LP Shunt, the Treatment of Choice in Idiopathic Intracranial Hypertension. (A 5 Years Experience at Lahore General Hospital, Lahore)
Keywords:
Lumboperitoneal shunt, Headache, Idiopathic intracranial hypertension,, Papilloedema.Abstract
Objective: The history, diagnosis, and therapy of idiopathic intracranial hypertension (IIH) are reviewed. Theo-ries of pathogenesis are considered, the clinical presentation is described, and potential diagnostic and thera-peutic challenges are explored. Keeping in view all these things efficacy of L.P Shunt is observed.
Material and Methods: A total of 35 patients were diagnosed as IHH according to the Modified Dandy’s criteria in our department from August 2007 to October 2012. An extensive literature review of IIH and related condi-tions was performed. The history of and rationale for the diagnosis and medical and surgical approaches to tre-atment are reviewed. Outcome of the patients’ with L.P shunt is observed.
Study Design: Prospective and analytic study.
Results: LP shunt addresses the cause of both headache and papilloedema more directly by effecting a global reduction of intracranial pressure. All patients underwent clinical, imaging, and CSF manometry evaluations. All patients showed failure or noncompliance to medical treatment and necessitated placement of an LP shunt. Among 35 patients who underwent LP shunt placement for IIH, 14 (40%) patients had severe and fulminant opening CSF pressures with values of more than 400 mm H2O. while in 21 (60%) patients opening CSF pressure was 260 to 400 mm H2O. symptoms of headache and papilloedema and visual obscuration improved in most of the patients. Shunt complications included two (0.7%) cases of shunt dislodgement and one (0.35%) case of shunt over drainage. Multiple potential contributing causes of intracranial hypertension must be excluded. On the basis of the advantages and disadvantages of different treatment modalities, we found L.P Shunt to be more effective and advantageous.
Conclusion: Idiopathic intracranial hypertension is the diagnosis of exclusion. Medical therapy has a very little role in relieving signs and symptoms of this disease. L.P Shunt should be the treatment option in IIH.
References
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4. Bartynski WS, Valliappan S, Uselman JH, Spearman MP. The adult radiographic shuntogram. AJNR Am J Neuroradiol 2000; 21: 721–726.
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6. Bell SM, Schreiner CM, Resnick E, Vorhees C, Scott WJ Jr. Exacerbation of acetazolamide teratogenesis by amiloride and its analogs active against Na / Hexchan-gers and Nachannels. Reprod Toxicol 1997; 11: 823–831.
7. Billson FA, Hudson RL. Surgical treatment of chronic papilledema in children. Br J Ophthalmol 1975; 59: 92–95.
8. Biousse V, Newman NJ, Lessell S. Audible pulsatile tinnitus in idiopathic intracranial hypertension. Neuro-logy 1998; 50: 1185–1186.
9. Birdwell BG, Yeager R, Whitsett TL. Pseudotumor cerebri: A complication of catheter – induced subcla-vian vein thrombosis. Arch Intern Med 1994; 154: 808–811.
10. Blaw ME. Associated and idiopathic intracranial hyper-tension in children. Postgrad Med 1971; 50: 191–195.
11. Bousser MG. Cerebral venous thrombosis: Diagnosis and management. J Neurol 2000; 247: 252–258.
12. Brazis PW, Lee AG. Elevated intracranial pressure and pseudotumor cerebri. Curr Opin Ophthalmol 1998; 9: 27–32.
13. Brockmeier B, Burbach H, Runge M, Altenkirch H. Ra-ised intracranial pressure in chronic respiratory disease. Lancet (letter) 1997; 349: 883.
14. Brodsky MC, Vaphiades M. Magnetic resonance imag-ing in pseudotumor cerebri. Ophthalmology 1998; 105: 1686–1693.
15. Brourman ND, Spoor TC, Ramocki JM. Optic nerve sheath decompression for pseudotumor cerebri. Arch Ophthalmol 1988; 106: 1378–1383.
16. Burde RM, Karp JS, Miller RN. Reversal of visual defi-cit with optic nerve decompression in long – standing pseudotumor cerebri. Am J Ophthalmol 1984; 77: 770–771.
17. Burgett RA, Purvin VA, Kawasaki A. Lumboperitoneal shunting for pseudotumor cerebri. Neurology 1997; 49: 734–739.
18. Campos SP, Olitsky S. Idiopathic intracranial hyperten-sion after l-thyroxine therapy for acquired primary hy-pothyroidism. Clin Pediatr 1995; 34: 334–337.
19. Cantu C, Barinagarrementeria F. Cerebral venous thro-mbosis associated with pregnancy and puerperium: Re-view of 67 cases. Stroke 1993; 24: 1880–1884.
20. Capobianco DJ, Brazis PW, Cheshire WP. Idiopathic intracranial hypertension and seventh nerve palsy. Hea-dache 1997; 37: 286–288.
21. Capriles LF. Intracranial hypertension and iron – defici-ency anemia. Arch Neurol 1963; 9: 147–153.
22. Carlow TJ, Glaser JS. Pseudotumor cerebri syndrome in systemic lupus erythematosus. JAMA 1974; 228: 197–200.
23. Chang D, Nagamoto G, Smith WE. Benign intracranial hypertension and chronic renal failure. Cleve Clin JMed 1992; 59: 419–422.
24. Ch’ien LT. Intracranial hypertension and sulfamethoxa-zole. N Engl J Med (letter) 1976; 283: 47.
25. Chiu AM, Chuenkongkaew WL, Cornblath WT, Trobe JD, Digre KB, Dotan SA, Musson KH, Eggenberger ER. Minocycline treatment and pseudotumor cerebri syndrome. Am J Ophthalmol 1998; 126: 116–121.
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27. Chumas PD, Kulkarni AV, Drake JM, Hoffman HJ, Humphreys RP, Rutka JT. Lumboperitoneal shunting: A retrospective study in the pediatric population. Neu-rosurgery 1993; 32: 376–383.
28. Chutarian AM, Gold AP, Braun CN. Benign intracra-nial hypertension and Bell’s palsy. N Engl J Med 1977; 296: 1214–1215.
29. Cognard C, Casasco A, Toevi M, Houdart E, Chiras J, Merland JJ. Dural arteriovenous fistulas as a cause of intracranial hypertension due to impairment of cranial venous outflow. J Neurol Neurosurg Psychiatry 1998; 65: 308–316.
30. Cohen DN. Intracranial hypertension and papilledema associated with nalidixic acid. Am J Ophthalmol 1973; 76: 680–682.
31. Comabella M, Montalban J, Lozano M, Codina A. L-hermitte’s sign in pseudotumor cerebri. J Neurol 1995; 242: 610–611.
32. Condulis N, Germain G, Charest N, Levy S, Carpenter TO. Pseudotumor cerebri: A presenting manifestation of Addison’s disease. Clin Pediatr 1997; 36: 711–713.
33. Corbett JJ: Problems in the diagnosis and treatment of pseudotumor cerebri. Can J Neurol Sci 1983; 10: 221–229.
34. Corbett JJ, Thompson HS. The rational management of idiopathic intracranial hypertension. Arch Neurol 1989; 46: 1049–1051.
35. Corbett JJ, Nerad JA, Tse DT, Anderson RL. Results of optic nerve sheath fenestration for pseudotumor cerebri: The lateral orbitotomy approach. Arch Ophthalmol 1988; 106: 1391–1397.
36. Corbett JJ, Savino PJ, Thompson HS, Kansu T, Schatz NJ, Orr LS, Hopson D. Visual loss in pseudotumor cerebri: Follow-up of 57 patients from 5 to 41 years and a profile of 14 patients with permanent severe visual loss. Arch Neurol 1982; 39: 461–474.
37. Couban S, Maxner CE. Cerebral venous sinus throm-bosis presenting as idiopathic intracranial hypertension. Can Med Assoc J 1991; 145: 657–659.
38. Cushing H, Noleson A. Notes on a series of intracranial tumor and conditions simulating them: Tumor suspects; tumors unverified; tumors verified. Arch Neurol Psych 1923; 10: 605–668.
39. Dandy WE. Intracranial pressure without brain tumor:Diagnosis and treatment. Ann Surg 1937; 106: 492–513.
40. Davidoff LM, Dyke CG. Hypertensive meningeal hy-drops: A syndrome frequently following infection in the middle ear or elsewhere in the body. Am J Ophthalmol 1937; 20: 908–927.
41. Davidson SI. A surgical approach to plerocephalic disc edema. Trans Ophthalmol Soc U K 1969; 89: 669–690.
42. Davies G, Zilkha KJ. Decompression of the optic nerve in benign intracranial hypertension. Trans Ophthalmol Soc U K 1976; 96: 427–429.
43. de Wecker L: On incision of the optic nerve in cases of neuroretinitis, in Fourth International Ophthalmological Congress: August, 1872. London, Savill Edwards, 1873: pp 11–14.
44. Digre KB, Corbett JJ. Idiopathic intracranial hyperten-sion (pseudotumor cerebri): A reappraisal. Neurology 2001; 7: 2–67.
46. Donaldson JO. Pathogenesis of pseudotumor cerebri syndromes. Neurology 1981; 31: 877–880.
47. Durcan FJ, Corbett JJ, Wall M. The incidence of pseu-dotumor cerebri: Population studies in Iowa and Loui-siana. Arch Neurol 1988; 45: 875–877.
48. Eggenberger ER, Miller NR, Vitale S. Lumboperitoneal shunt for the treatment of pseudotumor cerebri. Neuro-logy 1996; 46: 1524–1530.
49. Eisenberg HM, McComb JG, Lorenzo AV. Cerebrospi-nal fluid overproduction and hydrocephalus associated with choroid plexus papilloma. J Neurosurg 1974; 40: 381–385.
50. Fischer EG, Welch K, Shillito J. Syringomyelia follow-ing lumboperitoneal shunting for communicating hyd-rocephalus: Report of three cases. J Neurosurg 1977; 47: 96–100.
51. Fishman RA. The pathophysiology of pseudotumor cerebri: An unsolved puzzle. Arch Neurol 1984; 41: 257–258.
52. Fishman RA. Cerebrospinal Fluid in Diseases of the Nervous System. Philadelphia, W.B. Saunders Co., 1992.
53. Foley J. Benign forms of intracranial hypertension: ?Toxic? and ?otitic? hydrocephalus. Brain 1955; 78: 1–41.
54. Fujiwara S, Sawamura Y, Kato T, Abe H, Katusima H. Idiopathic intracranial hypertension in female homo-zygous twins. J Neurol Neurosurg Psychiatry 1997; 62: 652–654.
55. Galbraith JEK, Sullivan JH. Decompression of the peri-optic meninges for relief of papilledema. Am J Oph-thalmol 1973; 76: 687–692.
56. Gardner K, Cox T, Digre KB. Idiopathic intracranial hypertension associated with tetracycline use in frater-nal twins: Case reports and review. Neurology 1995; 45: 6–10.
57. Gass A, Barker GJ, Riordan – Eva P, MacManus D, Sanders M, Tofts PS, McDonald WI, Moseley IF, Mil-ler DH. MRI of the optic nerve in benign intracranialhypertension. Neuroradiology 1996; 38: 769–773.
58. Getenet JC, Croisile B, Vighetto A, Grochowicki M, Goudable B, Aimard G, Trillet M. Idiopathic intracra-nial hypertension after ofloxacin treatment. Acta Neurol Scand 1993; 87: 503–504.
59. Gettelfinger DM, Komen E. Superior sagittal sinus thrombosis. Arch Neurol 1977; 34: 2–6.
60. Gideon P, Sorensen PS, Thomsen C, Stahlberg F, Gjer-ris F, Henriksen O. Increased brain water self-diffusion in patients with idiopathic intracranial hypertension. AJNR Am J Neuroradiol 1995; 16: 381–387.
61. Giles C, Soble A. Intracranial hypertension and tetra-cycline therapy. Am J Ophthalmol 1971; 72: 981–982.
62. Giuseffi V, Wall M, Siegel PZ, Rojas PB. Symptoms and disease associations in idiopathic intracranial hy-pertension (pseudotumor cerebri): A case-control study. Neurology 1991; 41: 239–244.
63. Goh KY, Schatz NJ, Glaser JS. Optic nerve sheath fe-nestration for pseudotumor cerebri. J Neuroophthalmol 1997; 17: 86–91.
64. Greer M. Benign intracranial hypertension: Part I—Ma-stoiditis and lateral sinus obstruction. Neurology 1961; 12: 472–476.
65. Greer M. Management of benign intracranial hyperten-sion (pseudotumor cerebri). Clin Neurosurg 1968; 15: 161–174.
66. Guy J, Johnston PK, Corbett JJ, Day AL, Glaser JS. Treatment of visual loss in pseudotumor cerebri asso-ciated with uremia. Neurology 1990; 40: 28–32.
67. Halbach VV, Hieshima GB, Higashida RT, Reicher M. Carotid cavernous fistulae: Indications for urgent treat-ment. AJR Am J Roentgenol 1987; 149: 587–593.
68. Hamed LM, Glaser JS, Schatz NJ, Perez TH. Pseudo-tumor cerebri induced by danazol. Am J Ophthalmol 1989; 107: 105–110.
69. Hannerz J, Greitz D, Ericson K. Is there a relationship between obesity and intracranial hypertension? Int J Obes Relat Metab Disord 1995; 19: 240–244.
70. Hart A, David K, Powell M. The treatment of ?acquired tonsillar herniation? in pseudotumor cerebri. Br J Neu-rosurg 2000; 14: 563–565.
71. Herzau V, Baykal HE. Long – term outcome of optic nerve sheath fenestration in pseudotumor cerebri (in German). Klin Monatsbl Augenheilkd 1998; 213: 154–160.
72. Horton JC, Seiff SR, Pitts LH, Weinstein PR, Rosen-blum ML, Hoyt WF. Decompression of the optic nerve sheath for vision – threatening papilledema caused by dural sinus occlusion. Neurosurgery 1992; 31: 203–212.
73. Howman – Giles R, Uren RG, Johnston I. Cerebrospi-nal fluid physiology, clearance flow studies, and cere-brospinal fluid shunt studies, in Murray IPC, Ell PJ (eds): Nuclear Medicine in Clinical Diagnosis and Tre-atment. Edinburgh, Churchill Livingstone, 1998.
74. Huseman CA, Torkelson RD. Pseudotumor cerebri fol-lowing treatment of hypothalamic and primary hypo-thyroidism. Am J Dis Child 1984; 138: 927–931.
2. Baker RS, Carter D, Hendrick EB, Buncic JR. Visual loss in pseudotumor cerebri of childhood: A follow-up study. Arch Ophthalmol 1985; 103: 1681–1686.
3. Banta JT, Farris BK. Pseudotumor cerebri and optic nerve sheath decompression. Ophthalmology 2000; 107: 1907–1912.
4. Bartynski WS, Valliappan S, Uselman JH, Spearman MP. The adult radiographic shuntogram. AJNR Am J Neuroradiol 2000; 21: 721–726.
5. Bedford THB. The effect of increased intracranial ven-ous pressure on the pressure of the cerebrospinal fluid. Brain 1935; 58: 427–447.
6. Bell SM, Schreiner CM, Resnick E, Vorhees C, Scott WJ Jr. Exacerbation of acetazolamide teratogenesis by amiloride and its analogs active against Na / Hexchan-gers and Nachannels. Reprod Toxicol 1997; 11: 823–831.
7. Billson FA, Hudson RL. Surgical treatment of chronic papilledema in children. Br J Ophthalmol 1975; 59: 92–95.
8. Biousse V, Newman NJ, Lessell S. Audible pulsatile tinnitus in idiopathic intracranial hypertension. Neuro-logy 1998; 50: 1185–1186.
9. Birdwell BG, Yeager R, Whitsett TL. Pseudotumor cerebri: A complication of catheter – induced subcla-vian vein thrombosis. Arch Intern Med 1994; 154: 808–811.
10. Blaw ME. Associated and idiopathic intracranial hyper-tension in children. Postgrad Med 1971; 50: 191–195.
11. Bousser MG. Cerebral venous thrombosis: Diagnosis and management. J Neurol 2000; 247: 252–258.
12. Brazis PW, Lee AG. Elevated intracranial pressure and pseudotumor cerebri. Curr Opin Ophthalmol 1998; 9: 27–32.
13. Brockmeier B, Burbach H, Runge M, Altenkirch H. Ra-ised intracranial pressure in chronic respiratory disease. Lancet (letter) 1997; 349: 883.
14. Brodsky MC, Vaphiades M. Magnetic resonance imag-ing in pseudotumor cerebri. Ophthalmology 1998; 105: 1686–1693.
15. Brourman ND, Spoor TC, Ramocki JM. Optic nerve sheath decompression for pseudotumor cerebri. Arch Ophthalmol 1988; 106: 1378–1383.
16. Burde RM, Karp JS, Miller RN. Reversal of visual defi-cit with optic nerve decompression in long – standing pseudotumor cerebri. Am J Ophthalmol 1984; 77: 770–771.
17. Burgett RA, Purvin VA, Kawasaki A. Lumboperitoneal shunting for pseudotumor cerebri. Neurology 1997; 49: 734–739.
18. Campos SP, Olitsky S. Idiopathic intracranial hyperten-sion after l-thyroxine therapy for acquired primary hy-pothyroidism. Clin Pediatr 1995; 34: 334–337.
19. Cantu C, Barinagarrementeria F. Cerebral venous thro-mbosis associated with pregnancy and puerperium: Re-view of 67 cases. Stroke 1993; 24: 1880–1884.
20. Capobianco DJ, Brazis PW, Cheshire WP. Idiopathic intracranial hypertension and seventh nerve palsy. Hea-dache 1997; 37: 286–288.
21. Capriles LF. Intracranial hypertension and iron – defici-ency anemia. Arch Neurol 1963; 9: 147–153.
22. Carlow TJ, Glaser JS. Pseudotumor cerebri syndrome in systemic lupus erythematosus. JAMA 1974; 228: 197–200.
23. Chang D, Nagamoto G, Smith WE. Benign intracranial hypertension and chronic renal failure. Cleve Clin JMed 1992; 59: 419–422.
24. Ch’ien LT. Intracranial hypertension and sulfamethoxa-zole. N Engl J Med (letter) 1976; 283: 47.
25. Chiu AM, Chuenkongkaew WL, Cornblath WT, Trobe JD, Digre KB, Dotan SA, Musson KH, Eggenberger ER. Minocycline treatment and pseudotumor cerebri syndrome. Am J Ophthalmol 1998; 126: 116–121.
26. Chumas PD, Armstrong DC, Drake JM, Kulkarni AV, Hoffman HJ, Humphreys RP, Rutka JT, Hendrick EB. Tonsillar herniation: The rule rather than the exception after lumboperitoneal shunting in the pediatric popu-lation. J Neurosurg 1993; 78: 568–573.
27. Chumas PD, Kulkarni AV, Drake JM, Hoffman HJ, Humphreys RP, Rutka JT. Lumboperitoneal shunting: A retrospective study in the pediatric population. Neu-rosurgery 1993; 32: 376–383.
28. Chutarian AM, Gold AP, Braun CN. Benign intracra-nial hypertension and Bell’s palsy. N Engl J Med 1977; 296: 1214–1215.
29. Cognard C, Casasco A, Toevi M, Houdart E, Chiras J, Merland JJ. Dural arteriovenous fistulas as a cause of intracranial hypertension due to impairment of cranial venous outflow. J Neurol Neurosurg Psychiatry 1998; 65: 308–316.
30. Cohen DN. Intracranial hypertension and papilledema associated with nalidixic acid. Am J Ophthalmol 1973; 76: 680–682.
31. Comabella M, Montalban J, Lozano M, Codina A. L-hermitte’s sign in pseudotumor cerebri. J Neurol 1995; 242: 610–611.
32. Condulis N, Germain G, Charest N, Levy S, Carpenter TO. Pseudotumor cerebri: A presenting manifestation of Addison’s disease. Clin Pediatr 1997; 36: 711–713.
33. Corbett JJ: Problems in the diagnosis and treatment of pseudotumor cerebri. Can J Neurol Sci 1983; 10: 221–229.
34. Corbett JJ, Thompson HS. The rational management of idiopathic intracranial hypertension. Arch Neurol 1989; 46: 1049–1051.
35. Corbett JJ, Nerad JA, Tse DT, Anderson RL. Results of optic nerve sheath fenestration for pseudotumor cerebri: The lateral orbitotomy approach. Arch Ophthalmol 1988; 106: 1391–1397.
36. Corbett JJ, Savino PJ, Thompson HS, Kansu T, Schatz NJ, Orr LS, Hopson D. Visual loss in pseudotumor cerebri: Follow-up of 57 patients from 5 to 41 years and a profile of 14 patients with permanent severe visual loss. Arch Neurol 1982; 39: 461–474.
37. Couban S, Maxner CE. Cerebral venous sinus throm-bosis presenting as idiopathic intracranial hypertension. Can Med Assoc J 1991; 145: 657–659.
38. Cushing H, Noleson A. Notes on a series of intracranial tumor and conditions simulating them: Tumor suspects; tumors unverified; tumors verified. Arch Neurol Psych 1923; 10: 605–668.
39. Dandy WE. Intracranial pressure without brain tumor:Diagnosis and treatment. Ann Surg 1937; 106: 492–513.
40. Davidoff LM, Dyke CG. Hypertensive meningeal hy-drops: A syndrome frequently following infection in the middle ear or elsewhere in the body. Am J Ophthalmol 1937; 20: 908–927.
41. Davidson SI. A surgical approach to plerocephalic disc edema. Trans Ophthalmol Soc U K 1969; 89: 669–690.
42. Davies G, Zilkha KJ. Decompression of the optic nerve in benign intracranial hypertension. Trans Ophthalmol Soc U K 1976; 96: 427–429.
43. de Wecker L: On incision of the optic nerve in cases of neuroretinitis, in Fourth International Ophthalmological Congress: August, 1872. London, Savill Edwards, 1873: pp 11–14.
44. Digre KB, Corbett JJ. Idiopathic intracranial hyperten-sion (pseudotumor cerebri): A reappraisal. Neurology 2001; 7: 2–67.
46. Donaldson JO. Pathogenesis of pseudotumor cerebri syndromes. Neurology 1981; 31: 877–880.
47. Durcan FJ, Corbett JJ, Wall M. The incidence of pseu-dotumor cerebri: Population studies in Iowa and Loui-siana. Arch Neurol 1988; 45: 875–877.
48. Eggenberger ER, Miller NR, Vitale S. Lumboperitoneal shunt for the treatment of pseudotumor cerebri. Neuro-logy 1996; 46: 1524–1530.
49. Eisenberg HM, McComb JG, Lorenzo AV. Cerebrospi-nal fluid overproduction and hydrocephalus associated with choroid plexus papilloma. J Neurosurg 1974; 40: 381–385.
50. Fischer EG, Welch K, Shillito J. Syringomyelia follow-ing lumboperitoneal shunting for communicating hyd-rocephalus: Report of three cases. J Neurosurg 1977; 47: 96–100.
51. Fishman RA. The pathophysiology of pseudotumor cerebri: An unsolved puzzle. Arch Neurol 1984; 41: 257–258.
52. Fishman RA. Cerebrospinal Fluid in Diseases of the Nervous System. Philadelphia, W.B. Saunders Co., 1992.
53. Foley J. Benign forms of intracranial hypertension: ?Toxic? and ?otitic? hydrocephalus. Brain 1955; 78: 1–41.
54. Fujiwara S, Sawamura Y, Kato T, Abe H, Katusima H. Idiopathic intracranial hypertension in female homo-zygous twins. J Neurol Neurosurg Psychiatry 1997; 62: 652–654.
55. Galbraith JEK, Sullivan JH. Decompression of the peri-optic meninges for relief of papilledema. Am J Oph-thalmol 1973; 76: 687–692.
56. Gardner K, Cox T, Digre KB. Idiopathic intracranial hypertension associated with tetracycline use in frater-nal twins: Case reports and review. Neurology 1995; 45: 6–10.
57. Gass A, Barker GJ, Riordan – Eva P, MacManus D, Sanders M, Tofts PS, McDonald WI, Moseley IF, Mil-ler DH. MRI of the optic nerve in benign intracranialhypertension. Neuroradiology 1996; 38: 769–773.
58. Getenet JC, Croisile B, Vighetto A, Grochowicki M, Goudable B, Aimard G, Trillet M. Idiopathic intracra-nial hypertension after ofloxacin treatment. Acta Neurol Scand 1993; 87: 503–504.
59. Gettelfinger DM, Komen E. Superior sagittal sinus thrombosis. Arch Neurol 1977; 34: 2–6.
60. Gideon P, Sorensen PS, Thomsen C, Stahlberg F, Gjer-ris F, Henriksen O. Increased brain water self-diffusion in patients with idiopathic intracranial hypertension. AJNR Am J Neuroradiol 1995; 16: 381–387.
61. Giles C, Soble A. Intracranial hypertension and tetra-cycline therapy. Am J Ophthalmol 1971; 72: 981–982.
62. Giuseffi V, Wall M, Siegel PZ, Rojas PB. Symptoms and disease associations in idiopathic intracranial hy-pertension (pseudotumor cerebri): A case-control study. Neurology 1991; 41: 239–244.
63. Goh KY, Schatz NJ, Glaser JS. Optic nerve sheath fe-nestration for pseudotumor cerebri. J Neuroophthalmol 1997; 17: 86–91.
64. Greer M. Benign intracranial hypertension: Part I—Ma-stoiditis and lateral sinus obstruction. Neurology 1961; 12: 472–476.
65. Greer M. Management of benign intracranial hyperten-sion (pseudotumor cerebri). Clin Neurosurg 1968; 15: 161–174.
66. Guy J, Johnston PK, Corbett JJ, Day AL, Glaser JS. Treatment of visual loss in pseudotumor cerebri asso-ciated with uremia. Neurology 1990; 40: 28–32.
67. Halbach VV, Hieshima GB, Higashida RT, Reicher M. Carotid cavernous fistulae: Indications for urgent treat-ment. AJR Am J Roentgenol 1987; 149: 587–593.
68. Hamed LM, Glaser JS, Schatz NJ, Perez TH. Pseudo-tumor cerebri induced by danazol. Am J Ophthalmol 1989; 107: 105–110.
69. Hannerz J, Greitz D, Ericson K. Is there a relationship between obesity and intracranial hypertension? Int J Obes Relat Metab Disord 1995; 19: 240–244.
70. Hart A, David K, Powell M. The treatment of ?acquired tonsillar herniation? in pseudotumor cerebri. Br J Neu-rosurg 2000; 14: 563–565.
71. Herzau V, Baykal HE. Long – term outcome of optic nerve sheath fenestration in pseudotumor cerebri (in German). Klin Monatsbl Augenheilkd 1998; 213: 154–160.
72. Horton JC, Seiff SR, Pitts LH, Weinstein PR, Rosen-blum ML, Hoyt WF. Decompression of the optic nerve sheath for vision – threatening papilledema caused by dural sinus occlusion. Neurosurgery 1992; 31: 203–212.
73. Howman – Giles R, Uren RG, Johnston I. Cerebrospi-nal fluid physiology, clearance flow studies, and cere-brospinal fluid shunt studies, in Murray IPC, Ell PJ (eds): Nuclear Medicine in Clinical Diagnosis and Tre-atment. Edinburgh, Churchill Livingstone, 1998.
74. Huseman CA, Torkelson RD. Pseudotumor cerebri fol-lowing treatment of hypothalamic and primary hypo-thyroidism. Am J Dis Child 1984; 138: 927–931.
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