Pseudotumor cerebri: etiological factors, presenting features and prognosis in the western part of Turkey

The Vienna idiopathic intracranial hypertension database-An Austrian registry

BACKGROUND

Idiopathic intracranial hypertension (IIH) is becoming increasingly more prevalent bearing the risk of visual impairment and affecting the quality of life. Clinical presentation and outcome are heterogeneous. Large, well-characterized cohorts are scarce.

OBJECTIVE

To characterize the clinical spectrum, diagnostic findings, therapeutic management, and outcome of IIH.

METHODS

We identified patients with IIH according to modified Friedman criteria treated at our center between 2014 and 2021. The Vienna IIH database is described in detail.

RESULTS

Of 113 patients 89% were female (mean age 32.3 years). Median body mass index (BMI) was 31.8, with 85% overweight (BMI > 25) and 5% were classified as IIH without papilledema. Headache was present in 84% and showed migraine features in 43%. Median opening pressure in lumbar puncture was 31 cmH2O. Pharmacotherapy (predominantly acetazolamide) was established in 99%, 56% required at least 1 therapeutic lumbar puncture and 13% a surgical intervention. After a median 3.7 years follow-up, 57% had achieved significant weight loss, papilledema was present in 59% and headache in 76% (58% improved). Comparing initial presentation to follow-up, perimetry was abnormal in 67% vs. 50% (8% worsened, 24% improved) and transorbital sonography in 87% vs. 65% with a median optic nerve sheath diameter of 5.4 mm vs. 4.9 mm. Median peripapillary retinal nerve fiber layer thickness decreased from 199 µm to 99 µm and ganglion cell layer volume from 1.13 mm3 to 1.05 mm3.

CONCLUSION

The large representative Vienna IIH cohort characterizes IIH-related symptoms, diagnostic findings, treatment, and outcome emphasizing substantial long-term sequelae of IIH. Future analyses will aim to refine phenotyping and identify factors predicting outcome.

Headache in an Obese Adolescent Male: A Nonclassical Presentation of an Uncommon Disease

Background. Idiopathic intracranial hypertension (IIH), also known as pseudotumor cerebri, is a diagnosis of exclusion in the clinical scenario of increased intracranial pressure without an identifiable cause. This case report provides a brief review of current literature on IIH, important differential considerations to rule out prior to diagnosis, and relevant imaging findings of IIH. Case Presentation. An 18-year-old male presenting with headache and blurry vision was found to have signs of increased intracranial pressure on imaging without other abnormalities to explain the cause, suggesting IIH as a diagnosis. Conclusion. IIH is classically seen in overweight females of childbearing age but should be considered in all obese patients, including the pediatric population given the increasing rate of childhood obesity.

Idiopathic Intracranial Hypertension: Etiological factors, Clinical Features, and Prognosis

Introduction

Idiopathic intracranial hypertension (IIH) occurs due to increased intracranial pressure (ICP), is most commonly encountered in obese women, and may lead to loss of vision. This study aimed to determine the demographic features, clinical signs and symptoms, and radiological findings of patients with IIH, and to investigate the factors associated with the prognosis.

Methods

Patients with IIH who were examined and followed-up between January 1992-January 2012 in the Neuro-ophthalmology Unit were retrospectively evaluated. Patients were diagnosed based on the modified Dandy criteria.

Results

The mean age of 59 patients included in the study (female, 88.1%) was 30.25±13.12 years. Reported complaints were headache (78.0%), transient visual obscuration (45.8%), nausea (32.2%), dizziness (16.9%), and diplopia (13.6%). Of the patients 69.4% had visual field deficits, and 71% had papilledema (66.1% were bilateral). The rate of obesity was 20.3%. The prognosis was good in 64.7% of the patients, and 35.3% of the patients clinically worsened. Recurrence of symptoms was observed in 33% of the patients and 4 patients had severe permanent vision loss. Demographic features, initial complaints, mean ICP, and pathological magnetic resonance imaging findings were not associated with the prognosis. Delay in treatment and generalized constriction in the visual field were associated with the poor prognosis.

Conclusion

Compared to patients with IIH in the western population, obesity was less frequent in the present study. Initial visual field defects, especially the generalized constriction and delay to treatment were related to poor prognosis. Cessation of medical treatment was a factor for recurrence. Early diagnosis and appropriate treatment may subside the severity of permanent vision loss in fulminant IIH.

Idiopathic Intracranial Hypertension (Pseudotumor Cerebri): Descriptive Epidemiology, Clinical Features, and Visual Outcome in Parma, Italy, 1990 to 1999

Purpose

To ascertain the annual incidence rate and the clinical features, other than visual outcome, of idiopathic intracranial hypertension (IIH) in Parma, northern Italy.

METHODS

Neurologic care of people living in the Parma area is entirely provided by one private and two public hospitals. Medical records related to IIH were retrospectively reviewed for all Parma residents from 1990 through 1999.

Results

Ten patients (8 women and 2 men) were identified as having IIH according to modified Dandy criteria. Their age ranged from 16 to 53 years with a mean of 36 years at diagnosis. The annual age-adjusted rate per 100,000 is 0.28 for the total population. For women in reproductive age, the annual incidence rate is 0.65/100,000. For overweight women in reproductive age, the annual incidence rate is 2.7/100,000.

CONCLUSIONS

The incidence rate found in this study is lower than the incidence reported in previous US and Libyan studies. A significant difference in overweight distribution is observed comparing percentage of body weight between US and Parma populations. As overweight and obesity are important factors contributing to IIH development, it is possible that their low percentage in the Parma population may, at least partially, explain the low IIH incidence observed.

Idiopathic intracranial hypertension and obesity

Idiopathic intracranial hypertension (IIH), also known as primary pseudotumor cerebri syndrome (PTCS), is a condition of unknown etiology which affects primarily overweight, reproductive-aged women and causes increased intracranial pressure (ICP). This review discusses the recently revised diagnostic criteria for PTCS for adults and children. Additionally, the role of obesity in the epidemiology, etiology, and management of IIH as well as the current knowledge of obesity profiles and markers in IIH are reviewed. We also highlight the emerging, unifying theory of the neuroendocrine effects on the mineralocorticoid receptor to explain a possible mechanism for the increased cerebrospinal fluid production and ICP in secondary PTCS.

A rare case of Behçet's syndrome presenting with bilateral papillitis

A previously healthy 28-year-old white man complained of acute headache and mildly blurred vision since a month earlier which did not respond to analgesics. Brain magnetic resonance imaging was normal. He did not agree to be admitted and nor to additional testing by a neurologist and did not respond to oral acetazolamide. At the next visit (a month later), the ophthalmic examination showed the best corrective vision of 7/10 in both eyes, and 2 + cell in the right eye anterior chamber. Except for leukocytosis and positive C reactive protein, other tests (including cerebrospinal pressure and composition and brain magnetic resonance angiography) were normal. The rheumathologist consultation revealed a history of Behçet in the patient and his brother and HLA B5 was positive. Optic disc swelling significantly decreased with interavenous stroid and the headache disappeared. Two weeks later, visual acuity reached 9/10 and papillitis resolved.

Neuro-Behçet, pseudotumor cerebri and ocular signs: a rare association

Introduction: The central nervous system involvement in Behçet’s disease occurs in 5–30% of cases. The diagnosis of pseudotumor cerebri is even rarer (only 22 cases reported worldwide).

Purpose: To emphasize the importance of differential diagnosis in a case of pseudotumor cerebri in the context of ocular inflammation. Methods: V.A.V.R., a 31 year old female, was diagnosed with pan-uveitis on the left eye associated with recurrent bipolar aphthosis. During the etiological investigation, there was an onset of a left hemiparesis and facial palsy.

Results: The central nervous system (CNS) neuroradiological investigation revealed a space-occupying lesion within the right hemisphere with intense signal enhancement with gadolinium. It globally reached the nucleo-basal structures and induced deviation of the middle structures (including homolateral ventricle). Cytochemical analysis of cerebrospinal fluid (CSF) was negative for atypical cells. The ophthalmological features regressed with the corticosteroid and immunosuppressive therapy instituted. The final diagnosis was of pseudotumor cerebri in the context of Behçet’s disease.

Conclusion: In Behçet’s disease, a cerebral space-occupying lesion should lead to a diagnosis of pseudotumor cerebri. The correct diagnosis will determine an appropriate therapy and may prevent an inappropriate neurosurgical approach. The cortico and immunotherapy allowed a substantial regression of the lesion.

Clinical review: the surgical treatment of idiopathic pseudotumour cerebri (idiopathic intracranial hypertension)

To review the literature on the surgical treatment of idiopathic pseudotumour cerebri (PTC) [idiopathic intracranial hypertension (IIH)]. When medical therapy fails or when visual dysfunction deteriorates, surgical therapies for PTC should be considered. The main procedures performed include lumboperitoneal shunt (LPS), ventriculoperitoneal shunt (VPS) and optic nerve sheath fenestration (ONSF). Recently, venous sinus stenting procedures have been performed on selected patients with PTC, especially those with venous sinus occlusive disease. The literature is summarized and appraised in the form of a narrative review. It is evident that ONSF, LPS, VPS and, in selected cases, venous sinus stenting may improve vision and prevent deterioration of vision in patients with PTC. All of the procedures have their advantages and disadvantages and may fail with time no matter what procedure is used. Various authorities have vehemently advocated one or the other of these procedures. Until a prospective, randomized study comparing ONSF with LPS or VPS for PTC is performed, and until the role of venous sinus obstruction as the aetiology of PTC is better defined, the question of which surgical procedure is best for the treatment of PTC remains unanswered.

Idiopathic intracranial hypertension: a comparison between French and North-American white patients

OBJECTIVE

To compare French and American white patients with idiopathic intracranial hypertension (IIH), and to determine prognostic factors associated with visual loss.

METHODS

Medical records of all consecutive white patients with definite IIH seen between 2001 and 2006 in three French tertiary care medical centers and one American tertiary medical center were reviewed. Demographics, associated clinical features, and visual function at presentation and follow-up were collected. French white patients were compared to American white patients.

RESULTS

One hundred and thirty-four patients (66 French, 68 American) were included. American patients were 8.7 times more likely than French patients to have visual acuity 20/60 or worse or visual field constriction (95% CI: 2.1-36.1, p=0.0001). American patients were treated more aggressively than French patients. French patients were older (31 vs. 28 years, p=0.02) and more likely to have anemia (20 vs. 2%, p<0.001). American patients had a longer duration of symptoms prior to diagnosis (12 vs. 4 weeks, p=0.01) and longer follow-up than French patients (26 vs. 11 months, p=0.001). Multivariable analysis found that nationality was an independent risk factor for visual loss. French and American patients did not differ regarding gender proportion, frequency of obesity, sleep apnea, endocrine diseases, or systemic hypertension. Cerebrospinal fluid (CSF) opening pressures were similar in both groups.

CONCLUSION

American patients with IIH had worse visual outcomes than French patients despite more aggressive treatment. These differences are not explained by differences in previously known risk factors.

Racial differences in idiopathic intracranial hypertension

OBJECTIVE

To evaluate racial differences in idiopathic intracranial hypertension (IIH).

METHODS

Medical records of all consecutive patients with definite IIH seen between 1989 and 2006 were reviewed. Demographics, associated factors, and visual function at presentation and follow-up were collected. Black patients were compared to non-black patients.

RESULTS

We included 450 patients (197 black, 253 non-black). Obesity, systemic hypertension, anemia, and sleep apnea were more common in black patients than in non-black patients (p </= 0.01). CSF opening pressure was higher in black patients (40 vs 34 cm CSF, p < 0.001). Visual acuity, visual field loss, and degree of papilledema at presentation and follow-up were worse in black patients (p </= 0.01). Diagnostic and therapeutic measures were similar between black patients and non-black patients, except for optic nerve sheath fenestration (p = 0.01) and lumbar puncture (p = 0.03), both more commonly performed on black patients. The relative risk of severe visual loss for black patients compared with non-black patients was 3.5 (95% CI 2.0 to 5.8, p < 0.001) in at least one eye and 4.8 (95% CI 2.1 to 10.9, p < 0.001) in both eyes. Logistic regression analysis supported race, anemia, body mass index, and male gender as independent risk factors for severe visual loss and suggested that racial differences may be partially accounted for by differences in CSF opening pressure, body mass index, and frequency of anemia.

CONCLUSION

Black patients with idiopathic intracranial hypertension (IIH) were more likely than non-black patients with IIH to have severe visual loss in at least one eye. This difference did not appear to result from diagnosis, treatment, or access to care, but may partially relate to differences in other risk factors. Black patients have a more aggressive disease and may need closer follow-up and lower thresholds for early intervention.

Treatment of idiopathic intracranial hypertension: topiramate vs acetazolamide, an open-label study

OBJECTIVES - To assess the efficacy of topiramate in the treatment of idiopathic intracranial hypertension (IIH) and to compare it with acetazolamide. METHODS - Fourty patients diagnosed as IIH and randomly assigned to treatment with either acetazolamide or topiramate were assessed prospectively. Improvement in the visual fields at the end of third, sixth and twelfth months were taken into consideration. RESULTS - The demographic, clinical features and the cerebrospinal fluid (CSF) pressure of the two treatment groups were similar at the beginning of the study. When the follow-up visual field grades were compared with the visual field grades at the beginning of the study in each group a statistically significant improvement was detected with both drugs. When the results of the two treatment groups were compared with each other no statistically significant difference was present. Prominent weight loss was recorded in the topiramate group. CONCLUSIONS - Topiramate seems to be effective in the treatment of IIH. Weight reduction as well as the reduction of the CSF formation is the possible mechanism of action.

Perfusion and diffusion magnetic resonance imaging in idiopathic intracranial hypertension

OBJECTIVES

Idiopathic intracranial hypertension (IIH) is characterized by abnormal elevation of intracranial pressure without any underlying etiologic factor. Papilledema is the major clinical finding whereas neuroradiological imaging findings are almost always normal. The aim of this preliminary study was to determine if diffusion and perfusion magnetic resonance imaging in patients with IIH might be beneficial in the management of the disease.

MATERIALS AND METHODS

Prospectively, we evaluated standard magnetic resonance, magnetic resonance angiographies and venographies, diffusion and perfusion magnetic resonance findings of 16 patients with IIH and of 16 age-, sex-, and weight-matched normal individuals as a control group. Patients with IIH underwent a detailed neuroophthalmologic examination and lumbar puncture for evaluation of cerebrospinal fluid pressure. Magnetic resonance imaging was performed with 1.5 T equipment.

RESULTS

On physical examination, all patients had characteristic papilledema, varying degrees of headache, blurred vision and tinnitus. Cerebrospinal fluid pressure was higher than 250 mm H2O in all patients. A statistically significant decrease in cerebral blood flow in six patients, whereas insignificant increase in two were detected. Cerebral blood volume values were almost similar to normal control group's values. Significant mean transit time prolongation was found in six patients as well.

CONCLUSIONS

Idiopathic intracranial hypertension is a clinical syndrome which requires prompt diagnosis and a thorough evaluation. Treatment is crucial for preventing visual loss and improving associated symptoms. It is also important to detect cerebral perfusion changes, as cerebrovascular complications may be associated. Although our patient group is small for statistical evaluation, it is a preliminary study using perfusion and diffusion magnetic resonance which may contribute to IIH management.

Idiopathic intracranial hypertension in Dubai: nature and prognosis

OBJECTIVE

To evaluate the nature and course of idiopathic intracranial hypertension (IIH) in Dubai, UAE.

METHODS

In a retrospective study the medical records of 50 patients with IIH were reviewed. All of them were diagnosed according to the Modified Dandy Criteria.

RESULTS

There were 46 (92%) women. Mean age at presentation was 35.7 years. Obesity was the commonest associated factor (32%). Headache was reported in 98% followed by double vision (32%). Papilledema was present in all patients at the time of examination (100%). Perimetric study showed mild peripheral visual field constriction in 56%. Only two patients showed severe field constriction and one of them deteriorated rapidly and she became blind. The mean cerebrospinal fluid pressure was 302.5 mmH(2)O. The visual status improved significantly throughout the follow-up period.

CONCLUSIONS

Idiopathic intracranial hypertension has relatively benign course in this part of the world and more aggressive treatment is not recommended.

Clinical characterization of idiopathic intracranial hypertension at the Detroit Medical Center

BACKGROUND

Idiopathic intracranial hypertension (IIH), also known as pseudotumor cerebri (PTC), is a condition characterized by increased intracranial pressure without clinical, laboratory or radiologic evidence of an intracranial space-occupying lesion, meningeal inflammation or venous outflow obstruction. Previous population-based studies evaluated the presenting clinical features of IIH in North-Eastern Libya, Iowa, Louisiana, Minnesota, Northern Ireland, Israel and Western Turkey. However, we report the demographic patterns of a metropolitan North American city.

METHODS

We performed a retrospective study of all patients with an initial IIH diagnosis and follow-up at the Detroit Medical Center (DMC), Michigan from 1985 to 2002. Medical records of 174 patients were reviewed, with 77 patients fitting the diagnostic criteria.

RESULTS

Seventy-seven patients, 71 females (92.2%) and 6 males (7.8%) were identified. Age ranged from 10 to 50 years, with a mean of 34 years. Fifty patients (65%) were African-American and 24 patients (31%) were Caucasian. The most common presentation was isolated headache (28.6%). Nineteen patients (24.7%) were asymptomatic. Obesity was described in 65 of 74 patients (87.8%) evaluated for body dimensions.

CONCLUSIONS

We report an increased number of asymptomatic patients after routine ophthalmic examination. Obese females in metropolitan Detroit would benefit from routine eye evaluations to avoid potential visual loss related to papilledema.

Pseudotumor cerebri

Pseudotumor cerebri (PTC) is a syndrome of increased intracranial pressure without hydrocephalus or mass lesion and with normal cerebrospinal fluid (CSF) composition. Although often considered to be "idiopathic," detailed investigation has revealed a high incidence of venous outflow abnormalities in PTC syndrome patients. The thought that elevated intracranial venous sinus pressure is a "universal mechanism" for PTC syndrome of varying etiologies has been called into question by a study indicating that the increased venous pressure in idiopathic PTC patients is caused by the elevated intracranial pressure and not the reverse, suggesting that "the chicken is the CSF pressure elevation and the egg is the venous sinus pressure elevation." Vitamin A toxicity may play a role in the pathogenesis of idiopathic PTC. The treatment of PTC has two major goals: the alleviation of symptoms and preservation of visual function. When medical therapy fails or when visual dysfunction deteriorates, surgical therapies for PTC should be considered. The two main procedures performed include lumboperitoneal shunt and optic nerve sheath fenestration. Because of the association of PTC with venous sinus hypertension, some authors are considering venous sinus stenting for refractory cases of PTC. It is still unclear if primary treatment of the observed venous stenosis benefits patients with idiopathic PTC. This should be no surprise, as it is not certain whether the stenoses are the cause or the result of idiopathic PTC.

Pseudotumor cerebri

Pseudotumor cerebri is a perplexing syndrome of increased intra-cranial pressure without a space-occupying lesion. The terminology for the disorder has changed over the years and the diagnostic criteria revised to reflect advances in diagnostic technology and insights into the disease process. The classification and nomenclature depend on the presence or absence of an underlying cause. When the diagnostic criteria are followed, a secondary etiology is unlikely. When no secondary cause is identified, the syndrome is termed "idiopathic intracranial hypertension."