Thapliyal Mihika, Murayi Roger, Nowacki Amy S, Sindwani Raj, Woodard Troy, Soni Pranay, Vorster Sarel, Recinos Pablo F, Kshettry Varun R
1Cleveland Clinic Lerner College of Medicine, Case Western Reserve University School of Medicine, Cleveland.
2Department of Neurological Surgery, Neurological Institute, Cleveland Clinic, Cleveland.
J Neurosurg. 2024 Sep 27;142(2):507-516. doi: 10.3171/2024.6.JNS232723. Print 2025 Feb 1.
In this study, the authors assessed an algorithm for the diagnosis and management of idiopathic intracranial hypertension (IIH) in patients who had undergone surgical repair of skull base meningoencephaloceles presenting with spontaneous cerebrospinal fluid (sCSF) leakage.
The authors conducted an institutional retrospective review of patients surgically treated for skull base sCSF leaks between 2014 and 2021. Opening pressure (OP) measurements were taken intraoperatively. The algorithm recommended a ventriculoperitoneal shunt (VPS) for high-risk patients (OP ≥ 30 cm H2O), 4 weeks of acetazolamide plus a 2-week washout and repeat lumbar puncture (LP) at 6 weeks for intermediate-risk patients (OP = 20-29 cm H2O), and repeat LP at 4-6 weeks for low-risk patients (OP < 20 cm H2O). Demographics, radiographic characteristics, management adherence, and outcomes were analyzed.
Eighty patients with sCSF leakage were identified. The mean age was 51.9 years, and the mean body mass index was 36.3 kg/m2. The median follow-up was 8.3 months (IQR 3.3-19.7 months). The overall VPS rate was 15.0%. Three patients (3.8%) experienced acute recurrent leakage, and 3 (3.8%) developed remote recurrent leaks (mean time of 48.1 months). For the 50 patients with both intra- and postoperative OPs, the mean OPs were not significantly different (23.3 vs 23.0 cm H2O, respectively, p = 0.82). The mean variability between the two measurements was an absolute difference of 6.6 cm H2O. While 13 patients (26.0%) moved to a higher-risk category based on postoperative OP, 18 patients (36.0%) moved to a lower-risk category.
Utilizing an algorithm of direct meningoencephalocele repair and selective shunting, acute and remote CSF leak recurrence rates were each 3.8%, and the VPS rate was 15.0%. These data provide further insight into CSF dynamics in this population and argue against the theoretical concern that CSF pressure will increase postrepair. Significant intraindividual variability suggests multiple LPs may be necessary before committing to invasive IIH treatment. Further work is necessary to determine the optimal IIH management strategy.
在本研究中，作者评估了一种用于诊断和管理特发性颅内高压（IIH）的算法，该算法适用于接受过颅底脑膜脑膨出手术修复且伴有自发性脑脊液（sCSF）漏的患者。
作者对2014年至2021年期间接受颅底sCSF漏手术治疗的患者进行了机构回顾性研究。术中测量开放压力（OP）。该算法建议对高危患者（OP≥30 cm H₂O）行脑室腹腔分流术（VPS），对中危患者（OP = 20 - 29 cm H₂O）给予4周乙酰唑胺治疗加2周洗脱期，并在6周时重复腰椎穿刺（LP），对低危患者（OP < 20 cm H₂O）在4 - 6周时重复LP。分析了患者的人口统计学特征、影像学特征、治疗依从性和治疗结果。
共确定80例sCSF漏患者。平均年龄为51.9岁，平均体重指数为36.3 kg/m²。中位随访时间为8.3个月（四分位间距3.3 - 19.7个月）。总体VPS率为15.0%。3例患者（3.8%）出现急性复发性漏液，3例（3.8%）出现远期复发性漏液（平均时间为48.1个月）。对于50例术中和术后均有OP测量值的患者，平均OP值无显著差异（分别为23.3 cm H₂O和23.0 cm H₂O，p = 0.82）。两次测量之间的平均差异为绝对差值6.6 cm H₂O。虽然13例患者（26.0%）根据术后OP值进入更高风险类别，但18例患者（36.0%）进入更低风险类别。
采用直接脑膜脑膨出修复和选择性分流算法，急性和远期脑脊液漏复发率均为3.8%，VPS率为15.0%。这些数据为该人群的脑脊液动力学提供了进一步的见解，并反驳了脑脊液压力在修复后会升高的理论担忧。显著的个体内差异表明在进行侵入性IIH治疗之前可能需要多次腰椎穿刺。需要进一步开展工作以确定最佳的IIH管理策略。
