T he Point Counter-Point Feature on the best surgical treatment for idiopathic intracranial hypertension was most informative." 1 Our thanks to the authors who invested a great deal of effort reviewing not only their own work, but that of others. We were reminded of the saying that "To someone with a hammer, everything looks like a nail." The clearest solution for this treatment dilemma is in the pithy last sentence of Dr Dinkin's rebuttal: ". . . there is a role for all 3 procedures in the management of progressive idiopathic intracranial hypertension despite medical therapy."We in Sydney have been shunting and fenestrating for over 30 years, and stenting for the last 20 years. 2 What we recommend to patients depends both on the cause and the effect of the intracranial hypertension. For example, with fulminant idiopathic intracranial hypertension, we recommend an immediate optic nerve sheath fenestration of the worse side. 3 If there is no visual improvement within a week, then an optic nerve sheath fenestration of the better side is performed, followed by a transverse sinus stent.At the other end of the spectrum, for the patient without immediate visual threat who proves to have medically refractory disease over time, we recommend a stent. 4 For intracranial hypertension due to chronic venous sinus thrombosis, clot retrieval with venous sinus stenting is hazardous; here we recommend shunting if fenestration proves inadequate. Shunting is a procedure we otherwise avoid, given the almost guaranteed need for eventual shunt revision. 5 The ideal solution is a multidisciplinary pseudotumour cerebri clinic, where the management of each patient is considered by a panel consisting of an ophthalmologist, a neurologist, a neuro-interventionalist and a neurosurgeon.
