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IIH – Urgent Surgical Options — SCE Neurology MCQ

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HardCerebrovascular DiseaseIIH – Urgent Surgical OptionsSCE Neurology

A 55-year-old woman presents with rapidly progressive visual loss. Fundoscopy shows bilateral disc swelling with haemorrhages. MRI brain shows bilateral optic nerve sheath distension and an empty sella. LP opening pressure is 42 cmH₂O. She is not obese. Secondary causes of raised intracranial pressure have been excluded. Her visual fields are rapidly deteriorating despite maximum-dose acetazolamide. What urgent intervention should be performed?

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Correct answer: D — Both B and C are appropriate — the choice depends on whether headache or vision is the primary concern

In IIH with rapidly progressive visual loss threatening permanent blindness despite medical therapy, urgent surgical intervention is needed. The choice between optic nerve sheath fenestration (ONSF) and CSF diversion (LP or VP shunt) depends on the clinical priority: ONSF directly protects the optic nerve and is preferred when vision loss is the primary concern; CSF diversion is preferred when headache is the dominant problem or if ONSF fails. In practice, both approaches are valid and complementary. A: Therapeutic LP provides only temporary relief. E: Decompressive craniectomy is not used for IIH.

Reference: ABN IIH Guidelines (2018)