Skip to main content
Download PDF
Download ePub

MRI features of idiopathic intracranial hypertension are not prognostic of visual and headache outcome

The Journal of Headache and Pain volume 24, Article number: 97 (2023) Cite this article

Abstract

Background

In idiopathic intracranial hypertension (IIH), certain MRI features are promising diagnostic markers, but whether these have prognostic value is currently unknown.

Methods

We included patients from the Vienna-Idiopathic-Intracranial-Hypertension (VIIH) database with IIH according to Friedman criteria and cranial MRI performed at diagnosis. Presence of empty sella (ES), perioptic subarachnoid space distension (POSD) with or without optic nerve tortuosity (ONT), posterior globe flattening (PGF) and transverse sinus stenosis (TSS) was assessed and multivariable regression models regarding visual outcome (persistent visual impairment/visual worsening) and headache outcome (headache improvement/freedom of headache) were fitted.

Results

We included 84 IIH patients (88.1% female, mean age 33.5 years, median body mass index 33.7). At baseline, visual impairment was present in 70.2% and headache in 84.5% (54.8% chronic). Persistent visual impairment occurred in 58.3%, visual worsening in 13.1%, headache improvement was achieved in 83.8%, freedom of headache in 26.2%.

At least one MRI feature was found in 78.6% and 60.0% had ≥3 features with POSD most frequent (64.3%) followed by TSS (60.0%), ONT (46.4%), ES (44.0%) and PGF (23.8%).

In multivariable models, there was no association of any single MRI feature or their number with visual impairment, visual worsening, headache improvement or freedom.

Visual impairment at baseline predicted persistent visual impairment (odds ratio 6.3, p<0.001), but not visual worsening. Chronic headache at baseline was significantly associated with lower likelihood of headache freedom (odds ratio 0.48, p=0.013), but not with headache improvement.

Conclusions

MRI features of IIH are neither prognostic of visual nor headache outcome.

Peer Review reports

Introduction

Idiopathic intracranial hypertension (IIH), a syndrome of elevated intracranial pressure (ICP) with increasing prevalence but unclear etiology, bears not only the risk of visual impairment and chronic disabling headache, but also significant reduction of quality of life and considerable socioeconomic costs [1, 2].

Estimating prognosis at the time of diagnosis is currently very challenging as there is a large degree of interindividual heterogeneity in visual and headache outcome and a paucity of reliable outcome predictors [3, 4].

Neuroimaging is required for establishing IIH diagnosis in order to rule out secondary causes of elevated ICP [5]. There are also various MRI signs indicative of IIH such as empty sella (ES) sign, perioptic subarachnoid space distension (POSD) with or without optic nerve tortuosity (ONT), posterior globe flattening (PGF), and transverse sinus stenosis (TSS) [6]. A MRI displaying at least three out of these four signs is highly specific and moderately sensitive for elevated ICP, but absence of these findings does not rule out IIH and may depend upon rater experience [7, 8].

Apart from aiding in diagnosis, MRI features of IIH might also have prognostic value. However, currently available evidence in this regard is scarce, methodologically limited by small sample sizes, largely lacks adjustment for confounders, and thus, has delivered conflicting results [6, 9,10,11,12,13]. Furthermore, studies on prognostic impact of MRI in IIH have focused on visual outcome, largely leaving headache outcome aside.

Therefore, here we aimed to determine whether MRI features of IIH provide value for predicting visual and headache outcome in a large and well-characterized real-world cohort applying a thorough and pre-defined approach with multivariable analyses.

Methods

Patients and definitions

For this retrospective cohort study, we used the Vienna Idiopathic Intracranial Hypertension (VIIH) database, which is jointly established by the Departments of Neurology and Ophthalmology, serving as both primary and reference center mainly for Vienna and its geographical catchment area. By November 30th 2022, a cohort of 151 patients with IIH according to modified Friedman criteria had been included [5]. Details of the VIIH database are described elsewhere [14]. Briefly, standardized VIIH case reports include demographic data, disease specific parameters as well as documentation of diagnostic and therapeutic procedures. Data are collected retrospectively at first visit and prospectively whenever the patient returns for scheduled follow-up or unscheduled visits. Specialized neurologists and neuro-ophthalmologists performed all examinations. Headache history is assessed by a combination of history and a headache diary. Headache phenotype is classified according to ICHD-3 as either migraine-like, tension-type headache-like or unclassifiable [15]. All patients were treated according to best practice based on recommendation of weight loss, pharmacological treatment with acetazolamide, topiramate and/or furosemide, and invasive treatment options such as ventriculoperitoneal (VP) shunt in case of treatment refractory papilledema.

For the present study, we included all patients with definite IIH or IIH-WOP according to Friedman criteria for whom initial diagnostic MRI with images on file and a minimum follow-up of 12 months were available. Patients with probable IIH or suggested IIH-WOP according to Friedman criteria were excluded as well as any patients with secondary causes of intracranial hypertension [5]. We also excluded patients if (1) MRI had been performed more than 4 weeks before first diagnostic LP, or (2) LP was performed before MRI.

MRI scans were done on 1.5 or 3T MR scanners. MRI protocols differed in some detail but included at least T1 and T2w sequences in two different planes for excluding structural lesions and a venous non-contrast MR angiography or T1 post gadolinium sequence for excluding suspected sinus vein thrombosis. MRI images were independently reviewed by a senior neuroradiologist with extensive experience in IIH imaging (W.M.), who was blinded for clinical data. MRI features of IIH were defined as follows. ES sign was evaluated by assessing the degree of suprasellar herniation of CSF into the in the sagittal plane applying a cut-off of moderate herniation (≥ 1/3 of the sella height) [16]. POSD was defined as a uni- or bilateral optic nerve sheath width > 4 mm in the coronal plane of T2 weighted images [17]. ONT and PGF were based on a qualitative evaluation on axial T2 weighted images [17]. For TSS, the patency of each transverse sinus (left and right) was evaluated relative to the diameter of the lumen of the distal superior sagittal sinus with the narrowest segment of the transverse sinus used to determine the degree of stenosis. TSS was defined as uni- or bilateral stenosis of at least ≥ 50% [17, 18].

Headache and visual outcomes were assessed 12 months after IIH diagnosis applying the following definitions:

  • Persistent visual impairment: visual acuity ≥ 0.1 logarithm of the minimum angle of resolution (logMAR; determined by Sloan charts at distance after subjective refraction) and/or mean deviation <-2.0 in decibels (dB) in automated static threshold perimetry determined by 30 − 2 test with Swedish interactive threshold algorithm (SITA) [19].

  • Visual worsening: deterioration of visual acuity by ≥ 0.2 logMAR and/or mean deviation by ≥ 2.0 dB in static threshold perimetry compared to baseline.

  • Headache improvement: ≥50% reduction of headache severity (on the visual analogue scale) and/or headache frequency (expressed as headache days per month) compared to baseline.

  • Freedom of headache: <1 headache day per month.

As relevant covariables, visual impairment at baseline was defined as baseline visual acuity ≥ 0.1 logMAR and/or mean deviation <-2.0 dB in automated static threshold perimetry. Headache was classified as chronic if present on ≥ 15 days/month for ≥ 3 months.

Standard protocol approvals, registrations, patient consents, and reporting

The study was approved by the ethics committee of the Medical University Vienna (ethical approval number: 2216/2020). As this was a retrospective study, the need for written informed consent from study participants was waived by the ethics committee. This study adheres to the reporting guidelines outlined within the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) Statement.

Data availability statement

Data supporting the findings of this study are available from the corresponding author upon reasonable request by a qualified researcher and upon approval by the data-clearing committee of the Medical University of Vienna.

Statistics

Statistical analysis was performed using SPSS 26.0 (SPSS Inc, Chicago, IL, USA) and R-Statistical Software (Version 4.0.0). Categorical variables were expressed in absolute frequencies and percentages, continuous parametric variables as mean and standard deviation (SD) and continuous non-parametric variables as median with inter-quartile range (IQR) and absolute range (AR) as appropriate.

Univariable group comparisons were done by Chi-squared test, Mann-Whitney U test or independent t-test (with Welch’s correction in case of unequal standard deviations between the groups) as appropriate. Univariable correlations were analyzed by Pearson or Spearman test as appropriate.

Association of MRI features with headache and visual outcome parameters was tested by Firth’s bias-reduced logistic regression models (R package “logistf”, Version 1.24.1), a penalized likelihood-based method which increases estimator efficiency in logistic regression models with small samples [20]. In these models, every single MRI sign was defined as a dichotomous independent variable comparing absence and presence of ES, POSD, ONT, PGF, and TSS using absence as reference category. Dependent variables comprised persistent visual impairment, visual worsening, headache improvement and freedom of headache. Similar models were set up for the presence and absence of a certain number of MRI signs, setting the cut-off at ≥ 1 and ≥ 3, respectively.

Corrected Akaike information criterion (AICc) was employed to select the most parsimonious models among a pre-defined set of covariables based on clinical gestalt (for visual outcomes: age, BMI, CSF opening pressure, visual impairment at baseline; for headache outcomes: age, BMI, CSF opening pressure, chronic headache at baseline, baseline headache severity) as well as any other variables available at baseline associated with outcome parameters at a p-value < 0.2 in univariable analyses [21].

Predefined sensitivity analyses to determine potential confounding influence were conducted with the same model set-up removing patients with a) IIH without papilledema (IIH-WOP), patients with previous headache history (only for models regarding headache outcomes), c) separately removing each headache phenotype group (migraine-like, tension-type-like, unclassifiable; only for models regarding headache outcomes) and d) patients requiring invasive treatment (VP shunt).

Robustness to unidentified confounders was quantified with Rosenbaum sensitivity test for Hodges–Lehmann Γ [22]. Missing values were handled by multiple (20 times) imputation using the missing not at random (MNAR) approach with pooling of estimates according to Rubin’s rules [23]. Significance level was set at a two-sided p-value < 0.05 with Bonferroni correction for multiple testing.

Results

Eighty-four patients were included into the final study cohort. The inclusion/exclusion process is shown in Fig. 1. Cohort characteristics at baseline are given in Table 1. Expectedly, there was a female predominance (88.1%) with mean age at diagnosis at 33.5 years (SD 11.3) and median BMI at 33.7 (IQR 27.3–39.0). Median LP opening pressure was 31 cmH2O (IQR 28–39). Five patients (6.0%) were diagnosed with IIH-WOP (3 fulfilling diagnostic criteria with unilateral abducens palsy, 2 with bilateral abducens palsy). Of note, cohort characteristics did not significantly differ from the whole VIIH cohort (data not shown).

Fig. 1
figure 1

Flow chart of inclusion/exclusion process. MRI: magnetic resonance imaging. VIIH: Vienna Idiopathic Intracranial Hypertension database

Full size image

Overall, ES sign was present in 44.4%, POSD in 64.3%, ONT in 46.4%, and PGF in 23.8%. Of the 70 patients with available venous MRI angiography, 60% displayed TSS. At least one MRI feature was found in 78.6% and ≥ 3 features in 60.0%. Neither any single MRI feature nor the number of MRI features was associated with age, sex, BMI, symptoms at initial presentation, ophthalmological findings or LP opening pressure.

Table 1 Cohort characteristics
Full size table

Visual outcome

Overall, persistent visual impairment occurred in 58.3% and visual worsening in 13.1%.

In univariable analyses, patients with visual impairment at baseline (n = 62) had a significantly higher frequency of persistent visual impairment after 12 months (69.4% vs. 27.3%, p < 0.001) but not of further visual worsening (16.1% vs. 4.5%, p = 0.274). Neither age, sex, BMI, nor LP opening pressure were associated with persistent visual impairment or visual worsening.

Looking at the MRI signs, ONT was associated with a lower frequency of persistent visual impairment (30.6% vs. 68.6%, p < 0.001) as was the presence of ≥ 3 MRI features (74.2% vs. 48.7%, p = 0.049), while ES, POSD, PGF, TSS and ≥ 1 MRI feature were not (Supplemental Table 1). None of the MRI signs were associated with visual worsening.

In multivariable analyses, AICc suggested the models including baseline visual impairment as the most parsimonious ones concerning both persistent visual impairment and visual worsening, while age, BMI, and CSF opening pressure were not retained (Table 2). Here, baseline visual impairment was statistically significantly associated with an increased likelihood of persistent visual impairment (OR 6.24, 95% CI 2.09–18.7, p < 0.001). After adjusting for baseline visual impairment, neither any single MRI sign (ES, POSD, ONT, PGF, TSS) nor the number of detected MRI signs (≥ 1, ≥ 3) were significantly associated with either persistent visual impairment or visual worsening (Table 2).

As none of the five IIH-WOP patients showed persistent visual impairment or visual worsening, IIH-WOP could not be included into the regression models. Sensitivity analyses removing IIH-WOP patients did not significantly change results as was the case when removing patients requiring invasive treatment (n = 4), who all suffered persistent visual impairment and visual worsening after diagnosis.

Table 2 Multivariable regression models regarding visual outcome
Full size table

Headache outcome

Headache improvement was achieved in 83.3% and freedom of headache in 26.2%. Lower age was significantly correlated with headache improvement (rho − 0.256, p = 0.019) but not with freedom of headache. Patients with chronic headache at baseline (n = 43) had significantly lower frequency of headache freedom (14.6% vs. 37.2%, p = 0.025) but not headache improvement (81.4% vs. 85.4%, p = 0.772). Neither sex and BMI, nor LP opening pressure were associated with headache improvement and freedom. Also, neither headache frequency nor headache severity at baseline were significantly correlated with headache improvement. Of the five patients with IIH-WOP, all reached headache improvement but none freedom of headache.

Univariable analyses did not show any association between any MRI parameter (ES, POSD, ONT, PGF, TSS, ≥ 1 feature, ≥ 3 features) and either headache improvement or freedom of headache (Supplemental Table 2).

In multivariable analyses concerning headache improvement, AICc suggested a model including age and chronic headache at baseline as the most parsimonious model, while BMI, CSF opening pressure and baseline headache severity were not retained (Table 3). This model did not indicate any significant association between MRI features of IIH and headache improvement. Regarding freedom of headache, a model including chronic headache at baseline was the most parsimonious one, while age, BMI, CSF opening pressure and baseline headache severity were not retained (Table 3). Here, baseline chronic headache was significantly associated with a decreased likelihood of headache freedom (OR 0.48, 95% CI 0.17–0.91, p = 0.013), but there was no statistically significant association between any single MRI feature or their number and freedom of headache. As all five IIH-WOP patients showed headache improvement but none freedom of headache, IIH-WOP could not be included into the regression models. Sensitivity analyses removing IIH-WOP patients, patients with previous headache history, patients requiring invasive treatment as well as separately removing each headache phenotype group (migraine-like, tension-type-like, unclassifiable from the regression models did not significantly change the overall results or impact of single variables.

Table 3 Multivariable regression models regarding headache outcome
Full size table

Discussion

The aim of the present study was to determine whether MRI features of IIH are of value for predicting visual and headache outcome in a large and well-characterized real-world cohort.

To date, studies investigating prognostic value of MRI features of IIH largely focused on visual outcome and delivered conflicting results. One cross-sectional study reported that the presence of more than three MRI features correlated statistically significantly with the severity of vision loss at diagnosis, and a retrospective study indicated that TSS was associated with poor visual outcome [11, 12]. On the other hand, three retrospective studies found no association between MRI features and visual outcome [9, 10, 13]. These studies are limited by small sample sizes, a high likelihood of selection bias and lack adjustment for relevant confounders [9,10,11,12,13].

Applying thorough multivariable analyses based on a pre-defined approach designed to adjust for relevant confounders and multiple testing while also avoiding over-fitting, there was no association of any single MRI feature of IIH or their number with visual or headache outcome in the present study.

When analyzed in isolation, ONT and POSD displayed association with persistent visual impairment of our cohort. POSD and ONT, which is believed to occur due to pressure induced kinking by fixation of the optic nerve at proximal and distal points, presumably reflect increased CSF pressure in the optic nerve sheath [6]. While this would principally make POSD/ONT intriguing candidates for predicting visual outcome, multivariable analyses showed that this association is mostly mediated by visual impairment at baseline and, unfortunately, POSD/ONT did not provide independent additional prognostic value.

Overall, visual outcome in our cohort is well within the range of existing literature with about 60% displaying at least some degree of persistent visual impairment one year after diagnosis and a little over 10% suffering further visual worsening [10, 24, 25]. If visual impairment was already present at diagnosis, the odds of persistent visual impairment increased more than 6-fold constituting the only significant predictor of visual outcome in our cohort. This was expected and is in line with previous studies [10, 24,25,26].

Turning to headache outcome, improvement of headache frequency and/or severity was achieved in more than 80% of patients after one year of treatment in our cohort, while some degree of headache persisted in about three quarters of patients, both well in line with existing literature [27,28,29,30]. Studies investigating predictors of headache outcome in IIH are generally very scarce as most focus on visual outcome, likely because visual impairment is often considered more relevant and is also easier to measure in clinical practice. However, headache is indeed the main factor affecting quality of life in patients with IIH [31, 32]. Thus, identifying predictors of headache outcome is an unmet need in IIH. In our cohort, presence of headache already fulfilling criteria of chronic headache at baseline was the only factor remaining statistically significantly associated with headache outcome after conducting thorough multivariable analyses. Somewhat expectedly, chronic headache halved the odds for freedom of headache but not for headache improvement, as it is obviously easier to achieve a 50% reduction of monthly headache days or headache severity as opposed to less than one when starting with fifteen or more. This is in line with an earlier study, where longstanding headache was also associated with persistent headache after CSF shunting [33]. In agreement with previous findings, age, BMI and CSF opening pressure did not predict headache outcome [28]. Disappointingly, the investigated MRI features of IIH did not provide any independent prognostic information regarding headache improvement or freedom. It is well known that headache in IIH is not sufficiently explained by raised ICP alone [29, 30, 34]. As the pathophysiologic process underlying the development of MRI signs of IIH is likely primarily a correlate of raised ICP, this may explain the lack of an association with headache outcome.

Strengths and limitations

The strengths of the VIIH database are the large sample size of a population-based cohort encompassing most IIH patients from our geographic area with close-meshed, standardized follow-up reflecting the whole spectrum of a real-world cohort [14, 35].

However, some limitations are be acknowledged. The retrospective analyses of data collected in clinical routine creates a variety of possible biases, e.g. diagnostic accuracy may be lower in this type of IIH cohort compared to a strictly prospective cohort, although these are mitigated by the standardized data collection and thorough quality control applied within the VIIH. Treatment regimens followed best practice recommendations but naturally varied inter-individually, potentially inducing bias. We could not adjust multivariable models for treatment parameters as this would have caused over-fitting. While sensitivity analyses did not indicate bias by invasive treatment (VP shunt), a confounding influence of weight loss and/or pharmacological treatment cannot be excluded. However, Rosenbaum bounds did indicate only a small potential impact of hidden bias not accounted for in the multivariable models. Thus, it is unlikely that a true prognostic effect of MRI signs was missed due to unaccounted confounding. Importantly, MRI scans were done in a real-world setting, which includes different scanners and field strengths (1.5 and 3T) and varying image acquisition protocols. Mitigating this potential cause of bias is the blinded rating by a senior neuroradiologist with extensive experience in IIH imaging. IIH-WOP remains a controversial diagnosis potentially representing a distinct phenotype. Since sample size (n = 5) in our cohort was insufficient to conduct subgroup analyses, we could only perform sensitivity analyses removing IIH-WOP patients to exclude a confounding effect on our results.

Conclusion

MRI features of IIH are neither prognostic of visual nor headache outcome. Identifying reliable clinical or paraclinical predictors of outcome remains a critical area of need in IIH.

Availability of data and materials

Data supporting the findings of this study are available from the corresponding author upon reasonable request by a qualified researcher and upon approval by data-clearing unit of the Medical University Vienna.

References

  1. Radhakrishnan K, Ahlskog JE, Cross SA et al (1993) Idiopathic Intracranial Hypertension (Pseudotumor Cerebri): Descriptive Epidemiology in Rochester, Minn, 1976 to 1990. Arch Neurol-chicago 50(1):78–80

  2. Kilgore KP, Lee MS, Leavitt JA et al (2017) Re-evaluating the incidence of idiopathic intracranial hypertension in an era of increasing obesity. Ophthalmology 124:697–700

    Article  PubMed  Google Scholar 

  3. Raoof N, Hoffmann J (2021) Diagnosis and treatment of idiopathic intracranial hypertension. Cephalalgia 18(10):1266–8. https://0-doi-org.brum.beds.ac.uk/10.1111/j.1468-1331.2011.03372.x. Epub 2011 Mar 22

  4. Peng MG, Gokoffski KK (2021) Updates on recent developments in idiopathic intracranial hypertension. SN Compr Clin Medicine 3:1031–1041

    Article  Google Scholar 

  5. Friedman DI, Liu GT, Digre KB (2013) Revised diagnostic criteria for the pseudotumor cerebri syndrome in adults and children. Neurology 81:1159–1165

    Article  PubMed  Google Scholar 

  6. Barkatullah AF, Leishangthem L, Moss HE (2021) MRI findings as markers of idiopathic intracranial hypertension. Curr Opin Neurol 34(1):75–83. https://0-doi-org.brum.beds.ac.uk/10.1097/WCO.0000000000000885

  7. Mallery RM, Rehmani OF, Woo JH et al (2019) Utility of Magnetic Resonance Imaging Features for Improving the Diagnosis of Idiopathic Intracranial Hypertension Without Papilledema. J Neuro-ophthalmol 39(3):299–307. https://0-doi-org.brum.beds.ac.uk/10.1097/WNO.0000000000000767

  8. Bsteh G, Marik W, Macher S et al (2023) Impact of rater experience and referral question on detecting MRI features of idiopathic intracranial hypertension. Eur J Neurol. https://0-doi-org.brum.beds.ac.uk/10.1111/ene.15986. Online ahead of print

  9. Saindane AM, Bruce BB, Riggeal BD et al (2013) Association of MRI findings and visual outcome in idiopathic intracranial hypertension. Ajr Am J Roentgenol 201:412–418

    Article  PubMed  PubMed Central  Google Scholar 

  10. Agarwal A, Vibha D, Prasad K et al (2017) Predictors of poor visual outcome in patients with idiopathic intracranial hypertension (IIH): an ambispective cohort study. Clin Neurol Neurosur 159:13–18

    Article  Google Scholar 

  11. Prabhat N, Chandel S, Takkar DA et al (2021) Sensitivity and specificity of neuroimaging signs in patients with idiopathic intracranial hypertension. Neuroradiol J 34:421–427

    Article  PubMed  PubMed Central  Google Scholar 

  12. Chagot C, Blonski M, Machu J-L et al (2017) Idiopathic Intracranial Hypertension: Prognostic Factors and Multidisciplinary Management. J Obes 5348928. https://0-doi-org.brum.beds.ac.uk/10.1155/2017/5348928. Epub 2017 Aug 13.

  13. Eshtiaghi A, Zaslavsky K, Nicholson P et al (2022) Extent of transverse sinus stenosis does not predict visual outcomes in idiopathic intracranial hypertension. Eye 36:1390–1395

    Article  PubMed  Google Scholar 

  14. Pruckner P, Mitsch C, Macher S et al (2023) The Vienna Idiopathic Intracranial Hypertension (VIIH) database – an austrian registry. Wien Klin Wochenschr (2023) in press https://0-doi-org.brum.beds.ac.uk/10.21203/rs.3.rs-1638134/v1

    Article  Google Scholar 

  15. Headache Classification Committee of the International Headache Society (IHS)  The International Classification of Headache Disorders, 3rd edition (2018) Cephalalgia 38(1):1–211. https://0-doi-org.brum.beds.ac.uk/10.1177/0333102417738202

  16. Yuh WTC, Zhu M, Taoka T et al (2000) MR imaging of pituitary morphology in idiopathic intracranial hypertension. J Magn Reson Imaging 12:808–813

    Article  CAS  PubMed  Google Scholar 

  17. Kwee RM, Kwee TC (2019) Systematic review and meta-analysis of MRI signs for diagnosis of idiopathic intracranial hypertension. Eur J Radiol 116:106–115

    Article  PubMed  Google Scholar 

  18. Farb RI, Vanek I, Scott JN et al (2003) Idiopathic intracranial hypertension: the prevalence and morphology of sinovenous stenosis. Neurology 60:1418–1424

    Article  CAS  PubMed  Google Scholar 

  19. Rosser DA, Cousens SN, Murdoch IE et al (2003) How sensitive to clinical change are ETDRS logMAR Visual acuity measurements? Invest Ophth Vis Sci 44:3278–3281

    Article  Google Scholar 

  20. Heinze G, Schemper M (2002) A solution to the problem of separation in logistic regression. Statist Med 21:2409–2419

    Article  Google Scholar 

  21. Claeskens G (2016) Statistical model choice. Annu Rev Stat Appl 3:233–256

    Article  Google Scholar 

  22. Rosenbaum PR, Rubin DB (1984) Reducing Bias in Observational Studies using subclassification on the Propensity score. J Am Stat Assoc 79:516–524

    Article  Google Scholar 

  23. Council National Research. The Prevention and Treatment of Missing Data in Clinical Trials. National Academies Press, US (2010) (), Epub ahead of print 2010.  https://0-doi-org.brum.beds.ac.uk/10.17226/12955

  24. Wall M, Kupersmith MJ, Kieburtz KD et al (2014) The idiopathic intracranial hypertension treatment trial: Clinical Profile at Baseline. Jama Neurol 71:693–701

    Article  PubMed  PubMed Central  Google Scholar 

  25. Wall M, Johnson CA, Cello KE et al (2016) Visual field outcomes for the idiopathic intracranial hypertension treatment trial (IIHTT)visual field outcomes. Invest Ophth Vis Sci 57:805–812

    Article  CAS  Google Scholar 

  26. Tata G, Kisabay A, Gokcay F et al (2019) Idiopathic intracranial hypertension: are there predictors for visual outcome or recurrences? Clin Neurol Neurosur 183:105378

    Article  Google Scholar 

  27. Friedman DI, Rausch EA (2002) Headache diagnoses in patients with treated idiopathic intracranial hypertension. Neurology 58:1551–1553

    Article  PubMed  Google Scholar 

  28. Yri HM, Rönnbäck C, Wegener M et al (2014) The course of headache in idiopathic intracranial hypertension: a 12-month prospective follow‐up study. Eur J Neurol 21:1458–1464

    Article  CAS  PubMed  Google Scholar 

  29. Friedman DI (2019) Headaches in idiopathic intracranial hypertension. J Neuro-ophthalmol 39:82–93

    Article  Google Scholar 

  30. Simone RD, Sansone M, Bonavita V (2020) Headache in idiopathic intracranial hypertension. A CGRP-dependent head pain? Neurol Sci 41(Suppl 2):417–21. https://0-doi-org.brum.beds.ac.uk/10.1007/s10072-020-04641-w

  31. Mulla Y, Markey KA, Woolley RL et al (2015) Headache determines quality of life in idiopathic intracranial hypertension. J Headache Pain 16:45

    Article  PubMed  PubMed Central  Google Scholar 

  32. Witry M, Kindler C, Weller J et al (2021) The patients’ perspective on the burden of idiopathic intracranial hypertension. J Headache Pain 22:67

    Article  PubMed  PubMed Central  Google Scholar 

  33. Mcgirt MJ, Woodworth G, Thomas G et al (2004) Cerebrospinal fluid shunt placement for pseudotumor cerebri—associated intractable headache: predictors of treatment response and an analysis of long-term outcomes. J Neurosurg 101:627–632

    Article  PubMed  Google Scholar 

  34. Yiangou A, Mitchell JL, Vijay V et al (2020) Calcitonin gene related peptide monoclonal antibody treats headache in patients with active idiopathic intracranial hypertension. J Headache Pain 21:116

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  35. Bsteh G, Macher S, Krajnc N et al Idiopathic intracranial hypertension presenting with migraine phenotype is associated with unfavorable headache outcomes. Headache J Head Face Pain 63(5):601–10. https://0-doi-org.brum.beds.ac.uk/10.1111/head.14478. Epub 2023 Feb 8

Download references

Acknowledgements

We thank all the VIIH investigators, clinical research staff, and especially the patients for helping to collect these data. The named individuals were not compensated for their help.

VIIH investigators in alphabetical order: Bsteh, Gabriel (Department of Neurology, Medical University of Vienna); Kircher, Karl (Department of Ophthalmology, Medical University of Vienna); Krajnc, Nik (Department of Neurology, Medical University of Vienna); Macher, Stefan (Department of Neurology, Medical University of Vienna); Michl, Martin (Department of Ophthalmology, Medical University of Vienna); Mitsch, Christoph (Department of Ophthalmology, Medical University of Vienna); Pemp, Berthold (Department of Ophthalmology, Medical University of Vienna); Reitner, Andreas (Department of Ophthalmology, Medical University of Vienna); Wöber, Christian (Department of Neurology, Medical University of Vienna); Zebenholzer, Karin (Department of Neurology, Medical University of Vienna).

Funding

There was no funding to this research.

Author information

Author notes

  1. Gabriel Bsteh and Wolfgang Marik  contributed equally to this work.

Authors and Affiliations

  1. Department of Neurology, Medical University of Vienna, Vienna, Austria

    Gabriel Bsteh, Nik Krajnc, Stefan Macher, Philip Pruckner & Christian Wöber

  2. Comprehensive Center for Clinical Neurosciences & Mental Health, Medical University of Vienna, Vienna, Austria

    Gabriel Bsteh, Wolfgang Marik, Nik Krajnc, Stefan Macher, Philip Pruckner, Klaus Novak & Christian Wöber

  3. Department of Neuroradiology, Medical University of Vienna, Vienna, Austria

    Wolfgang Marik

  4. Department of Ophthalmology, Medical University of Vienna, Vienna, Austria

    Christoph Mitsch & Berthold Pemp

  5. Department of Neurosurgery, Medical University of Vienna, Vienna, Austria

    Klaus Novak

Authors
  1. Gabriel Bsteh
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Wolfgang Marik
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Nik Krajnc
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Stefan Macher
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. Christoph Mitsch
    View author publications

    You can also search for this author in PubMed Google Scholar

  6. Philip Pruckner
    View author publications

    You can also search for this author in PubMed Google Scholar

  7. Klaus Novak
    View author publications

    You can also search for this author in PubMed Google Scholar

  8. Christian Wöber
    View author publications

    You can also search for this author in PubMed Google Scholar

  9. Berthold Pemp
    View author publications

    You can also search for this author in PubMed Google Scholar

Contributions

GB: study concept and design, acquisition of data, statistical analysis and interpretation of data, drafting of manuscript (contributed equally). WM: study concept and design, acquisition of data, rating of MRI images (gold-standard), interpretation of data, drafting of manuscript (contributed equally). SM: acquisition of data, interpretation of data, critical revision of manuscript for intellectual content. VS: rating of MRI images (junior rater), critical revision of manuscript for intellectual content. NK: acquisition of data, interpretation of data, critical revision of manuscript for intellectual content. PP: acquisition of data, interpretation of data, critical revision of manuscript for intellectual content. CM: acquisition of data, interpretation of data, critical revision of manuscript for intellectual content. KN: acquisition of data, interpretation of data, critical revision of manuscript for intellectual content. CW: acquisition of data, interpretation of data, critical revision of manuscript for intellectual content. BP: study concept and design, acquisition of data, statistical analysis and interpretation of data, drafting of manuscript, study supervision.

Corresponding author

Correspondence to Gabriel Bsteh.

Ethics declarations

Ethics approval and consent to participate

The study was approved by the ethics committee of the Medical University Vienna (approval number: 2216/2020). As this is a retrospective documentation of clinical routine data, the need for written informed consent from study participants was waived by the ethics committee.

Consent for publication

Not applicable.

Competing interests

GB: has participated in meetings sponsored by, received speaker honoraria or travel funding from Biogen, Celgene/BMS, Lilly, Merck, Novartis, Roche, Sanofi-Genzyme and Teva, and received honoraria for consulting Biogen, Celgene/BMS, Novartis, Roche, Sanofi-Genzyme and Teva. He has received unrestricted research grants from Celgene/BMS and Novartis. WM: declares no conflict of interest relevant to this study. SM: declares no conflict of interest relevant to this study. VS: declares no conflict of interest relevant to this study/ NK: has participated in meetings sponsored by, received speaker honoraria or travel funding from BMS/Celgene, Janssen-Cilag, Merck, Novartis, Roche and Sanofi-Genzyme and held a grant for a Multiple Sclerosis Clinical Training Fellowship Programme from the European Committee for Treatment and Research in Multiple Sclerosis (ECTRIMS). PP: declares no conflict of interest relevant to this study. CM: declares no conflict of interest relevant to this study. KN: declares no conflict of interest relevant to this study. CW: has received honoraria consultancy/speaking from Apomedica, Curelator, Eli Lilly, Grünenthal, Hermes, Novartis, Pfizer, Ratiopharm/Teva, and Stada. BP: declares no conflict of interest relevant to this study.

Additional information

Publisher’s Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Supplementary Information

Additional file 1: Supplemental Table 1.

Association of MRI features of IIH with visual outcome.

Additional file 2: Supplemental Table 2.

Association of MRI features of IIH with headache outcome.

Rights and permissions

Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated in a credit line to the data.

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Bsteh, G., Marik, W., Krajnc, N. et al. MRI features of idiopathic intracranial hypertension are not prognostic of visual and headache outcome. J Headache Pain 24, 97 (2023). https://0-doi-org.brum.beds.ac.uk/10.1186/s10194-023-01641-x

Download citation

  • Received:

  • Accepted:

  • Published:

  • DOI: https://0-doi-org.brum.beds.ac.uk/10.1186/s10194-023-01641-x

Keywords

The Journal of Headache and Pain

ISSN: 1129-2377

Contact us