Idiopathic intracranial hypertension: Difference between revisions
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**CSF lab studies by [[lumbar puncture]] are negative | **CSF lab studies by [[lumbar puncture]] are negative | ||
**No special CSF studies need to be sent, unless differential includes etiologies for infection, hemorrhage, etc | **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 | **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) | *Outpatient visual field testing is the most important method for following these patients (Humphrey VF's) | ||
Revision as of 03:16, 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 OCPs, vitamin A, tetracycline and thyroid disorders
Clinical Features
- Tends to occur in young, obese women
- Headache
- 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
- Vision blurring
- Papilledema
- can be visualized with ultrasound
- Irregular menses or amenorrhea
- Neuro exam often normal
- May have cranial nerve palsies if severe, most often abducens nerve palsy
Differential Diagnosis
Headache
Common
Killers
- Meningitis/encephalitis
- Myocardial ischemia
- Retropharyngeal abscess
- Intracranial Hemorrhage (ICH)
- SAH / sentinel bleed
- Acute obstructive hydrocephalus
- Space occupying lesions
- CVA
- Carbon monoxide poisoning
- Basilar artery dissection
- Preeclampsia
- Cerebral venous thrombosis
- Hypertensive emergency
- Depression
Maimers
- Giant cell arteritis of temporal artery (temporal arteritis)
- Idiopathic intracranial hypertension (Pseudotumor Cerebri)
- Acute Glaucoma
- Acute sinusitis
- Cavernous sinus thrombosis or cerebral sinus thrombosis
- Carotid artery dissection
Others
- Trigeminal neuralgia
- TMJ pain
- Post-lumbar puncture headache
- Dehydration
- Analgesia abuse
- Various ocular and dental problems
- Herpes zoster ophthalmicus
- Herpes zoster oticus
- Cryptococcosis
- Febrile headache (e.g. pyelonephritis, nonspecific viral infection)
- Ophthalmoplegic migraine
- Superior Vena Cava Syndrome
Aseptic Meningitis
- Viral
- Tuberculosis
- Lyme disease
- Syphilis
- Leptospirosis
- Fungal (AIDS, transplant, chemotherapy, chronic steroid use)
- Noninfectious
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
- Repeat LPs (decrease CSF pressure) - large volume LPs on the order of 30-40 cc of CSF
- Acetazolamide 500mg BID (decrease CSF production)
- Furosemide 20mg PO BID, give potassium supp as needed
- Weight loss
- CSF Shunt
- Optic nerve sheath fenestration
Disposition
- Admit for:
- Severe pain
- Focal findings
- Vision changes
- Otherwise, discharge with ophtho follow up for formal visual field monitoring