An update of idiopathic intracranial hypertension

Cerebral Venous Sinus Thrombosis (CVST): A Clinically Significant Neurological Condition

Cerebral venous sinus thrombosis (CVST), a rare but deadly disorder, causes papilledema as well as a number of frequent clinical symptoms, including excruciating headaches, focal seizures, and paralysis on one or both sides of the body. In this intriguing case study, we present the clinical narrative of a 45-year-old man who sought medical attention due to severe headaches persisting for two days. Concurrently, he experienced an abrupt onset of tingling and numbness in his left upper arm. Remarkably, magnetic resonance venography (MRV) revealed an absence of the sigmoid sinus, left transverse sinus, left jugular vein, and superior sagittal sinus, adding complexity to the diagnostic puzzle. Despite this anomaly, conventional brain MRI findings appeared normal. The patient reported a significant reduction in headache intensity following treatment, which included a year-long course of anticoagulant therapy. Subsequently, he gradually regained his health, underscoring the importance of multidisciplinary approaches in managing such challenging cases. This example emphasizes the significance of considering CVST while developing a differential diagnosis of various neurological disorders. Given the vast spectrum of clinical symptoms associated with CVST, it should be taken into account as a potential causative factor in a number of neurological illnesses, in order for patients to experience the best outcomes, quick diagnosis, and quality care.

Spontaneous CSF fistula as a manifestation of idiopathic intracranial hypertension

INTRODUCTION

Spontaneous cerebrospinal fluid (CSF) fistula, of unknown origin, is a rare condition whose aetiology is increasingly related to idiopathic intracranial hypertension (IIH). This study tries to raise awareness that they should not be considered as two different processes, but that fistulas can be a form of debut, requiring a study and subsequent treatment. Repair techniques are described, as well as the study of HII.

RESULTS

We treated 8 patients, 5 women and three men, aged between 46 and 72 years, with a diagnosis of spontaneous CSF fistula, four nasal and four otics who underwent surgical treatment. After repair, a diagnostic study was performed for IIH by MRI and Angio-MRI, presenting in all cases a transverse venous sinus stenosis. The intracranial pressure values obtained by lumbar puncture showed values of 20mm Hg or higher. All patients were diagnosed with HII. The one-year follow-up did not reveal any recurrence of the fistulas, maintaining a control of the HII.

CONCLUSION

Despite their low frequency of both cranial CSF fistula and IIH, an association of both conditions should be considered by continuing the study and surveillance of these patients after fistula closure.

Comparison of Idiopathic Intracranial Hypertension Patients With and Without Anemia

BACKGROUND

Idiopathic intracranial hypertension (IIH) is a condition of elevated intracranial pressure without an identifiable cause. It mostly affects young obese women but has been reported in individuals newly diagnosed with anemia or with chronic anemia. The relationship between anemia and IIH is not well elucidated. This study aims to characterize the course of IIH in anemic patients.

METHODS

Consecutive patients with IIH were recruited from neuro-ophthalmology clinics. Subsequent retrospective chart review obtained information on symptoms, complete blood counts (CBCs), visual acuity, visual fields, and optic disc edema at baseline and follow-up. Anemia was diagnosed by hemoglobin <120 g/L (women) and <130 g/L (men).

RESULTS

One hundred twenty-three patients with IIH were recruited for this study, and 22.8% (28/123) had anemia. More anemic individuals had mild-to-moderate visual acuity impairment (logarithm of minimum angle of resolution 0.3-1, P = 0.01) and worse automated mean deviation ( P = 0.048). The median follow-up time was 47.4 weeks (interquartile range:20.1-91.8). Fifteen of 28 patients with anemia received anemia treatment and showed a trend toward increased hemoglobin. At follow-up, there were no differences in the visual acuity, but patients with anemia had worse automated mean deviation on visual fields ( P = 0.045).

CONCLUSIONS

IIH patients with anemia had worse visual function at presentation and worse final visual field parameters. This suggests that CBCs should be obtained for patients with papilledema because it may influence final visual outcome.

Emergent cerebral venous stenting: A valid treatment option for fulminant idiopathic intracranial hypertension

BACKGROUND

Fulminant idiopathic intracranial hypertension (FIIH) is characterized by rapid, severe, progressive vision loss and often treated surgically. Cerebral transverse venous stenting (CTVS) is efficacious in IIH patients, but emergent CTVS in FIIH is rarely reported. We present our experience with emergent CTVS in patients with FIIH.

METHODS

Since 01/2019, an institutional protocol allowed emergent CTVS in FIIH patients with bilateral transverse sinus stenosis and gradient pressure > 15 on digital subtraction angiography (DSA). We retrospectively analyzed a prospective registry of all IIH patients with details of neurological and neuro-ophthalmological assessments before and after treatment, and subjective assessments of headache and tinnitus were made pre-and post-procedure.

RESULTS

259 IIH patients, including 49 who underwent CTVS, were registered. Among them, five female patients met inclusion criteria for FIIH and underwent emergent CTVS. FIIH patients were younger (18.8 ± 1.64 vs 27.7 ± 4.85, p < 0.01), mean BMI was lower (30.8 ± 10.57 vs 34.6 ± 4.3, p < 0.01), and lumbar puncture opening pressure higher (454 ± vs 361 ± 99.4, p < 0.01) than that of IIH patients. They presented with acute visual loss, severe headache, papilledema, significant bilateral transverse sinus stenosis on CT-venography, and mean dominant side gradient pressure of 26.4 ± 6.2 on DSA. CTVS was performed without significant complications, resulting in remarkable improvement in headache, optical coherence tomography, and visual fields within 1 week. At 1-year follow-up (four patients) and 6-month follow-up (1 patient), there was complete resolution of papilledema and headache, and marked improvement in visual acuity.

CONCLUSIONS

In these patients, emergent-CTVS was a safe and effective treatment option for FIIH. Further evaluation is warranted.

Optic nerve sheath fenestration: A second lease at sight

Purpose

To study the safety and efficacy of optic nerve sheath fenestration surgery in patients with optic disc edema due to different etiologies.

Methods

Records of 18 eyes of 15 patients who underwent optic nerve sheath fenestration for vision threatening optic disc edema were reviewed retrospectively, and results were analyzed. Improvement of visual acuity was the main measure of outcome. Improved visual fields, resolution of optic disc edema, diplopia, and headache were other benefits that were observed.

Results

Fifteen patients between 13 and 54 years of age were included in the study. Three patients underwent successive bilateral surgery. Idiopathic intracranial hypertension was the most common cause for optic disc edema and was found in 80% of the patients. Mean preoperative logMAR acuity was -1.9789 ± 1.46270, which improved to -0.9022 ± 1.23181 (p < 0.005) in the operated eye, and mean logMAR acuity of contralateral eye improved from -1.3378 ± 1.50107 to -1.0667 ± 1.33813 (p < 0.05).

Conclusion

Early optic nerve sheath fenestration is an effective modality for treating optic disc edema due to a wide myriad of causes and helps resolve the associated symptoms.

Anemia and Idiopathic Intracranial Hypertension: A Case-Control Study

BACKGROUND

Idiopathic intracranial hypertension (IIH) is a condition that mostly affects obese women of childbearing age but has been reported to be temporally related to new diagnoses of anemia. Despite these reports, the association between anemia and IIH remains controversial. The present study aimed to understand the strength of association between anemia and IIH through a case-control design.

METHODS

Consecutive IIH patients were recruited from neuro-ophthalmology clinics and matched by age and sex to consecutive patients attending neuro-ophthalmology clinics with diagnoses other than IIH. Complete blood counts (CBCs) were reviewed within 6 months of neuro-ophthalmology presentation, and anemia was diagnosed by hemoglobin of <120 g/L in women and <130 g/L in men. Anemia was classified as microcytic (mean corpuscular volume (MCV) < 80 fL), normocytic (MCV 80-100 fL), and macrocytic (MCV > 100 fL) as well as mild (hemoglobin >110 g/L), moderate (hemoglobin 80-109 g/L), and severe (hemoglobin <80 g/L).

RESULTS

One hundred twenty-three IIH patients and 113 controls were included in the study. More IIH patients than controls had anemia (22.8%, 28/123 vs 10.6%, 12/113, P = 0.01) with an odds ratio of 2.48 (95% CI: 1.19, 5.16). There were no differences in severity of anemia or MCV between IIH patients and controls, with anemia most often being mild (57.1%, 16/28 vs 75%, 9/12) and normocytic (50.0%, 14/28 vs 50.0%, 6/12). However, 17.9% (5/28) of IIH patients had severe anemia compared with zero in the control group. IIH patients had a higher mean platelet count than controls ( P < 0.001), and there were no differences on leukocyte counts.

CONCLUSION

Idiopathic intracranial hypertension patients have a higher prevalence of anemia compared with non-IIH neuro-ophthalmology patients. The anemia was mostly mild and may be explained by other factors related to worse health status and obesity, including low socioeconomic status, poor nutrition, and polycystic ovary syndrome. However, as a CBC is a widely available test and anemia may influence the IIH disease course, we propose that this test be obtained in all patients with new papilledema.

Association between RS3763040 polymorphism of the AQP4 and idiopathic intracranial hypertension in a Spanish Caucasian population

Background

Idiopathic intracranial hypertension (IIH) is a condition of increased intracranial pressure of unknown aetiology. Principal symptoms are headache, visual disturbances, and obesity, together with elevated intracranial pressure. Unspecified MRI, despite normal ventricle size, suggests alterations in the water flux cellular mediated by the brain water channel aquaporin-4 (AQP4). The association among IIH, cerebral spinal fluid malfunction, reabsorption, and functional or regulatory modifications of AQP4 is a hypothesis not confirmed.

Methods

Blood samples were collected from 72 Spanish Caucasian patients with IIH. A genetic association study was performed with bi-allelic SNPs rs1049305 and rs10244884 in AQ1 and rs2075575, rs3763043, and rs3763040 in AQ4. Genetic data were compared with 94 healthy Caucasian control. Statistics studies were assessed by Pearson's χ 2 tests for 2 × 2 (alleles) or 3 × 2 (genotypes) contingency tables. A P value < 0.05 was considered to be statistically significant.

Results

Statistically significant differences were found when comparing the results of the rs3763040 polymorphism of the AQ4 locus of IIH patients with controls, in genotypic frequencies (P = 0.0442) and allele frequencies (P = 0.0171). Furthermore, a statistically significant difference (P = 0.0207) was found in individuals carrying and not carrying the minor allele (GG + GA individuals vs GG homozygotes). No statistically significant differences were found when comparing allele and genotypic frequencies for SNPs rs1049305 and rs10244884 of AQ1 and rs2075575 and rs3763043 of AQ4.

Conclusions

The association of AQP4 and specifically of its polymorphic variant rs3763040 with IIH should be validated in other ethnic groups in order to assess more precisely the role of AQP4 in the etiopathogenesis of IIH.

A case report of cerebral venous sinus thrombosis presenting with rapidly progressive dementia

Background

Cerebral venous sinus thrombosis (CVST) is a rare but serious and treatable cause of neurologic symptoms. Due to the variable clinical presentation, CVST was often misdiagnosed. According to published case reports, common clinical manifestations of CVST include headache, focal neurological deficit, epilepsy, papilledema, etc. It is rare, nevertheless, to mention cases of rapidly progressive dementia (RPD).

Case presentation

We reported a case of a 62-year-old retired male accountant, a Han Chinese from eastern China, who initially presented with slow response and memory decline. Until 2 months later, his memory declined and slow response deteriorated significantly, and he could not even complete simple tasks like brushing his teeth, washing his face, washing his feet, and dressing himself, and sometimes developed fecal incontinence. His neuropsychological test demonstrated severe cognitive decline. The cerebrospinal fluid (CSF) studies revealed markedly high opening pressure (260 mm of water), and coagulation tests indicated a mild elevation of D-Dimer of 1.19 mg/L. The magnetic resonance venography (MRV) showed thrombosis of the left transverse sinus, sigmoid sinus, and jugular venous bulb and was diagnosed as CVST. He switched from subcutaneous low molecular weight heparin (LMWH) and transitioned to oral anticoagulants at the time of discharge. The repeated CSF studies revealed normal opening pressure. After 5 days of anticoagulant treatment, his symptoms considerably improved, and a 1-month follow-up revealed that he had fully healed with no signs of recurrence.

Conclusion

This case demonstrated the clinical heterogeneity of CVST, which should be taken into account for differential diagnosis of RPD. This case study also offered fresh data for the categorization of the clinical traits and the diagnosis of CVST.

Case Report of Idiopathic Intracranial Hypertension in Pregnancy

Idiopathic intracranial hypertension (IIH) is a disease of increased intracranial pressure with an unknown cause that is seen most often in women during their childbearing years. Women can be under care for IIH when they become pregnant, or it may occur during pregnancy. In the past, women with IIH who became pregnant were often counseled to terminate their pregnancies, to give birth early, and even to be sterilized to prevent future pregnancies. Today, multiple therapeutic options are available. In this case report, I describe the case of a woman with IIH who was treated with a cerebral spinal fluid shunt and gave birth to two sets of twins. This case report adds new information to the limited nursing literature currently available on this disease.

The diagnostic dilemma of idiopathic intracranial hypertension in a child with acute lymphoblastic leukemia: COVID-19 or cytosine arabinoside?

Background

Idiopathic intracranial hypertension is a rare neurological condition among children. Its manifestations vary from mild headaches to loss of vision. Although rare, COVID-19 infection and high dose cytosine arabinoside have been reported as risk factors for this neurological disorder. In patients with acute leukemia, idiopathic intracranial hypertension diagnosis is simple, but finding its etiology can be difficult.

Case presentation

We report a case of a 9-year-old boy with an ongoing treatment for T-acute lymphoblastic leukemia presenting with persistent headaches and diplopia. A diagnosis of idiopathic intracranial hypertension was retained based on clinical, imaging and laboratory findings. Due to its rarity, we describe its clinical and therapeutic features and highlight the challenging etiological dilemma between COVID-19 infection and high dose cytosine arabinoside administration.

Conclusion

Persistent headache in a pediatric patient with leukemia can be due to many neurological disorders other than leukemic relapse. Given the improvement of the neurological symptoms after the SARS-CoV-2 PCR negativization and the successful re-introduction of high dose cytosine Arabinoside, the diagnosis of idiopathic intracranial hypertension associated with Covid-19 infection was withheld.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12883-022-02689-z.

"More Guts Than Brains?"-The Role of Gut Microbiota in Idiopathic Intracranial Hypertension

BACKGROUND

Idiopathic intracranial hypertension syndrome (IIH) is most common among obese women. Weight loss is an important factor in improving papilledema. Over the last decade, growing evidence has identified gut microbiota as a potential factor in the pathophysiology of obesity. Accordingly, we investigated whether the gut microbiome is modified in IIH patients compared with healthy controls, and provide possible new treatment venues.

METHODS

Shotgun metagenomic sequencing of the gut microbiome of 25 cases of IIH patients (according to the modified Dandy criteria) and 20 healthy controls. Participants were further stratified according to their body mass index. The total DNA from each sample was extracted using the PureLink Microbiome DNA Purification Kit A29789 (Invitrogen, Thermo Fisher Scientific, US). Library preparation was performed using the Nextera DNA Flex Library Prep Kit. Samples were sequenced on the Illumina Novaseq 6000 device. A list of bacterial species that significantly differed between the IIH patients and healthy controls was produced in addition to species diversity. In addition, patients' cohort alone was analyzed, (excluding the healthy controls), and the effect of acetazolamide treatment on their gut microbiota was analyzed.

RESULTS

IIH patients have a lower diversity of bacterial species compared with healthy individuals. These bacteria, that is, Lactobacillus ruminis (L. ruminis) (p<6.95E-08), Atopobium parvulum (p<3.9E-03), Megamonas hypermegale (p<5.61E-03), Ruminococcus gnavus (p<1.29E-02), MEL.A1 (p<3.04E-02), and Streptococcus sp. I-G2 (p<3.04E-02), were previously characterized with beneficial health effects. Moreover, we found that Lactobacillus brevis, a beneficial bacterium as well, is more abundant in acetazolamide treated patients (p<7.07E-06).

CONCLUSIONS

Gut microbiota plays a potential role in IIH etiology and therefore, can provide a promising new treatment approach for this disease.

Thinning of the Skull Base and Calvarial Thickness in Patients With Idiopathic Intracranial Hypertension

BACKGROUND

Idiopathic intracranial hypertension (IIH) is a disorder characterized by elevated intracranial pressure without secondary causes on neuroimaging. IIH typically occurs in young, obese female patients and, when severe, can cause permanent and irreversible vision loss. The association between skull base thinning in patients with intracranial hypertension and obesity has been previously reported; however, no study has reported these findings in IIH. The goal of our study is to determine whether IIH is independently associated with skull base and calvarial thinning.

METHODS

A retrospective, matched case-control study was performed. Each patient diagnosed with IIH (case) was matched with a patient diagnosed with headache (control) by age, gender, and race. Patients were included if they underwent computed tomographic imaging of the head, maxillofacial, or orbits within 3 months of their diagnosis. Exclusion criteria were history of skull base or frontal bone pathology because of surgery or skull trauma, central nervous system infections, or incomplete radiologic data. Patient demographics, medical history, clinical examination, and skull base, calvarial, and zygoma thickness were recorded. Skull base thickness was measured by the height of the auditory canal in the coronal plane. Calvarial thickness was measured just anterior to the foramen rotundum in the coronal plane. Extracranial zygoma thickness was measured and used as an internal imaging control because the zygoma is not subject to intracranial forces.

RESULTS

One hundred twenty-six patients were included in the study, 63 cases and 63 controls. Each group comprised 61 female patients (97%), 24 (38%) Caucasian, 23 (37%) black, 1 (2%) Asian, and 15 (24%) others. The average age was 31.5 ± 8.7 years. Patients with IIH were more likely to be obese (n = 60, 95%) compared with the control patients (n = 23, 37%, P < 0.001). All patients with IIH underwent lumbar puncture (LP) with an average opening pressure (OP) of 40.5 ± 15.6 cm H2O, whereas only 13 (20%) controls underwent an LP with a mean OP of 19.5 ± 8.5 cm H2O. There was no statistical difference in mean visual acuity between the IIH and control groups (logMar 0.22 [20/30] ± 0.45 vs logMar 0.09 [20/25] ± 0.30, P = 0.093, respectively). Compared with the controls, patients with IIH were more likely to have headache (97% vs 74%, P = 0.001), pulsatile tinnitus (48% vs 7%, P < 0.001), horizontal binocular diplopia (24% vs 4%, P = 0.006), confrontational visual field deficit (23% vs 2%, P = 0.003), and papilledema (74% vs 0%, P < 0.001). Patients with IIH had thinner skull base and calvarium width compared with the controls (mean skull base thickness 4.17 ± 0.94 mm vs 5.05 ± 1.12 mm, P < 0.001 and mean calvarial width 1.50 ± 0.50 mm vs 1.71 ± 0.61 mm, P = 0.024). Zygoma thickness was similar in both groups (mean zygoma thickness 1.18 ± 0.30 mm in the IIH group vs 1.26 ± 0.35 mm in the control group, P = 0.105). In a subgroup analysis controlling for obesity (body mass index >30 kg/m2), there was no statistically significant difference in skull base, calvarial, or zygoma thickness between obese and nonobese patients.

CONCLUSIONS

Patients with IIH have thinner mean skull base and calvarial thickness compared with the controls. There was no difference in the mean extracranial zygoma thickness, which was the internal imaging control. Contrary to previous reports, we did not find an association between obesity and skull base or calvarial thinning. These findings suggest that IIH is associated with skull base and calvarial thinning.

Posterior fossa volume in idiopathic intracranial hypertension: a magnetic resonance imaging-based study

BACKGROUND

The etiology of idiopathic intracranial hypertension (IIH) is uncertain. Studies suggest the fundamental cause of the Chiari 1 malformation, a congenitally hypoplastic posterior fossa, may explain the genesis of IIH in some patients.

PURPOSE

To assess the hypothesis that linear and volumetric measurements of the posterior fossa (PF) can be used as predictors of IIH.

MATERIAL AND METHODS

A retrospective analysis of magnetic resonance imaging (MRI) studies on 27 patients with IIH and 14 matched controls was performed. A volumetric sagittal magnetization prepared rapid acquisition gradient echo sequence was used to derive 10 linear cephalometric measurements. Total intracranial and bony posterior fossa volumes (PFVs) were derived by manual segmentation. The ratio of PFV to total intracranial volume was calculated.

RESULTS

In total, 41 participants were included, all women. Participants with IIH had higher median body mass index (BMI). No significant differences in linear cephalometric measurements, total intracranial volumes, and PFVs between the groups were identified. Linear measurements were not predictive of volumetric measurements. However, on multivariate logistic regression analysis, the likelihood of IIH decreased significantly per unit increase in relative PFV (odds ratio [OR]=3.66 × 10^-50; 95% confidence interval [CI]=1.39 × 10^-108 to 1.22 × 10^-5; P = 0.04). Conversely, the likelihood of IIH increased per unit BMI increase (OR=1.19; 95% CI=1.04-1.47; P = 0.02).

CONCLUSION

MRI-based volumetric measurements imply that PF alterations may be partly responsible for the development of IIH and Chiari 1 malformations. Symptoms of IIH may arise due to an interplay between these and metabolic, hormonal, or other factors.

Detecting Cognitive Impairment in Idiopathic Intracranial Hypertension Using Ocular Motor and Neuropsychological Testing

Objective: To determine whether cognitive impairments in patients with Idiopathic Intracranial Hypertension (IIH) are correlated with changes in visual processing, weight, waist circumference, mood or headache, and whether they change over time.

Methods: Twenty-two newly diagnosed IIH patients participated, with a subset assessed longitudinally at 3 and 6 months. Both conventional and novel ocular motor tests of cognition were included: Symbol Digit Modalities Test (SDMT), Stroop Colour and Word Test (SCWT), Digit Span, California Verbal Learning Test (CVLT), prosaccade (PS) task, antisaccade (AS) task, interleaved antisaccade-prosaccade (AS-PS) task. Patients also completed headache, mood, and visual functioning questionnaires.

Results: IIH patients performed more poorly than controls on the SDMT (p< 0.001), SCWT (p = 0.021), Digit Span test (p< 0.001) and CVLT (p = 0.004) at baseline, and generated a higher proportion of AS errors in both the AS (p< 0.001) and AS-PS tasks (p = 0.007). Further, IIH patients exhibited prolonged latencies on the cognitively complex AS-PS task (p = 0.034). While weight, waist circumference, headache and mood did not predict performance on any experimental measure, increased retinal nerve fibre layer (RNFL) was associated with AS error rate on both the block [F_{(3, 19)}=3.22, B = 0.30, p = 0.022] and AS-PS task [F_{(3, 20)} = 2.65, B = 0.363, p = 0.013]. Unlike ocular motor changes, impairments revealed on conventional tests of cognition persisted up to 6 months.

Conclusion: We found multi-domain cognitive impairments in IIH patients that were unrelated to clinical characteristics. Marked ocular motor inhibitory control deficits were predicted by RNFL thickness but remained distinct from other cognitive changes, underscoring the significance of visual processing changes in IIH.

Incidental idiopathic intracranial hypertension

Objective: Idiopathic intracranial hypertension (IIH) is a neuro-ophthalmological syndrome of unknown cause that can be vision-threatening, so an early diagnosis is crucial.

Case report: We reported a case of a 68-year-old asymptomatic male referred with a cataract in his right eye (OD). Best-corrected visual acuity (BCVA) was 70 letters (20/ 40) in the OD and 85 letters (20/ 20) in the left eye (OS). Ophthalmological examination revealed a significant nuclear cataract in the OD that explained the visual acuity. Fundus imaging showed a faint nasal margin elevation of the optic disc of both eyes (OU). Optical coherence tomography (OCT) revealed a sectorial retinal nerve fiber layer (RNFL) atrophy in the inferior quadrant in the OS. Nevertheless, visual field (VF) did not demonstrate defects. Neuroimaging was normal and examination of CSF revealed an opening pressure of 500 mmH2O. A diagnosis of IIH was confirmed and acetazolamide 250 mg twice daily was recommended. After 12 months of follow-up, RNFL thickness remained stable and VF did not confirm defects.

Conclusion: A routine eye examination was the onset of IIH in our case. Thus, the ophthalmologist played a crucial role in the early diagnosis of this syndrome. Papilledema is usually a key criterion for IIH, so after its detection, exclusion diagnosis and treatment should be initiated in order to avoid permanent visual loss.

OCT Based Interpretation of the Optic Nerve Head Anatomy and Prevalence of Optic Disc Drusen in Patients with Idiopathic Intracranial Hypertension (IIH)

We aimed to systematically examine the optic nerve head anatomy in patients with idiopathic intracranial hypertension (IIH) using a standardized optical coherence tomography (OCT) protocol. The study retrospectively included 32 patients diagnosed from 2014 to 2021 with IIH. Using OCT, in accordance with a standardized scanning protocol for patients with optic disc drusen, the presence of optic disc drusen, prelaminar hyperreflective lines, peripapillary hyperreflective ovoid mass-like structures, the retinal nerve fiber layer thickness, and macular ganglion cell layer volume was obtained. Optic disc drusen were found in 3.1%, hyperreflective lines in 31.3%, and peripapillary hyperreflective ovoid mass-like structures in 81.3% of all IIH patients at least three months after the time of diagnosis. We found no significant differences in retinal nerve fiber layer thickness or macular ganglion cell layer volume in patients with hyperreflective lines or PHOMS respectively compared to patients without hyperreflective lines (p = 0.1285 and p = 0.1835). In conclusion, the prevalence of optic disc drusen in IIH patients is similar to the reported prevalence in the general population. The high prevalence of hyperreflective lines and peripapillary hyperreflective ovoid mass-like structures in IIH patients suggest these structures be a result of crowding in the optic nerve head caused by papilledema.

Neutrophil-to-lymphocyte and platelet-to-lymphocyte ratios as inflammation markers in patients with papilledema due to idiopathic intracranial hypertension

Purpose:

The aim of this study was to investigate the role of inflammation in the pathogenesis of idiopathic intracranial hypertension (IIH) using the neutrophil-to-lymphocyte ratio (NLR) and platelet-to-lymphocyte ratio (PLR) as inflammation markers.

Methods:

The files of 33 IIH patients and 33 controls were screened for this retrospective study. For each patient, the NLR and PLR values were calculated using a single fasting blood sample. For both eyes, papilledema (PE) grades, best-corrected visual acuity (BCVA), retinal nerve fiber layer thickness (RNFLT), and ganglion cell layer thickness (GCLT) measurements were recorded along with the demographic data, including body mass index (BMI), and complete neurological and ophthalmological findings. Comparisons between the two groups and between the IIH patients with and without PE were made. The associations of NLR and PLR with all other parameters were analyzed independently from age, gender, and BMI.

Results:

NLR and PLR were higher in patients with IIH than controls (P < 0.05). They were also higher in patients with PE (P < 0.05) in the IIH group. NLR and PLR were found to be associated with BCVA (P < 0.001 and P = 0.023, respectively), global RNFLT (P = 0.004 and 0.012, respectively), RNFLT of the temporal quadrant (P < 0.001 and P = 0.042, respectively) and PE grade (P < 0.001 and P = 0.035, respectively).

Conclusion:

The NLR and PLR values and their associations with BCVA, RNFLT, and PE support the hypothesis that inflammation is a very important component of the pathogenesis of IIH.

Optic Nerve Sheath Fenestration for Papilledema Due to Cerebral Venous Sinus Thrombosis Associated with Antiphospholipid Syndrome: A Case Report

Patient: Male, 21-year-old

Final Diagnosis: Antiphospholipid antibody syndrome • cerebral venous sinus thrombosis

Symptoms: Blurring of vision • confusion • fever • headache

Medication: —

Clinical Procedure: Laboratory • magnetic resonance imaging

Specialty: Neurology • Ophthalmology

Combined accuracy of optic nerve sheath diameter, strain ratio, and shear wave elastography of the optic nerve in patients with idiopathic intracranial hypertension

PURPOSE

This study assessed the combined accuracy of optic nerve sheath diameter (ONSD), strain ratio (SR), and shear wave elastography (SWE) of the optic nerve (ON) in patients with idiopathic intracranial hypertension (IIH).

METHODS

This prospective study was carried out on both ONs of 34 consecutive patients diagnosed with IIH and 16 age- and sex-matched healthy volunteers. All of the study participants were women. The ONSD, SR, and SWE of the ON were measured. The severity of papilledema of IIH patients was sub-classified into mild papilledema and moderate/severe papilledema.

RESULTS

The mean ONSD (5.6±1.1 mm), SR (0.7±0.1), and SWE (30.1±16.7 kPa) of the IIH patients were significantly different (P=0.001) from the ONSD (4.1±0.5 mm), SR (0.9±0.1), and SWE (8.2±3.4 kPa) of controls. The cutoff values of ONSD, SR, and SWE of the ON for differentiating IIH patients from controls were 5.45 mm, 0.8, and 10.3 kPa with areas under the curve (AUCs) of 0.91, 0.86, and 0.96 and accuracy values of 91%, 81%, and 93%, respectively. Combined SWE and ONSD and combined SWE, ONSD, and SR for differentiating IIH patients from controls revealed AUCs of 0.98 and 0.99 and accuracy values of 96% and 96%, respectively. ONSD, SR, and SWE showed significant differences between mild and moderate/severe papilledema (P=0.001). Papilledema was correlated with SWE (r=0.8, P=0.001), ONSD (r=0.4, P=0.001), and SR (r=-0.4, P=0.001).

CONCLUSION

The combination of ONSD, SR, and SWE may be helpful for diagnosing IIH, and a good indicator of the degree of papilledema.

Venous Sinus Stenosis Treatment in Pediatric Idiopathic Intracranial Hypertension: Illustrative Case and Literature Review

OBJECTIVE

To review the literature of venous sinus stenosis (VSS) treatment in children for idiopathic intracranial hypertension (IIH) and present our own institutional case.

METHODS

A literature review was conducted using the PubMed and MEDLINE databases up to June 2020. From 134 studies that were screened, 6 studies were chosen for analysis that included patients <18 years old, a diagnosis of IIH that fit Dandy diagnostic criteria, and angiogram obtained to assess for VSS. IIH symptoms experienced in the pediatric population and efficacy of venous sinus stenting were analyzed.

RESULTS

Eleven patients identified in the literature and 1 patient from our institution were included in the analysis. There was no statistically significant difference in pressure gradient response to stenting between male and female patients (P = 0.424) or patients with body mass index >90th percentile (P = 0.626). Larger decreases in pressure gradient after stent placement correlated with headache resolution (P = 0.0005). Patients who underwent unilateral stenting showed greater reduction in pressure gradient compared with patients who underwent bilateral stenting (average change 24 mm Hg vs. 5.75 mm Hg, P = 0.003).

CONCLUSIONS

Our analysis showed that VSS treatment has the potential to be a safe option for IIH in pediatric patients. VSS treatment has shown similar results to traditional cerebrospinal fluid diversion procedures, with a lower complication rate and need for revision. More studies should be conducted to analyze the long-term efficacy and safety of VSS treatment in pediatric patients with IIH.

Peripapillary microperimetry for the diagnosis and follow-up of papilledema in cases treated for idiopathic intracranial hypertension

OBJECTIVES

To evaluate the use of peripapillary microperimetry in the diagnosis and follow-up of medically and surgically treated cases of papilledema due to idiopathic intracranial hypertension (IIH).

METHODS

This study was a prospective non-comparative observational case series of patients with IIH. All patients underwent full ophthalmological examination, radiological imaging, and lumbar puncture, as well as microperimetric measurements around the optic nerve head. Patients were classified into a medical group, treated by weight reduction and acetazolamide, and a surgical group, treated by optic nerve sheath fenestration. Peripapillary microperimetric examinations were done at presentation and after one-month of treatment. Findings were compared to values obtained from an age-matched healthy control group.

RESULTS

The study included 78 eyes of 39 patients diagnosed with IIH and 32 eyes of 16 healthy control subjects. The average of the sum of the 12 peripapillary microperimetric thresholds for both eyes of IIH cases before treatment was 53.4±59.9 dB, while for controls it was 171±14.0 dB (p<0.001). After 1 month of treatment, it improved to 86.7±56.1 dB (p<0.001) in IIH cases. Analyzed separately, the medical group improved from 68.9±43.4 dB to 105.2±76.5 dB (p<0.001), while the surgical group improved from 13.5±21.9 dB to 54.9±35.5 dB (p<0.001). Several potential roles for peripapillary microperimetry use in IIH management were identified including confirming papilledema diagnosis, follow up of treatment, and selection of cases for surgery.

CONCLUSION

Microperimetry can accurately and quantitatively monitor changes in peripapillary retinal sensitivity in patients undergoing treatment for papilledema due to IIH.

Coexistence of idiopathic intracranial hypertension and optic disc drusen in a latin american patient: case report

Optic nerve drusen are acellular concretions of calcium located in the parenchyma of the optical nerve head described as the most common cause of pseudo-papilloedema, which makes it difficult to differentiate from a true optical disc oedema. Despite it being rare, the drusen of the optic nerve and the papilloedema secondary to idiopathic intracranial hypertension can coexist in the same patient. The case is presented of a 34 year-old woman referred to the Ophthalmology Department with visual discomfort, headaches, and pulsatile tinnitus of two months onset. In the physical examination there was bilateral blurring of the optic disc margin with absence of spontaneous venous pulsation. The diagnosis of idiopathic intracranial hypertension was made by lumbar puncture with the measurement of the opening pressure, and due to the findings of the magnetic resonance scan of the brain and the eye sockets. The optic nerve drusen was an incidental finding in an optical coherence tomography angiography, which would later be confirmed with an eye ultrasound. To our knowledge, this the first case reported in Latin America of the coexistence of optic nerve drusen and papilloedema secondary to idiopathic intracranial hypertension.

Idiopathic intracranial hypertension with stenosis of a solitary occipital venous sinus treated with stenting

A 47-year-old live kidney-donor woman presented with headaches and blurred vision. Neuro-ophthalmological examination demonstrated papilledema and right eye inferior nasal defect. Brain MRV showed no sinus thrombosis but solitary right venous sinus draining the torcular Herophili to right jugular bulb. Lumbar puncture revealed elevated CSF opening pressure of 40 cm H₂O with normal composition. She was diagnosed with idiopathic intracranial hypertension (IIH). She did not tolerate medical management and declined CSF diversion surgery. Cerebral angiography and venography showed venous outflow drainage from torcular Herophili through a solitary occipital sinus which has distal severe stenosis and pressure gradient of 10 mmHg. Balloon angioplasty and stenting of the occipital sinus were performed. Post-stenting, the stenosis and pressure gradient resolved. At 3-months follow-up, her symptoms and papilledema had resolved and CSF opening pressure was normal at 15 cm H2O. Aberrant cerebral venous anatomy may cause IIH and can be treatable with neuroendovascular techniques.

Neuro-Ophthalmological Manifestations of Obstructive Sleep Apnea: Current Perspectives

Obstructive sleep apnea (OSA) is a disease of obstructed airways during sleep that significantly impacts the quality of life and increases the risk of various systemic diseases. OSA has been studied as a risk factor for a number of neuro-ophthalmic conditions and a strong relationship has been established with non-arteritic anterior ischemic optic neuropathy (NAION). The incidence of glaucoma and stroke have also been significantly associated with OSA and are conditions that may also be seen by neuro-ophthalmologists. Patients with NAION have a significantly higher incidence of OSA and OSA diagnosis significantly increases the risk for NAION development. Non-compliance with continuous positive airway pressure (CPAP) in OSA patients has also been found to be a risk factor for fellow-eye involvement and there is increasing evidence to suggest that every patient with NAION should be formally evaluated with polysomnography. The relationship between OSA and idiopathic intracranial hypertension (IIH) has also been studied, but the relationship between these two conditions is less clear. There is insufficient evidence to recommend routine eye examinations in OSA patients for papilledema and conducting a sleep study for a newly diagnosed IIH patient should be left to the discretion of the clinician based on other symptoms and risk factors of OSA.

A systematic review of surgical treatments of idiopathic intracranial hypertension (IIH)

Idiopathic intracranial hypertension denotes raised intracranial pressure in the absence of an identifiable cause and presents with symptoms relating to elevated ICP, namely headaches and visual deterioration. Treatment of IIH aims at reducing intracranial pressure, relieving headache and salvaging patients' vision. Surgical interventions are recommended for medically refractory IIH and include CSF diversion techniques, optic nerve sheath fenestration, bariatric surgery and venous sinus stenting. Prospective studies on the surgical options for IIH are scant and no evidence-based guidelines for the surgical management of medically refractory IIH have been established. A search in Cochrane Library, MEDLINE and EMBASE from 1 January 1985 to 19 April 2019 for controlled or observational studies on the surgical treatment of IIH (defined in accordance with the modified Dandy or the modified Friedman criteria) in adults yielded 109 admissible studies. VSS improved papilledema, visual fields and headaches in 87.1%, 72.7% and 72.1% of the patients respectively, with a 2.3% severe complication rate and 11.3% failure rate. CSF diversion techniques diminished papilledema, visual field deterioration and headaches in 78.9%, 66.8% and 69.8% of the cases and are associated with a 9.4 severe complication rate and a 43.4% failure rate. ONSF ameliorated papilledema, visual field defects and headaches in 90.5, 65.2% and 49.3% of patients. Severe complication rate was 2.2% and failure rate was 9.4%. This is currently the largest systematic review for the available operative modalities for IIH. VSS provided the best results in headache resolution and visual outcomes, with low failure rates and a very favourable complication profile. In light of this, VSS ought to be regarded as the first-line surgical modality for the treatment of medically refractory IIH.

Lumbar puncture rapidly improves olfaction in patients with idiopathic intracranial hypertension: A cohort study

BACKGROUND

A lumbar puncture constitutes an important diagnostic procedure in the evaluation of idiopathic intracranial hypertension. Chronic overflow of cerebrospinal fluid into the sheaths of the olfactory nerves appears to be related to olfactory impairment in these patients. Here, we asked whether cerebrospinal fluid drainage in idiopathic intracranial hypertension patients improves olfactory function.

METHODS

Fourteen idiopathic intracranial hypertension patients and 14 neurologic control patients were investigated before and after lumbar puncture using the extended Sniffin' Sticks procedure. We assessed odor threshold, discrimination, and identification. In idiopathic intracranial hypertension patients, cerebrospinal fluid was drained until cerebrospinal fluid pressure had normalized. In addition, a third group of 14 healthy controls participated in the two smell tests at similar intervals.

RESULTS

Relative to healthy controls, threshold, discrimination, and identification composite scores before lumbar puncture were significantly lower in idiopathic intracranial hypertension patients and also in neurologic controls. Following lumbar puncture, threshold, discrimination, and identification scores for neurologic controls remained unchanged whereas idiopathic intracranial hypertension patients showed robust improvement on the composite score as well as on all three subscores (all changes: p < 0.003), quickly regaining olfactory function in the normal range. Cerebrospinal fluid opening pressure was significantly correlated with improvement in threshold, discrimination, and identification score upon cerebrospinal fluid drainage (r = 0.609, p = 0.021).

CONCLUSION

Olfactory impairment is an important, yet underappreciated, clinical feature of idiopathic intracranial hypertension. Lowering of increased intracranial pressure improves hyposmia. Our findings shed new light on the pathophysiology of cerebrospinal fluid circulation in idiopathic intracranial hypertension.

Custom Shunt System for Increased Baseline Intracranial Pressure in a Patient with Idiopathic Intracranial Hypertension

BACKGROUND

Standard treatment of idiopathic intracranial hypertension (IIH) involves reduction of intracranial pressure (ICP) to normal range, often via a ventriculoperitoneal shunt (VPS). We describe a case of a middle-aged man who presented with symptoms consistent with IIH. After ICP was normalized with a VPS, the patient had neurologic deterioration into a coma. He completely recovered after a month when his ICP was allowed to increase and remain above the normal range.

CASE DESCRIPTION

A 50-year-old man presented with daily headaches, visual loss (right > left), and increased lumbar opening pressure consistent with IIH. A VPS was inserted using a Strata II valve with a pressure setting of 1.5, lowering ICP into the normal range. The patient initially had a normal postoperative course, but then became comatose and developed imaging signs consistent with intracranial hypotension. A Codman Certas valve was placed at a setting of 7 and a distal slit-cut peritoneal catheter was used (as opposed to standard open output). This custom system drained at pressure >26 mm Hg based on intraoperative manometry. The patient tolerated this well and is currently planned for a gradual reduction in ICP with valve setting adjustments as an outpatient.

CONCLUSIONS

In patients with chronic IIH, reduction to normal ICP may unexpectedly lead to encephalopathic changes. Personalized shunts may facilitate reduction of ICP to still elevated but tolerable levels in these patients.

Pseudotumour Cerebri Syndrome in China: A Cohort Study

Pseudotumour cerebri syndrome (PTCS) remains to be fully investigated in Chinese patients and our study reported PTCS-related clinical differences between Chinese patients and Western patients. This study enrolled 55 consecutive patients (females: 44, median age: 37 y, age range: 14–62 y) with PTCS diagnosed from October 2015 to December 2017. Nine (16.4%, females) patients had primary PTCS, and 46 (83.6%) had secondary PTCS (P = 0.001). At presentation, 81.8% of patients had grade >3 papilloedema, with 23.6% having diffusely constricted fields. Mean subarachnoid space around the optic nerve measured by retrobulbar ultrasonography during lumbar puncture was 1.12 ± 0.17 mm and decreased to 0.86 ± 0.11 mm after treatment. Optical coherence tomography (OCT) showed that 92.9% of eyes with intact macular ganglion cell-inner plexiform layer (GCIPL) at baseline had good outcomes after treatment. Patients’ demographic and clinical characteristics showed that secondary PTCS was more common than primary idiopathic intracranial hypertension in Chinese patients. Polycystic ovarian syndrome was the main associated factor in females. Poor visual function was common at presentation. Noninvasive ocular ultrasonography and OCT are the prognostic indicators of PTCS treatment in intracranial pressure and visual function, respectively, after PTCS treatment.

Pediatric liver diseases and ocular changes: What hepatologists and ophthalmologists should know and share with each other

Several rare pediatric liver disorders are accompanied by ophthalmic signs whose awareness and early identification may be of value in confirming/accelerating their diagnosis. Many of these signs are asymptomatic and can only be detected with an ophthalmological examination. Corneal signs are described in patients with Wilson's disease, Alagille's syndrome and some liver storage diseases. Cataract plays an important role to diagnose galactosemia. Retinal involvement is seen in some peroxisomal disorders (e.g. Zellweger's syndrome), in mucopolysaccharidoses (pigmentary retinopathy), and in Niemann-Pick disease (macular cherry red spot). In mucopolysaccharidoses optic nerve can be involved as optic atrophy secondary to pigmentary retinopathy or to chronic papilledema. Children with neonatal cholestasis due to hypopituitarism may present septo-optic dysplasia. Several infectious agents have an ophthalmological/hepatic involvement in the fetal life and/or thereafter. Some mitochondrial liver diseases, such as Pearson's syndrome, present pigmentary retinopathy and a chronic progressive external ophthalmoplegia. Finally, some drugs while protecting the liver may damage the ocular system as seen with long-term glucocorticoids and Nitisinone administration. This review provides a synopsis of those conditions that hepatologists and ophthalmologists should share among themselves to better take care of patients. Synoptic tables are presented to facilitate the mutual understanding of the issues.

Idiopathic intracranial hypertension in pediatric and adolescent patients

Objectives

Pediatric idiopathic intracranial hypertension is a rare condition, but inappropriate diagnosis and management may lead to devastating outcome with loss of vision and lifelong handicap. Dandy criteria are used for diagnosis of idiopathic intracranial hypertension (IIH) in adult, but these criteria cannot be applied in all pediatric patients.

The aim of this study is to evaluate the diagnostic criteria and outcome of management of IIH in pediatric patients.

Methods

Nineteen patients with IIH and age less than 16 years old have been evaluated for the diagnostic criteria and outcome of management. The patients were classified according to the secondary sexual criteria into adolescent IIH and pediatric IIH. Full neurological and ophthalmological evaluation was completed in all patients. The patients were managed and followed up for a mean period of 12 ± 8.6 months at Zagazig University hospitals or Kingdom Hospital in the time period from 2009 to 2018.

Results

Nineteen patients (16 females and 3 males) had been diagnosed and treated with idiopathic intracranial hypertension, their age is between 4 and 15 years, and the patients have been divided into two groups. Group I (pediatric IIH) involved 9 patients (6 females and 3 males), and their age is ranging between 4 and 9 years with mean age 5.56 ± 1.9 years while group II (adolescent IIH) involved 10 patients, all of them are females and their age ranges between 12 and 15 years with mean age 13.5 ± 1.3. Diagnostic criteria of the patients are papilledema, symptoms and signs of intracranial hypertension, and elevated CSF opening pressure with normal MRI. Headache, delayed school performance, and sixth nerve palsy are the most common clinical finding in the patients of group I while headache is the most common presenting symptom in group II. Anemia and otitis media are the most common associated risk factors in group I while obesity and female gender were the most common associated risk factors in group II. The minimum value for opening pressure in group I is 180 mmH2O while the minimum value in group II is 250 mm. 16 patients improved after the first lumbar puncture and drainage of CSF; two patients improved after repeated lumbar puncture while lumbo-peritoneal shunt was inserted for two patients, both of them were in group II. Recurrence was diagnosed in four patients (21%), one of them (11.1%) was in group I while three of them (30%) were in group II.

Conclusion

Pediatric idiopathic intracranial hypertension can be classified into two subtypes: pediatric type and adolescent type according to the secondary sexual criteria.

Modified Dandy criteria can be applied for the diagnosis of adolescent type, but pediatric type is not associated with obesity, has no female predominance, and usually responds to the initial lumbar puncture with a low rate of recurrence.

Intracranial Venous Pressures Manometry for Patients With Idiopathic Intracranial Hypertension: Under Awake Setting or General Anesthesia

Background and Purpose: Venous sinus stenting (VSS) is a well-acknowledged treatment strategy for patients with a high venous sinus pressure gradient across the site of outflow obstruction. It is not clear whether intracranial venous pressure manometry should be performed awake or under general anesthesia (GA). The aim of this study is to compare the accuracy of venous manometry performed under GA or awake setting, and to evaluate stenting candidates to be determined under awake setting or under GA.

Methods: The manometry results of 32 patients with idiopathic intracranial hypertension (IIH) were recorded under awake setting and general anesthesia before stenting. Mean venous pressures (MVPs) and trans-stenosis pressure gradients were obtained and compared between awake setting and general anesthesia status.

Results: MVPs and trans-stenosis pressure gradients of 32 patients under GA and awake pressure setting were recorded. MVPs in the superior sagittal sinus, torcula, and transverse sinus were lower in the GA group, without statistical significant difference (P > 0.05). MVPs were significantly higher in the sigmoid sinus and jugular bulb under GA group (p < 0.05). Mean trans-stenosis pressure gradient was significantly lower in the group under GA (p < 0.05).

Conclusions: Intracranial venous pressure seems to be affected by different levels of consciousness. Our study reveals that intracranial venous pressure is lower under general anesthesia than in the awake setting, which may have a potential impact on patient selection for venous sinus stenting.

Persistent Cerebrospinal Fluid Leukocytosis: Could this be Idiopathic Intracranial Hypertension?

A 37-year-old female, a known epileptic, presented to the neurology clinic with a seven-day history of persistent bilateral headache not improving with analgesics. Her neurological and systemic examinations were unremarkable except for right optic disc edema. Magnetic resonance imaging (MRI) brain and magnetic resonance venography (MRV) were normal but her cerebrospinal fluid (CSF) opening pressure was 280 mm of water with a CSF white cell count of 214. The patient showed improvement following treatment with intravenous antibiotics and acyclovir. She returned a week later with double vision and blurring in both eyes. Examination showed bilateral sixth nerve palsies and bilateral optic disc edema with left fundal hemorrhages. The spinal tap was repeated again, which showed a CSF opening pressure of 500 mm of water and the white cell count was 48. Extensive investigations for etiologies were mostly unrevealing. The patient was started on acetazolamide and topiramate combined with a large-volume therapeutic CSF tap. She continued to improve subsequently and was at the baseline functional state at three months, with complete resolution of hemorrhages and optic disc edema. Idiopathic intracranial hypertension (IIH) may present with persistent abnormal CSF with a high white cell count. Therefore, this must be diagnosed with caution, as it may be misdiagnosed and wrongly treated for other causes.

Idiopathic intracranial hypertension presenting with isolated unilateral facial nerve palsy: a case report

BACKGROUND

Idiopathic intracranial hypertension, also known as pseudotumor cerebri, is a disorder characterized by increased intracranial pressure of unclear pathogenesis in the absence of other structural and obstructive lesions that is predominantly, although not exclusively, seen in obese women of childbearing age. Patients with idiopathic intracranial hypertension commonly present with a headache, transient visual obscurations, and intracranial noises with some cranial nerves occasionally involved, most commonly CN VI. We report idiopathic intracranial hypertension presenting with isolated complete unilateral facial nerve palsy, as the sole cranial nerve involved, which is a presentation rarely reported in the literature.

CASE PRESENTATION

A 40-year-old Hispanic woman with a history of obesity and hypertension presented to our emergency department complaining of bifrontal headache for 3 days associated with nausea, vomiting, transient visual disturbances, and a picture of right-sided cranial nerve VII palsy. Her neurologic examination including other cranial nerves was otherwise normal, but a fundus examination revealed bilateral grade II papilledema. Imaging studies ruled out structural and obstructive lesions as possible causes of her symptoms and lumber puncture results were unremarkable except for an increased opening pressure. She was then started on prednisone and acetazolamide. Two days later, she reported a dramatic improvement in both headache and facial nerve palsy.

CONCLUSIONS

Idiopathic intracranial hypertension should be suspected in obese young women presenting with headache and transient visual complaints and some cranial nerve abnormalities. Idiopathic intracranial hypertension is a diagnosis of exclusion and imaging studies should always be performed to rule out other structural and obstructive lesions. In this case report, we aimed to draw attention to the possibility of idiopathic intracranial hypertension presenting with unilateral cranial nerve VII palsy as the only cranial nerve involved, which needs a high index of suspicion by clinicians. The mechanisms of cranial nerve VII palsy in idiopathic intracranial hypertension are not well understood and prompt further investigation.