdom
Address for correspondence Marios C. Papadopoulos, MD FRCS(SN), Department of Neurosurgery, St. George’s Hospital, Atkinson Morley Wing Blackshaw Road, London SW17 0QT, United Kingdom (e-mail: [email protected]).
J Neurol Surg A 2015;76:76–78.
Abstract Keywords
► benign intracranial hypertension ► decompressive craniectomy ► ventriculoperitoneal shunt
Idiopathic intracranial hypertension is a difficult condition to manage. We present a novel treatment that substantially improved the headaches and reduced admissions and shunt revision surgery in a patient. We inserted a ventriculoperitoneal shunt, performed subtemporal craniectomies, and instructed our patient to apply different sized headbands to allow her to anticipate and control her own intracranial pressure: a tight headband for low-pressure headaches; no band for high-pressure headaches. Magnetic resonance imaging and intracranial pressure monitoring revealed this was not a placebo effect.
Introduction Idiopathic intracranial hypertension (IIH) is a poorly understood condition that primarily affects overweight young women.1 If untreated, the elevated intracranial pressure (ICP) damages the optic discs causing visual impairment. Some patients respond to acetazolamide that reduces the formation of cerebrospinal fluid (CSF), but most have CSF diversion by lumboperitoneal or ventriculoperitoneal (VP) shunt. Lumboperitoneal shunts often migrate or block.2 VP shunts are awkward to insert into the small lateral ventricles and often poorly control the elevated ICP because the slit ventricles intermittently cause shunt blockage.3 IIH patients typically have many shunt revisions. Programmable shunts were introduced to address these issues. Theoretical advantages include easily adjustable drainage thresholds to allow for differences between patients. Currently there is no good evidence in favor of programmable versus fixed pressure valves for hydrocephalus in general.4 Some neurosurgeons advocate subtemporal craniectomies. These eliminate the risk of visual loss, resolve the slit ventricle syndrome (thus allowing previously obstructed shunts to work), and decrease the number of hospital admissions.5 However, the craniectomies cause low-ICP headaches
received May 25, 2013 accepted after revision January 16, 2014 published online May 12, 2014
that can be disabling. Programmable gravitational shunts, which have a higher valve opening pressure in the upright compared with the supine position, might reduce low-ICP headaches, but they have not been evaluated in IIH. An emerging treatment option is venous stenting, from the observation of transverse sinus stenosis in IIH patients.6 A systematic review showed symptomatic improvement after sagittal sinus stenting, but with only short-term follow up and significant complications of restenosis, vessel perforation, stent migration, and hemorrhage from anticoagulation. More than 90% of patients with IIH who undergo bariatric surgery have symptom resolution.7 This is only suitable in very obese patients, whose vision is not at immediate risk because the weight loss occurs over time. In the National Health Service, eligibility for bariatric surgery requires a body mass index > 35, and, even then, waiting lists are long. Therefore, IIH remains a major management problem. We present a simple way of managing IIH that allowed our patient to anticipate and control her own ICP.
Case Report A 28-year-old woman attended outpatients with headaches and blurred vision. She was known to have IIH and had
© 2015 Georg Thieme Verlag KG Stuttgart · New York
DOI http://dx.doi.org/ 10.1055/s-0034-1373662. ISSN 2193-6315.
This document was downloaded for personal use only. Unauthorized distribution is strictly prohibited.
76
Patient-Controlled Intracranial Pressure for IIH
77
to 10/10 in severity, but afterward the headaches occurred once or twice a day with maximum 5/10 severity. During her last admission, we investigated whether the headband controls the headache by compressing the brain and altering the ICP. By MR imaging, applying a tight headband caused the brain surface to become concave at the craniectomy sites (►Fig. 1B), indicating brain compression. We monitored ICP for 24 hours by inserting a Codman pressure probe into the right frontal lobe. The data indicate that applying the headband raises ICP by 5 to 8 mm Hg when lying or sitting (►Fig. 1C).
Discussion In our patient, subtemporal craniectomies and headbanding improved the headaches and resulted in no further emergency scans or admissions. This is unlikely to be placebo because MR imaging revealed a change in brain shape, and ICP monitoring revealed a consistent increase in ICP with the headbanding. The concept of headbanding to reduce disabling orthostatic headaches of intracranial hypotension is simple. We suggest that a tight headband compresses each temporal lobe by 3 mm, which causes a sufficient rise in ICP over the threshold to ameliorate low-pressure symptoms. Headbanding might also treat headaches through mechanisms not studied here, such as cushioning high-amplitude ICP waves. Theoretical adverse effects of headbanding include reduced brain microcirculation venous congestion, and epilepsy. We detected no complications of headbanding in our patient to date, and an MR brain after 5 months of using the headbands revealed no evidence of injury at the craniectomy sites (►Fig. 2). There is a paucity of literature addressing any adverse effects of brain compression through cranial defects in general, with only theoretical complications and one case
Fig. 1 Headbanding for idiopathic intracranial hypertension. (A) The patient wearing a headband she designed herself. (B) Magnetic resonance scans without () versus with (þ) headband while lying flat. Brain surface contour at craniectomy site outlined. (C) Intracranial pressure (ICP) measurements without () versus with (þ) headband. Top section shows representative ICP traces; bottom section shows data summary when lying flat and sitting up. Each dot represents ICP averaged over 10 minutes; lines show means. p < 0.05. Journal of Neurological Surgery—Part A
Vol. 76
No. A1/2015
This document was downloaded for personal use only. Unauthorized distribution is strictly prohibited.
previously been treated with acetazolamide and multiple shunt revisions elsewhere. On examination, she had reduced visual acuities and bilateral papilledema. In addition, there was an exposed shunt reservoir that eroded through the scalp. We changed her shunt system as an emergency. Over the next year, she was seen five times with headaches and had five scans with one shunt revision including insertion of a programmable shunt valve. A year after her first outpatient visit she developed slit ventricle syndrome with intermittently high ICP, reduced visual acuities (6/36 left, 6/9 right), and papilledema. Intracranial magnetic resonance (MR) venogram was normal. We treated this with subtemporal craniectomies. Her visual acuities improved to 6/6 left and 6/6 right and the papilledema resolved, but she developed low-ICP headaches for which she was seen in outpatients once, and admitted once, and which were uncontrolled by reprogramming the shunt valve. We decided to use a novel approach to manage these headaches by instructing her to wear headbands of different diameters. Such headbands are made of elastic material and are easily obtainable from clothing shops. If she had a severe low-ICP headache, she wore a tight headband, for milder lowICP headache a looser headband, and for high-ICP headaches no headband. With time she learned to anticipate the headache, and she would apply the appropriate headband before the onset. For example, she applied a tight headband before sitting up from lying flat. She made her own headbands using different designs to match her clothes (►Fig. 1A). It has been 10 months since the craniectomies and use of headbands. The ability to anticipate and control her own ICP has reduced her headaches substantially. In the 4 years before the craniectomies and headbanding, she had 22 events (shunt revisions, inpatient admissions, emergency outpatient visits) versus no events in the 10 months after. Before the craniectomies and headbanding the headaches were constant and up
Werndle et al.
Patient-Controlled Intracranial Pressure for IIH
Werndle et al. positive psychological effect that distracts from the negative effect of the headache. We conclude that headbanding might be rarely indicated in patients with IIH who have intractable headaches despite VP shunting and subtemporal craniectomies.
References 1 Wall M. Idiopathic intracranial hypertension: mechanisms of
2 3 4
5
Fig. 2 Magnetic resonance (MR) imaging of the craniectomy sites. MR fluid-attenuated inversion recovery sequence axial cut through the subtemporal craniectomies (outlined) does not show any evidence of cortical damage after 5 months of headbanding.
report of trauma following a fall.8,9 Therefore, headbanding is likely to be safe. The main advantage of headbanding is that it allows patients to anticipate and control their ICP, thereby taking charge of their symptoms. This is analogous to patientcontrolled analgesia for pain management. The headband is also a fashion accessory; spending time to choose the color and pattern of the headband to match clothes may create a
Journal of Neurological Surgery—Part A
Vol. 76
No. A1/2015
6
7
8
9
visual loss and disease management. Semin Neurol 2000;20(1): 89–95 Garton HJ. Cerebrospinal fluid diversion procedures. J Neuroophthalmol 2004;24(2):146–155 Rekate HL. Shunt-related headaches: the slit ventricle syndromes. Childs Nerv Syst 2008;24(4):423–430 Ringel F, Schramm J, Meyer B. Comparison of programmable shunt valves vs standard valves for communicating hydrocephalus of adults: a retrospective analysis of 407 patients. Surg Neurol 2005; 63(1):36–41; discussion 41 Buxton N, Punt J. Subtemporal decompression: the treatment of noncompliant ventricle syndrome. Neurosurgery 1999;44(3): 513–518; discussion 518–519 Arac A, Lee M, Steinberg GK, Marcellus M, Marks MP. Efficacy of endovascular stenting in dural venous sinus stenosis for the treatment of idiopathic intracranial hypertension. Neurosurg Focus 2009;27(5):E14 Fridley J, Foroozan R, Sherman V, Brandt ML, Yoshor D. Bariatric surgery for the treatment of idiopathic intracranial hypertension. J Neurosurg 2011;114(1):34–39 Boström S, Bobinski L, Zsigmond P, Theodorsson A. Improved brain protection at decompressive craniectomy—a new method using Palacos R-40 (methylmethacrylate). Acta Neurochir (Wien) 2005; 147(3):279–281; discussion 281 Honeybul S. Decompressive craniectomy: a new complication. J Clin Neurosci 2009;16(5):727–729
This document was downloaded for personal use only. Unauthorized distribution is strictly prohibited.
78
Copyright of Journal of Neurological Surgery. Part A. Central European Neurosurgery is the property of Georg Thieme Verlag Stuttgart and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
