Medication-induced intracranial hypertension in dermatology

Idiopathic intracranial hypertension: Diagnosis, monitoring and treatment

INTRODUCTION

Idiopathic intracranial hypertension (IIH) is a disorder typically affecting young, obese women, producing a syndrome of increased intracranial pressure without identifiable cause.

STATE OF THE ART

Despite a large number of hypotheses and publications over the past decade, the etiology of IIH is still unknown. There continues to be no evidence-based consensus or formal guidelines regarding management and treatment of the disease. Treatment studies show that the diagnostic lumbar puncture is a valuable intervention beyond its diagnostic importance, and that weight management is critical. However, many questions remain, regarding the efficacy of acetazolamide, cerebrospinal fluid (CSF) shunting procedures, optic nerve sheath fenestration, and cerebral transverse venous sinus stenting. Identification of subgroups of patients at high-risk for irreversible visual loss, such as black patients, men, morbidly obese patients, and patients with fulminant IIH, helps determine management approaches and refine follow-up strategies.

PERSPECTIVE

Better understanding of the pathophysiology and ongoing clinical trials will hopefully help inform treatment strategies over the next few years.

All-Trans Retinoic Acid-Induced Pseudotumor Cerebri during Induction Therapy for Acute Promyelocytic Leukemia: A Case Report and Literature Review

All-trans retinoic acid (ATRA), a derivative of vitamin A, is an essential component in the treatment of acute promyelocytic leukemia (APL). Though considered to be a relatively safe drug, use of ATRA can lead to several side effects such as retinoic acid syndrome and pseudotumor cerebri (PC). PC is a rare disorder characterized by neurologic and ocular signs and symptoms of increased intracranial pressure, but with normal cerebrospinal fluid composition and normal brain imaging. Most of the previous studies suggest that PC, as a complication of ATRA therapy, occurs predominantly in the pediatric age group. Herein, we report a rare case of ATRA-induced PC in a 38-year-old woman undergoing induction treatment for APL. Symptoms improved with discontinuation of ATRA and treatment with acetazolamide. Concomitant administration of medications such as triazole antifungals which influence the cytochrome P-450 system can exacerbate this potential complication of ATRA. In this paper, we also review the current literature, provide a descriptive analysis of clinical features, and discuss the principles of management of ATRA-induced PC.

Update on the pathophysiology and management of idiopathic intracranial hypertension

Idiopathic intracranial hypertension is a disease of unknown aetiology, typically affecting young obese women, producing a syndrome of increased intracranial pressure without identifiable cause. Despite a large number of hypotheses and publications over the past decade, the aetiology is still unknown. Vitamin A metabolism, adipose tissue as an actively secreting endocrine tissue and cerebral venous abnormalities are areas of active study regarding the pathophysiology of idiopathic intracranial hypertension. There continues to be no evidence based consensus or formal guidelines regarding management and treatment of the disease. Treatment studies show that the diagnostic lumbar puncture is a valuable intervention beyond its diagnostic importance, and that weight management is critical. However, many questions remain regarding the efficacy of acetazolamide, CSF shunting procedures and cerebral transverse venous sinus stenting.

Transverse sinus stenting for idiopathic intracranial hypertension: a review of 52 patients and of model predictions

BACKGROUND AND PURPOSE

Transverse sinus stenosis is common in patients with IIH. While the role of transverse sinus stenosis in IIH pathogenesis remains controversial, modeling studies suggest that stent placement within a transverse sinus stenosis with a significant pressure gradient should decrease cerebral venous pressure, improve CSF resorption in the venous system, and thereby reduce intracranial (CSF) pressure, improving the symptoms of IIH and reducing papilledema. We aimed to determine if IIH could be reliably treated by stent placement in transverse sinus stenosis.

MATERIALS AND METHODS

We reviewed the clinical, venographic, and intracranial pressure data before and after stent placement in transverse sinus stenosis in 52 of our own patients with IIH unresponsive to maximum acceptable medical treatment, treated since 2001 and followed between 2 months and 9 years.

RESULTS

Before stent placement, the mean superior sagittal sinus pressure was 34 mm Hg (462 mm H(2)0) with a mean transverse sinus stenosis gradient of 20 mm Hg. The mean lumbar CSF pressure before stent placement was 322 mm H(2)O. In all 52 patients, stent placement immediately eliminated the TSS pressure gradient, rapidly improved IIH symptoms, and abolished papilledema. In 6 patients, symptom relapse (headache) was associated with increased venous pressure and recurrent stenosis adjacent to the previous stent. In these cases, placement of another stent again removed the transverse sinus stenosis pressure gradient and improved symptoms. Of the 52 patients, 49 have been cured of all IIH symptoms.

CONCLUSIONS

These findings indicate a role for transverse sinus stent placement in the management of selected patients with IIH.

Doxycycline for malaria chemoprophylaxis and treatment: report from the CDC expert meeting on malaria chemoprophylaxis

Doxycycline, a synthetically derived tetracycline, is a partially efficacious causal prophylactic (liver stage of Plasmodium) drug and a slow acting blood schizontocidal agent highly effective for the prevention of malaria. When used in conjunction with a fast acting schizontocidal agent, it is also highly effective for malaria treatment. Doxycycline is especially useful as a prophylaxis in areas with chloroquine and multidrug-resistant Plasmodium falciparum malaria. Although not recommended for pregnant women and children < 8 years of age, severe adverse events are rarely reported for doxycycline. This report examines the evidence behind current recommendations for the use of doxycycline for malaria and summarizes the available literature on its safety and tolerability.

More than meets the eye? Redefining idiopathic intracranial hypertension

Idiopathic intracranial hypertension (IIH) is a disease of unknown etiology associated with increased intracranial pressure, predominantly affecting obese females of childbearing age. The history of IIH is quite unique, featuring only limited advancements in evidenced-based treatments, but boasting literally countless changes in nomenclature, proposed etiology, and conceptual approach. Despite its elusive pathogenesis, an evolution of our approach to IIH can be traced sequentially through identifiable periods. Contemporary research suggests that we are approaching a new phase in IIH, redefining it as a global neurologic syndrome with more far-reaching effects than previously realized.

A severe case of tetracycline-induced intracranial hypertension

Tetracykline is a first-line treatment of the common skin disorder acne vulgaris. A rare side effect of tetracycline treatment is intracranial hypertension also called pseudotumor cerebri (PTC). We report a severe case of PTC with cranial nerve palsy and visual loss in a 16 year old girl following acne vulgaris treatment with tetracycline.

Avaliação dos efeitos adversos clínicos e alterações laboratoriais em pacientes com acne vulgar tratados com isotretinoína oral

FUNDAMENTOS: A isotretinoína oral revolucionou o manejo da acne. Os efeitos adversos observados, durante o tratamento, são divididos em dois grupos: mucocutâneos e sistêmicos. Anormalidades laboratoriais, principalmente, as dislipidemias e aumento das enzimas hepáticas são relatados. OBJETIVO: Avaliar a tolerabilidade da isotretinoína oral, com atenção, no metabolismo lipídico, função hepática e reações adversas clínicas. MÉTODOS: Foram incluídos 150 pacientes com diagnóstico clínico de acne submetidos a tratamento com isotretinoína oral. Avaliações clínicas e laboratoriais foram feitas, após um mês e a cada três meses, até completar o tratamento. RESULTADOS: Dos 150 pacientes 48% eram do sexo feminino e 52% do sexo masculino. A idade variou de 15 a 32 anos. Quanto aos efeitos adversos cutâneos e mucosos da isotretinoína, queilite foi o mais frequente, ocorrendo em 94% pacientes. Efeitos clínicos sistêmicos foram bem menos comuns. Os níveis de colesterol, triglicerídeos, transaminases, foram avaliados e não mostraram alterações significativas, ao longo do tratamento. CONCLUSÃO: Os pacientes apresentaram efeitos adversos, compatíveis com os da literatura, e, em sua maioria, controlados com medicações sintomáticas. Podemos concluir que a isotretinoína é uma droga segura, em relação a seus efeitos adversos, tanto clínicos como laboratoriais.

Doxycycline-induced pseudotumor cerebri

Tetracyclines are a commonly prescribed medication for the treatment of acne vulgaris that are associated with pseudotumor cerebri (PTC). With doxycycline specifically, however, the incidence of PTC is very rare. A patient was using oral doxycycline and topical retinoids for acne, and within two months she developed PTC. This case illustrates that despite the rarity of doxycycline-induced PTC, patients and physicians should be aware of this possibility. Furthermore, in the setting of new-onset headaches or visual changes, early ophthalmologic examination for papilledema is recommended for early diagnosis.

Increased intracranial pressure in a case of pediatric multiple sclerosis

A 15-year-old girl presented to our emergency department with dizziness, anorexia, nausea, and malaise. Clinical examination and magnetic resonance imaging studies showed characteristic features of multiple sclerosis. Surprisingly, a diagnostic lumbar puncture showed significant intracranial hypertension in addition to numerous oligoclonal bands, elevated immunoglobulin G index and immunoglobulin G/albumin ratio in the cerebrospinal fluid. It is proposed that a large burden of active demyelinating disease may cause increased intracranial pressure, thus providing an additional sound rationale for prompt therapeutic administration of intravenous high-dose steroids.

Management of intracranial hypertension

Effective management of intracranial hypertension involves meticulous avoidance of factors that precipitate or aggravate increased intracranial pressure. When intracranial pressure becomes elevated, it is important to rule out new mass lesions that should be surgically evacuated. Medical management of increased intracranial pressure should include sedation, drainage of cerebrospinal fluid, and osmotherapy with either mannitol or hypertonic saline. For intracranial hypertension refractory to initial medical management, barbiturate coma, hypothermia, or decompressive craniectomy should be considered. Steroids are not indicated and may be harmful in the treatment of intracranial hypertension resulting from traumatic brain injury.

Risk management of nutritional supplements in chronic illness: the implications for the care of cancer and depression

The use of complementary medicines in patients suffering from chronic illnesses such as cancer and depression is widely documented. Current studies suggest that the prevalence of the use of complementary medicines in patients with cancer ranges from 7% to 80%. In patients suffering from severe depression the use of complementary medicines may be >40%. The aim of the present review is to systematically explore the main dimensions that clinicians have to consider when advising patients suffering from these conditions. The Medline and Cochrane databases were searched for evidence relating to the benefits and risks of supplements in the treatment of cancer and depression, including the potential interactions with pharmaco- and radiotherapy. Supplements predominantly used by patients with cancer include vitamins A, C and E, β-carotene and ubiquinone 10. Supplements predominantly used by patients with depression include S-adenosylmethionine, l-tryptophan and 5-hydroxytryptophan and inositol. Supplements potentially used by both groups include n-3 fatty acids, Se and folic acid. Four dimensions are identified and discussed: effectiveness; safety; communication; medico-legal aspects. These dimensions have to be addressed in an illness- and case-specific context. This task can be complex given the emerging clinical evidence, patients' own preferences and expectations and current prescribing guidelines.

Management of intracranial hypertension

Effective treatment of intracranial hypertension involves meticulous avoidance of factors that precipitate or aggravate increased intracranial pressure. When intracranial pressure becomes elevated, it is important to rule out new mass lesions that should be surgically evacuated. medical management of increased intracranial pressure should include sedation and paralysis, drainage of cerebrospinal fluid, and osmotherapy with either mannitol or hypertonic saline. For intracranial hypertension refractory to initial medical management, barbiturate coma, hypothermia, or decompressive craniectomy should be considered. Steroids are not indicated and may be harmful in the treatment of intracranial hypertension resulting from traumatic brain injury.

Profiles of obesity, weight gain, and quality of life in idiopathic intracranial hypertension (pseudotumor cerebri)

PURPOSE

Obesity and weight gain are known risk factors for idiopathic intracranial hypertension (IIH; or pseudotumor cerebri). The authors examined profiles of body mass index (BMI) and patterns of weight gain associated with IIH. They also examined vision-specific health-related quality of life (HRQOL) in newly diagnosed IIH patients and explored the relative contribution of obesity and weight gain to overall HRQOL in this disorder.

DESIGN

Matched case-control study.

METHODS

Female patients with newly diagnosed IIH (n = 34) and other neuro-ophthalmologic disorders (n = 41) were enrolled in a case-control study to assess patterns of self-reported weight gain. The HRQOL was examined using the 25-Item National Eye Institute Visual Function Questionnaire (NEI-VFQ-25) and the SF-36 Health Survey (Physical Components Summary and Mental Components Summary [MCS]).

RESULTS

Higher BMIs were associated with greater risk of IIH (P = .003, logistic regression analysis adjusting for case-control matching), as were higher percentages of weight gain during the year before symptom onset (P = .004). Moderate weight gain (5% to 15%) was associated with a greater risk of IIH among both obese and nonobese patients. Obesity and weight gain influenced the relation between HRQOL and IIH only for subscale scores reflecting mental health (SF-36 MCS). The NEI-VFQ-25 and SF-36 subscale scores were lower in IIH compared with other neuro-ophthalmologic disorders and published norms.

CONCLUSIONS

Higher levels of weight gain and BMI are associated with greater risk of IIH. Even nonobese patients (BMI <30) are at greater risk for IIH in the setting of moderate weight gain. Vision-specific and overall HRQOL are affected to a greater extent in IIH than in other neuro-ophthalmologic disorders.

The use of vitamin A-deficient diets and jugular vein ligation to increase intracranial pressure in chickens (Gallus gallus)

A technique was developed to record intracranial cerebrospinal fluid pressure (iCSFp) in chicks and mature chickens. Using that procedure, 2 methods were found to effect a significant elevation in intracranial pressure: 1) feeding a purified diet to roosters for 40 d containing 25% of the bird's requirement for vitamin A, and 2) ligating both jugular veins in birds. The purified diet significantly reduced plasma retinol levels from 1.080 to 0.046 microg/mL, and iCSFp was significantly elevated from 63.0 to 106.0 mmH2O (P < or = 0.05). Two limitations for using hypovitaminosis A diets were capillary fragility and a cisterna magna that did not develop to the size of that structure in birds of the same age fed control diets with adequate vitamin A content. The second procedure, a reversible surgical technique, showed that within 2.5 h from jugular vein ligation, intracranial pressure rose to 109.7 mmH2O, comparable with levels attained following feeding a vitamin A deficient diet to roosters. Bilateral clamping of the jugular veins overnight resulted in an elevation of iCSFp to 127 +/- 8.86 mmH2O. Results suggest that the chicken may be a useful animal model to investigate intracranial hypertension and its accompanying headaches known to occur in humans.