Perspective from Brad Sutton, OD, FAAO
Disclosures: Mollan reports receiving personal fees from Allergan, Chiesi Farmaceutici, Heidelberg Engineering, Invex Therapeutics, Neurodiem, Novartis, Roche, Santen Pharmaceutical and Santhera Pharmaceuticals outside the submitted work. Please see the study for all other authors’ relevant financial disclosures.
September 16, 2021
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Bariatric surgery reduces intracranial pressure, weight in women with IIH

Perspective from Brad Sutton, OD, FAAO
Disclosures: Mollan reports receiving personal fees from Allergan, Chiesi Farmaceutici, Heidelberg Engineering, Invex Therapeutics, Neurodiem, Novartis, Roche, Santen Pharmaceutical and Santhera Pharmaceuticals outside the submitted work. Please see the study for all other authors’ relevant financial disclosures.
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Bariatric surgery led to “significantly lower” intracranial pressure and weight in women with idiopathic intracranial hypertension compared with community weight management intervention, according to findings published in JAMA Neurology.

“We hypothesized that bariatric surgery would be superior to a community weight management intervention in reducing intracranial pressure (ICP) among patients with IIH because of greater sustained weight loss,” Susan P. Mollan, MBcHB, member of the department of Ophthalmology at the University Hospitals Birmingham NHS Foundation Trust, and colleagues wrote. “We therefore conducted a multicenter randomized clinical trial (Idiopathic Intracranial Hypertension Weight Trial [IIH:WT]) comparing bariatric surgery with a community weight management intervention to evaluate which approach was more effective in decreasing ICP among participants with active IIH, with the primary end point being lumbar puncture opening pressure measured after 12 months.”

While previous studies had shown an association between bariatric surgery and long-term weight loss as well as remission of idiopathic intracranial hypertension (IIH), there was no evidence from randomized clinical trials prior to IIH:WT.

In the 5-year randomized clinical trial, Mollan and colleagues analyzed 66 women with active IIH and a BMI of 35 kg/m2 or higher (mean age, 32 years; 55% white; 5% Black, African or Caribbean) at five hospitals in the U.K. between March 1, 2014, and May 25, 2017. They randomly assigned participants 1:1 to receive either a community weight management intervention (Weight Watchers; CWM arm) or bariatric surgery (surgery arm). Participants provided a complete medical history, clinical measurements and a headache diary throughout the study.

The primary outcome was any change in ICP measured specifically by lumbar puncture opening pressure at the 12-month mark. ICP at 24 months was considered a secondary outcome, in addition to contrast sensitivity, visual acuity, perimetric mean deviation and quality of life.

Twelve months into the clinical trial, only 64 women remained, and 54 were included in the primary outcome analysis. In the bariatric surgery arm, researchers observed significantly lower ICP (adjusted mean difference, 6 cm cerebrospinal fluid (CSF); 95% CI, 9.5 to 2.4 cm CSF), significantly lower weight (adjusted mean difference, 21.4 kg; 95% CI, 32.1 to 10.7 kg) and significantly improved quality of life (adjusted mean difference, 7.3; 95% CI, 0.2-14.4;) compared with the CWM arm. The bariatric surgery arm continued to show significant improvements compared with the CWM arm at 24 months.

The investigators concluded that bariatric surgery was more effective than community weight management in patients with active IIH when trying to reduce ICP, disease remission and improve quality of life.

The limitations of this study include a small participant pool, which made it difficult for researchers to recommend one surgery over another.

“These cardiovascular improvements and their positive implications for other comorbidities, such as polycystic ovarian syndrome, may be of additional benefit for those with IIH because IIH is associated with a [twofold] increased risk of worse cardiovascular outcomes and polycystic ovarian syndrome,” Mollan and colleagues wrote. “Future clinical trials should investigate which type of bariatric surgical procedure is superior for patients with IIH.”