Can Lumbar Puncture Be Safely Deferred in Patients With Mild Presumed Idiopathic Intracranial Hypertension?

Authors: Amir R. Vosoughi, Edward Margolin, Jonathan A. Micieli.

Disclosure Block: A.R. Vosoughi: None. E. Margolin: None. J.A. Micieli: None.

Abstract Body:

Purpose: Lumbar puncture (LP) is performed to exclude secondary causes in patients suspected of idiopathic intracranial hypertension (IIH). However, LPs may be difficult to obtain, are subject to technical issues and may have complications. The goal of this study was to determine whether LP could be safely deferred in patients with mild vision loss and papilledema from presumed IIH.
Study Design: This was a retrospective study of patients with presumed IIH and papilledema determined by clinical exam and ancillary testing who did not undergo LP.
Methods: Inclusion criteria included: i) no symptoms suspicious for systemic infectious/neoplastic/inflammatory processes ii) no secondary causes of raised ICP seen on MRI/MRV iii) OCT-RNFL thickness <300um iv) Humphrey mean deviation (MD) <-5.00dB v) at least one follow-up visit. Clinical characteristics, final visual outcome and diagnosis were retrieved. The presence and severity of an empty sella were determined based on review of mid-sagittal T1-MRI images. An empty sella was graded on a scale from 1 (normal) to 5 (no pituitary tissue visible).
Results: A total of 132 eyes of 68 patients (66 female and 2 male) were included in the study. Mean+SD age was 31.4+10.2 years and BMI was 35.1+6.8kg/m². Systemic symptoms included headache (n=47), pulsatile tinnitus (n=28), transient visual obscurations (n=10) and diplopia (n=2). Presenting logMAR visual acuity was 0.020+0.090, Humphrey MD was -2.23+1.38dB and OCT RNFL thickness was 150.8+48.4um. An empty or partially empty sella was present in 91% of patients and average sella grade was 3.20+1.15. Patients were followed for a mean number of 63.3+78.3 weeks, no additional cause of intracranial hypertension was discovered and all patients remained systemically well. All patients were counselled on weight loss, 31 patients lost at least some weight, and 2 patients were started on acetazolamide. There was a significant improvement in the Humphrey MD (-1.73+1.74dB; p<0.001) and OCT RNFL thickness (128.1+38.6um; p<0.001) at final follow-up.
Conclusions: Patients with mild vision loss and papilledema from presumed IIH can be safely followed without LP. Deferring LP in this patient group can result in significant cost and human resource savings. Most patients with mild vision loss and papilledema from presumed IIH can be managed without pharmacologic treatment.