Bariatric Surgery Versus GLP-1RAs in Idiopathic Intracranial Hypertension: A Propensity Matched Multi-Institutional Cohort.

Abstract

Idiopathic intracranial hypertension (IIH) is strongly associated with obesity with weight reduction as a central component to management. The relative effectiveness of bariatric surgery (BS) vs glucagon-like peptide-1 receptor agonist (GLP-1RA) therapy remains uncertain. This study aimed to assess the short-term and long-term effectiveness of GLP-1RA therapy vs BS for symptom control in patients with IIH. This multicenter retrospective cohort study used the TriNetX Research Network. Adults aged 18 years or older with IIH and body mass index (BMI) ≥40 who underwent BS or initiated GLP-1RA therapy were included. Propensity score-matched cohorts were created to balance demographics, comorbidities, symptoms, and medication use. The primary outcomes were persistence or recurrence of IIH-related symptoms (headache, papilledema, visual deficits). Secondary outcomes included BMI change, nausea/vomiting, lumbar punctures, cerebrospinal fluid shunting, venous sinus stenting, and use of carbonic anhydrase inhibitors (CAIs) or topiramate. Outcomes were assessed at 3 to 18 months and >18 months postintervention. Among 3185 eligible patients (1982 GLP-1RA; 1203 BS), 946 matched pairs had 3 to 18 months of follow-up and 963 matched pairs had >18 months. At 3 to 18 months, BS achieved greater BMI reduction (mean 35.6 vs 40.5, P < .01) and lower rates of papilledema (hazard ratio [HR]: 4.65 [1.89, 11.43], P < .01), CAI use (HR: 2.86 [1.37, 5.99], P < .01), and topiramate use (HR: 1.71 [1.06, 2.77], P = .02). However, other outcomes were comparable. At >18 months of follow-up, the 2 arms were comparable in time-to-event analyses, although GLP-1RA patients had higher hazards of nausea/vomiting (HR: 1.78 [1.15, 2.77], P = .01) and CAI use (HR: 2.37 [1.09, 5.16], P = .03). BS achieved greater early weight loss and symptom improvement, while GLP-1RA therapy provided comparable outcomes in long-term. BS remains the most effective intervention for rapid benefit, but GLP-1RAs may represent a durable nonsurgical alternative, supporting individualized treatment selection based on comorbidities, preferences, cost, and surgical candidacy.