the presence and degree of symptoms ( i.e. headache , vision loss ) , the severity of vision loss , and any apparent progression are all crucial factors in deciding on urgency of treatment . the first step in treating any ptc patient is to identify and ameliorate conditions such as anaemia , causative medications , obesity , obstructive sleep apnea , and venous sinus thrombosis . factors consistent with poor visual prognosis such as high - grade papilledema , macular oedema , venous sinus thrombosis , and systemic hypertension may support a more aggressive form of treatment . immediate aggressive management is often advocated in cases of severe or rapidly progressive vision loss , and in cases at higher risk of rapid progression ( male sex , black race ) regardless of disease severity . as obesity and/or recent weight gain are the main identifiable ptc risk factors in most patients , a defined weight loss program should be initiated regardless of disease severity . observation without medical or surgical intervention may be indicated in an asymptomatic patient who presents with papilledema and understands the importance of clinical monitoring for progression . the precise relationship between weight gain or obesity and raised icp is not clear , but the benefits of weight reduction have been demonstrated repeatedly . in a study of 25 obese women , in addition , in individuals whose ptc is in remission , prevention of weight fluctuation has been shown to be critical in prevention of recurrence . studies have demonstrated that loss of approximately 6% of body weight is associated with a reduction in papilledema and discontinuation of systemic treatment . to most effectively assist a patient in weight loss , the help of a registered dietician or nutritionist should be enlisted . if weight loss through diet and exercise fails , bariatric surgery has been shown to positively benefit iih , although this is clearly more invasive and carries risks of anastomotic leaks , small bowel obstruction , malabsorption , and gastrointestinal bleeding . medical treatment is indicated in the setting of good vision when a patient 's primary symptom is headache . carbonic anhydrase inhibitors ( cai ) are the treatment of choice , although no prospective data confirm their effectiveness . a pilot trial by ball et al . the iih treatment trial is a multicenter , double - blind , placebo - controlled north american clinical trial that is currently enrolling patients to evaluate the benefit of acetazolamide versus placebo in the setting of a structured weight loss program . acetazolamide ( diamox ) and methazolamide ( neptazane ) inhibit carbonic anhydrase in the choroid plexus , ostensibly decreasing csf production . acetazolamide in adult patients is usually started at 1 g daily ( 250 mg qid or 500 mg bid ) , with a maximum recommended daily dose of 4 g. side - effects include paraesthesias , lethargy , and altered taste and may limit dosage . although non - cai diuretics ( i.e. furosemide , chlorthalidone , spironolactone ) have been used in the treatment of ptc , their efficacy in reducing icp is unclear . hypokalemia may occur with any of these agents , and blood electrolytes should be monitored . corticosteroids are not generally recommended for routine use in ptc , although they will lower icp acutely . corticosteroid withdrawal is associated with a rebound increase in icp , and the long - term side - effects , including weight gain and fluid retention , are even less desirable in ptc patients . intravenous corticosteroid may reduce acute optic disc swelling in fulminant disease , while an urgent surgical procedure is arranged . many patients have headache that is separate from the icp and thus benefit from topiramate 's action on migraine . an open - label study comparing topiramate and acetazolamide demonstrated equivalence in reduction of papilledema and headache , and topiramate use was associated with greater weight loss . octreotide , an inhibitor of growth hormone and insulin - like growth factor 1 , is not routinely used , but is being research and has been shown to reduce icp . initial surgical treatment of ptc is indicated when there is severe optic neuropathy , either acute or rapidly progressive , or medical treatment failure . csf diversion ( ventriculoperitoneal [ vp ] , ventriculoatrial [ va ] , or lumboperitoneal [ lp ] shunting ) and optic nerve sheath decompression ( onsd ) are most commonly performed , with subtemporal decompression reserved for extreme cases . the decision between csf diversion procedures and onsd depends on the availability of local resources and on the patient 's particular signs and symptoms . cerebrospinal fluid shunting is the most widely performed surgical treatment for ptc , and it is useful in the treatment of papilledema , headache , and visual loss . shunting results in rapid normalization of the icp , resolution of papilledema , and improvement of vision . all shunt procedures have a high long - term failure rate and often need revision because of obstruction or failure . in a case series and literature review by abubaker et al . , the failure rate was higher for vp shunts ( 14% ) than lp shunts ( 11% ) , but the revision rates were higher for lp shunts ( 60% ) than vp shunts ( 30% ) . va / vp shunting may be more effective than lp shunting in relieving headache , but it is more technically challenging to place the catheter into the typically normal or small ventricles of ptc patients . optic nerve sheath decompression effectively treats patients with papilledema and severe visual loss but does not improve headache in most patients . onsd rapidly reduces papilledema on the operated side and occasionally on the contralateral side as well . the procedure probably has little effect on icp , but clinical improvement is likely due to local reduction in pressure on the nerve by lowering the intrasheath pressure . long - term effectiveness may be due to fibrous scar formation between the dura and the optic nerve , thus creating a barrier that protects the anterior optic nerve from icp . patients with improvement or apparent remission after onsd should remain under close follow - up , as long - term visual decline may still occur . focal stenosis of the distal transverse sinus may be seen in the majority of ptc patients and is absent in obese controls . while in some cases , the stenosis is a consequence of elevated icp , several studies have demonstrated that a pressure gradient may persist across the stenotic segment even after icp is normalized by lumbar or cervical puncture . in such cases , the stenosis may be the cause of icp elevation , and endovascular stenting may be pursued if medical management is inadequate to relieve headache or papilledema . numerous reports of stent placement for sinus stenosis suggest tremendous success with 100% reduction of the intracranial sinus pressure . in a recent report from our institution , we described in detail the visual outcomes in 12 patients who underwent venous sinus stenting for ptc after failing maximal tolerated medical therapy . a manometric gradient of > 4 mmhg was found in all patients ( range 5 - 28 mmhg ) with reduction or resolution after stenting . eleven of 12 patients had visual improvement or stability , and headache either resolved or improved in 7 patients . we did identify 2 patients who developed a new stenosis proximal to the stent , and we postulate that the triangular anatomy of the venous sinus may contribute to collapse of the segment immediately proximal to the cylindrical stent . future modification of stent size may prevent this occurrence . based on our data and those of others , we obtain contrast - enhanced magnetic resonance venography in all ptc patients and consider stenting in appropriate cases . potential complications of venous stenting include stent migration , venous sinus perforation , in - stent thrombosis , subdural hemorrhage , and recurrent stenosis proximal to the stent . as in our experience , kumpe et al . reported persistent headache following stent placement in 10 of 12 female patients with headache prior to the procedure . poststenting headache is often different in character than that caused by elevated icp , resolves gradually , and is likely due to local irritation of the meninges following stent placement . pseudotumor cerebri may be unrecognized before pregnancy or associated with excessive weight gain ; worsening of existing ptc in pregnancy has been described . acetazolamide is rated as class c by the us fda and is typically used if needed after 20 weeks gestation . a recent retrospective study showed no adverse effects from its inadvertent use earlier in gestation , but could not establish the safety of doing so . in addition , onsd or csf shunting can be performed , though the shunt may obstruct as the uterus enlarges . treatment of ptc must be tailored to the patient 's presenting symptoms , vision , and comorbidities . a multidisciplinary team and often multiple treatment forms are necessary . while no clear recommendations exist , a careful consideration of a patient 's particular presentation can lead a clinician to the most effective and appropriate treatment .
aims : the aim was to identify pseudotumor cerebri treatment options and assess their efficacy.setting and design : review article.materials and methods : existing literature and the authors experience were reviewed.results:treatment options range from observation to surgical intervention . 
 weight loss and medical treatment may be utilized in cases without vision loss or in combination with surgical treatment . 
 cerebrospinal fluid shunting procedures and/or optic nerve sheath decompression is indicated for severe vision loss or headache unresponsive to medical management . 
 the recent use of endovascular stenting of transverse sinus stenoses has also demonstrated benefit in patients with pseudotumor cerebri.conclusion:while each treatment form may be successful individually , a multimodal approach is typically utilized with treatments selected on a case - by - case basis .