The Vienna Intracranial Hypertension Score for Predicting Elevated Cerebrospinal Fluid Opening Pressure in Patients Evaluated for Idiopathic Intracranial Hypertension

Abstract Background. Increasing recognition of radiological and ophthalmological findings suggestive of intracranial hypertension has created diagnostic uncertainty in patients evaluated for suspected idiopathic intracranial hypertension (IIH). We aimed to identify independent predictors of elevated cerebrospinal fluid opening pressure (CSF-OP) and derive a clinical prediction model for pre-lumbar puncture risk stratification. Methods. This retrospective study included adults from the Vienna Intracranial Hypertension (VIIH) database who underwent diagnostic lumbar puncture for suspected IIH with documented CSF-OP, brain MRI, and comprehensive ophthalmological assessment. Univariable and multivariable logistic regression models were used to identify predictors of elevated CSF-OP (≥ 25cmH₂O) and to derive the Vienna Intracranial Hypertension Score (VIHS). The diagnostic performance of the VIHS was evaluated using receiver operating characteristic (ROC) analysis. In addition, the VIHS was compared to the Pre-Lumbar Puncture Idiopathic Intracranial Hypertension Scale (PLIHS). Results. A total of 148 patients were included (median age 31.5 years [range 18–81], 87.2% female), of whom 86 (58.1%) had elevated CSF-OP. In multivariable analyses, age ≤ 40 years (OR 3.37, 95% CI 1.21–10.0; 1 point), body mass index ≥ 30 kg/m² (OR 3.44, 95% CI 1.27–9.98; 1 point), papilledema severity (Frisén grade ≥ 2; OR 2.78, 95% CI 1.03–7.85; 1 point), and transverse sinus stenosis (OR 4.61, 95% CI 1.67–13.9; 2 points) were independently associated with elevated CSF-OP and incorporated into the VIHS. The VIHS demonstrated superior discriminative performance compared with the externally validated PLIHS (AUC 0.79, 95% CI 0.71–0.87 vs. 0.67, 95% CI 0.57–0.77), with increasing VIHS categories associated with a shift toward higher CSF-OP and a probability of elevated CSF-OP of 87.8% among patients with VIHS ≥ 4. Conclusions. The VIHS provides a pragmatic tool for pre-lumbar puncture risk stratification in suspected IIH, with high scores identifying patients with a high probability of elevated CSF-OP. Low scores, however, do not reliably exclude elevated CSF-OP.