Utility of intracranial pressure monitoring in idiopathic intracranial hypertension patients with refractory headaches: an 8-year, single-surgeon, specialized-center retrospective study.

OBJECTIVE

Idiopathic intracranial hypertension (IIH) is a complex disorder characterized by chronically elevated intracranial pressure (ICP) resulting in headaches and the threat of vision loss. In patients with refractory symptoms despite standard treatments, invasive ICP monitoring (ICPm) may provide critical physiological insights to guide management. However, data on the clinical utility of ICPm in IIH remain limited. This study aimed to evaluate the clinical utility of ICPm in IIH patients with refractory symptoms.

METHODS

The authors performed a retrospective analysis of the medical records of 158 adults with IIH who underwent intraparenchymal ICPm for refractory headaches from 2016 to 2023. ICP data were classified into patterns of normal, high, low, or mixed pressure. Multilevel binomial regression models were used to assess predictors of symptom improvement, adjusting for ICPm indication, final diagnosis, and intervention type. Symptom changes were evaluated at follow-up.

RESULTS

The cohort was predominantly female (89.9%), with a mean age of 38.9 ± 10.9 years. All patients presented with chronic headaches, with 35.4% reporting positional headaches, 54.4% visual disturbances, and 24.7% auditory symptoms. Indications for ICPm included shunt dysregulation (52.5%), suspected CSF leakage (36.1%), and elevated ICP (11.4%). Prior to ICPm, 63.9% of patients had CSF shunts in place. ICPm revealed normal pressure in 55.0%, high pressure in 10.8%, low pressure in 22.2%, and mixed patterns in 12.0% of patients. Based on ICPm findings, 42.4% of patients underwent shunt-related interventions, 6.3% received medical therapy, and 34.2% were referred to relevant clinics. Symptom improvement was observed in 46.2% of patients with headaches and > 70% with visual and auditory symptoms. Multivariable analysis showed that older age (OR 0.69, 95% CI 0.48-1.00; p = 0.05) and non-ICP-directed treatments (symptomatic management and referral, both p < 0.02) were associated with lower odds of headache improvement, while the presence of an empty sella on imaging correlated with higher odds of improvement (OR 2.82, 95% CI 1.07-7.46; p = 0.04). ICPm indications had comparable odds of improvement. Referrals and non-ICP-modifying treatments were associated with lower odds of symptom improvement.

CONCLUSIONS

ICPm is a valuable tool in managing IIH patients with refractory symptoms, providing diagnostic clarity, guiding management decisions, and potentially avoiding unnecessary interventions. These findings underscore the heterogeneity of ICP dynamics in IIH and support ICPm as an important adjunct in complex cases.