Idiopathic Intracranial Hypertension in Children and Adolescents with Obesity: A Narrative Review

Highlights: What are the main findings? The increasing incidence of IIH in children and adolescents is strongly linked to the global obesity epidemic. Weight loss (6–10%) remains the cornerstone of treatment, with bariatric surgery and new anti-obesity medications (GLP-1 agonists) emerging as highly effective options for long-term IIH remission. What is the implication of the main finding? The complex pathophysiology—linking obesity, hormones, and CNS pressure—mandates a multidisciplinary team (Neuro-Ophthalmology, Pediatric Endocrinology, Nutrition) for optimal patient prognosis. Since weight loss is the only etiological treatment, therapeutic strategies must prioritize prompt, effective weight reduction, incorporating newer anti-obesity agents and surgical options in refractory adolescent cases to prevent permanent vision loss. Background: Idiopathic intracranial hypertension (IIH), also known as primary pseudotumor cerebri, is characterized by increased intracranial pressure (ICP) without an identifiable cause. It can lead to significant morbidity, including permanent vision loss, especially in younger children. The exact cause of IIH is still unclear, but excess adiposity seems to be a key risk factor. Current treatment options are unsatisfactory, but research is exploring novel therapies targeting obesity-related mechanisms. Methods: Narrative review of the literature aimed at summarizing current knowledge regarding the epidemiology, pathophysiology, clinical features, treatment options and long-term outcomes for pediatric IIH, with a particular focus on the link with obesity. Results: The incidence of IIH is rising, mirroring the obesity epidemic. Excess adiposity, predominantly visceral, might cause IIH through several factors such as decreased venous return, hormone dysregulation, inflammation, obstructive sleep apnea, and dysfunction of the glymphatic system. The extent of weight loss required and the most appropriate strategy to achieve it are still uncertain. Given the difficulty in achieving and maintaining weight loss with dietary strategies, bariatric surgery and weight loss medications are emerging as effective options for long-term remission of both obesity and IIH. Conclusions: IIH is a rare and poorly understood disease. At present, weight loss represents the only treatment that addresses the pathophysiology of IIH. The role and potential as standalone or synergistic therapies of weight loss drugs and bariatric surgery for IIH in adolescents require future research.