Bariatric surgery reduces intracranial pressure, weight in women with IIH
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Bariatric surgery led to “significantly lower” intracranial pressure and weight in women with idiopathic intracranial hypertension compared with community weight management intervention, according to findings published in JAMA Neurology.
“We hypothesized that bariatric surgery would be superior to a community weight management intervention in reducing intracranial pressure (ICP) among patients with IIH because of greater sustained weight loss,” Susan P. Mollan, MBcHB, member of the department of Ophthalmology at the University Hospitals Birmingham NHS Foundation Trust, and colleagues wrote. “We therefore conducted a multicenter randomized clinical trial (Idiopathic Intracranial Hypertension Weight Trial [IIH:WT]) comparing bariatric surgery with a community weight management intervention to evaluate which approach was more effective in decreasing ICP among participants with active IIH, with the primary end point being lumbar puncture opening pressure measured after 12 months.”
While previous studies had shown an association between bariatric surgery and long-term weight loss as well as remission of idiopathic intracranial hypertension (IIH), there was no evidence from randomized clinical trials prior to IIH:WT.
In the 5-year randomized clinical trial, Mollan and colleagues analyzed 66 women with active IIH and a BMI of 35 kg/m2 or higher (mean age, 32 years; 55% white; 5% Black, African or Caribbean) at five hospitals in the U.K. between March 1, 2014, and May 25, 2017. They randomly assigned participants 1:1 to receive either a community weight management intervention (Weight Watchers; CWM arm) or bariatric surgery (surgery arm). Participants provided a complete medical history, clinical measurements and a headache diary throughout the study.
The primary outcome was any change in ICP measured specifically by lumbar puncture opening pressure at the 12-month mark. ICP at 24 months was considered a secondary outcome, in addition to contrast sensitivity, visual acuity, perimetric mean deviation and quality of life.
Twelve months into the clinical trial, only 64 women remained, and 54 were included in the primary outcome analysis. In the bariatric surgery arm, researchers observed significantly lower ICP (adjusted mean difference, 6 cm cerebrospinal fluid (CSF); 95% CI, 9.5 to 2.4 cm CSF), significantly lower weight (adjusted mean difference, 21.4 kg; 95% CI, 32.1 to 10.7 kg) and significantly improved quality of life (adjusted mean difference, 7.3; 95% CI, 0.2-14.4;) compared with the CWM arm. The bariatric surgery arm continued to show significant improvements compared with the CWM arm at 24 months.
The investigators concluded that bariatric surgery was more effective than community weight management in patients with active IIH when trying to reduce ICP, disease remission and improve quality of life.
The limitations of this study include a small participant pool, which made it difficult for researchers to recommend one surgery over another.
“These cardiovascular improvements and their positive implications for other comorbidities, such as polycystic ovarian syndrome, may be of additional benefit for those with IIH because IIH is associated with a [twofold] increased risk of worse cardiovascular outcomes and polycystic ovarian syndrome,” Mollan and colleagues wrote. “Future clinical trials should investigate which type of bariatric surgical procedure is superior for patients with IIH.”
Perspective
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IIH is a disease entity frequently encountered by eye care practitioners due to its tendency to lead to papilledema. IIH most often develops in overweight women of child bearing age. Weight loss plays a major role in the systemic management of IIH.
This study, the Idiopathic Intracranial Hypertension Weight Trial, was undertaken to compare the effectiveness of community weight loss management programs vs. bariatric surgery at reducing ICP in patients with IIH. It was a prospective study conducted in England that recruited women with IIH aged 18 to 55 years. Sixty-six women were enrolled; 33 into the community weight loss management study arm and 33 into the bariatric surgery arm. Not all the 66 women completed the study. When those participants who completed the study were analyzed, those who participated in the bariatric surgery arm had significantly more weight loss, which led to significantly more reduction in ICP at both 12 and 24 months.
As eye care practitioners, we are not tasked with systemically managing IIH. However, with the significant impact that increased ICP can have on the optic nerves, it is important that our patients obtain the best possible systemic care to preserve visual function. The results of this study indicate that bariatric surgery should perhaps be considered more often in patients with IIH. However, bariatric surgery has some significant potential risks and complications, and is not appropriate for everyone. As is so often the case in medicine, one size truly does not fit all, and each case should be approached individually, considering all factors relevant to the individual involved.
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