Benign intracranial hypertension following corticosteroid withdrawal in childhood

Prevalence of Adrenal Insufficiency and Glucocorticoid Use in Pediatric Pseudotumor Cerebri Syndrome

BACKGROUND

The pathophysiology underlying pseudotumor cerebri syndrome (PTCS) is complex and not well understood. There are clear differences between PTCS in adults and pediatrics. Few and isolated case reports have suggested that adrenal function may be involved, yet no large cohort study has examined this relationship.

METHODS

We conducted a retrospective single-center study of children who presented with a diagnosis of PTCS and had cortisol testing measured between January 2010 and September 2019. We included all subjects meeting the revised PTCS diagnostic criteria after the chart review. Based on morning, random or 1-μg cosyntropin stimulated cortisol levels, adrenal functioning was classified as: (1) insufficient (peak cortisol <16 μg/dL and AM cortisol <5 μg/dL), (2) at risk (peak cortisol 16-20 μg/dL, AM cortisol 5-13 μg/dL, or random <13 μg/dL), or (3) sufficient (peak cortisol >20 μg/dL and AM or random cortisol >13 μg/dL).

RESULTS

A total of 398 individuals were reviewed, and 64 were included for analysis. Of these, 40.6% were men, of mixed race and ethnicity with a mean age of 10.5 (SD 4.7) years. Of these, 23% and 52% had insufficient or at-risk cortisol levels. The majority of those in the insufficient (70%) or at-risk (80%) groups were exposed to topical, nasal, or inhaled glucocorticoids but not systemic. Only 60% and 12% of those with PTCS with insufficient or at-risk cortisol testing, respectively, underwent definitive testing with a stimulation test.

CONCLUSIONS

Glucocorticoid use and hypocortisolism are prevalent in PTCS and need consideration as a potential underlying cause. Most children had insufficient or at-risk cortisol levels, and many did not undergo further testing/workup. Children who present with PTCS, particularly young, males should be evaluated for adrenal insufficiency and its risk factors, including nonsystemic steroids. Prospective studies are necessary to further evaluate the effect of cortisol in relation to pediatric PTCS.

Papilledema in Chronic Inflammatory Demyelinating Polyradiculoneuropathy (CIDP): A Pediatric Case and Review of the Literature

OBJECTIVE

To analyze the available literature on papilledema in chronic inflammatory demyelinating polyradiculoneuropathy (CIDP), report the first detailed pediatric case, and explore the underlying pathophysiology.

METHODS

First, we conducted a comprehensive literature review of all cases of papilledema in CIDP. Next, we reviewed each case, incorporating only those including cerebrospinal fluid analysis into the results. Finally, we present our pediatric patient.

RESULTS

Our literature review yielded a total of 9 adult and no pediatric cases. Cerebrospinal fluid protein and opening pressures were elevated in all cases. They were also elevated in our pediatric case.

CONCLUSION

Prolonged periods of active immune-mediated inflammation is likely a cause of papilledema in adult CIDP, and possibly also in our pediatric case.

Pseudotumor cerebri-Case report

An 46-year-old Caucasian woman was diagnosed with idiopathic intracranial hypertension (IIH) after presenting with papilledema and bilateral visual blurring. Lumbar puncture revealed an opening pressure of more than 550 mmH2O. Cerebral magnetic resonance imaging (MRI) showed bilateral flattening of the posterior sclera, enhancement of the prelaminar optic nerve, distension of the perioptic subarachnoid space, intraocular protrusion of the prelaminar optic nerve and empty sella. The main purpose of the treatment was to release the symptoms and preserve the vision. It was initiated the general treatment with Mannitol 20%, 250 ml/day, Acetazolamide 2x500 mg/day and B-vitamins. After discharge the patient followed a treatment with acetazolamide 2x250 mg/ daily doses and oral potassium supplements 30 mg bid/day. Key words: pseudotumor cerebri, idiopatic intracranial hypertension, papilledema,

Infantile Idiopathic Intracranial Hypertension: A Case Study and Review of the Literature

Idiopathic intracranial hypertension, or pseudotumor cerebri, is an increase in cerebrospinal fluid pressure of unknown etiology. It is mostly seen in adults, less frequently in adolescents, rarely in younger children. Only 5 infants meeting idiopathic intracranial hypertension criteria have been mentioned in the literature. We report a case of a previously healthy 9-month-old boy who presented with irritability, decreased appetite, and a bulging fontanelle. Computed tomography (CT) head imaging and cerebrospinal fluid studies revealed normal results. The patient's symptoms transiently resolved after the initial lumbar puncture, but 11 days later, his fontanelle bulged again. A second lumbar puncture revealed an elevated opening pressure of 35 cmH₂O and led to a diagnosis of idiopathic intracranial hypertension in accordance with the modified Dandy Criteria. Treatment with acetazolamide at a dose of 25 mg/kg/d was initiated and the patient remained symptom-free for 6 weeks, followed by another relapse. His acetazolamide dose was increased to 37 mg/kg/d, with no further relapses to date. A diagnosis of idiopathic intracranial hypertension is challenging in infants, because the patients cannot yet verbalize typical idiopathic intracranial hypertension-related symptoms such as positional headaches, diplopia, or pulsatile tinnitus. Furthermore, it is more difficult to assess papilledema in that age group. If undetected and untreated, idiopathic intracranial hypertension may result in permanent visual deficits. Little is known about idiopathic intracranial hypertension in infants, and age-specific treatment guidelines are lacking. We discuss this rare case of infantile idiopathic intracranial hypertension and provide a review of the literature, including an overview of disease characteristics and outcomes of idiopathic intracranial hypertension in this very young age group.

Idiopathic intracranial hypertension as a presenting sign of adrenal insufficiency

Idiopathic intracranial hypertension is a diagnosis of exclusion defined by elevated intracranial pressure without mass lesions or hydrocephalus. Causes of idiopathic intracranial hypertension include obesity, vitamin derangements, antibiotics, corticosteroids, and autoimmune disorders. Cushing’s disease and Addison’s disease have been associated with idiopathic intracranial hypertension. Secondary adrenal insufficiency following withdrawal of inhaled corticosteroids has been found to be a relatively common phenomenon. This case describes an 11-year-old boy who was previously on inhaled corticosteroids for severe asthma who presented with secondary adrenal insufficiency after withdrawal of steroids. The adrenal insufficiency presented as idiopathic intracranial hypertension. We described the hospital course and process of diagnosis for this child with secondary adrenal insufficiency following withdrawal of inhaled corticosteroids. The association between the discontinuation of this patient’s corticosteroids and his onset of headache suggests secondary adrenal insufficiency as the most likely cause of his idiopathic intracranial hypertension. The gradual improvement in his symptoms after steroid replacement further supports this. Due to the significant prevalence of children using inhaled corticosteroids, it is important for clinicians to be aware of the potential for the withdrawal of these drugs to induce hypothalamic–pituitary–adrenal axis suppression.

Pediatric Intracranial Hypertension

Primary (idiopathic) intracranial hypertension has been considered to be a rare entity, but with no precise estimates of the pediatric incidence in the United States. There have been attempts to revise the criteria over the years and adapt the adult criteria for use in pediatrics. The clinical presentation varies with age, and symptoms tending to be less obvious in younger individuals. In the prepubertal population, incidentally discovered optic disc edema is relatively common. By far the most consistent symptom is headache; other symptoms include nausea, vomiting tinnitus, and diplopia. Treatment mainstays include weight loss when appropriate and acetazolamide. Furosemide may exhibit a synergistic benefit when used in conjunction with acetazolamide. Surgical interventions are required relatively infrequently, but include optic nerve sheath fenestration and cerebrospinal fluid shunting. Pain and permanent vision loss are the two major complications of this disorder and these manifestations justify aggressive treatment. Once intracranial hypertension has resolved, up to two thirds of patients develop a new or chronic headache type that is different from their initial presenting headache.

Cerebrospinal Fluid Rhinorrhea Secondary to Idiopathic Intracranial Hypertension: Long-term Outcomes of Endoscopic Repairs

Background

Endoscopic endonasal repair of cerebrospinal fluid (CSF) rhinorrhea secondary to idiopathic intracranial hypertension (IIH), also known as pseudotumor cerebri or benign intracranial hypertension, has varying success rates, from 25–87%, with minimal morbidity. However, often these series have a relatively short-term follow-up. Given the pathophysiology of IIH, long-term follow-up is necessary to identify true CSF leak recurrence rates. Our investigation aimed to evaluate long-term outcomes in endoscopically repaired CSF leaks.

Methods

A retrospective chart review of all the patients with CSF rhinorrhea due to IIH who met inclusion criteria between 1996 and 2009. Outcome measures included the following: demographics, intracranial pressure, location of skull base defect, presence of encephalocele and/or meningoencephalocele, surgical repair technique, treatment with acetazolamide, whether a ventriculoperitoneal shunt was inserted, location of recurrence, history of meningitis or previous sinus surgery, and duration of follow-up.

Results

Thirty-two patients with a total of 44 skull base defects were reviewed over a mean follow-up of 10.2 years. The mean body mass index and intracranial pressure were 36.8 kg/m2 and 27.7 cm H2O, respectively. Seven patients (18%) required revision surgery at the same site or a distant site. We found no statistical significance that identified the recurrence risk in the outcome measurements most likely due to our small failure rate. However, early recurrences were noted to recur at the same repair site, whereas late recurrences were noted to recur at a distant site along the skull base.

Conclusion

IIH is an increasingly recognized entity treated by otorhinolaryngologists. We present the first long-term IIH CSF leak repair series. Long-term follow-up is necessary because delayed CSF leaks occur in this population.

Papilledema: epidemiology, etiology, and clinical management

Papilledema is optic disc swelling due to high intracranial pressure. Possible conditions causing high intracranial pressure and papilledema include intracerebral mass lesions, cerebral hemorrhage, head trauma, meningitis, hydrocephalus, spinal cord lesions, impairment of cerebral sinus drainage, anomalies of the cranium, and idiopathic intracranial hypertension (IIH). Irrespective of the cause, visual loss is the feared morbidity of papilledema, and the main mechanism of optic nerve damage is intraneuronal ischemia secondary to axoplasmic flow stasis. Treatment is directed at correcting the underlying cause. In cases where there is no other identifiable cause for intracranial hypertension (ie, IIH) the available options include both medical and surgical modalities. Weight loss and diuretics remain the mainstays for treatment of IIH, and surgery is typically reserved for patients who fail, are intolerant to, or non-compliant with maximum medical therapy.

Idiopathic intracranial hypertension (pseudotumor cerebri): recognition, treatment, and ongoing management

OPINION STATEMENT

Idiopathic intracranial hypertension (IIH, pseudotumor cerebri) is a syndrome of elevated intracranial pressure of unknown cause that occurs predominantly in obese women of childbearing age. It is a diagnosis of exclusion and, therefore, other causes of increased intracranial pressure must be sought with history, imaging, and cerebrospinal fluid examination before the diagnosis can be made. IIH produces symptoms and signs of increased intracranial pressure, including papilledema. If untreated, papilledema can cause progressive irreversible visual loss and optic atrophy. The treatment approach depends on the severity and time course of symptoms and visual loss, as determined by formal visual field testing. The main goals of treatment are alleviation of symptoms, including headache, and preservation of vision. All overweight IIH patients should be encouraged to enter a weight-management program with a goal of 5-10 % weight loss, along with a low-salt diet. When there is mild visual loss, medical treatment with acetazolamide should be initiated. Other medical treatments can be added or substituted when acetazolamide is insufficient as monotherapy or poorly tolerated. When visual loss is more severe or rapidly progressive, surgical interventions, such as optic nerve sheath fenestration or cerebrospinal fluid shunting, may be required to prevent further irreversible visual loss. The choice of intervention depends on the relative severity of symptoms and visual loss, as well as local expertise. At present, the role of transverse venous sinus stenting remains unclear. Although there are no evidence-based data to guide therapy, there is an ongoing randomized double-blind placebo-controlled treatment trial, investigating diet and acetazolamide therapy for IIH.

Pseudotumor cerebri in a child receiving peritoneal dialysis: Recovery of vision after lumbo-pleural shunt

A 9-year-old boy with end-stage renal disease who was receiving continuous ambulatory peritoneal dialysis (CAPD) presented with acute visual loss and was found to have papilledema. Neuroimaging and cerebrospinal fluid (CSF) analysis were normal. The lumbar puncture opening pressure was 290 mm of water so the diagnosis of pseudotumor cerebri (PTC) was entertained. Medical treatment was not an option because of renal insufficiency; neither was lumbo-peritoneal shunting, because of the peritoneal dialysis. After a lumbo-pleural shunt was placed, there was marked improvement in symptoms. The lumbo-pleural shunt is a reasonable option for treatment for PTC in patients on CAPD who require a CSF divergence procedure.

Pseudotumor cerebri

INTRODUCTION

Pseudotumor cerebri is a condition characterized by raised intracranial pressure, normal CSF contents, and normal brain with normal or small ventricles on imaging studies. It affects predominantly obese women of childbearing age; however, its incidence seems to be increasing among adolescent and children. While among older children the clinical picture is similar to that of adults, younger children present demographic and clinical peculiarities. Different diagnostic criteria for adults and pre-pubertal children have been proposed. Etiology and pathogenesis are still unclear, particular concerning the role of obstruction to venous outflow.

METHODS

An extensive literature review concerning all the aspects of pseudotumor cerebri has been performed, both among adults and pre-pubertal children.

CONCLUSION

Pseudotumor cerebri is an avoidable cause of visual loss, both in adults and children. Few diagnostic measures are usually sufficient to determine the correct diagnosis. Since pseudotumor cerebri is a diagnosis of exclusion, the differential diagnosis work out is of special importance. Modern neuroimaging techniques, especially magnetic resonance imaging and magnetic resonance venography may clarify the role of obstruction to venous outflow in each case. Various therapeutic options are available: medical, surgical, and endovascular procedures may be used to prevent irreversible visual loss. Treatment is usually effective, and most patients will experience complete resolution of symptoms without persistent deficits.

Idiopathic intracranial hypertension in children: a review and algorithm

This updated review of pediatric idiopathic intracranial hypertension focuses on epidemiology, clinical presentations, diagnostic criteria, evaluation, clinical course, and treatment. General guidelines for the clinical management of idiopathic intracranial hypertension are discussed. A new algorithm outlines an efficient management strategy for the initial diagnostic evaluation of children with signs or symptoms of intracranial hypertension. This algorithm provides a systematic approach to initial evaluation and management, and identifies important decision-making factors. The risk of permanent visual loss with idiopathic intracranial hypertension necessitates a prompt, thorough collaborative approach in the management of patients. Although idiopathic intracranial hypertension has been recognized for over a century, the need remains for prospectively collected data to promote a better understanding of the etiology, risk factors, evaluative methods, and effective treatments for children with this syndrome.

Idiopathic intracranial hypertension

Idiopathic intracranial hypertension ((IIH) is characterized by increased cerebrospinal fluid pressure of unknown cause. It is predominantly a disease of women in the childbearing years. Although the cause of IIH remains obscure, it has become clear that loss of visual function is common and patients may progress to blindness if untreated. Diagnosis should adhere to the modified Dandy criteria and other causes of intracranial hypertension sought. IIH patient management should include serial perimetry and optic disc grading or photography. The proper therapy can then be selected and visual loss prevented or reversed. Although there are no evidence-based data to guide therapy, there is an ongoing randomized double-blind controlled treatment trial of IIH investigating diet and medical therapy.

Idiopathic intracranial hypertension

Idiopathic intracranial hypertension (IIH) is a condition which affects predominantly overweight women and is characterized by raised intracranial pressure without any identifiable pathology in the brain and with normal cerebrospinal fluid (CSF) composition. The cause of IIH is unclear and as such it remains a diagnosis of exclusion. Although the pathophysiology of IIH remains elusive, some observations have recently been added to our understanding of this, including the presence of transverse sinus stenosis on many patients and the possible role of leptin and inflammation in the disease pathogenesis. Headache is the most common symptom and papilloedema is the major clinical finding. Choices of medical treatment are limited to the use of diuretics particularly acetazolamide and encouragement of weight loss. Surgical therapies such as CSF diversion procedures and fenestration of the optic nerve may be necessary in some cases with persistent symptoms or progressive visual deterioration. While not life-threatening, IIH has a significant morbidity with up to 25% of patients developing visual impairment from optic atrophy. Visual surveillance is therefore vital. Long-term follow-up is recommended as the disease may worsen after an initial period of stability.

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

PURPOSE

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

DESIGN

Matched case-control study.

METHODS

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

RESULTS

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

CONCLUSIONS

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

What is new about idiopathic intracranial hypertension? An updated review of mechanism and treatment

Idiopathic intracranial hypertension (IIH) is the syndrome of raised intracranial pressure without clinical, laboratory or radiological evidence of intracranial pathology. IIH is a relatively rare disease but rapidly increasing incidence is reported due to a global increasing incidence of obesity. Disease course is generally said to be self-limiting within a few months. However, some patients experience a disabling condition of chronic severe headache and visual disturbances for years that limit their capacity to work. Permanent visual defects are serious and not infrequent complications. The pathophysiology of IIH is still not fully understood. Advances in neuroimaging techniques have facilitated the exclusion of associated conditions that may mimic IIH. No causal treatment is yet known for IIH and existing treatment is symptomatic and rarely sufficient. The aim of this review is to provide an updated overview of this potentially disabling disease which may show a future escalating incidence due to obesity. Theories of pathogenesis, diagnostic criteria and treatment strategies are discussed.

Idiopathic intracranial hypertension

Idiopathic intracranial hypertension is common in obese women and can lead to significant visual impairment. First described more than 100 years ago, the cause of the disorder remains unknown. Despite a multitude of proposed links, the aetiology has never been established. Impairment of cerebrospinal-fluid reabsorption is the most likely underlying pathophysiological cause of the raised pressure, but this notion has yet to be proven. Cerebral venous sinus abnormalities associated with the disorder need further exploration. Although the major symptoms of headache and visual disturbance are well documented, most data for disease outcome have been from small retrospective case series. No randomised controlled trials of treatment have been done and the management is controversial. The importance of weight loss needs clarification, the role of diuretics is uncertain, and which surgical intervention is the most effective and safe is unknown. Prospective trials to examine these issues are urgently needed.

Idiopathic intracranial hypertension

Idiopathic intracranial hypertension results from cerebral oedema. The symptoms and signs of the condition are reviewed, especially the risks of visual failure if the condition is prolonged without adequate treatment. The most significant symptom in childhood is headache, and the most important sign is papilloedema. The difficulties of diagnosis are discussed, especially the cerebral oedema that can occur on the withdrawal of steroid therapy, and the increased intracranial pressure that may develop with minimal forms of craniostenosis. The causes of intracranial hypertension are many, and include ear infections, venous sinus thrombosis, the use of certain drugs, and as a complication of acute disseminated encephalomyelitis and Cushing's disease, and impaired renal function. The condition may remit spontaneously, but even so a careful watch must be kept on visual acuity. If treatment is needed various drugs can be tried, and if the response is unsatisfactory repeated lumbar punctures will be indicated. It is rarely necessary to consider surgical intervention such as cerebral decompression.

Pseudotumor cerebri in patients with Cushing's disease

OBJECTIVE

To discuss the manifestation of pseudotumor cerebri during the course of correcting the hypercortisolism of Cushing's disease.

METHODS

We describe the clinical, biochemical, and neuro-ophthalmologic findings in a patient in whom pseudotumor cerebri developed during correction of the hypercortisolism of Cushing's disease. In addition, we review the relationship between pseudotumor cerebri and Cushing's disease in the literature.

RESULTS

A 44-year-old woman with Cushing's disease underwent total adrenalectomy after two unsuccessful transsphenoidal operations. She developed daily headaches 2 weeks postoperatively while taking 60 mg of hydrocortisone daily. She noticed a visual floater 8 weeks postoperatively, and a prompt ophthalmologic evaluation revealed papilledema. We diagnosed pseudotumor cerebri on the basis of symptoms and signs of intracranial hypertension, unremarkable findings on neuroimaging and cerebrospinal fluid analysis, and a substantially increased cerebrospinal fluid pressure. After 8 weeks of treatment with furosemide, the headaches and papilledema resolved, and the patient was able to reduce her dose of hydrocortisone to 30 mg daily. Pseudotumor cerebri has been associated with adrenocortical insufficiency and gluco- corticoid withdrawal and can lead to loss of vision. A literature review revealed 6 previous patients in whom pseudotumor cerebri developed in association with Cushing's disease. In all but one case, the pseudotumor cerebri manifested 2 to 4 weeks after treatment of hypercortisolism or cessation of hydrocortisone replacement.

CONCLUSION

Symptoms of intracranial hypertension such as headache occurring in a patient recently withdrawn from exogenous or endogenous corticosteroids should prompt consideration of the presence of pseudotumor cerebri.

Steroids and brain atrophy in multiple sclerosis

In this review, we focus on different pathogenetic mechanisms of corticosteroids that induce short- and long-term brain volume fluctuations in a variety of systemic conditions and disorders, as well as on corticosteroid-induced immunomodulatory, immunosuppressive and anti-inflammatory mechanisms that contribute to the slowdown of brain atrophy progression in patients with multiple sclerosis (MS). It appears that chronic low-dose treatment with corticosteroids may contribute to irreversible loss of brain tissue in a variety of autoimmune diseases. This side effect of steroid therapy is probably mediated by steroid-induced protein catabolism mechanism. Evidence is mounting that high-dose corticosteroids may induce reversible short-term brain volume changes due to loss of intracellular water and reduction of abnormal vascular permeability, without there having been axonal loss. Other apoptotic and selective inhibiting mechanisms have been proposed to explain the nature of corticosteroid-induced brain volume fluctuations. It has been shown that chronic use of high dose intravenous methylprednisolone (IVMP) in patients with MS may limit brain atrophy progression over the long-term via different immunological mechanisms, including downregulation of adhesion molecule expression on endothelial cells, decreased cytokine and matrix metalloproteinase secretion, decreased autoreactive T-cell-mediated inflammation and T-cell apoptosis induction, blood-brain barrier closure, demyelination inhibition and, possibly, remyelination promotion. Studies in nonhuman primates have confirmed that short-term brain volume fluctuations may be induced by corticosteroid treatment, but that they are inconsistent, potentially reversible and probably dependent upon individual susceptibility to the effects of corticosteroids. Further longitudinal studies are needed to elucidate pathogenetic mechanisms contributing to brain volume fluctuations in autoimmune diseases and multiple sclerosis.

Medication-induced intracranial hypertension in dermatology

Pseudotumor cerebri (PTC) is a syndrome of intracranial hypertension that is idiopathic or from an identified secondary cause. It is characterized by headaches and visual manifestations. The hallmark of PTC is papilledema and the feared consequence is visual loss that may be severe and permanent. The idiopathic form generally occurs in obese women of childbearing age. Various medications may produce PTC in patients at any age, including children. Several medications used in dermatology, particularly those used in the treatment of acne vulgaris, are associated with PTC. There is a strong association with tetracycline usage. Minocycline and doxycycline have also been linked to PTC, although there are relatively few reported cases. PTC has also been described with retinoids, including vitamin A (retinol) and isotretinoin. Although corticosteroids are often used to lower intracranial pressure acutely, corticosteroid withdrawal after long-term administration may induce increased intracranial pressure. A high index of suspicion, early diagnosis and treatment generally yield a good prognosis.

Recent developments in idiopathic intracranial hypertension (IIH)

Idiopathic intracranial hypertension is a disease with a predilection for young obese women. The most common symptoms are headache, transient visual obscuration and pulsatile tinnitus. The only focal neurologic finding is false-localizing 6th cranial nerve palsy. Papilledema is usually present and this can lead to optic atrophy with progressive permanent visual loss. The earliest visual loss is constriction of peripheral visual field, usually starting with the inferior nasal quadrant. Numerous theories have been entertained as to the pathogenesis but this still remains an open controversy. The most prevalent current theories involve increased resistance to cerebrospinal fluid reabsorption at the arachnoid granulations, either from intrinsic disease in the granulations or secondary to elevated pressure in the dural venous sinuses into which the cerebrospinal fluid is absorbed across the granulations. The syndrome of idiopathic intracranial hypertension was long ago recognized as a complication of recurrent otitis media with resultant thrombosis of the transverse and sigmoid dural venous sinuses. Cases secondary to dural venous sinus thrombosis are seldom encountered today because the incidence of chronic otitis is much less than in the past. The prevalent concept has been that the idiopathic cases in obese young women were not associated with pathology in the dural venous sinuses. A recent study using ATECO MR venography, which the authors claim to be more reliable than even conventional catheter venography, has demonstrated stenosis of the transverse and sigmoid dural venous sinuses distinguishes cases of idiopathic intracranial hypertension from controls with a high degree of sensitivity and specificity. The authors believe the stenosis is secondary to intracranial hypertension but that it may further aggravate the hypertension when it occurs.

Idiopathic intracranial hypertension

OBJECTIVE

The history, diagnosis, and therapy of idiopathic intracranial hypertension (IIH) (pseudotumor cerebri) are reviewed. Theories of pathogenesis are considered, the clinical presentation is described, and potential diagnostic and therapeutic challenges are explored.

METHODS

An extensive literature review of IIH and related conditions (secondary pseudotumor syndromes) was performed. The history of and rationale for the diagnosis and medical and surgical approaches to treatment are reviewed. Available outcome studies are presented.

RESULTS

Diagnosis of IIH requires that the modified Dandy criteria be satisfied. Multiple potential contributing causes of intracranial hypertension must be identified or excluded. The clinical presentation most often includes headaches and papilledema, but many other findings have been described. The most important goal of therapy is to prevent or arrest progressive visual loss. Medical therapies include alleviation of associated systemic diseases, discontinuation of contributing medications, provision of carbonic anhydrase inhibitors, and weight loss. Surgical therapies include lumboperitoneal shunting, ventriculoperitoneal shunting, and optic nerve sheath fenestration. On the basis of the advantages and disadvantages of these treatment modalities, a suggested treatment paradigm is presented.

CONCLUSION

Idiopathic intracranial hypertension is the term to be adopted instead of pseudotumor cerebri. IIH remains an enigmatic diagnosis of exclusion. However, prompt diagnosis and thorough evaluation and treatment are crucial for preventing visual loss and improving associated symptoms.

Idiopathic Intracranial Hypertension

The syndrome of intracranial hypertension without structural brain or cerebrospinal fluid abnormalities and without identifiable cause, now most appropriately termed idiopathic intracranial hypertension, was described over a century ago. Although the pathogenesis of this condition remains unknown, diagnostic and therapeutic developments during the past two decades have substantially advanced patient management.

Problems in childhood obesity

Clearly, obesity prevention should be at the forefront of our approach to this epidemic problem and the goal of health care providers, public health officials, community, and families. The problems of the obese child are no longer solely those of increased risk for disease, but of disease itself. Health care providers are increasingly challenged to provide evaluation and treatment for the serious comorbidities and complications of obesity in childhood. Many of these comorbidities and complications are "invisible" and require careful and focused history and laboratory evaluation to elicit. Treatment of the complication and comorbidity should be focused on preventing progression, reversing the disease process, and, ultimately, achieving control of obesity with family-based lifestyle changes that will allow the child to maintain a healthy balance between his or her genetic predisposition and the environment.

Idiopathic "benign" intracranial hypertension: case series and review

Idiopathic "benign" intracranial hypertension is an uncommon but important cause of headache that can lead to visual loss. This study was undertaken to review our experience in the diagnosis and management of idiopathic intracranial hypertension, giving special attention to treatments used. A retrospective chart review was conducted on 32 patients diagnosed with idiopathic intracranial hypertension between 1984 and 1995. Subjects included 23 females and ranged in age from 2 to 17.5 years. Headache was the most common symptom, followed by nausea and vomiting, double vision, and visual loss. Papilledema was the most common sign. Others were VIth cranial nerve palsy and compromised visual acuity at or within 3 months of presentation. Management included administration of acetazolamide or corticosteroids, lumboperitoneal shunt, optic nerve fenestration, and repeat lumbar puncture. Treatment combinations were used in 40% of cases. During follow-up, headache, papilledema, and decreased visual acuity persisted for longer than 10 months in a significant number of patients. We conclude that idiopathic intracranial hypertension causes significant short- and long-term morbidity with no proven effective treatment available. A prospective study is needed to establish the indications for treatment and the efficacy of the treatments used.

[Benign intracranial hypertension: an unrecognized complication of corticosteroid therapy]

BACKGROUND

Benign intracranial hypertension is due to an increased intracranial pressure of unknown cause. The initial symptoms, complications and associations with medical conditions are discussed.

CASE REPORT

A 6-year-old girl developed symptoms of benign intracranial hypertension following reduction of oral corticosteroid therapy. Laboratory studies and head-computed tomographic scan were normal. Examination of the optic discs showed bilateral papilledema and the cerebrospinal fluid pressure was increased. The patient was given prednisone therapy 1 mg/kg daily initially, associated with acetazolamide, and removal of 25 mL of cerebrospinal fluid. All the symptoms resolved and the treatment was gradually decreased. The child developed no further visual failure.

CONCLUSION

Benign intracranial hypertension with the risk of permanent visual loss is a complication underrecognized in children. All patients receiving large doses of the corticosteroids who complain of headache or blurring vision, particularly following a reduction of corticosteroid dosage, should have an ophtalmoscopic examination to exclude this complication.

Optic disc swelling in Crohn's disease

PURPOSE

To provide a review of the causes of optic disc swelling in patients suffering from inflammatory bowel disease.

METHODS

Two illustrative cases of bilateral optic disc swelling are presented: one in a patient known to have Crohn's disease and the other in a patient whose investigations revealed the disease. The possible causes of optic disc swelling in inflammatory bowel disease, based on a literature review, are tabulated and discussed with reference to the presented cases.

RESULTS/CONCLUSIONS

Optic disc swelling is a rare complication of inflammatory bowel disease. Previously reported cases have been attributed to peripapillary inflammation, optic disc ischaemia or intracranial hypertension. Postulated causes of optic nerve ischaemia include a local vasculitis or general hypercoagulability. The underlying aetiology of intracranial hypertension is often elusive. Older studies suggest a relationship between corticosteroid treatment and/or iron deficiency anaemia, while modern imaging emphasises the need to exclude dural venous sinus thrombosis.

Papilloedema, a complication of progressive diaphyseal dysplasia: a series of three case reports

BACKGROUND/AIMS

Progressive diaphyseal dysplasia (PDD) is a rare, autosomal dominant, osteosclerotic dysplasia affecting both endochondrally and intramembranously derived bones. Severely affected patients can develop progressive stenosis of the optic canals and compressive optic neuropathy. Although raised intracranial pressure (ICP) has been described in patients with PDD in whom visual loss has occurred, the elevation of ICP in those patients has been thought to be either non-contributory or only partially responsible for the accompanying visual loss.

METHODS

Three cases were reviewed and the clinical and radiological characteristics are described here.

RESULTS

All three patients had bilateral optic disc swelling with no radiological evidence of either compressive optic neuropathy or thrombosis of the intracranial venous sinuses. The aetiology of the disc swelling was proved to be papilloedema in the first two cases and was probably the dominant cause in the third case.

CONCLUSION

The visual loss documented in at least two of the three patients reported appears to be solely attributable to raised ICP. Normalisation of the ICP has led to an improvement and stabilisation of the visual function in all three patients. Patients with PDD probably require periodic ophthalmic assessments.

Potentially prothrombotic abnormalities of coagulation in benign intracranial hypertension

OBJECTIVE

Benign intracranial hypertension (BIH) may be caused by intracranial venous sinus thrombosis. Cerebral angiograms may, however, be normal in patients with BIH that are associated with conditions with an increased risk of venous thrombosis. This raises the possibility that unrecognised non-occlusive venous thrombus might impede CSF drainage. This study therefore examined the strength of the association between risk factors for thrombosis and BIH.

METHODS

The incidence of prothrombotic abnormalities among a mixed prospectively and retrospectively investigated cohort of 38 patients with BIH, was compared with healthy obese subjects, and patients with other neurological diseases. Prothrombotic abnormalities investigated included anticardiolipin antibodies, lupus anticoagulant, antithrombin III, proteins C and S, plasma fibrinogen, kaolin cephalin clotting time, prothrombin time, and full blood counts.

RESULTS

Evidence for the presence of an antiphospholipid antibody was found in 32% of cases. Cases of familial deficiency of antithrombin III, thrombocytosis, and polycythaemia were also noted. Additionally, an increased concentration of plasma fibrinogen was found in 26%. A coagulation abnormality was more often detectable in those subjects with normal or low body mass index and in those tested within six months of onset.

CONCLUSION

There is a thrombotic pathogenesis in some cases of BIH.

Idiopathic intracranial hypertension

Although the cause of IIH remains obscure, it has become clear that loss of visual function is common and patients may progress to blindness. Diagnosis should adhere to the modified Dandy criteria. Recent case-control studies cast doubt on the validity of many frequently cited conditions associated with IIH. Valid associations include obesity, recent weight gain, female gender, vitamin A intoxication, and steroid withdrawal. IIH patient management should include serial perimetry using a sensitive disease-specific strategy. This is done so the proper therapy can be selected and visual loss prevented or reversed.

Idiopathic intracranial hypertension in children: the Iowa experience

Idiopathic intracranial hypertension is an uncommon condition in children and is seen only about once a year in a large referral hospital. Sex incidence is equal, and obesity is a feature in about one third of patients. This article reviews the 30-year experience in an institution where idiopathic intracranial hypertension in adults has been extensively studied. Symptomatic causes of intracranial hypertension and both medical and surgical therapeutic options are reviewed.

Pseudotumor cerebri associated with corticosteroid withdrawal in inflammatory bowel disease

We treated two patients with Crohn's disease and one patient with ulcerative colitis who developed headache, papilledema, and intracranial hypertension (pseudotumor cerebri) during corticosteroid withdrawal. One had four separate episodes with corticosteroid withdrawal, which suggested a causal relationship. This association between pseudotumor cerebri and corticosteroid withdrawal has been documented in children, but is rare in adults with inflammatory bowel disease.

Benign intracranial hypertension during prednisolone treatment for inflammatory bowel disease

Benign intracranial hypertension (BIH, pseudotumour cerebri) is a rare condition with unknown aetiology although hormonal influences have been implicated. It occurs spontaneously, particularly in young obese women, and is associated with several drug treatments including corticosteroids. Two young adult women are described in whom headache and papilloedema in association with raised intracranial pressure occurred during prednisolone treatment for inflammatory bowel disease. This provides further evidence of the risk of BIH during corticosteroid treatment and has not been described before in adults with this condition. Advice is given to gastroenterologists to use corticosteroids with caution in adults, particularly young, fertile female patients. The treatment of a severe relapse of colitis in a patient who has had one episode of steroid related BIH remains a dilemma.

Pseudotumor cerebri with vision impairment in two children with renal transplantation

The syndrome of pseudotumor cerebri consists of headaches, difficulty with vision and papilledema associated with raised intracranial pressure (ICP) without localizing neurological mass lesions. Recently, an association of pseudotumor cerebri and renal insufficiency, chronic dialysis or renal transplantation has been noted. Loss of vision remains a serious threat in children with pseudotumor cerebri. We report two children who developed pseudotumor cerebri with impairment of vision 5 years after renal transplantation. An awareness of this association should prompt the nephrologist to investigate and treat the symptoms of raised ICP to prevent visual loss.

Pediatric pseudotumor cerebri (idiopathic intracranial hypertension)

This review focuses on the features of pseudotumor cerebri in the pediatric age group. There is no sex predilection in children, and obesity does not appear to be an important factor. Infants and young children may present with irritability, apathy, or somnolence, rather than headache. Dizziness and ataxia may also occur. Papilledema is infrequently noted in pediatric patients if the fontanelles are open or the sutures are split. Pre-adolescents appear more likely than adults or adolescents to have manifestations of their pseudotumor cerebri other than headache and papilledema, including lateral rectus pareses, vertical strabismus, facial paresis, back and neck pain. Among the etiologies that are particularly pertinent to children are tetracycline therapy, malnutrition or renutrition, and the correction of hypothyroidism. Children with pseudotumor cerebri are at risk for visual loss and their visual function must be closely monitored. Surgical intervention is imperative when vision is threatened.

Idiopathic intracranial hypertension: report of seven cases

We describe seven patients with idiopathic intracranial hypertension (IIH), a disorder, mostly in young women, characterized by papilledema, elevated cerebrospinal fluid (CSF) pressure, normal CSF composition, and normal neuroradiologic studies. Obesity, the most consistent etiologic association, was present in two of our patients. Hypothalamic compression in IIH may induce increased appetite and result in weight gain. Use of trimethoprim/sulfamethoxazole has been reported to be associated with IIH and was seen in one of our patients. IIH is an important diagnostic consideration in the differential diagnosis for a patient with headache, visual disturbances, and papilledema.