Gastric surgery for pseudotumor cerebri associated with severe obesity.
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OBJECTIVE: To study the efficacy of gastric surgery-induced weight loss for the treatment of pseudotumor cerebri (PTC). SUMMARY BACKGROUND DATA: Pseudotumor cerebri (also called idiopathic intracranial hypertension), a known complication of severe obesity, is associated with severe headaches, pulsatile tinnitus, elevated cerebrospinal fluid (CSF) pressures, and normal brain imaging. The authors have found in previous clinical and animal studies that PTC in obese persons is probably secondary to a chronic increase in intraabdominal pressure leading to increased intrathoracic pressure. CSF-peritoneal shunts have a high failure rate, probably because they involve shunting from a high-pressure system to another high-pressure zone. In an earlier study of gastric bypass surgery in eight patients, CSF pressure decreased from 353+/-35 to 168+/-12 mm H2O at 34+/-8 months after surgery, with resolution of headaches in all. METHODS: Twenty-four severely obese women underwent bariatric surgery--23 gastric bypasses and one laparoscopic adjustable gastric banding--62+/-52 months ago for the control of severe obesity associated with PTC. CSF pressures were 324+/-83 mm H2O. Additional PTC central nervous system and cranial nerve problems included peripheral visual field loss, trigeminal neuralgia, recurrent Bell's palsy, and pulsatile tinnitus. Spontaneous CSF rhinorrhea occurred in one patient, and hemiplegia with homonymous hemianopsia developed as a complication of ventriculoperitoneal shunt placement in another. There were two occluded lumboperitoneal shunts and another functional but ineffective lumboperitoneal shunt. Additional obesity comorbidity in these patients included degenerative joint disease, gastroesophageal reflux disease, hypertension, urinary stress incontinence, sleep apnea, obesity hypoventilation, and type II diabetes mellitus. RESULTS: At 1 year after bariatric surgery, 19 patients lost an average of 45+/-12 kg, which was 71+/-18% of their excess weight. Their body mass index and percentage of ideal body weight had fallen to 30+/-5 kg/m2 and 133+/-22%, respectively. In four patients, less than 1 year had elapsed since surgery. Five patients were lost to follow-up. Surgically induced weight loss was associated with resolution of headache and pulsatile tinnitus in all but one patient within 4 months of the procedure. The cranial nerve dysfunctions resolved in all patients. The patient with CSF rhinorrhea had resolution within 4 weeks of gastric bypass. Of the 19 patients not lost to follow-up, 2 regained weight, with recurrence of headache and pulsatile tinnitus. Additional resolved associated comorbidities were 6/14 degenerative joint disease, 9/10 gastroesophageal reflux disorder, 2/6 hypertension, and all with sleep apnea, hypoventilation, type II diabetes mellitus, and urinary incontinence. CONCLUSIONS: Bariatric surgery is the long-term procedure of choice for severely obese patients with PTC and is shown to have a much higher rate of success than CSF-peritoneal shunting reported in the literature, as well as providing resolution of additional obesity comorbidity. Increased intraabdominal pressure associated with central obesity is the probable etiology of PTC, a condition that should no longer be considered idiopathic. (+info)
Unilateral papilledema after bone marrow transplantation.
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We describe a patient who developed unilateral papilledema after allogeneic BMT. This is a rare manifestation of pseudotumor cerebri, which results from elevated intracranial pressure caused by cyclosporin A. The papilledema usually involves the fundi bilaterally, but unilateral involvement has been described. Congenital anomalies, compression and adhesion of the optic nerve sheath are its causes. In this patient, the right optic fundus was spared although leukemic infiltration was present on this side and high-dose irradiation (72 Gy) was given. Although papilledema is a sensitive marker of elevated intracranial pressure, this sign may be masked by constriction of the optic sheath in patients who suffer from leukemic infiltration of the central nervous system and receive high doses of cranial irradiation. (+info)
Computer tomography of the brain in Hamilton.
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Computer tomography, a new noninvasive, rapid and easily tolerated technique of brain examination, has been evaluated by analysis of 1000 examinations. It is much more sensitive than conventional radiographic techniques and can resolve soft-tissue structures that differ only slightly in density. It also provides direct visualization of the ventricular system. The range of clinical applications is wide; it is especially useful in differentiating intracerebral hemorrhage from infarction, and in demonstrating many brain tumours, particularly supratentorial, though enhancement with a water-soluble contrast medium injected intravenously is often necessary. (+info)
Non-invasive screening for surgical intracranial lesions.
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The value and reliability of the combined results of skull radiographs, electroencephalography, echoencephalography, isotope angiography, and brain scanning in 147 patients suspected of having an intracranial space occupying lesions are analysed. The overall accuracy of the technique was 79%. No false negatives were found. The advantages of adopting the system proposed by the authors in everyday clinical work is discussed. (+info)
Idiopathic intracranial hypertension; incidence, presenting features and outcome in Northern Ireland (1991-1995).
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OBJECTIVES: To determine the age and sex specific incidence rates, presenting features, and visual outcome of idiopathic intracranial hypertension in Northern Ireland. METHODS: A case-note review of all patients with idiopathic intracranial hypertension, diagnosed at the Royal Victoria Hospital, Belfast between 1991 and 1995. RESULTS: Forty-two patients were identified corresponding to an average annual incidence rate per 100,000 persons of 0.5 for the total and 0.9 for the female population. The commonest presenting symptoms were headache (84%), transient visual obscurations (61%) and sustained visual loss (34%). Impaired Snellen visual acuity and visual field loss were documented in 21% and 62% of patients respectively at presentation, and in 24% and 39% at last follow-up. One patient suffered deterioration in visual functioning sufficient to interfere with normal daily activities. CONCLUSIONS: The age and sex specific incidence rates of IIH in Northern Ireland are lower than have been reported in previous population-based series. Disabling visual loss occurs in a small number of patients despite all interventions. (+info)
A 39-year-old woman was admitted with complaints of headache and nasal discharge on the left for 3 months which was later on proved to be cerebrospinal fluid (CSF). Neurological examination found no abnormalities except bilateral papilledema. Neuroimaging demonstrated enlargement of the lamina cribrosa foramina through which the olfactory nerves pass, as well as empty sella and cerebral cortical atrophy. Bone mineral densitometry showed osteopenia. CSF Ca++ and blood parathyroid hormone levels were elevated. CSF pressure was 280 mmH2O. Bilateral frontal craniotomy was performed to expose the anterior fossa. Foraminal enlargement at the lamina cribrosa was confirmed, and islands of extra-osseous calcifications on the arachnoid membrane were identified. The base of the anterior fossa was repaired intradurally with fascial graft and fibrin glue on both sides. No CSF leakage was noted at 1-year follow up. Spontaneous CSF leakage probably resulted from enlargement of the foramina at the lamina cribrosa due to Ca++ mobilization from bones and pseudotumor cerebri not to the extent of hydrocephalus caused by poor CSF absorption at the arachnoid granulations obliterated by extra-osseous calcareous accumulation. (+info)
Recurrent pseudotumor cerebri in systemic lupus erythematosus: a case report.
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Pseudotumor cerebri is an uncommon manifestation of neuropsychiatric systemic lupus erythematosus (SLE), and is characterized by an elevated intracranial pressure, papilledema with occasional abducens nerve paresis, absence of a space-occupying lesion or ventricular enlargement, and normal cerebrospinal fluid chemical and hematological constituents. Pseudotumor cerebri has been reported in a few sporadic cases in patients with systemic lupus erythematosus. However, the recurrent pseudotumor cerebri in patients with systemic lupus erythematosus which has been rarely reported, has not been reported in Korea. We experienced a 30-yr-old female patient with SLE who was presented with second attack of severe intractable headache. She was diagnosed pseudotumor cerebri twice and successfully treated with corticosteroid. Headache is the common symptom in patients with neuropsychiatric SLE and attributable to various causes. We suggest that it is important to define the cause of headache in patients with SLE and pseudotumor cerebri should be included in the spectrum of clinical manifestations during the course of SLE as a cause of headache. (+info)
Cerebral venous sinus thrombosis: a clinical study of 23 cases.
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OBJECTIVE: To describe the etiologies, clinical features and diagnosis of cerebral venous sinus thrombosis. METHODS: We reviewed the records of 23 patients admitted with a documented diagnosis of cerebral venous sinus thrombosis from 1991 through 1999 in the Beijing Tiantan Hospital. RESULTS: Infection was the major condition associated with cerebral venous sinus thrombosis. Pseudotumor cerebri syndrome was the most common manifestation, while hemiplegia, seizure and unconsciousness may occur alone or in association. The diagnostic sensitivity of computed tomography (CT), magnetic resonance imaging (MRI) and digital subtract angiography (DSA) were 59%, 86% and 100%, respectively. The sensitivity of MRI with magnetic resonance angiography (MRA) reached 96%. CONCLUSION: As the clinical findings were found to be nonspecific, CT combined with DSA, or MRI with MRA turns out to be valuable for the early diagnosis of cerebral venous sinus thrombosis. (+info)