Difference between revisions of "Idiopathic intracranial hypertension"

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(Background)
 
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*Also known as pseudotumor cerebri/benign intracranial hypertension (BIH)
 
*Also known as pseudotumor cerebri/benign intracranial hypertension (BIH)
 
*Cause is idiopathic, but believed be due to impaired CSF absorption at arachnoid villi
 
*Cause is idiopathic, but believed be due to impaired CSF absorption at arachnoid villi
*Associated with OCPs, vitamin A, [[tetracycline]] and thyroid disorders
+
*Associated with obesity, weight gain, pregnancy, cyclosporine, OCPs, vitamin A >100,000 U/day, [[tetracycline]], amiodarone, sulfa antibiotics, lithium, thyroid disorders, and historically nalidixic acid (rarely used). Systemic steroid intake and withdrawal may also be causative.
  
 
==Clinical Features==
 
==Clinical Features==
#[[Headache]]
+
*Tends to occur in young, obese women
#[[Nausea and Vomiting]]
+
*[[Headache]]
#Vision blurring
+
**Tend to be worse at night or first thing in the morning
 +
**Frequently starts as dull occipital pain, may become diffuse and throbbing
 +
**Typically worse with maneuvers to increase ICP
 +
*[[Nausea and Vomiting]]
 +
*[[blurred vision|Vision blurring]]
 +
*[[Papilledema]]
 +
**can be visualized with [[Ocular ultrasound|ultrasound]]
 +
*Irregular menses or amenorrhea
 +
*[[Neuro exam]] often normal
 +
**May have [[cranial nerve palsies]] if severe, most often [[abducens nerve palsy]]
  
 
==Differential Diagnosis==
 
==Differential Diagnosis==
*Aneurysm rupture and [[Subarachnoid Hemorrhage]]
+
{{Headache DDX}}
*Brain tumor
 
*[[Encephalitis]]
 
*[[Head Injury]]
 
*Hydrocephalus (increased CSF)
 
*Hypertensive brain hemorrhage
 
*Intraventricular hemorrhage
 
*[[Cerebral venous sinus thrombosis]]
 
*[[Meningitis]]
 
*[[Subdural Hematoma]]
 
*[[Status epilepticus]]
 
*[[Stroke]]
 
  
 
==Evaluation==
 
==Evaluation==
#Young, obese women
+
*Ocular exam including pupillary examination, ocular motility, assessment for dyschromatopsia (color plates). Also obtain systemic vitals such as blood pressure and temperature
#[[Headache]] (worse in AM / with manuvers increasing ICP)
+
*[[head CT|CT]] (negative or slit-like ventricles).
#Papilledema (optic atrophy/vision loss)
+
*Typically, MRI and MR venogram of the orbit and brain to rule out secondary causes of intracranial pressure such as [[cerebral venous sinus thrombosis]]. If normal, the patient may need LP to determine opening pressure and r/o other causes of optic nerve edema.
##can be visualized with [[Ocular ultrasound|ultrasound]]
+
*Consider ocular ultrasound (simple, non-invasive) to assess optic nerve diameter. Source: https://www.ncbi.nlm.nih.gov/pubmed/27168453
#[[Neuro Exam]] frequently normal
+
*[[LP]] (Opening pressure >25)
##May have cranial nerve palsies in severe, most often CN 6
+
**CSF lab studies by [[lumbar puncture]] are negative
 
+
**No special CSF studies need to be sent, unless differential includes etiologies for infection, hemorrhage, etc
===Work-Up===
+
**Recognize that in rare cases, LP's can cause reactive meningeal enhancement (which is why some practitioners delay LP until after MRI). This practice might not be supported in cases where LP is necessary.  Source: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5727706/
#CT scan (negative or slit-like ventricles)
+
*Outpatient visual field testing is the most important method for following these patients (Humphrey VF's)
#[[LP]] (Opening pressure >25)
 
#MR venogram (to r/o cerebral venous sinus thrombosis)
 
  
 
==Management==
 
==Management==
#Repeat [[LP]]s (decrease CSF pressure) - large volume LPs on the order of 30-40 cc of CSF
+
*Treatment may be indicated in the following situations: severe/intractable headache, evidence of progressive decrease in visual acuity or visual field loss. Some ophthalmologists suggest treating all patients with papilledema.
#[[Acetazolamide]] 500mg BID (decrease CSF production)
+
*Weight loss
#[[Furosemide]] 20mg PO BID, give potassium supp as needed
+
*[[Acetazolamide]] 250mg QID (or 500mg BID) initially building up to 500-1000mg QID if tolerated. Use with caution in sulfa-allergic patients. (decreases CSF production)
#Weight loss
+
*Discontinue any causative medications
#CSF Shunt
+
*Short course of systemic steroids, especially if any plans for surgical intervention
#Optic nerve sheath fenestration
+
*Repeat [[LP]]s (decrease CSF pressure) - large volume LPs on the order of 30-40 cc of CSF
 +
*[[Furosemide]] 20mg PO BID, give potassium supp as needed
 +
*If above treatments are unsuccessful, surgical treatments may be considered.
 +
**CSF Shunt (ventriculoperitoneal or lumboperitoneal) is often effective if vision is threatened
 +
**Optic nerve sheath fenestration
  
 
==Disposition==
 
==Disposition==
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==External Links==
 
==External Links==
[http://www.stemlynspodcast.org/mobile/e/an-approach-to-headache-in-the-ed-induction-series/ Induction to EM: An approach to headache in the ED. St.Emlyn’s]
+
*[http://www.stemlynspodcast.org/mobile/e/an-approach-to-headache-in-the-ed-induction-series/ Induction to EM: An approach to headache in the ED. St.Emlyn’s]
  
 
==See Also==
 
==See Also==
[[Ocular ultrasound]]
+
*[[Ocular ultrasound]]
  
 
==References==
 
==References==

Latest revision as of 03:27, 4 March 2020

Background

  • Also known as pseudotumor cerebri/benign intracranial hypertension (BIH)
  • Cause is idiopathic, but believed be due to impaired CSF absorption at arachnoid villi
  • Associated with obesity, weight gain, pregnancy, cyclosporine, OCPs, vitamin A >100,000 U/day, tetracycline, amiodarone, sulfa antibiotics, lithium, thyroid disorders, and historically nalidixic acid (rarely used). Systemic steroid intake and withdrawal may also be causative.

Clinical Features

Differential Diagnosis

Headache

Common

Killers

Maimers

Others

Aseptic Meningitis

Evaluation

  • Ocular exam including pupillary examination, ocular motility, assessment for dyschromatopsia (color plates). Also obtain systemic vitals such as blood pressure and temperature
  • CT (negative or slit-like ventricles).
  • Typically, MRI and MR venogram of the orbit and brain to rule out secondary causes of intracranial pressure such as cerebral venous sinus thrombosis. If normal, the patient may need LP to determine opening pressure and r/o other causes of optic nerve edema.
  • Consider ocular ultrasound (simple, non-invasive) to assess optic nerve diameter. Source: https://www.ncbi.nlm.nih.gov/pubmed/27168453
  • LP (Opening pressure >25)
    • CSF lab studies by lumbar puncture are negative
    • No special CSF studies need to be sent, unless differential includes etiologies for infection, hemorrhage, etc
    • Recognize that in rare cases, LP's can cause reactive meningeal enhancement (which is why some practitioners delay LP until after MRI). This practice might not be supported in cases where LP is necessary. Source: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5727706/
  • Outpatient visual field testing is the most important method for following these patients (Humphrey VF's)

Management

  • Treatment may be indicated in the following situations: severe/intractable headache, evidence of progressive decrease in visual acuity or visual field loss. Some ophthalmologists suggest treating all patients with papilledema.
  • Weight loss
  • Acetazolamide 250mg QID (or 500mg BID) initially building up to 500-1000mg QID if tolerated. Use with caution in sulfa-allergic patients. (decreases CSF production)
  • Discontinue any causative medications
  • Short course of systemic steroids, especially if any plans for surgical intervention
  • Repeat LPs (decrease CSF pressure) - large volume LPs on the order of 30-40 cc of CSF
  • Furosemide 20mg PO BID, give potassium supp as needed
  • If above treatments are unsuccessful, surgical treatments may be considered.
    • CSF Shunt (ventriculoperitoneal or lumboperitoneal) is often effective if vision is threatened
    • Optic nerve sheath fenestration

Disposition

  • Admit for:
    • Severe pain
    • Focal findings
    • Vision changes
  • Otherwise, discharge with ophtho follow up for formal visual field monitoring

External Links

See Also

References