Bariatric Surgery or Non-surgical Weight Loss for Idiopathic Intracranial Hypertension? A Systematic Review and Comparison of Meta-analyses
Bariatric Surgery or Non-surgical Weight Loss for Idiopathic Intracranial Hypertension? A Systematic Review and Comparison of Meta-analyses
James H. Manfield 0 1 2
Kenny K-H. Yu 0 1 2
Evangelos Efthimiou 0 1 2
Ara Darzi 0 1 2
Thanos Athanasiou 0 1 2
Hutan Ashrafian 0 1 2
0 Department of Surgery and Cancer, Imperial College London, 3rd Floor Chelsea and Westminster Hospital Campus , 369 Fulham Road, London SW10 9NH , UK
1 Department of Bariatric Surgery, Chelsea and Westminster Hospital , London , UK
2 Department of Neurosurgery, Royal Preston Hospital , Preston, Lancashire , UK
Background Idiopathic intracranial hypertension (IIH) is associated with obesity and weight loss by any means is considered beneficial in this condition. Objectives This study aims to appraise bariatric surgery vs. non-surgical weight-loss (medical, behavioural and lifestyle) interventions in IIH management. Methods A systematic review and meta-analyses of surgical and non-surgical studies. Results Bariatric surgery achieved 100% papilloedema resolution and a reduction in headache symptoms in 90.2%. Nonsurgical methods offered improvement in papilloedema in 66.7%, visual field defects in 75.4% and headache symptoms in 23.2%. Surgical BMI decrease was 17.5 vs. 4.2 for nonsurgical methods. Conclusions Whilst both bariatric surgery and non-surgical weight loss offer significant beneficial effects on IIH symptomatology, future studies should address the lack of prospective and randomised trials to establish the optimal role for these interventions.
Idiopathic intracranial hypertension; Pseudotumor cerebri; Benign intracranial hypertension; Obesity; Bariatric surgery; Metabolic surgery; Weight loss
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The worldwide burden of idiopathic intracranial hypertension
(IIH) continues to rise with the current annual incidence
estimated at up to 21 per 100,000 per year in obese young women
[1]. This increase occurs in the context of a concomitant rise in
obesity rates; in the USA, more than a third of adults are now
obese, compared with around 11% worldwide, with a further
third overweight (body mass index (BMI) 25–30 kg/m2). In
2013, the American Medical Association declared obesity as a
genuine disease state [2].
IIH, also known as pseudotumour cerebri, is a clinical
diagnosis defined by criteria that comprise symptoms and signs
of intracranial pressure (e.g. headache, papilloedema and
visual loss), elevated intracranial pressure (e.g. on lumbar
puncture) with normal cerebrospinal fluid (CSF) composition and
without any other cause identified on neuroimaging or other
evaluations [3].
Although previously called benign intracranial
hypertension, it is not a benign disorder with many patients suffering
intractable, disabling headaches with a significant risk of
severe and permanent visual loss [4] seen in up to 30% [5].
The pathogenesis of IIH remains unclear, although several
risk factors have been identified [6]. IIH is most prevalent in
obese females of reproductive age [7]; at least 90% of patients
are female with obesity prevalence ranging from 70.5 to 94%
[8–10] and recent weight gain is a further significant factor for
its development [2].
Weight loss is traditionally advocated for all overweight
IIH patients and remains the cornerstone of management as
it generally improves symptomology [11]. Although lifestyle
weight-loss interventions, comprising exercise promotion and
dietary modification are widely advised, long-term weight
control and accordingly IIH outcomes remain suboptimal [4].
Bariatric surgery is an alternate way of sustainably
reducing both excess weight and IIH symptomology [12], whilst
also improving glycaemic control and cardiovascular and
cancer risk [13, 14]. A previous review of 65 patients
demonstrated that following bariatric surgery 92% (60/65) had
improvement in IIH outcomes [15]. Although there is also evidence
suggesting that non-surgical interventions, including a recent
multicentre RCT of weight loss vs. weight loss with
acetazolamide [16], may improve IIH outcomes via weight reduction
and possibly additional mechanisms, there are lack of studies
directly comparing these treatment strategies.
The aim of this paper was therefore to systematically
review the current evidence and concomitantly appraise both
bariatric surgery and non-surgical weight-loss interventions
in the management of IIH, via the assessment of visual
outcomes (papilloedema and visual field deficits), symptoms
(headache), intracranial pressure (via cerebrospinal fluid
opening pressure measurement) and BMI as summary
outcome parameters.
The review was performed according to guidelines from the
preferred reporting items for systematic reviews and
metaanalyses (PRISMA) [17]. A broad search of the electronic
literature was performed applying the following search terms:
surgical studies: ‘bariatr$ or obesity surg$ or gastr$ surg$’ and
‘intracranial hypertension or pseudotumo$’ and non-surgical
studies: ‘weight loss OR weight reduc$’ and ‘intra (...truncated)