Surgery and Other Things

So we talked about acetazolamide. It is a terrible terrible drug, but it means I still get to see so I try not to complain. The other drugs used to treat IIH are all carbonic anhydrase inhibitors like acetazolamide. They are not used as often, but are sometimes used in conjunction with acetazolamide and when acetazolamide cannot be tolerated. So in essence, they're all pretty much the same.

Corticosteroids are also occasionally used but they are more for helping acute symptoms of swollen optic nerves. I was prescribed steroids to help clear up my double vision. They worked. They can actually cause a rise in pressure when they are discontinued.

Optic Nerve Fenestration (image credit)

There is also the good old fashioned lumbar puncture (spinal tap). This is actually a relatively painless procedure (thanks to the local) done to measure intracranial pressure and provide some relief of acute symptoms. It is not a permanent fix. To put it in perspective, I had a spinal tap on a Tuesday, my pressure was 60. I was back in the hospital by Thursday with a horrific headache and my pressure was already back up to 40. Cerebrospinal fluid builds quickly. Your body is constantly making it and if it is not being absorbed effectively it doesn't take long for that pressure to climb.

There are two surgical options for patients with IIH, but these are used only as a means of last resort. They are used if medication is not effective or if the patient is in imminent danger of permanent vision loss.

The first is an optic nerve fenestration. Pictured to the right a window is cut in the sheath that surrounds the optic nerve allowing fluid to escape putting less pressure on the nerve and therefore decreasing swelling. This is done when sight is in danger and is less about decreasing pressure than it is about saving sight.
The other surgical option is a shunt placement. Shunts help to drain fluid into another place in the body where they can be absorbed. The most common place in the stomach. Shunts can be placed in a few places

Lumboperitoneal Shunt (LP Shunt) image credit

This shunt is placed in the spinal chord and drains into the stomach where the cerebrospinal fluid can be absorbed.

Ventriculoperitoneal Shunt (VP Shunt) image credit

A VP shunt is placed in the brain and most often drains cerebrospinal fluid into the stomach where in can be absorbed.

There is a third type, but it is only used when an LP or VP shunt is impossible.

When I tell people about IIH, they think to themselves well get a shunt and quit your complaining. Shunts are tricky little buggers. Some people have absolutely no issues while some (to the tune of 50%) of people have to have constant revisions. Shunts can become blocked causing infection and can also malfunction causing a build up of cerebrospinal fluid. Shunts can also take too much cerebrospinal fluid causing low pressure headaches that can lead to a bleed in the brain.

If you have gotten this far, I thank you. I will totally have cute cake pictures for you later!