Intracranial fluid dynamics changes in idiopathic intracranial hypertension: Pre and post therapy

Objective: Idiopathic Intracranial Hypertension (IIH) is a condition of unknown etiology frequently associated with dural sinus stenosis. There is emerging evidence that venous sinus stenting is an effective treatment. We use phase contrast cine MRI to observe changes in flow dynamics of multiple intracranial fluids and their response to different treatments in a patient with IIH. Methods: We quantified the following parameters at the level of the aqueduct of Sylvius and the cervical C2C3: Cerebrospinal Fluid (CSF), arterial and venous flow; CSF velocity amplitude; artero-venous delay (AVD); artero-CSF delay and percentage of venous outflow normalized to total arterial inflow (tIJV/tA). Analyses were run before Lumbar Puncture (LP) (A), after LP (B), after medical therapy (C) and after venous stent placements deployed at two separate times (D and E). Results: AVD and tIJV/tA improved only after CSF removal and after stent placements. CSF velocity amplitude remained elevated. Arterial flow profile showed a dramatic reduction after LP with improvement in mean venous flow. This report is the first to demonstrate interactive changes in intracranial fluid dynamics that occur before and after different therapeutic interventions in IIH. Conclusion: The data provide valuable information regarding changes in different fluid compartments suggesting a profound redistribution of pressures along fluid compartments after different treatments. We discuss how increased intracranial venous blood could be “tumoral” in IIH and facilitating its outflow could be therapeutic.