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Chisholm JT, Abou-Jaoude MM, Hessler AB, Sudhakar P. Pseudotumor Cerebri Syndrome with Resolution After Discontinuing High Vitamin A Containing Dietary Supplement: Case Report and Review. Neuroophthalmology 2018; 42:169-175. [PMID: 29796052 DOI: 10.1080/01658107.2017.1367931] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2017] [Revised: 08/11/2017] [Accepted: 08/12/2017] [Indexed: 10/18/2022] Open
Abstract
A 24-year-old non-obese, but slightly overweight, female presented with a two-week history of progressive severe headache associated with two days of blurry vision. Clinical exam was significant for bilateral papilledema and an enlarged blind spot on visual field testing. Contrast enhanced MRI head revealed no space occupying lesion. A lumbar puncture revealed an elevated opening pressure of 38 cm H2O with normal cerebrospinal fluid composition leading to a diagnosis of pseudotumor cerebri syndrome (PTCS). The patient lacked the typical risk factors of high body mass index or obvious antecedent medications; however, on subsequent questioning, she was chronically ingesting a high vitamin A containing weight loss dietary supplement (Thrive W® - Table 1), which we believe had caused intracranial hypertension. Discontinuation of the diet pill and treatment with acetazolamide led to marked improvement of her PTCS. This case highlights the fact that non-traditional products or medications with high vitamin A may cause pseudotumor cerebri, which treating physicians should assess for while dealing with non-obese PTCS patients.
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Affiliation(s)
- Jason T Chisholm
- Department of Neurology, University of Kentucky, Lexington, Kentucky, USA
| | | | - Amy B Hessler
- Department of Neurology, University of Kentucky, Lexington, Kentucky, USA
| | - Padmaja Sudhakar
- Department of Neurology, University of Kentucky, Lexington, Kentucky, USA
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52
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Ba-Ali S, Jensen RH, Larsen LS, Lund-Andersen H, Hamann S. The Melanopsin-Mediated Pupillary Light Response Is Not Changed in Patients with Newly Diagnosed Idiopathic Intracranial Hypertension. Neuroophthalmology 2018; 42:65-72. [PMID: 29563950 DOI: 10.1080/01658107.2017.1344251] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2017] [Revised: 06/07/2017] [Accepted: 06/15/2017] [Indexed: 10/19/2022] Open
Abstract
Previously, it has been reported that melanopsin-mediated pupillary light response (PLR), measured with pupillometry, is reduced in patients with idiopathic intracranial hypertension (IIH), indicating the clinical utility of the tool in the diagnosis of IIH. In the current study, the authors aimed to measure the PLR in 13 treatment-naive patients with new-onset IIH and 13 healthy controls. In contrast to the previous report, which was based on patients with longstanding IIH (n = 13), the authors found no significant difference in the melanopsin-mediated PLR (p = 0.48).
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Affiliation(s)
- Shakoor Ba-Ali
- Department of Ophthalmology, Rigshospitalet, Glostrup, Denmark.,Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Rigmor Højland Jensen
- Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark.,Department of Neurology, Danish Headache Center, Rigshospitalet, Glostrup, Denmark
| | - Line Sofie Larsen
- Department of Neurology, Danish Headache Center, Rigshospitalet, Glostrup, Denmark
| | - Henrik Lund-Andersen
- Department of Ophthalmology, Rigshospitalet, Glostrup, Denmark.,Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Steffen Hamann
- Department of Ophthalmology, Rigshospitalet, Glostrup, Denmark.,Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
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Abstract
PURPOSE OF REVIEW The purpose of this review is to provide an update on pediatric intracranial hypertension. RECENT FINDINGS The annual pediatric incidence is estimated at 0.63 per 100,000 in the USA and 0.71 per 100,000 in Britain. The Idiopathic Intracranial Hypertension Treatment Trial found improvement in visual fields, optical coherence tomography, Frisen grade, and quality of life with acetazolamide compared to placebo in adult patients, and these findings have been translated to the pediatric population. Pediatric intracranial hypertension is a disorder that if left untreated can lead to poor quality of life and morbidity. There are no current treatment studies in pediatrics, but adult data suggests acetazolamide remains an acceptable first-line medication.
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Affiliation(s)
- Shawn C Aylward
- Department of Neurology, Nationwide Children's Hospital, The Ohio State University College of Medicine, 700 Children's Drive, Columbus, OH, 43205, USA.
| | - Amanda L Way
- Department of Ophthalmology, Nationwide Children's Hospital, Columbus, OH, USA
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Real time optic nerve sheath diameter measurement during lumbar puncture. Am J Emerg Med 2018; 36:736.e1-736.e3. [PMID: 29338967 DOI: 10.1016/j.ajem.2018.01.037] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2018] [Accepted: 01/10/2018] [Indexed: 11/21/2022] Open
Abstract
Measurement of optic nerve sheath diameter (ONSD) using point of care ultrasound has been used to indirectly assess the intracranial pressure (ICP) particularly in conditions where it is raised. Direct pressure measurements using probes reaching the ventricle system correlated with ONSD using ultrasound. Attempts were made to measure the ONSD pre and post lumbar puncture (LP) after draining cerebrospinal fluid (CSF) as well as post ventricular shunt placement. We report ONSD measurement and demonstrate dynamic changes during LP in a patient with known idiopathic intracranial hypertension (IIH).
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Inger HE, Rogers DL, McGregor ML, Aylward SC, Reem RE. Diagnostic criteria in pediatric intracranial hypertension. J AAPOS 2017; 21:492-495.e2. [PMID: 29081363 DOI: 10.1016/j.jaapos.2017.08.003] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/07/2017] [Revised: 08/14/2017] [Accepted: 08/17/2017] [Indexed: 10/18/2022]
Abstract
BACKGROUND The modified Dandy criteria and the newer diagnostic criteria for pseudotumor cerebri syndrome (PTCS) are both used to diagnose intracranial hypertension (IH). In comparison to the modified Dandy criteria, the PTCS criteria stratify the IH diagnosis into definite, probable, and suggested categories, exclude clinical symptoms, and use radiologic evidence for diagnosis. There is a lack of consensus on which criteria should be used in the pediatric population. The purpose of this study was to compare the diagnostic criteria for PTCS to the modified Dandy criteria and to identify limitations within both sets of criteria. METHODS The PTCS criteria were retrospectively applied to 50 patients originally diagnosed with IH under the modified Dandy criteria. RESULTS Of the 50 patients, 31 (62%) met diagnostic criteria for definite PTCS, 10 (20%) met criteria for probable PTCS, and 9 patients (18%) failed to meet sufficient PTCS criteria for diagnosis. CONCLUSIONS Although the PTCS criteria use objective data to make the IH diagnosis, we found subjective symptoms to be useful indicators of disease in this group of patients. Additionally, distinguishing probable from definite IH may not have clinical relevance, because both groups were treated similarly. The absence of radiographic evidence of IH should not preclude a diagnosis of the condition, as it was present in a minority of patients included in this study. Further research is needed to clarify the disease process in patients who present with signs and symptoms of elevated intracranial pressure but lack ocular pathology.
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Affiliation(s)
- Hilliary E Inger
- Department of Ophthalmology, Nationwide Children's Hospital, The Ohio State University College of Medicine, Columbus, Ohio
| | - David L Rogers
- Department of Ophthalmology, Nationwide Children's Hospital, The Ohio State University College of Medicine, Columbus, Ohio
| | - Mary Lou McGregor
- Department of Ophthalmology, Nationwide Children's Hospital, The Ohio State University College of Medicine, Columbus, Ohio
| | - Shawn C Aylward
- Department of Neurology, Nationwide Children's Hospital, The Ohio State University College of Medicine, Columbus, OH
| | - Rachel E Reem
- Department of Ophthalmology, Nationwide Children's Hospital, The Ohio State University College of Medicine, Columbus, Ohio.
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Venous Sinus Stenting in the Management of Patients with Intracranial Hypertension Manifesting with Skull Base Cerebrospinal Fluid Leaks. World Neurosurg 2017. [DOI: 10.1016/j.wneu.2017.06.087] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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57
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Greywal T, Zaenglein AL, Baldwin HE, Bhatia N, Chernoff KA, Del Rosso JQ, Eichenfield LF, Levin MH, Leyden JJ, Thiboutot DM, Webster GF, Friedlander SF. Evidence-based recommendations for the management of acne fulminans and its variants. J Am Acad Dermatol 2017; 77:109-117. [DOI: 10.1016/j.jaad.2016.11.028] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2016] [Revised: 11/09/2016] [Accepted: 11/11/2016] [Indexed: 11/28/2022]
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Tarrats L, Hernández G, Busquets JM, Portela JC, Serrano LA, González-Sepúlveda L, Sánchez-Pérez JR. Outcomes of endoscopic optic nerve decompression in patients with idiopathic intracranial hypertension. Int Forum Allergy Rhinol 2017; 7:615-623. [PMID: 28383199 DOI: 10.1002/alr.21927] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2016] [Revised: 01/22/2017] [Accepted: 01/24/2017] [Indexed: 12/14/2022]
Abstract
BACKGROUND The conventional treatment for idiopathic intracranial hypertension involves weight loss, steroids, diuretics, and/or serial lumbar punctures; however, if the symptoms persist or worsen, surgical intervention is recommended. Surgical options include cerebrospinal fluid diversion procedures, such as ventriculoperitoneal and lumboperitoneal shunts, and optic nerve decompression with nerve sheath fenestration. The latter can be carried out using an endoscopic approach, but the outcomes of this technique have not been firmly established. METHODS This systematic review examined the outcomes of performing endoscopic optic nerve decompression (EOND) in patients with idiopathic intracranial hypertension (IIH). Six studies were included for a total of 34 patients. RESULTS The patients presented with visual field disturbances (32 of 32 [100%]), visual acuity disruptions (33 of 34 [97.1%]), papilledema (26 of 34 [76.5%]), and persistent headache (30 of 33 [90.1%]). The mean duration of symptoms ranged from 7 to 32 months. Overall, the patients showed post-EOND improvement in signs and symptoms associated with IIH, specifically visual field deficits (93.8%), visual acuity (85.3%), papilledema (81.4%), and headaches (81.8%). Interestingly, 11 cases showed postoperative improvement in their symptoms with bony decompression of the optic canal alone, without nerve sheath fenestration. There were no major adverse events or complications reported with this approach. CONCLUSION EOND appears to be a promising and safe surgical alternative for patients with IIH who fail to respond to medical treatment. Further studies are needed before we can attest to the clinical validity of this procedure.
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Affiliation(s)
- Luisam Tarrats
- Department of Otolaryngology Head & Neck Surgery, Medical Sciences Campus, University of Puerto Rico, San Juan, Puerto Rico
| | - Gabriel Hernández
- Department of Otolaryngology Head & Neck Surgery, Medical Sciences Campus, University of Puerto Rico, San Juan, Puerto Rico
| | - José M Busquets
- Department of Otolaryngology Head & Neck Surgery, Medical Sciences Campus, University of Puerto Rico, San Juan, Puerto Rico
| | - Juan C Portela
- Department of Otolaryngology Head & Neck Surgery, Medical Sciences Campus, University of Puerto Rico, San Juan, Puerto Rico
| | - Luis A Serrano
- Department of Ophthalmology, Medical Sciences Campus, University of Puerto Rico, San Juan, Puerto Rico
| | | | - José R Sánchez-Pérez
- Department of Otolaryngology Head & Neck Surgery, Medical Sciences Campus, University of Puerto Rico, San Juan, Puerto Rico
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Stevens SM, Rizk HG, Golnik K, Andaluz N, Samy RN, Meyer TA, Lambert PR. Idiopathic intracranial hypertension: Contemporary review and implications for the otolaryngologist. Laryngoscope 2017; 128:248-256. [PMID: 28349571 DOI: 10.1002/lary.26581] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/16/2017] [Indexed: 11/11/2022]
Abstract
OBJECTIVES 1) Review controversies pertaining to the pathophysiology, diagnosis, and treatment of idiopathic intracranial hypertension. 2) Discuss the evolving role of otolaryngologists in managing this disease and related disorders. DATA SOURCES Primary literature review, Centers for Disease Control and Prevention website, International Classification of Headache Disorders, Second Edition. METHODS A comprehensive review of the primary literature was performed from 1990 to 2016 utilizing keywords idiopathic intracranial hypertension, pseudotumor cerebri, benign intracranial hypertension, spontaneous cerebrospinal fluid leak, and encephalocele. Articles were included at the discretion of the authors based on novel and/or historical contributions to the literature. RESULTS The incidence of idiopathic intracranial hypertension is increasing along with the obesity epidemic. Undiagnosed patients may present to otolaryngologists with pulsatile tinnitus, dizziness, sleep apnea, and spontaneous cerebrospinal fluid leaks. Although diagnosis is predicated upon imaging findings and lumbar puncture, radiographic signs including empty sella, optic nerve dilation, and globe flattening may suggest the diagnosis. The most effective intervention is weight loss combined with acetazolamide. Surgery is reserved for severe or refractory symptoms and can be highly morbid. Otolaryngologists are increasingly responsible for managing a number of secondary disorders including cerebrospinal fluid rhinorrhea and otorrhea. Failure to manage intracranial hypertension may lead to adverse surgical outcomes. CONCLUSIONS The knowledge base for idiopathic intracranial hypertension has greatly expanded over the past 25 years. This disease is associated with a number of conditions directly relevant to otolaryngologists. A keen understanding of this disorder and its management may optimize outcomes in a growing number of patients. Laryngoscope, 128:248-256, 2018.
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Affiliation(s)
- Shawn M Stevens
- Department of Otolaryngology-Head and Neck Surgery, University of Cincinnati, Cincinnati, Ohio, U.S.A
| | - Habib G Rizk
- Department of Otolaryngology-Head and Neck Surgery, Medical University of South Carolina, Charleston, South Carolina, U.S.A
| | - Karl Golnik
- Department of Ophthalmology, Cincinnati Eye Institute, Cincinnati, Ohio, U.S.A
| | - Norberto Andaluz
- Division of Skull Base Surgery, Mayfield Brain & Spine, Cincinnati, Ohio, U.S.A
| | - Ravi N Samy
- Department of Otolaryngology-Head and Neck Surgery, University of Cincinnati College of Medicine and Neurosensory Disorders Center at University of Cincinnati Neuroscience Institute, Cincinnati, Ohio, U.S.A
| | - Ted A Meyer
- Department of Otolaryngology-Head and Neck Surgery, Medical University of South Carolina, Charleston, South Carolina, U.S.A
| | - Paul R Lambert
- Department of Otolaryngology-Head and Neck Surgery, Medical University of South Carolina, Charleston, South Carolina, U.S.A
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An update on idiopathic intracranial hypertension. Acta Neurochir (Wien) 2017; 159:491-499. [PMID: 28013373 DOI: 10.1007/s00701-016-3050-7] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2016] [Accepted: 12/06/2016] [Indexed: 10/20/2022]
Abstract
BACKGROUND Idiopathic intracranial hypertension (IIH) is still a grey area in the knowledge of the aetiology, diagnosis and management of neurosurgical diseases. The definition of IIH has been reviewed over time and many hypotheses have been expressed as cause of the disease. The literature supplies very little evidence-based information to guide our decision-making process when it comes to treat the disease. In this review we sum up the latest information regarding the aetiology and therapy of IIH. Additionally, we make an attempt to unify the diagnostic criteria of Dandy, Friedman and Wall established from 1937 to date. METHOD In this narrative review, we attempt to update the current standpoint to IIH, evaluate the input until now and consider future directions for research. The vast majority of the literature consisted of cohort studies, case control studies, systematic reviews and other narrative reviews. RESULTS Pathophysiology: The incidence of IIH is steadily increasing. Several pathophysiological theories have been proposed in the literature based on the flow of cerebrospinal fluid. DIAGNOSIS We attempt to fuse all the three diagnostic approaches published in the literature that detect IIH, while preserving the individual characteristics of each approach. TREATMENT Based on evidence-based trials, the current use of acetazolamide in comparison with placebo or with topiramate has been evaluated. In the interventions' field, there seems to be a consonance about the alarming symptoms and what the most suitable operation is in each case. There is some disagreement about the indications for venous sinus transversus stenting and its risk/benefit ratio. CONCLUSIONS Until now there is no class I guideline to which our decision-making can be based on for the management of IIH. A lack of systematic reviews and randomised control trials has been noted. If we focused our research on that, we could develop a standardised treatment protocol.
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61
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Gordon LK. Optic Nerve. Handb Exp Pharmacol 2017; 242:369-386. [PMID: 27787712 DOI: 10.1007/164_2016_19] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
Abstract
Optic nerve diseases arise from many different etiologies including inflammatory, neoplastic, genetic, infectious, ischemic, and idiopathic. Understanding some of the characteristics of the most common optic neuropathies along with therapeutic approaches to these diseases is helpful in designing recommendations for individual patients. Although many optic neuropathies have no specific treatment, some do, and it is those potentially treatable or preventable conditions which need to be recognized in order to help patients regain their sight or develop a better understanding of their own prognosis. In this chapter several diseases are discussed including idiopathic intracranial hypertension, optic neuritis, ischemic optic neuropathies, hereditary optic neuropathies, trauma, and primary tumors of the optic nerve. For each condition there is a presentation of the signs and symptoms of the disease, in some conditions the evaluation and diagnostic criteria are highlighted, and where possible, current therapy or past trials are discussed.
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Affiliation(s)
- Lynn K Gordon
- Stein Eye Institute, David Geffen School of Medicine at UCLA, Los Angeles, CA, 90095, USA.
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62
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Aylward SC, Reem RE. Pediatric Intracranial Hypertension. Pediatr Neurol 2017; 66:32-43. [PMID: 27940011 DOI: 10.1016/j.pediatrneurol.2016.08.010] [Citation(s) in RCA: 45] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/22/2016] [Revised: 08/08/2016] [Accepted: 08/10/2016] [Indexed: 10/21/2022]
Abstract
Primary (idiopathic) intracranial hypertension has been considered to be a rare entity, but with no precise estimates of the pediatric incidence in the United States. There have been attempts to revise the criteria over the years and adapt the adult criteria for use in pediatrics. The clinical presentation varies with age, and symptoms tending to be less obvious in younger individuals. In the prepubertal population, incidentally discovered optic disc edema is relatively common. By far the most consistent symptom is headache; other symptoms include nausea, vomiting tinnitus, and diplopia. Treatment mainstays include weight loss when appropriate and acetazolamide. Furosemide may exhibit a synergistic benefit when used in conjunction with acetazolamide. Surgical interventions are required relatively infrequently, but include optic nerve sheath fenestration and cerebrospinal fluid shunting. Pain and permanent vision loss are the two major complications of this disorder and these manifestations justify aggressive treatment. Once intracranial hypertension has resolved, up to two thirds of patients develop a new or chronic headache type that is different from their initial presenting headache.
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Affiliation(s)
- Shawn C Aylward
- Department of Neurology, Nationwide Children's Hospital, Columbus, Ohio.
| | - Rachel E Reem
- Department of Ophthalmology, Nationwide Children's Hospital, Columbus, Ohio
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Idiopathic Intracranial Hypertension After Surgical Treatment of Cushing Disease: Case Report and Review of Management Strategies. World Neurosurg 2016; 96:611.e15-611.e18. [DOI: 10.1016/j.wneu.2016.09.008] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2016] [Revised: 08/30/2016] [Accepted: 09/01/2016] [Indexed: 11/22/2022]
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Mollan SP, Ali F, Hassan-Smith G, Botfield H, Friedman DI, Sinclair AJ. Evolving evidence in adult idiopathic intracranial hypertension: pathophysiology and management. J Neurol Neurosurg Psychiatry 2016; 87:982-92. [PMID: 26888960 PMCID: PMC5013119 DOI: 10.1136/jnnp-2015-311302] [Citation(s) in RCA: 146] [Impact Index Per Article: 18.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/01/2015] [Accepted: 01/19/2016] [Indexed: 01/12/2023]
Abstract
Idiopathic intracranial hypertension (IIH) is a rare but important disease associated with significant morbidity. There is an expected rise in prevalence in line with the escalating global burden of obesity. Modern revisions in the terminology and diagnostic criteria for IIH help guide clinicians in investigations and researchers in standardising recruitment criteria for clinical trials. The pathophysiology of IIH is incompletely characterised; suggested underpinning mechanisms include the role of cerebrospinal fluid regulation as well as metabolic and endocrinological perspectives. Recent treatment trials are providing insights into the management but debate still surrounds key areas in treatment. This review will provide an up-to-date discussion on the potential pathogenic mechanisms and management of IIH.
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Affiliation(s)
- Susan P Mollan
- Birmingham Neuro-Ophthalmology Unit, Ophthalmology Department, University Hospitals Birmingham NHS Trust, Queen Elizabeth Hospital Birmingham, Birmingham, UK
| | - Fizzah Ali
- Neurometabolism, Institute of Metabolism and Systems Research, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
| | - Ghaniah Hassan-Smith
- Neurometabolism, Institute of Metabolism and Systems Research, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK Neurology Department, University Hospitals Birmingham NHS Trust, Queen Elizabeth Hospital Birmingham, Birmingham, UK
| | - Hannah Botfield
- Neurometabolism, Institute of Metabolism and Systems Research, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
| | - Deborah I Friedman
- Department of Neurology and Neurotherapeutics, University of Texas Southwestern Medical Center, Dallas, Texas, USA Department of Ophthalmology, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Alexandra J Sinclair
- Neurometabolism, Institute of Metabolism and Systems Research, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK Neurology Department, University Hospitals Birmingham NHS Trust, Queen Elizabeth Hospital Birmingham, Birmingham, UK
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Jensen RH, Radojicic A, Yri H. The diagnosis and management of idiopathic intracranial hypertension and the associated headache. Ther Adv Neurol Disord 2016; 9:317-26. [PMID: 27366239 PMCID: PMC4916517 DOI: 10.1177/1756285616635987] [Citation(s) in RCA: 42] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023] Open
Abstract
Idiopathic intracranial hypertension (IIH) is a challenging disorder with a rapid increasing incidence due to a close relation to obesity. The onset of symptoms is often insidious and patients may see many different specialists before the IIH diagnosis is settled. A summary of diagnosis, symptoms, headache characteristics and course, as well as existing evidence of treatment strategies is presented and strategies for investigations and management are proposed.
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Affiliation(s)
- Rigmor Højland Jensen
- Danish Headache Center, Department of Neurology, Rigshospitalet-Glostrup, University of Copenhagen, Denmark
| | | | - Hanne Yri
- Danish Headache Center, Department of Neurology, University of Copenhagen, Rigshospitalet-Glostrup, 2600 Glostrup, Denmark
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Abstract
OBJECTIVES Sixth cranial nerve (SCN) palsy is an uncommon but important neurological problem in patients admitted to pediatric emergency department. The underlying etiology of SCN palsy has a wide range from viral infections to intracranial tumors; therefore, a careful and systematic approach is necessary while examining these patients. METHODS Fourteen patients who presented with acute SCN paralysis to pediatric emergency department during the last 10 years were examined. RESULTS The age at the time of admission ranged between 14 months and 16 years (median, 9.5 years). Of the 14 patients, 5 were girls and 9 were boys. A total of 3 of the 14 patients had bilateral cranial nerve VI paralysis, and 9 patients had additional abnormal findings on neurological examination. Neuroimaging studies included cranial tomography (n = 3) and brain magnetic resonance imaging in all patients. The underlying etiology was malignancy (n = 3); glioma, medulloblastoma, acute lymphoblastic leukemia, and dural sinus thrombosis (n = 2); as well as Guillain-Barre syndrome (n = 2), multiple sclerosis (n = 1), pseudotumor cerebri (n = 1), and meningitis (n = 1). The remaining 4 patients had miscellaneous benign etiologies. CONCLUSIONS Other lesions of primary brain tumors causing increased intracranial pressure constitute 50% of the underlying etiology, followed by Guillain-Barre syndrome (14.2%). However, these patients had neurological symptoms signs, in addition to diplopia or SCN paralysis. Patients admitted to pediatric emergency department with acute SCN paralysis should be examined in detail to disclose the underlying etiology especially if they present with additional clinical signs or symptoms.
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67
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Gragasin FS, Chiarella AB. Use of an Intrathecal Catheter for Analgesia, Anesthesia, and Therapy in an Obstetric Patient with Pseudotumor Cerebri Syndrome. ACTA ACUST UNITED AC 2016; 6:160-2. [PMID: 26825990 DOI: 10.1213/xaa.0000000000000279] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Pseudotumor cerebri syndrome (PTCS) is a rare disorder chiefly observed in obese women of childbearing age. We describe a case of a parturient with PTCS managed successfully with an intrathecal catheter, after inadvertent dural puncture, for labor analgesia, surgical anesthesia, and treatment of headache because of intracranial hypertension during the peripartum period. Prolonged placement of the intrathecal catheter (i.e., >24 hours) may have contributed to the absence of postdural puncture headache symptoms and an uneventful postpartum period. Intrathecal catheter placement may therefore be a viable option in patients with PTCS should inadvertent dural puncture occur.
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Affiliation(s)
- Ferrante S Gragasin
- From the Department of Anesthesiology and Pain Medicine, University of Alberta, and the Royal Alexandra Hospital, Edmonton, Alberta, Canada
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Smith KA, Peterson JC, Arnold PM, Camarata PJ, Whittaker TJ, Abraham MG. A case series of dural venous sinus stenting in idiopathic intracranial hypertension: association of outcomes with optical coherence tomography. Int J Neurosci 2016; 127:145-153. [PMID: 26863329 DOI: 10.3109/00207454.2016.1152967] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
Purpose/Aim: Pseudotumor cerebri or idiopathic intracranial hypertension (IIH) is characterized by increased intracranial pressure of unknown etiology. A subset of patients has shown benefit from endovascular dural venous sinus stenting (DVSS). We sought to identify a population of IIH patients who underwent DVSS to assess outcomes. MATERIALS AND METHODS A retrospective study was performed to identify IIH patients with dural sinus stenosis treated with DVSS. Outcome measures included dural sinus pressure gradients, peripapillary retinal nerve fiber layer (RNFL) thickness using optical coherence tomography and improvement in symptoms. RESULTS Seventeen patients underwent DVSS. Average pre- and post-intervention pressure gradients were 23.06 and 1.18 mmHg, respectively (p < 0.0001). Sixteen (94%) noted improvement in headache, fourteen (82%) had visual improvement and all (100%) patients had improved main symptom. Of 11 patients with optical coherence tomography, 8 showed decreased RNFL thickness and 3 remained stable; furthermore, these 11 patients had improved vision with improved papilledema in 8, lack of pre-existing papilledema in 2 and stable, mild edema in 1 patient. CONCLUSIONS Our series of patients with dural sinus stenosis demonstrated improvement in vision and reduction in RNFL thickness. DVSS appears to be a useful treatment for IIH patients with dural sinus stenosis.
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Affiliation(s)
| | | | | | | | | | - Michael G Abraham
- c Department of Interventional Radiology.,d Department of Neurology , University of Kansas Medical Center , Kansas City , KS , USA
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70
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Abstract
A secondary headache may develop de novo or in patients with a history of primary headaches, and a thorough history and neurological exam often helps to suspect a secondary etiology. The causes of secondary headaches include tumors, vascular etiologies, structural brain disorders, infection, inflammation, and alterations of cerebrospinal fluid pressure dynamics. Computed tomography (CT) is very sensitive for detecting acute hemorrhage but magnetic resonance imaging (MRI) is preferred over a head CT in subacute and non-emergent cases. Obtaining the correct diagnosis may include incorporation of intravenous contrast agents, special imaging sequences, and functional imaging techniques.
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Affiliation(s)
- Priyanka Chaudhry
- Baylor Neuroscience Headache Center, 9101 N. Central Expressway, Suite 400, Dallas, TX, 75231, USA,
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Paley GL, Sheldon CA, Burrows EK, Chilutti MR, Liu GT, McCormack SE. Overweight and obesity in pediatric secondary pseudotumor cerebri syndrome. Am J Ophthalmol 2015; 159:344-52.e1. [PMID: 25447107 DOI: 10.1016/j.ajo.2014.11.003] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2014] [Revised: 10/30/2014] [Accepted: 11/01/2014] [Indexed: 10/24/2022]
Abstract
PURPOSE To examine the clinical, demographic, and anthropometric patient characteristics of secondary pseudotumor cerebri syndrome in children and adolescents based on the recently revised diagnostic criteria. DESIGN Retrospective observational case series. METHODS Patients seen at a tertiary children's hospital for pseudotumor cerebri syndrome were classified as having either primary idiopathic (n = 59) or secondary pseudotumor cerebri syndrome (n = 16), as rigorously defined by recently revised diagnostic criteria. Outcomes included body mass index Z-scores (BMI-Z), height and weight Z-scores, demographics, and clinical features at presentation, such as headache, sixth nerve palsy, and cerebrospinal fluid (CSF) opening pressure. RESULTS In this cohort, the associated conditions and exposures seen in definite secondary pseudotumor cerebri syndrome included tetracycline-class antibiotics (n = 11), chronic kidney disease (n = 3), withdrawal from chronic glucocorticoids (n = 1), and lithium (n = 1). Other associations observed in the possible secondary pseudotumor cerebri syndrome group included Down syndrome, vitamin A derivatives, and growth hormone. In comparison with primary pseudotumor cerebri syndrome, definite secondary pseudotumor cerebri syndrome patients were on average older (15.0 vs 11.6 years; P = .003, Mann-Whitney test). According to US Centers for Disease Control (CDC) classifications, 79% of children with secondary pseudotumor cerebri syndrome were either overweight or obese (36% overweight [n = 5] and 43% obese [n = 6]), as compared to 32% nationally. CONCLUSIONS Even when a potential inciting exposure is identified for pediatric pseudotumor cerebri syndrome, the possible contribution of overweight and obesity should be considered.
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