|Year : 2016 | Volume
| Issue : 1 | Page : 33-36
Lumbar puncture as a single modality for treatment of idiopathic intracranial hypertension during pregnancy
Ehab Mohamed Eissa1, Lamiaa Ibrahim Daker2, Mona Mohamed Shaban3, Mohamed I Hegazy4
1 Department of Neurosurgery, Cairo University, Cairo, Egypt
2 Department of Neurology, El Fayoum University, Al Fayoum, Egypt
3 Department of Obstetrics and Gynecology, Cairo University, Cairo, Egypt
4 Department of Obstetrics and Gynecology, Cairo University, Department of Neurology, Cairo University, CairoCairo, Egypt
|Date of Submission||23-Apr-2015|
|Date of Acceptance||28-Aug-2015|
|Date of Web Publication||15-Feb-2016|
Mohamed I Hegazy
MD, Department of Neurology, Cairo University, Cairo, 11435
Source of Support: None, Conflict of Interest: None
Idiopathic intracranial hypertension (IIH) is seen typically in obese women in their child-bearing age, management of patients with IIH during pregnancy can be problematic.
The purpose of this study is to assess spinal tapping as a single modality for treatment of IIH during pregnancy.
Patients and methods
This was a prospective case series of seven pregnant women with IIH who underwent full neurological and ophthalmological evaluation including perimetry and neuroimaging studies. They were followed up and treated using only spinal tapping.
Spinal tapping either single or multiple sessions can control IIH safely during pregnancy with a success rate of 86%.
Spinal tapping is recommended as a single treatment modality in pregnant women with IIH.
Keywords: Idiopathic intracranial hypertension, lumbar puncture, pregnancy
|How to cite this article:|
Eissa EM, Daker LI, Shaban MM, Hegazy MI. Lumbar puncture as a single modality for treatment of idiopathic intracranial hypertension during pregnancy. Egypt J Neurol Psychiatry Neurosurg 2016;53:33-6
|How to cite this URL:|
Eissa EM, Daker LI, Shaban MM, Hegazy MI. Lumbar puncture as a single modality for treatment of idiopathic intracranial hypertension during pregnancy. Egypt J Neurol Psychiatry Neurosurg [serial online] 2016 [cited 2018 Oct 20];53:33-6. Available from: http://www.ejnpn.eg.net/text.asp?2016/53/1/33/176367
| Introduction|| |
Idiopathic intracranial hypertension (IIH) previously known as pseudotumor cerebri is a syndrome in which intracranial pressure is elevated with normal cerebrospinal fluid (CSF) composition and no evidence of hydrocephalus or mass lesion. It is seen typically in obese women of child-bearing age with annual incidence of 19.3 per 100 000 .
The most common symptoms of IIH are headaches, occurring in ∼90% of cases and visual disturbances including transient visual obscurations and diplopia ,. The typical signs include papilledema, associated initially with enlarged blind spots, followed by arcuate visual field defects when there is progression .
Diagnosis of IIH is made by exclusion using the modified Dandy criteria [Table 1] which require an increased intra-cranial pressure (ICP) greater than 250 mmH 2 O and ruling out other pathologies of CSF examination and radiological imaging .
The pathophysiological mechanisms causing increased ICP for patients with IIH are not well understood. Possible causes include excess production of CSF, decreased CSF absorption, and increased cerebral venous sinus pressure . Since IIH particularly affects obese women, it was suggested that hormones may play a role in the pathogenesis of the disease .
Previously, most researchers believed that IIH was triggered or exacerbated by pregnancy . However, IIH occurs in pregnancies at the same rate as the general population, IIH can occur in any trimester, thus the association of pregnancy with IIH is probably only a measure of the fact that IIH affects women of child-bearing age .
It was postulated that the management and treatment of patients with IIH during pregnancy can be problematic. In women who are not pregnant, first-line treatment usually emphasizes weight loss by diet and the use of carbonic anhydrase inhibitors that may be teratogenic . The purpose of this study is to assess spinal tapping as a single modality for treatment of IIH during pregnancy.
| Patients and methods|| |
This was a prospective case series of seven pregnant women diagnosed with IIH according to the modified Dandy criteria  managed at Cairo and Fayoum University Hospitals. The patients underwent full neurological and ophthalmological evaluation including visual acuity, fundus examination and perimetry. Neuroimaging studies including MRI brain (sagittal, coronal, axial cuts in all sequences) and magnetic resonance venography using 1.5-T Philips Intera scanner (Philips Healthcare, Amsterdam, the Netherlands) were done to exclude hydrocephalus, mass lesions or other pathologies. All patients underwent full prenatal assessment till the end of their pregnancies. All patients were treated with lumbar puncture (LP) and spinal tapping as a single modality for treatment of increased intracranial pressure, patients were subjected to single or multiple serial tapping according to follow-up (perimetry, fundus examination and headache). LP was performed under local anesthesia using 20-G needle that was inserted under complete aseptic precautions in L4-L5 vertebral space. The opening pressure was measured followed by continuous CSF drainage till the pressure decreases below 200 mmH 2 O. Ethical committee approval was obtained before the study and informed consent was acquired from patients.
| Results|| |
The patients' data are summarized in [Table 2]. The age of included patients ranged from 27 to 38 years. There were five primigravida and two multigravida patients. Six of them were overweight; their BMI ≥ 25 kg/m 2 . Four patients were presented in the first trimester and three patients presented in the second trimester.
The main presentation in all patients was headache and visual disturbances in the form of diplopia and transient visual obscuration. One patient showed visual deterioration. The fundus examination of all patients showed mild to moderate grades of papilledema. One patient showed visual field defect in the form of unilateral enlarged blind spot with nasal arcuate scotoma.
All cases underwent treatment by only LP and spinal tapping to relieve symptoms of increased ICP either once or repeated according to their follow-up by fundus examination for papilledema, perimetry and improvement of the symptoms. The CSF opening pressure ranged from 250 to 500 mmH 2 O with a mean of 310 ± 87.55.
Four cases improved clinically after single CSF LP. Two cases were improved after two CSF LPs. It should be mentioned that three of the previously mentioned six cases show recurrence of manifestations after labor that was relieved by medical treatment.
Only one patient (case 1) presented at ∼12 weeks of gestation with recurrent attacks of transient visual obscurations; this patient needed repeated spinal tapping till the end of pregnancy. Her CSF opening pressure ranged from 280 to 500 mmH 2 O and the patient underwent shunt operation after labor due to nonimprovement of the symptoms on medical treatment initiated after labor.
| Discussion|| |
The exact etiology of IIH is unknown. Although it is often considered to be idiopathic, detailed investigation has revealed a high incidence of venous drainage abnormalities in IIH patients . At least two primary mechanisms for the increased CSF pressure in IIH have been proposed and supported by experimental data, increased CSF production causing vasogenic extracellular brain edema and a low CSF outflow at the arachnoid villi .
The prevalence of pregnant women with IIH is between 2 and 12%. It was postulated that pregnancy and exogenous estrogens are thought to promote or worsen IIH. It is postulated that hypofibrinolysis and thrombophilia seen with high estrogen levels (pregnancy, obesity, exogenous estrogen administration, polycystic ovarian syndrome) lead to thrombosis of arachnoid villi and reduced CSF absorption .
In this study, the pregnant women presented at the first and second trimester of pregnancy with IIH; these results were in concordance with Huna-Baron and Kupersmith  who reported that the onset of IIH was in the first half of pregnancy; other series demonstrated that IIH could occur in any trimester of pregnancy .
It was found in this study that six (85%) patients were overweight which supports the notion that obesity could contribute to the pathogenesis of IIH. The postulated mechanism is that central obesity raises the intra-abdominal pressure, which elevates pleural pressure and cardiac filling pressures, which hinders venous return from the brain and leads to elevated intracranial venous pressure and elevated intracranial pressure . Bagga et al.  investigated three cases of IIH during pregnancy; all women in that series were obese and presented with IIH symptoms during pregnancy, which resolved postpartum, IIH may appear or worsen during pregnancy and usually disappear after delivery.
In nonpregnant IIH patients, weight loss and diet are considered integral parts of IIH treatment. In pregnancy, however, significant caloric restriction is not a recommended approach in these patients as it may not allow adequate fetal growth and results in ketosis .
Acetazolamide is considered the first-line medical treatment for IIH. It is preferred after 20 weeks because sacrococcygeal teratoma was reported with earlier use . At high doses it may produce birth defects and limb anomalies in animals, but there is limited clinical or experimental evidence supporting adverse effect of the drug on pregnancy outcomes in human. It is classified as category C drug in pregnancy .
Other medical treatments indicated for IIH include furosemide and corticosteroids. Furosemide decreases intracranial pressure by diuresis and by reduction of the transport of sodium ions in the brain. Furosemide has been classified as a category C drug . Corticosteroids are classified as a category B risk in pregnancy and recommended for short-term use in acute visual decline. Steroids are known to cause lip and palate defects in animals and prevent early fetal lung maturation .
LP and spinal tapping is an effective tool in management of pregnant women with IIH as it directly reduces intracranial pressure immediately . It allows CSF drainage and reduces CSF pressure. Repeated spinal fluid drainage by LP can help in improving symptoms of IIH during pregnancy and preventing permanent loss of vision ,.
In this study, all patients underwent LP and spinal tapping as a single modality to relieve CSF pressure; it was found that four (57%) cases needed single LP, while two (28%) cases needed two LP sessions to relieve their symptoms. Moreover, these six (85%) patients showed clinical improvement on ophthalmological examination as the papilledema improved and optic disc borders became more distinct. Fifty percent (three patients) of these cases showed recurrence of the manifestations after labor (at different periods) that was relieved by medical treatment.
One case (15%) needed repeated LP and tapping, the opening pressures in this case were 500, 420, 440 and 280 mmH 2 O on the successive LPs. The pressures after tapping of fluid were consistently below the 250 mmH 2 O threshold. The patient showed clinical improvement of the symptoms temporarily. There was no clinical improvement on ophthalmological examination; the patient underwent thecoperitoneal shunting after labor.
Golan et al.  reviewed eight cases and evaluated the course of their disease as well as the course of their pregnancies. Only three had IIH symptoms during their first pregnancy and all cases were treated with acetazolamide which led to resolution of their symptoms. There were no congenital abnormalities detected except in one patient who had premature placental rupture at 28 weeks. The neonate was later diagnosed as mild cerebral palsy.
Huna-Baron and Kupersmith  evaluated different management tools in 12 patients presented with IIH during pregnancy. Four patients were taking acetazolamide early in their pregnancy. Although they had normal full-term deliveries, there were two intrauterine fetal deaths at 5 months of pregnancy. The two cases that underwent serial LP had a favorable outcome with complete resolution of their symptoms.
All IIH cases who participated in this study underwent LP either single or repeated sessions. All cases preferred LPs over the medical management as there were five (75%) patients primigravida and they chose the LP to avoid the possible congenital anomalies caused by acetazolamide. The main limitation of this study was the limited number of subjects (seven patients) and this is attributed to the reluctance of pregnant women to enroll in clinical studies especially those involving treatments and interventions; this observation is universal and can be observed in literature about managing IIH in pregnancy ,,. Friedman and Jacobson  advised repeated LP as a therapeutic option in pregnant IIH patients as the patients showed satisfactory results regarding the headache and visual function. Badve et al.  stated that the repeated spinal fluid drainage by LP can help improving the symptoms of IIH in pregnancy and preventing permanent vision loss as was the case with our patients. LP and spinal tapping is considered to be the treatment of choice during pregnancy.
| Conclusion|| |
LP and spinal fluid tapping either single or multiple sessions can control IIH safely during pregnancy with a success rate of 86%, with special care to those cases with progressive deterioration of vision despite repeated LPs in which a thecoperitoneal shunt may be needed.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Badve M, McConnell M, Shah T, Ondecko-Ligda K, Poutous G, Vallejo M, et al
. Idiopathic intracranial hypertension in pregnancy treated with serial lumbar punctures. Int J Clin Med 2011; 2
Kesler A, Kupferminc M. Idiopathic intracranial hypertension and pregnancy. Clin Obstet Gynecol 2013; 56
Huna-Baron R, Kupersmith MJ. Idiopathic intracranial hypertension in pregnancy. J Neurol 2002; 249
Friedman DI, Jacobson DM. Diagnostic criteria for idiopathic intracranial hypertension. Neurology 2002; 59
Durcan FJ, Corbett JJ, Wall M. The incidence of pseudotumor cerebri: population studies in Iowa and Louisiana. Arch Neurol 1988; 45
Powell JL. Pseudotumor cerebri and pregnancy. Obstet Gynecol 1972; 40
Digre KB, Varner MW, Corbett JJ. Pseudotumor cerebri and pregnancy. Neurology 1988; 34
Kupersmith MJ, Gamell L, Turbin R, Peck V, Spiegel P, Wall M. Effects of weight loss on the course of idiopathic intracranial hypertension in women. Neurology 1998; 50
Brazis PW. Pseudotumor cerebri. Curr Neurol Neurosci Rep 2004; 4
Radhakrishnan K, Ahlskog JE, Garrity JA, Kurland LT. Idiopathic intracranial hypertension. Mayo Clin Proc 1994; 69
Glueck CJ, Aregawi D, Goldenberg N, Golnik KC, Sieve L, Wang P. Idiopathic intracranial hypertension, polycystic-ovary syndrome, and thrombophilia. J Lab Clin Med 2005; 145
Guiseffi V, Wall M, Siegel PZ, Rojas PB. Symptoms and disease associations in idiopathic intracranial hypertension (pseudotumor cerebri): a case control study. Neurology 1991; 41
Bagga R, Jain V, Das CP, Gupta KR, Gopalan S, Malhotra S. Choice of therapy and mode of delivery in idiopathic intracranial hypertension during pregnancy. Medscape Gen Med 2005; 7
Lee AG, Pless M, Falardeau J, Capozzoli T, Wall M, Kardon RH. The use of acetazolamide in idiopathic intracranial hypertension during pregnancy. Am J Ophthalmol 2005; 139
Tang RA, Dorotheo EU, Schiffman JS, Bahrani HM. Medical and surgical management of idiopathic intracranial hypertension in pregnancy. Curr Neurol Neurosci Rep 2005; 4
Abouleish E, Ali V, Tang RA. Benign intracranial hypertension and anesthesia for cesarean section. Anesthesiology 1985; 63
Golan S, Maslovitz S, Kupferminc M, Kesler A. Management and outcome of consecutive pregnancies complicated by idiopathic intracranial hypertension. IMAJ 2013; 1:160-165.
[Table 1], [Table 2]