Ventriculoperitoneal shunt treatment in a pregnant renal transplant recipient with idiopathic intracranial hypertension: Case report and review of the literature

Abstract

Idiopathic intracranial hypertension (IIH) is a relatively uncommon disorder characterised by raised intracranial pressure without an established pathogenesis. Diagnosis of IIH requires the demonstration of symptoms and signs referable only to elevated intracranial pressure; cerebrospinal fluid (CSF) opening pressure >25cm HO measured in the lateral decubitus position; normal CSF composition; and no evidence for an underlying structural cause demonstrated by using MRI or contrast-enhanced CT scan for typical patients and MRI and MR venography for atypical patients such as man, children and those with low body mass index. We present a 38-year old primigravid renal transplant patient at 7 weeks of gestation who presented with 2 weeks of intense, throbbing, holocranial headache, nausea, vomiting, photophobia, diplopia and progressive visual loss. When medical treatment fails and/or not appropriate to use due to the reported of teratogenic risks in pregnant women, surgical interventions gain importance. In this particular patient, venticuloperitoneal shunt was chosen as the CSF diversion technique. In this case report indications, contraindications in addition to outcomes regarding headache, vision loss and the resolution of papilloedema of the present surgery options for IIH are discussed.

Surgical Management of Idiopathic Intracranial Hypertension in Pregnancy

“…The symptoms of IIH in pregnant and nonpregnant patients are similar, with headache occurring in up to 90% of cases (10). Multiple different headache phenotypes have been described, generally worsening with Valsalva-type maneuvers (due to increased ICP), and associated with nausea, vomiting, and photophobia (4,11). Permanent vision loss, the most concerning feature of IIH, is more common in fulminant IIH patients, who make up 10%-20% of IIH patients (4,10).…”

“…LP is not contraindicated in pregnancy, and there is reported efficacy for improvement in both headache and vision in pregnant patients with IIH (3,4,8,10). There have been 28 patients who received therapeutic serial LP (up to 11 LP in 1 report) (2,11,(18)(19)(20)(21)(22)(23)(24)(25)(26)(27)(28)(29)(30). Further details regarding the frequency of LP, indications for repeat LP (symptoms or regular timing) were not available in many cases, and assessment and analysis of patient outcomes overall is challenging because most patients also received other interventions concurrently.…”

“…Most of these studies were not specific to pregnant patients, but given that neither LP nor VP shunting is contraindicated in pregnancy, we believe that these studies can apply to an otherwise normal pregnancy. In pregnancy, there have been 11 reported cases of lumboperitoneal shunt (LPS) insertion (reported between 1979 and 2017), and only 1 case of ventriculoperitoneal shunt (VPS) insertion (reported in 2018) in pregnant IIH patients (2,3,11,25,27,29,(47)(48)(49). Of these patients, most had tried other less invasive treatments before undergoing shunting.…”

“…In pregnancy, there have been 11 reported cases of lumboperitoneal shunt (LPS) insertion (reported between 1979 and 2017), and only 1 case of ventriculoperitoneal shunt (VPS) insertion (reported in 2018) in pregnant IIH patients (2,3,11,25,27,29,47–49). Of these patients, most had tried other less invasive treatments before undergoing shunting.…”