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Cerebrospinal Fluid Removal for Idiopathic Intracranial Hypertension

Less Cerebrospinal Fluid Is Best

Perloff, Michael D. MD, PhD; Parikh, Simy K. MD; Fiorito-Torres, Franchesca MD; McAdams, Matthew T. MD; Rayhill, Melissa L. MD

doi: 10.1097/WNO.0000000000000759
Original Contribution

Background: Although lumbar punctures (LPs) are used for diagnostic evaluation in idiopathic intracranial hypertension (IIH), they can also provide relief from IIH-associated headache. Conversely, low-pressure headache secondary to LP can be debilitating. Low-volume cerebrospinal fluid (CSF) removal to a “high-normal” closing pressure (CP), approximately 18–20 cm H2O, may result in relief of IIH-associated headache with a lowered frequency of post-LP headache.

Methods: We conducted a single-center retrospective analysis from 2011 to 2016 of patients who underwent fluoroscopic LPs aiming for high-normal CPs. Inclusion criteria were as follows: 1) pre-existing diagnosis of IIH, or opening pressure (OP) and clinical findings diagnostic for IIH; 2) height and weight recorded within 1 year; 3) documented LP data parameters; and 4) one week post-LP follow-up documenting whether headache was worse, unchanged, or better.

Results: One hundred forty-six patients met the inclusion criteria. Mean age was 34.9 years ± 11.0, and mean body mass index was 39.2 kg/m2 ± 10.5. Mean volume removed was 9.7 mL ± 4.6. The mean CP was 17.9 cm H2O ±2.7. The mean pressure change (OP-CP) per volume removed was 1.50 cm H2O/mL ±0.6. Headache symptoms at follow-up were improved in 64% (80/125) of patients, worse in 26% (33/125), and unchanged in 10% (12/125). Eleven patients were headache-free, and 11 patients required hospital care for post-LP headache.

Conclusions: Low-volume CSF removal to approximately 18 cm H2O resulted in relief of IIH-associated headache in most patients and a low incidence of post-LP headache. Although clinically variable, these data suggest that for every 1 mL of CSF removed, the CP decreases approximately 1.5 cm H2O.

Department of Neurology (MDP), Boston University School of Medicine, Boston University Medical Center, Boston, Massachusetts; Jefferson Headache Center (SKP), Thomas Jefferson University, Philadelphia, Pennsylvania; Department of Neurology (FF-T), University of Puerto Rico School of Medicine, San Juan, Puerto Rico; UF Health Neurology Department (MTM), McKnight Brain Institute (L3-100), Gainesville, Florida; and Department of Neurology (MLR), Jacobs School of Medicine and Biomedical Sciences, The State University of New York, Buffalo, New York.

Address correspondence to Michael D. Perloff, MD, PhD, Department of Neurology, Boston University School of Medicine 72 E. Concord Street, C3, Boston, MA 02118; E-mail:

The authors report no conflicts of interest.

© 2019 by North American Neuro-Ophthalmology Society