Surgical outcomes in pediatric idiopathic intracranial hypertension: a systematic review and meta-analysis of CSF shunting, optic nerve sheath fenestration, and venous sinus stenting

OBJECTIVE: Pediatric idiopathic intracranial hypertension (IIH) is a rare condition characterized by elevated intracranial pressure (ICP) without an identifiable cause. Although most patients respond to medical therapy, refractory cases might require surgical intervention, particularly if the patient experiences visual deterioration. Data on the outcomes of CSF shunting, optic nerve sheath fenestration (ONSF), and venous sinus stenting (VSS) for patients with pediatric IIH are inconsistent across studies. METHODS: A literature search was conducted from January 1990 until July 2025 across 3 databases. Eligible studies included patients younger than 18 years with primary, medically refractory IIH with visual impairment who underwent CSF shunt placement, ONSF, or VSS. Primary outcomes included improvement in headache, papilledema, visual acuity, and reoperation rates. Meta-analyses of the proportion of patients whose symptoms improved were performed with subgroup analyses by intervention type. RESULTS: The authors identified and included 54 studies with 150 patients (53% were female; in multipatient studies, the mean age range was 3.2-15 years, the mean BMI was 23.6-32 kg/m2, and the mean opening pressure was 270-550 mm H2O). Procedures comprised CSF shunting (n = 68), ONSF (n = 45), and VSS (n = 37). Across all studies, the headache rate improved by 80% (shunt 83%, ONSF 62%, VSS 84%), papilledema by 88% (shunt 90%, ONSF 88%, VSS 86%), and visual acuity by 67% (shunt 52%, ONSF 82%, VSS 70%). The overall reintervention rate was 22% (shunt 24%, ONSF 5%, VSS 30%). No primary outcome subgroup differences were statistically significant. CONCLUSIONS: Symptom and ophthalmological improvement were similar across surgical modalities in pediatric patients with IIH with vision-threatening papilledema. ONSF offers high visual acuity preservation with low reintervention rates, making it well suited for urgent vision preservation. CSF shunt placement provides global intracranial pressure control that alleviates associated symptoms, but it is associated with frequent revisions. VSS is effective for patients with venous sinus stenosis and a pressure gradient and thus requires these important prerequisites before stent placement. Larger, pediatric-specific comparative studies are needed to optimize surgical decision-making.