New Study Highlights Effectiveness of Bariatric Surgery for Idiopathic Intracranial Hypertension

New findings from Cleveland Clinic researchers suggest that bariatric surgery can effectively alleviate or improve symptoms related to idiopathic intracranial hypertension (IIH). The group observed that some patients with IIH who underwent a bariatric procedure reported an improvement in their symptoms and were able to decrease their use of medications. They believe their findings can help guide treatment decisions and reinforce the notion that sustained weight loss is essential for long-term remission of IIH.

Although once considered rare, IIH has followed the trend of rising obesity rates in the United States and subsequently become a greater medical concern over the past several decades. The condition, a chronic neurological disease that can present with severe headaches and papilledema, is thought to be related to cerebral flow dynamics. It is thought to be linked to obesity, although the correlation is not fully understood.

“The current treatments for IIH — carbonic anhydrase inhibitors, anticonvulsants, and cerebrospinal fluid (CSF) diversion procedures— are all intended to alleviate symptoms,” says Xiaoxi Feng, MD, a bariatric, foregut and general surgeon at Cleveland Clinic and one of the paper’s authors. “While these medications can help, they all have their own adverse side effect profiles. They also don’t halt disease progression.”

She continues, “With this study, we wanted to develop a better understanding of whether bariatric surgery is effective at reducing IIH symptoms and improving our patients’ quality of life. We focused on IIH medication usage and treatments before and after bariatric surgery as a way to measure effectiveness.”

Study design

The retrospective observational study included data from 97 patients (98% female, median age 46.7 years) with obesity and a diagnosis of IIH. All patients had also undergone bariatric surgery (Roux-en-Y gastric bypass [n = 66, 68%], sleeve gastrectomy [n = 27, 27.8%] and gastric banding [n = 4, 4.1%]) at Cleveland Clinic between 2005 and 2023. The median age at the time of surgery was 37.7 years, and the median follow-up was 3.0 years. The median preoperative weight and BMI were 130 kg and 48.3 kg/m², respectively, and the median postoperative weight and BMI were 97.8 kg and 36.7 kg/m², respectively. These weight loss numbers track with the multitude of other studies corroborating the effectiveness of metabolic surgery.

The authors found significant improvements or resolutions of headache (p < .001), visual field deficits (p < .001), papilledema (p < .001) and visual symptoms (p = .007), postoperatively. There was also a significant decrease in the number of IIH medications patients took postoperatively compared to preoperatively (p < .001) and a significant decrease in the dosage of both topiramate and acetazolamide (p < .001 for both).

“Some of the patients also underwent more invasive procedures, such as ventriculoperitoneal, lumboperitoneal, and ventriculoatrial shunts; craniectomy; and venous stents,” says Dr. Feng. “Although more patients had these procedures done preoperatively than postoperatively [27 vs 17, respectively], we found that the number of procedures done preoperatively and postoperatively was not statistically significant [p = .090].”

The group also performed a sensitivity analysis to exclude the 17 patients who had undergone more invasive procedures after bariatric surgery. They found that there were still significant improvements or resolutions in headaches among this group of 80 patients (p < 0.001), papilledema (p < 0.001), visual field deficits (p < .001) and visual symptoms (p = .002). The number of medications this group took for their IIH postoperatively also significantly decreased compared to their preoperative medication amount (p < .001).

Takeaways

“Bariatric surgery has proven to be a safe, effective and durable treatment modality for patients with IIH,” says Raul Rosenthal, MD, Director of the Bariatric & Metabolic Institute at Cleveland Clinic Weston Hospital and one of the study’s authors. “It has also proven to be the best treatment modality for patients with acute onset of IIH with loss of visual acuity.”

The research group hopes their findings demonstrate that bariatric surgery should be considered as a treatment option for patients who are concurrently affected by obesity and IIH. Weight loss from the bariatric surgery could help ameliorate IIH symptoms and decrease medication use, in addition to its positive benefits on other obesity-related comorbidities.

“Many of the current options for managing IIH are focused on relieving symptoms associated with intracranial hypertension and preserving vision, but they don’t really help halt disease progression,” says Dr. Feng. “Sustained weight loss is crucial for long-term control of IIH, and our findings show that bariatric surgery can assist patients in achieving this.”