Idiopathic Intracranial Hypertension: Review of Clinical Syndrome, Imaging Findings, and Treatment

The diagnostic value of MRI findings in pediatric idiopathic intracranial hypertension: a case-control study

BACKGROUND

Idiopathic intracranial hypertension (IIH) is a rare medical condition in children. Based on the different radiological findings reported in various studies in pediatric IIH, this study was conducted to determine the diagnostic value of MRI findings in diagnosing IIH in children.

METHODS

In this retrospective study, the medical records of all children aged 1 to 18 years who visited Ghaem Hospital in Mashhad, Iran, between 2012 and 2022 and were diagnosed with IIH were gathered. Forty-nine cases of children with IIH and 48 control cases of children with the first unprovoked seizure with no indications of increased intracranial pressure for comparison were selected. Patient demographic information and MRI findings were extracted. The comparison between different MRI findings in the case and control groups was conducted using statistical tests.

RESULTS

In the case group, the mean diameter of the subarachnoid space expansion around the optic nerve was 5.96 ± 1.21, compared to 4.79 ± 0.33 in the control group, with statistically significant difference (P < 0.001). All the patients with flattening of the posterior globe or transverse sinus stenosis were in the case group, and the frequency of these findings in the case group was significantly higher than in the control group (P < 0.001). The majority of patients (95.5%) classified under category 3 and 4 of empty sella were part of the case group, and the statistical test results indicated a significant difference between the two groups (P < 0.001). The optic nerve sheath diameter cut-off of 5.35 mm, when used for expansion of the subarachnoid space around the optic nerve, with a sensitivity of 82% and a specificity of 100% in diagnosing IIH.

CONCLUSION

The most reliable diagnostic indicators for diagnosing IIH in children are perioptic subarachnoid space expansion with high sensitivity, and posterior globe flattening and transverse sinus stenosis with high specificity.

An Efficient CNN-Based Method for Intracranial Hemorrhage Segmentation from Computerized Tomography Imaging

Intracranial hemorrhage (ICH) resulting from traumatic brain injury is a serious issue, often leading to death or long-term disability if not promptly diagnosed. Currently, doctors primarily use Computerized Tomography (CT) scans to detect and precisely locate a hemorrhage, typically interpreted by radiologists. However, this diagnostic process heavily relies on the expertise of medical professionals. To address potential errors, computer-aided diagnosis systems have been developed. In this study, we propose a new method that enhances the localization and segmentation of ICH lesions in CT scans by using multiple images created through different data augmentation techniques. We integrate residual connections into a U-Net-based segmentation network to improve the training efficiency. Our experiments, based on 82 CT scans from traumatic brain injury patients, validate the effectiveness of our approach, achieving an IOU score of 0.807 ± 0.03 for ICH segmentation using 10-fold cross-validation.

The role of arachnoid granulations in idiopathic intracranial hypertension

OBJECTIVES

Idiopathic intracranial hypertension (IIH) is a disease defined by elevated intracranial pressure (ICP) without an established etiology. Arachnoid granulations (AG) are conduits for CSF resorption from the subarachnoid space to the venous system. AG have been implicated to play a central role in maintaining CSF homeostasis. We tested the hypothesis that patients with fewer visible AG on MRI are more likely to present with IIH.

METHODS

In this institutional review board (Institutional Review Board)-approved retrospective chart review study, 65 patients with a clinical diagnosis of idiopathic intracranial hypertension were compared to 144 control patients who met inclusion/exclusion criteria. Patients' signs and symptoms pertaining to IIH were obtained through the electronic medical record Brain MR images were reviewed for the number and distribution of AGs indenting the dural venous sinuses. The presence of imaging and clinical findings associated with long standing increased ICP was noted. Propensity score method (with inverse probability weighting technique) was used to compare case and control groups.

RESULTS

In the control group, the number of AG indenting the dural venous sinuses on MRI (NAG) was lower in women compared to men when matched for age (20-45 yo) and BMI (>30 kg/m2). The NAG was lower in 20-45 yo females in the IIH group as compared to the 20-45 yo females in the control group. This statistically significant difference persists when controlled for BMI. In contrast, the NAG in >45 yo females in the IIH group trended higher compared to the >45 yo females in the control group.

CONCLUSION

Our results suggest that alterations in arachnoid granulations could play a role in the development of IIH.

Distinctive electro-clinical, neuroimaging and histopathological features of temporal encephaloceles associated to epilepsy

OBJECTIVE

Encephaloceles (ENCs) may cause clinical complications, including drug-resistant epilepsy that can be cured with epilepsy surgery.

METHODS

We describe clinical, diagnostic, and neuropathological findings of 12 patients with temporal ENC and epilepsy evaluated for surgery and compare them with a control group of 26 temporal lobe epilepsy (TLE) patients.

RESULTS

Six patients had unilateral and 6 bilateral temporal ENCs. Compared to TLEs, ENCs showed i) later epilepsy onset, ii) higher prevalence of psychiatric comorbidities, iii) no history of febrile convulsions, and iv) ictal semiology differences. Seven patients had MRI signs of gliosis, and 9 of intracranial hypertension. Interictal EEG analysis in ENCs demonstrated significant differences with controls: prominent activity in the beta/gamma frequency bands in frontal regions, interictal short sequences of low-voltage fast activity, and less frequent and more localized interictal epileptiform discharges. Ictal EEG patterns analyzed in 9 ENCs showed delayed and slower contralateral spread compared to TLEs. All ENCs that underwent surgery (7 lobectomies and 1 lesionectomy) are in Engel class I. Neuropathological examination revealed 4 patterns: herniated brain fragments, focal layer I distortion, white matter septa extending into the cortex, and altered gyral profile.

CONCLUSIONS AND SIGNIFICANCE

The described peculiarities might help clinicians to suspect the presence of largely underdiagnosed ENCs.

A rare finding of bilateral facial canal meningoceles involving the tympanic segment in suspected idiopathic intracranial hypertension

Meningoceles are a common radiological feature found in cases of idiopathic intracranial hypertension (IIH). Rarely, they can affect the facial canal within the petrous temporal bone, leading to symptoms such as facial nerve palsy, hearing loss or meningitis. This is the first case report that describes bilateral facial canal meningoceles involving the tympanic segment of the canal. Prominent Meckel's caves were also seen on MRI, a feature commonly associated with IIH.

Dural sinus narrowing in patients with spontaneous anterior skull base cerebrospinal fluid leak

Objectives

Current evidence suggests a link between idiopathic intracranial hypertension (IIH) and spontaneous cerebrospinal fluid (sCSF) leak, as well as between IIH and dural venous sinus (DVS) narrowing. However, there are limited data linking DVS narrowing and sCSF leak. This study aims to determine the prevalence of DVS narrowing in patients with sCSF leak.

Methods

A retrospective review of all patients with sCSF leak that presented to a tertiary academic center from 2008 to 2019. Preoperative imaging was independently reviewed by two neuroradiologists to evaluate for DVS narrowing. Available literature was used to estimate the prevalence of DVS narrowing in the general population to allow for comparison. Data were analyzed using Exact binomial test.

Results

Analysis of 25 patients with appropriate imaging revealed the majority were women (21/25, 84%) with a mean age of 51.89 years (SD 13.96). The majority of these patients were found to have narrowing of the DVS (20/25, 80%). In patient with sCSF leaks, there was a significantly higher proportion of patients with DVS narrowing compared with published literature examining this condition in the general population (80% vs. 40%, CI 0.59-0.93, p < .001).

Conclusion

The prevalence of DVS narrowing in patients with sCSF leaks is substantial and likely greater than the general population. Moreover, there appears to be narrowing in most patients with sCSF leak. Preoperative radiological evaluation of the DVS using MR venography may be useful in patients with sCSF leaks as DVS stenosis may be an underdiagnosed etiology. Further study is needed to evaluate this.

Level of Evidence

IV.

A False Pituitary Tumor

A false pituitary tumor describes pituitary enlargement due to intracranial hypotension. Reported previously primarily in the neurological literature, we present this case referred to endocrinology for evaluation of a pituitary mass. A 24-year-old male was referred to endocrinology for evaluation of pituitary enlargement without a hypo-enhancing lesion on magnetic resonance imaging (MRI). The main symptom reported was headache that was worse in the standing position and in the afternoon. He had no symptoms or signs of pituitary mass-effect, or hormone excess or deficiencies. Past medical history was relevant for a history of nerve schwannoma status post resection with subsequent spinal fusion. Biochemical evaluation of pituitary hormones was normal. Upon review of his pituitary MRI, other abnormalities seen were suggestive of intracranial hypotension. Based on his history and imaging findings, he was diagnosed with intracranial hypotension causing a "false pituitary tumor" rather than pituitary enlargement or abnormality. Further evaluation revealed multiple spinal leaks that were patched. His symptoms subsided within a few days of repair. Endocrinologists should be aware of the possible misdiagnosis of a pituitary mass due to intracranial hypotension.

Current and emerging diagnostic and management approaches for idiopathic intracranial hypertension

INTRODUCTION

Idiopathic intracranial hypertension is characterized by raised intracranial pressure that triggers disabling headaches and can cause permanent visual loss. There is an increased incidence and prevalence of the condition linked to location-specific obesity rates. There are no licensed treatments for the condition. The majority of approaches to managing the disease prioritize resolution of papilledema. However, evidence is emerging that idiopathic intracranial hypertension is a systemic metabolic disease.

AREAS COVERED

The aim of this review is to present the emerging pathophysiology evidence which is leading to novel targeted therapeutics. The diagnostic pathway is outlined. The current and potential management approaches for idiopathic intracranial hypertension are also discussed.

EXPERT OPINION

Idiopathic intracranial hypertension is a condition with metabolic dysregulation with systemic manifestations that are present over and above what can be expl.ained by obesity alone. While most of the current management of this condition focuses on the eyes, future management needs to address the disabling headaches and the systemic risks of preeclampsia, gestational diabetes, and major cardiovascular events.

Neuroimaging in the diagnosis and treatment of intracranial pressure disorders

OBJECTIVE

To review the clinical features, proposed pathophysiology, and the role of medical imaging in the diagnosis and treatment of idiopathic intracranial hypertension and spontaneous intracranial hypotension.

METHODS

The authors conducted a narrative review of the current literature on intracranial hypertension and hypotension syndromes, with a focus on imaging findings and role of neurointerventional radiology as a therapeutic option for these pathologies.

RESULTS

Idiopathic intracranial hypertension commonly presents in obese women of childbearing age, being headache and papilledema the main clinical manifestations. Characteristic radiological findings consist of increased cerebrospinal fluid around the optic nerve, partially empty sella turcica and stenosis of the transverse sinuses. Transverse sinus stenting is a treatment alternative that has proven valuable utility in the recent years. Spontaneous intracranial hypotension in most of cases presents with orthostatic headache and has predilection for female population. The typical radiological features in the brain consist of subdural fluid collections, enhancement of the dura, engorgement of the venous structures, pituitary enlargement, and sagging of the brain. In this pathology, a cerebrospinal fluid leak in the spine associated with a defect in the dura, meningeal diverticulum, or a cerebrospinal fluid-venous leak must be actively ruled out.

CONCLUSIONS

Neurologic complaints secondary to changes in intracranial pressure exhibit certain clinical features that in combination with fairly specific radiological patterns allow a highly accurate diagnosis. The diverse specialists in neurosciences should be aware of the multiple image modalities in the study of these syndromes as well as the treatment alternatives by neurointerventional radiology.

The neurophysiological approach to misophonia: Theory and treatment

Clinical observations of hundreds of patients who exhibited decreased tolerance to sound showed that many of them could not be diagnosed as having hyperacusis when negative reactions to a sound depend only on its physical characteristics. In the majority of these patients, the physical characteristics of bothersome sounds were secondary, and patients were able to tolerate other sounds with levels higher than sounds bothersome for them. The dominant feature determining the presence and strength of negative reactions are specific to a given patient's patterns and meaning of bothersome sounds. Moreover, negative reactions frequently depend on the situation in which the offensive sound is presented or by whom it is produced. Importantly, physiological and emotional reactions to bothersome sounds are very similar (even identical) for both hyperacusis and misophonia, so reactions cannot be used to diagnose and differentiate them. To label this non-reported phenomenon, we coined the term misophonia in 2001. Incorporating clinical observations into the framework of knowledge of brain functions allowed us to propose a neurophysiological model for misophonia. The observation that the physical characterization of misophonic trigger was secondary and frequently irrelevant suggested that the auditory pathways are working in identical manner in people with as in without misophonia. Descriptions of negative reactions indicated that the limbic and sympathetic parts of the autonomic nervous systems are involved but without manifestations of general malfunction of these systems. Patients with misophonia could not control internal emotional reactions (even when fully realizing that these reactions are disproportionate to benign sounds evoking them) suggesting that subconscious, conditioned reflexes linking the auditory system with other systems in the brain are the core mechanisms of misophonia. Consequently, the strength of functional connections between various systems in the brain plays a dominant role in misophonia, and the functional properties of the individual systems may be perfectly within the norms. Based on the postulated model, we proposed a treatment for misophonia, focused on the extinction of conditioned reflexes linking the auditory system with other systems in the brain. Treatment consists of specific counseling and sound therapy. It has been used for over 20 years with a published success rate of 83%.

Idiopathic intracranial hypertension imaging approaches and the implications in patient management

Idiopathic intracranial hypertension (IIH) represents a clinical disease entity without a clear etiology, that if left untreated, can result in severe outcomes, including permanent vision loss. For this reason, early diagnosis and treatment is necessary. Historically, the role of cross-sectional imaging has been to rule out secondary or emergent causes of increased intracranial pressure, including tumor, infection, hydrocephalus, or venous thrombosis. MRI and MRV, however, can serve as valuable imaging tools to not only rule out causes for secondary intracranial hypertension but can also detect indirect signs of IIH resultant from increased intracranial pressure, and demonstrate potentially treatable sinus venous stenosis. Digital subtraction venographic imaging also plays a central role in both diagnosis and treatment, providing enhanced anatomic delineation and temporal flow evaluation, quantitative assessment of the pressure gradient across a venous stenosis, treatment guidance, and immediate opportunity for endovascular therapy. In this review, we discuss the multiple modalities for imaging IIH, their limitations, and their contributions to the management of IIH.

Idiopathic Intracranial Hypertension - Challenges and Pearls

Idiopathic intracranial hypertension (IIH) is defined as a syndrome of raised intracranial pressure with normal imaging of the brain and cerebrospinal fluid (CSF) composition. There is a rising incidence and prevalence of this disease related to the increased prevalence of obesity. It typically affects women of working age, and headache is the predominant morbidity in over 90%. The disease is also more prevalent in young males. There are many controversies and myths that surround IIH. There are currently few treatment options for IIH, management is typically medical with those experiencing progressive visual loss undergoing surgical procedures. Weight loss and venous sinus stenting are a few therapies directed at the etiology.

Papilledema: A Review of the Pathophysiology, Imaging Findings, and Mimics

Increased intracranial pressure is the most common cause of papilledema. Multiple etiologies such as cerebral edema, hydrocephalus, space occupying lesions, infection, and idiopathic intracranial hypertension among others should be considered. Imaging plays a critical role in the detection of pathologies that can cause papilledema. MRI with contrast and CE-MRV, in particular, are key for the diagnosis of idiopathic intracranial hypertension. This review will focus in common and infrequent causes of papilledema, the role of imaging in patients with papilledema as well as its potential mimickers.

Spontaneous globe subluxation: a case report and review of the literature

Background

Spontaneous globe subluxation (SGS) is an atraumatic anterior dislocation of the eyeball. It is exceedingly rare. Understanding SGS predisposing factors may help uncover its etiology and undertake vision-saving management.

Case presentation

A 48-year-old female presented to the ED with her right eye out of its socket. She reported blurry vision, photophobia, and pain in the affected eye. She was unable to close her right eyelid and was in obvious distress. On arrival, her blood pressure was elevated. Her medical history was notable for hypertension and obesity. On physical examination, extraocular eye movements were not intact, and the globe appeared whole and round. She was also unable to count fingers with the affected eye. There was no visible trauma to the face. Multiple wet gauzes with sterile saline were placed over the displaced eyeball. Direct and even pressure was applied on the globe. Within 30 s, the globe was reduced back in. The patient was able to close her eyelids and reports substantial pain relief with reduction. A CT scan of the orbits was then obtained, demonstrating mild bilateral proptosis. The globes were normal and symmetric. No intraconal or extraconal abscess or infection was seen. There were no intraconal or extraconal masses. There was no acute orbital traumatic injury, no avulsion of the optic nerve, ocular rupture, or retrobulbar hematoma. After reviewing the case with an ophthalmologist, a follow-up appointment with the ophthalmologist was arranged. The patient was discharged on erythromycin ointment. Post-discharge investigation of the CT imaging revealed dilated optic nerve sheaths, tortuosity of the optic nerve, and empty sella.

Conclusions

In addition to causing distress and severe anxiety, SGS poses numerous immediate as well as long-term complications. Traction of the optic nerve and retinal vasculature may potentially cause retinal venous congestion and loss of visual acuity with potential vision loss. In the absence of known risk factors or disease processes, orbital imaging and serological studies for thyroid ophthalmopathy should be considered.

Idiopathic Intracranial Hypertension is Associated with a Higher Burden of Visible Cerebral Perivascular Spaces: The Glymphatic Connection

BACKGROUND AND PURPOSE

Research suggests a connection between idiopathic intracranial hypertension and the cerebral glymphatic system. We hypothesized that visible dilated perivascular spaces, possible glymphatic pathways, would be more prevalent in patients with idiopathic intracranial hypertension. This prevalence could provide a biomarker and add evidence to the glymphatic connection in the pathogenesis of idiopathic intracranial hypertension.

MATERIALS AND METHODS

We evaluated 36 adult (older than 21 years of age) patients with idiopathic intracranial hypertension and 19 controls, 21-69 years of age, who underwent a standardized MR imaging protocol that included high-resolution precontrast T2- and T1-weighted images. All patients had complete neuro-ophthalmic examinations for papilledema. The number of visible perivascular spaces was evaluated using a comprehensive 4-point qualitative rating scale, which graded the number of visible perivascular spaces in the centrum semiovale and basal ganglia; a 2-point scale was used for the midbrain. Readers were blinded to patient diagnoses. Continuous variables were compared using a Student t test.

RESULTS

The mean number of visible perivascular spaces overall was greater in the idiopathic intracranial hypertension group than in controls (4.5 [SD, 1.9] versus 2.9 [SD, 1.9], respectively; P = .004). This finding was significant for centrum semiovale idiopathic intracranial hypertension (2.3 [SD, 1.4] versus controls, 1.3 [SD, 1.1], P = .003) and basal ganglia idiopathic intracranial hypertension (1.7 [SD, 0.6] versus controls, 1.2 [SD, 0.7], P = .009). There was no significant difference in midbrain idiopathic intracranial hypertension (0.5 [SD, 0.5] versus controls, 0.4 [SD, 0.5], P = .47).

CONCLUSIONS

Idiopathic intracranial hypertension is associated with an increased number of visible intracranial perivascular spaces. This finding provides insight into the pathophysiology of idiopathic intracranial hypertension, suggesting a possible relationship between idiopathic intracranial hypertension and glymphatic dysfunction and providing another useful biomarker for the disease.

Pediatric Intracranial Hypertension: A Spotlight on Imaging, the Idiopathic Intracranial Hypertension Treatment Trial, and COVID-19 Associated Cases

Primary intracranial hypertension (PIH) is characterized by clinical signs of increased intracranial pressure, papilledema, elevated opening pressure, and absence of mass lesion, hydrocephalus, or meningeal enhancement on neuroimaging. Visual changes are a common presenting feature and if untreated there is risk of irreversible vision loss. There have been recent proposed changes to the criteria for PIH along with studies looking at the differences in imaging characteristics between adult and pediatric PIH. The presence of transverse sinus stenosis alone was highly sensitive and specific for pediatric PIH. The Idiopathic Intracranial Hypertension Treatment Trial was an adult, multicenter study that examined the use of acetazolamide and weight loss on the course of PIH. The study confirmed many previously held beliefs including the most common presenting symptom in PIH is headache. Most patients present with bilateral papilledema with 58.2% of patients having symmetric Frisen scale grading and within one grade in 92.8%. Although diplopia is a common reported symptom, very few have evidence of cranial nerve palsy. Male gender, high-grade papilledema, and decreased visual acuity at presentation are risk factors for treatment failure. Acetazolamide use is associated with mild metabolic acidosis. During acetazolamide treatment, monitoring for hypokalemia or aplastic anemia is not recommended. Monitoring transaminases in the titration phase of treatment should be considered due to a case of transaminitis and pancreatitis with elevated lipase. Newer case reports have also seen associations of secondary intracranial hypertension with concurrent COVID-19 infection and MIS-C.

The Pre-Lumbar puncture Intracranial Hypertension Scale (PLIHS): A practical scale to identify subjects with normal cerebrospinal fluid pressure in the management of idiopathic intracranial hypertension

BACKGROUND

Idiopathic Intracranial Hypertension (IIH) diagnosis requires lumbar puncture to measure cerebrospinal fluid (CSF) pressure. The Pre-Lumbar puncture Intracranial Hypertension Scale (PLIHS) is aimed to detect cases that will show raised or normal CSF opening pressure.

METHODS

Retrospective analysis of records of patients who underwent lumbar puncture for suspect IIH. The target was CSF opening pressure ≥ 250 mmH2O, whereas a set of known neurological, neuro-ophthalmological and neuro-radiological parameters, plus obesity, were used as predictors in a logistic regression model. The PLIHS was based on significant predictors and a cut-off was validated using chi-squared test around CSF opening pressure ≥ 250 and < 200 mmH2O.

RESULTS

Records of 162 patients were included: CSF opening pressure was <200 mmH2O in 40 and ≥ 250 mmH2O in 95 patients; 85 fulfilled IIH diagnosis. PLIHS is based on Frisén grade 2 or higher papilledema, tinnitus, empty sella, perioptic subarachnoid space distension, and obesity. Score range is 0-7: correlation with CSF opening pressure is 0.508 (p < .001), and PLIHS score is different between subjects not diagnosed with IIH, and those diagnosed with IIH both with and without papilledema (p < .001). PLIHS score ≤ 2 identifies cerebrospinal fluid pressure < 200 mmH2O; PLIHS score ≥ 3 identifies CSF opening pressure ≥ 250 mmH2O, IIH diagnosis, visual acuity ≤0.7, and optic nerve atrophy.

CONCLUSIONS

The PLIHS, can be used to identify patients who will particularly need LP, thus helping with the organization of the diagnostic work-up by optimising healthcare resources and potentially limit the likelihood to incur in LP-related adverse events.

Imaging Characteristics of Sigmoid Sinus Wall Anomalies, Idiopathic Intracranial Hypertension, and Spontaneous CSF Leaks

OBJECTIVE

To assess the frequency of radiographic features of elevated intracranial pressure (ICP) in patients with sigmoid sinus wall anomalies (SSWA) and compare to those in idiopathic intracranial hypertension (IIH) and spontaneous CSF (sCSF) leaks.

STUDY DESIGN

Retrospective review.

SETTING

Tertiary care center.

PATIENTS

110 patients - 62 SSWAs, 19 IIH, 29 sCSF leaks.

MAIN OUTCOME MEASURES

Demographics, comorbidities and radiographic features by diagnosis.

RESULTS

Imaging findings indicative of elevated ICP were similar across all three groups, as were body mass index, hyperlipidemia and diabetes. On univariate analysis, sCSF leak patients were significantly older than SSWA (60 vs. 41 years, p < 0.001) and IIH (60 vs. 40 years, p < 0.001) patients. They had a greater prevalence of arachnoid granulations than SSWA (75.8% vs. 37.1%, p < 0.01) and tegmen dehiscence than both SSWA and IIH (93.1% vs. 75.8% vs. 57.8%, p = 0.01), though a lower prevalence of empty sella than SSWA (44.8% vs. 72.5%, p < 0.001). SSWAs were present in roughly 44.3% of IIH and sCSF leak patients, and IIH in roughly 15.8% of SSWA and sCSF leak patients. Age (OR = 1.1, p = 0.001), hypertension (OR = 8.3, p = 0.01) and empty sella (OR = 0.1, p = 0.01) were predictive of sCSF leaks compared to SSWAs on multivariate analysis.

CONCLUSIONS

Many radiographic and clinical features of elevated ICP are found at similar rates among patients with SSWA, IIH and sCSF leaks, suggesting a common underlying process. SSWAs seem to present earlier along this spectrum of phenotypes, while sCSF leaks present later. Differences in age, metabolic syndrome and ICP may influence a patient's clinical presentation.

Rapidly progressive medulloblastoma initially mimicking idiopathic intracranial hypertension and Chiari I malformation: A case report

Introduction

Medulloblastoma (MDB) often causes signs and symptoms of elevated intracranial pressure (ICP) with imaging findings of mass lesion. Here, we report a case of MDB who initially presented with clinical features imitating idiopathic intracranial hypertension (IIH) and Chiari I malformation (CIM).

Case presentation

A 19-year-old man had clinical symptoms of elevated ICP without mass lesion on imaging. He was initially diagnosed with IIH and CIM, which underwent shunt surgery and posterior fossa decompression. Later on, he had recurrent symptoms, and the new imaging revealed the development of MDB in the right cerebellar hemisphere. After tumor resection, the patient rapidly deteriorated with spinal metastases.

Discussion and conclusion

Management of the coexistence between IIH and CIM in patients with rising ICP is complicated. MDB is one of the aggressive malignant brain tumors showing a wide range of imaging features, including non-enhancing mass. Therefore, recognizing the possibility of brain tumors mimicking IIH or CIM is crucial.

•

The coexistence of idiopathic intracranial hypertension (IIH) and Chiari I malformation (CIM) is complicated.

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Medulloblastoma (MDB) can present with a wide range of imaging features, including non-enhancing mass.

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Exclusion of the secondary cause of rising intracranial pressure is necessary before making the diagnosis of IIH or CIM

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Early diagnosis, including subtype of MDB, and urgent treatment are crucial for better outcome.

Brain MRI and Ophthalmic Biomarkers of Intracranial Pressure

OBJECTIVE

To evaluate the utility of brain MRI and ophthalmic biomarkers for the prediction of intracranial hypertension, we have studied the association between 6 biomarkers and 24-hour intracranial pressure (ICP) monitoring results in 45 patients.

METHODS

This single-center observational study includes patients who underwent 24-hour ICP monitoring, brain MRI (within 3 months), and ophthalmic assessment (during ICP monitoring). Six biomarkers were investigated: pituitary gland shape, vertical tortuosity of the optic nerve, distension of the optic nerve sheath, optic disc protrusion (MRI), papilledema (slit lamp biomicroscopy), and spontaneous venous pulsations (SVP, infrared video recordings).

RESULTS

Forty-five patients (mean age 39 ± 14 years, 38 women) met the inclusion criteria. All 6 biomarkers had a significant association with 24-hour ICP. Concave pituitary gland was observed with moderately elevated median ICP. Protrusion of the optic disc (MRI), papilledema, and absence of SVP were associated with the highest median ICP values. Twenty patients had raised ICP (median 24-hour ICP >5.96 mm Hg, cutoff obtained through Youden index calculation). Patients with all normal biomarkers had normal median ICP in 94% (standard error 6%) of the cases. All patients with ≥3 abnormal biomarkers had intracranial hypertension. The combination of at least 1 abnormal biomarker in MRI and ophthalmic assessments was highly suggestive of intracranial hypertension (area under the curve 0.94, 95% confidence interval 0.93-0.94) CONCLUSIONS: Brain MRI and ophthalmic biomarkers can noninvasively guide the management of patients with suspected CSF dynamics abnormalities. Patients with multiple abnormal biomarkers (≥3) or a combination of abnormal MRI and ophthalmic biomarkers are likely to have intracranial hypertension and should be managed promptly.

Idiopathic Intracranial Hypertension and Multiple Sclerosis

Unexplained elevated intracranial pressure occasionally develops in individuals with Multiple Sclerosis (MS). Visual symptoms and signs are common to both conditions. An awareness of this association is particularly relevant due to the increased incidence of headache in MS and the frequent overlap of symptoms and signs in both conditions.

Dural venous sinus thrombosis after lumbar puncture in a patient with idiopathic intracranial hypertension

INTRODUCTION

Idiopathic intracranial hypertension (IIH) is one of the most common causes of papilloedema seen by ophthalmologists and neurologists. Patients with IIH routinely undergo lumbar puncture (LP) for diagnosis. Dural venous sinus thrombosis (DVST) is a rare complication of cerebrospinal fluid pressure (CSF)-lowering procedures such as lumbar puncture and epidural and may be an intracranial complication of IIH.

CASE DESCRIPTION

A 29-year-old obese woman was diagnosed with severe idiopathic intracranial hypertension (IIH) after she presented with new-onset headache, pulsatile tinnitus and blurred vision. Magnetic resonance imaging (MRI) and venography (MRV) were normal apart from signs of intracranial hypertension. Lumbar puncture (LP) revealed an opening pressure of 40 cm of water. Due to the severity of the papilloedema and vision loss, she was referred for a ventriculoperitoneal shunt and found to have venous sinus thrombosis involving the superior sagittal sinus on the pre-operative computed tomography (CT) head 5 days after the LP. CT venography (CTV) one day later and MRV 3 days later showed significant worsening as the thrombosis extended into the deep venous system. She was started on therapeutic heparin and her symptoms and vision improved and she did not develop any neurological complications.

CONCLUSIONS

DVST should be considered in IIH patients who have worsening papilloedema or symptoms of intracranial hypertension. Repeat venous imaging can prevent devastating consequences such as venous infarcts of haemorrhage in these patients.

An update on idiopathic intracranial hypertension in adults: a look at pathophysiology, diagnostic approach and management

Idiopathic intracranial hypertension is a neurological syndrome determined by a rise in intracranial pressure without a detectable cause. Course and prognosis may be changeable, requiring a multidisciplinary approach for its diagnosis and management. Although its precise pathogenesis is still unknown, many studies have been carried out to define the possible causal and associated factors, such as retinoids, steroid hormones, body mass index and recent weight gains, cytokines and adipokines levels. The clinical presentation can be variable including chronic headache, disturbance of vision, diplopia and tinnitus. Even if papilloedema is considered the most specific sign, it could not be observed in more than 5% of patients during the evaluation of the fundus oculi. Neuroradiological signs acquire greater importance in patients who do not present papilloedema and may suggest the diagnosis of idiopathic intracranial hypertension. Other assessments can be useful in the diagnostic process, such as optical coherence tomography, visual evoked potentials, ocular ultrasonography and fundus fluorescein angiography and autofluorescence. Nonetheless, cerebrospinal fluid pressure measurement is required to establish a definite diagnosis. Management may be different, since surgical procedures or lumbar punctures are often required when symptoms develop rapidly leading to a loss of visual function. Apart from these cases, patients can be treated with a pharmacological approach and low-calorie diet, but they also need to be monitored over time since relapses years later are not uncommon.