1. HEADACHE IN THE SEVERELY OBESE Harvey Sugerman, MD, FACS, FASMBS Editor: Surgery for Obesity and Related Diseases Co-owner, Chief Medical Officer: Spark Medical, LLC (manufacturer of negative abdominal pressure device: the Abshell)

2. HEADACHE IN THE SEVERELY OBESE Pseudotumor Cerebri –AKA: Idiopathic Intracranial Hypertension (IIH) and Benign Intracranial Hypertension –Signs/Symptoms –Pathophysiology Migraine ??? Headaches Preeclampsia Negative Abdominal Pressure Device

3. PSEUDOTUMOR CEREBRI SYMPTOMS Constant headache, worse in morning Double vision (6 th Cranial Nerve) Pulsatile tinnitus Nausea, vomiting 25% Asymptomatic until vision loss Elevated CSF pressure (> 250 mm Hg) Papilledema Other cranial nerve abnormalities (V, VII)

4. PSEUDOTUMOR CEREBRI DIAGNOSIS CT Scan or MRI –No Intracranial Mass –Empty Sella Turcica –Narrow Ventricles Elevated CSF on Lumbar Puncture –> 250 mm H 2 O

5. PSEUDOTUMOR CEREBRI INCIDENCE 1/100,000 Overall; 19/100,000 in obese Fundus imaging in bariatric patients + Ophthalmological examination + spinal fluid pressure measurement: 0.9% (9/1,000)* Obesity present in 94% of pseudotumor patients * Handallah IN … Ali M. Higher than expected prevalence of pseudotumor cerebri: a prospective study. Surg Obes Rel Dis (in press)

6. PSEUDOTUMOR CEREBRI TREATMENT Acetozolamide Repeated lumbar drainage Lumboperitoneal shunt Optic nerve fenestration BARIATRIC SURGERY

8. PSEUDOTUMOR PATHOPHYSIOLOGY Increased Intra-abdominal Pressure Why is it rarely seen in men? –92% Women –Combined effects with female hormones?

10. GBP CORRECTS PSEUDOTUMOR CEREBRI Significant Decrease in Headaches Significant Decrease in Pulsatile Tinnitus Significant Decrease in CSF Pressure Relieves Cranial Nerve Palsies: I (Visual Field Cuts), III (Ocumolotor), V (Bell’s Palsy), VII (Tic Doloreux), VIII (Tinnitus)

11. MIGRAINE HEADACHES* 102/702 patients had physician diagnosed migraine headaches 81 followed for > 12 mos after RYGB Clinical improvement within 8 mos in 89% of patients: 57 total and 15 partial resolution Those who had migraine headaches prior to compared to after the development of obesity had a lower frequency of improvement with weight loss * Gunay Y, et al. Surg Obes Relat Dis (in press)

12. MIGRAIINES? All didn’t undergo examinations for papilledema All 81 patients responded to an anti-migraine medication with an acute attack CSF pressure was not measured Only 25/81 had an aura with their headache * Gunay Y, et al. Roux-en-Y gastric bypass achieves substantial resolution of migraine headache in the severely obese: a 9-year experience in 81 patients. Surg Obes Rel Dis (in press).

13. MIGRAINE VS. PSEUDOTUMOR Does pseudotumor require papilledema? Pseudotumor, according to Modified Dandy criteria, requires a CSF opening pressure > 250 mm H 2 O Could headaches result from an increased CSF pressure < 250 mm H 2 O? No way to measure CSF pressure without spinal tap Hypothesis: “pseudotumor” under-diagnosed

14. ECLAMPSIA/PREECLAMPSIA Could increased intra-abdominal pressure be the cause of eclampsia/preeclampsia secondary to impaired jugular venous flow? Would application of the externally applied negative abdominal pressure device be an effective treatment for preeclampsia?

15. PREECLAMPSIA Venous flow bassically passive; doesn’t take much IAP to decrease it Decreased venous flow leads to decreased capillary and arterial flow –Extremities: edema –Uterus: placental/fetal ischemia –Kidney: hypertension, proteinuria –Liver/Spleen: HELLP syndrome –Lung : Hypoxemia, ARDS –Cerebral flow: headache/seizure

16. WHY NOT ALL PREGNANCIES? INCREASED FREQUENCY IN: Morbidly Obese Women Twin + pregnancies Later vs. earlier gestation Primiparas Previous Preeclampsia

31. THE ANSWER THIS SUMMER IN PADUA!

35. Or maybe my son-in-law’s right: I’m just a modern day Don Quixote