Traits differ between idiopathic intracranial hypertension diagnosed younger, older
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Later idiopathic intracranial hypertension diagnoses occurred less often in women with slightly lower cerebrospinal fluid opening pressure and fewer headaches, according to a retrospective, clinical cohort study.
“Few studies have investigated the clinical features of patient conditions diagnosed as [idiopathic intracranial hypertension (IIH)] later in life, and the authors are unaware of any studies describing a large cohort of older patients. ...” Peter A. Downie, of University of Minnesota’s department of ophthalmology and visual neurosciences, and colleagues wrote in American Journal of Ophthalmology. “Further characterization of this older patient population would advance understanding subtleties in clinical manifestations and help with diagnosis and management of this rare disorder.”
Downie and colleagues collected data from University of Minnesota, Mayo Clinic, University of Oklahoma and Washington University in St. Louis and compared 65 patients diagnosed with IIH aged older than 50 years with matched participants diagnosed before age 50 years. Participants diagnosed earlier were randomly selected by each academic center.
In the older group, 51 participants (78.5%) were women, while there were 60 women in the younger group (92.3%). The older group had fewer headaches at presentation (50.8% vs. 80% in the younger group), slightly lower cerebrospinal fluid (CSF) opening pressure (33 cm H2O vs. 34 cm H2O), more often incidentally discovered papilledema (29.2% vs. 10.8%) and other medical conditions such as hypertension (69.2% vs. 7.7%). They also were less likely to use cycline antibiotics (0% vs. 10.8%).
Later diagnosis was not associated with worse outcomes or need for surgery.
The researchers noted this was the largest analysis to their knowledge of IIH diagnosed later in life. They wrote that their results confirmed the findings of previous smaller studies and furthered knowledge of IIH in older people.
“Older patients diagnosed with IIH could represent new recognition of longstanding IIH, where these patients did not seek earlier care due to having relatively mild symptoms,” Downie and colleagues wrote. “This could account for lower rates of headache and more frequent presentation with incidental papilledema on routine examination.”
Limitations included few patients diagnosed with IIH after age 50 years, retrospective design and lack of consecutive controls.
Clinically, the researchers suggested management should be similar for later and earlier diagnosed IIH because presentation, treatment and outcomes are similar between the two groups.
Perspective
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The classic patient demographics for IIH typically identify as obese women at a mean age of 30 years. However, as with any condition, patients can present with IIH that do not match with the typical profile. The authors in this investigation performed a multi-center retrospective analysis of 65 patients who were greater than two standard deviations above the mean age of IIH diagnosis: 50 years. The purpose was to identify characteristics and clinical findings in IIH patients older than 50 that might differ from those with a mean age of 30 years, who were used as the control cohort.
The investigators scrutinized an extensive list of potential variables such as BMI, medications, visual signs and symptoms, and treatment outcomes, but found very few large discriminating differences between the two populations. Even those findings that were somewhat statistically significant might not be so if the study cohort was in fact larger. The study patients were from Missouri, Minnesota and Oklahoma and may not represent all regions of the country, as only the percentage Caucasian was reported. Of note, there was a higher prevalence of systemic conditions in the older cohort (diabetes, hypertension, sleep apnea and thyroid disease) but this was determined to be more a factor of age rather than impacting the IIH.
The takeaway from the study remains: Older patients with IIH will more likely be discovered incidentally and be less symptomatic than their younger counterparts. From a practitioner perspective when evaluating this age cohort, we must also rule out other causes of disc swelling such as sleep apnea, malignant hypertension, diabetic papillopathy and ischemic optic neuropathy, as the prevalence of systemic conditions is much higher.
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