Visual outcomes and headache following interventions for idiopathic intracranial hypertension

The optimal surgical management for medically refractory idiopathic intracranial hypertension (IIH) is not well established. Few studies have directly compared headache and visual outcomes across treatment modalities. A systematic analysis of case series was conducted to compare therapeutic efficacies among currently available interventions. The electronic databases from EMBASE (1980-17 September 2013), Medline (1980-17 September 2013), Cochrane databases, and references of review articles was searched. All publications reporting headache and visual outcomes following intervention for IIH were included. A total of 457 manuscripts were selected and full text analysis produced 30 studies with extractable data. All studies constituted Class III evidence. Overall, 332 patients treated by optic nerve sheath fenestration (ONSF), 287 by lumboperitoneal shunt (LPS), 61 by ventriculoperitoneal shunt (VPS), and 88 by dural venous sinus stenting, were identified. Visual acuity improved in 49.3%, 56.6%, 67.2% and 84.6% of patients following VPS, LPS, ONSF, and stent placements, respectively. Resolution of papilledema was noted in 59.9% to 97.1%. Postoperative headache improved in 36.5%, 62.5%, 75.2%, and 82.9% of patients treated with ONSF, VPS, LPS, and stenting, respectively. Shunt revision was more frequent for LPS compared to VPS (46% versus 36%; p<0.2). Among the LPS revisions, 87.5% occurred within the first 12 months following initial surgery. Our pooled analysis indicated an overall similar improvement in visual outcomes across treatment modalities, and a modest improvement in headache following cerebrospinal fluid shunting and endovascular stent placement. Based on currently available literature, there is insufficient evidence to recommend or reject any treatments modalities for IIH.