In women with idiopathic intracranial hypertension (IIH) and a body mass index (BMI) of 35 or greater, bariatric surgery was a more effective means of reducing intracranial pressure and maintaining disease remission compared to a 5-year randomized one Weight Loss Program in Community Trial showed.
Women who underwent bariatric surgery had significantly lower intracranial pressure after 12 months, as measured by the opening pressure of the lumbar puncture, with adjusted mean differences in cerebrospinal fluid (CSF) of -6.0 cm (95% CI -9.5 to -2.4, P = 0.001) -8.2 cm (95% CI -12.2 to -4.2 cm, P <0.001) after 24 months compared to the weight loss arm, reported Dr. Alexandra Sinclair from the University of Birmingham in England and co-author.
Weight was also significantly lower in the bariatric surgery arm, with adjusted mean differences of -21.4 kg (95% CI -32.1 to -10.7, P <0.001) at 12 months and -26.6 kg ( 95% CI -37.5 to -15.7). P <0.001) after 24 months they wrote in JAMA Neurology.
IIH-related intracranial pressure causes optic disc swelling or papillary edema, generally leading to chronic headaches (often migraines), potentially permanent vision loss, and, unsurprisingly, an adverse effect on patients’ quality of life, the authors say.
Those who had bariatric surgery showed significant change after 12 months (adjusted mean difference 7.3, 95% CI 0.2-14.4, P = 0.04) and after 24 months (adjusted mean) the assessment of the physical components of the 36-point short-form health survey difference 10.4, 95% CI 3.0-17.9, P = 0.006).
The study “documented significant improvements in the assessment of physical components, physical functioning of energy and fatigue, and general health after bariatric surgery … [which] has been associated with quality of life benefits as well as IIH remission, “wrote Sinclair and colleagues.
For the UK hospital study, a total of 66 women (mean age 32 years) diagnosed with active IIH who had tried unsuccessfully to achieve adequate weight loss for at least 6 months were randomly selected to either have surgery (n = 33 ) or to receive a weight face-to-face sessions of the observers (n = 33) from March 1, 2014 to May 25, 2017. The study population had a mean lumbar puncture opening pressure of 35.5 cm CSF and similar baseline features. About 15% were Black, African, or Caribbean, or of mixed race, and about 29% were on total acetazolamide treatment.
The primary result was a change in intracranial pressure as measured by the opening pressure of the lumbar puncture after 12 months as assessed in an intention-to-treat analysis. Secondary results included lumbar puncture opening pressure at 24 months, as well as visual acuity, contrast sensitivity, perimetric mean deviation, and quality of life at 12 and 24 months.
The changes in the degree of papilledema, headache disability, visual function and other IIH symptoms were similar for both groups, as were the anxiety and depression scores.
Weight loss is often difficult for patients with IIH, some of whom may have underlying polycystic ovarian syndrome, noted Dr. Deborah Friedman of the MPH of the University of Texas Southwestern Medical Center at Dallas noted in an accompanying editorial.
In addition, organized weight loss programs are often impractical for patients with IIH, disproportionately affecting low-income black women in the United States, creating socio-economic disparities that, in addition to symptoms, limit access to individual nutrition programs.
“Especially 14 [of the 33] Participants who were randomly chosen to be the weight management arm never attended a Weight Watchers session, 2 participants withdrew from the study, and 2 participants underwent bariatric surgery themselves … [which may suggest] a general frustration with nutritional management in patients with IIH, “Friedman wrote.
In a bariatric surgery, the lumbar puncture opening pressure was “reduced to a level that, on average, barely reached the threshold (25 cm CSF) to qualify for a diagnosis of IIH,” she noted. “”[O]Outcomes such as visual function, various symptoms of IIH, and headache obstruction improved similarly in both treatment groups. “
This shows that controlling CSF pressure is often insufficient to minimize headache strain, she said. “Still, bariatric surgery offers significant benefits in terms of metabolic syndrome, hypertension, cardiovascular risk, and overall medical health.”
Friedman also noted that a post hoc analysis found greater reductions in the use of acetazolamide, topiramate, and headache prevention drugs in surgical patients during the study, compared with a small difference between those in the weight management arm.
Sinclair and his team acknowledged that the small number of participants prevented them from evaluating patient-centered outcomes and recommending what type of bariatric surgery would be best for patients with IIH that should be investigated in future studies. In addition, the results do not directly inform about treatment for men or women with a BMI less than 35.
Disclosure
The study was funded by a grant from the National Institute for Health Research and a grant from the Medical Research Council.
Sinclair reported that he received grants from the Medical Research Council and funding through a Sir Jules Thorn Award for Biomedical Science while conducting the study.
Other co-authors reported links to industry.
Friedman reported no conflicts of interest.
