A systematic review of surgical treatments of IIH

A systematic review is the questioning of the large databases of the medical literature to analyze all the published articles on a specific subject.

This review compares the results of the three main surgeries to treat IIH patients who have failed medical therapy. The three main procedures to treat IIH are: shunting of the cerebrospinal fluid (shunting), optic nerve sheath fenestration (ONSF) and venous sinus stenting (VSS). Additionally, the study also included a few cases of morbidly obese patients who underwent bariatric surgery to lose weight. This review included 2302 patients.

The authors analyzed the results of these surgeries on various symptoms and examination findings of IIH such as papilledema, visual field deterioration, and headaches. They also analyzed the rate of severe complications and the rate of recurrence (deterioration after initial improvement). The results are summarized in the table below.

Papilledema improved Visual field improved Headaches improved Severe complications Recurrences
ONSF 90.5% 65.2% 49.3% 2.2% 9.4%
Shunting 78.9% 66.8% 69.8% 9.4% 39.1%
VSS 87.1% 72.7% 72.1% 2.3% 13.1%

For the 4th procedure, bariatric surgery, few patients had ophthalmologic examinations so the statistics are not reliable, but most patients (42/45) had improvement of their headaches.

The authors concluded that shunting is the most frequent procedure to treat IIH symptoms,, provides good improvement of headaches and visual signs, but has high failure and complication rates. ONSF is very effective on visual symptoms and has few severe complications but is not very effective in treating headaches. VSS had the best results in improving the visual symptoms and headaches and had less recurrences than shunting. However, some complications of VSS were very severe and the authors proposed that new devices were needed to perform VSS more safely. Finally, they propose that “VSS should be the first-line surgical treatment in patients with medically refractory IIH”.

Kalyvas et al.: A systematic review of surgical treatments of idiopathic intracranial hypertension (IIH). Published in 2020. https://doi.org/10.1007/s10143-020-01288-1