Long-term visual outcome in idiopathic intracranial hypertension

Idiopathic intracranial hypertension in Asians: a retrospective dual-center study

BACKGROUND

There have been limited data on idiopathic intracranial hypertension (IIH) in Asians and there remain uncertainties whether a cerebrospinal fluid (CSF) pressure of 250 mm CSF is an optimum diagnostic cutoff. The aims of the present study included (1) characterization of IIH patients in Taiwan, (2) comparisons among different diagnostic criteria for IIH, and (3) comparisons between patients with CSF pressures of > 250 and 200-250 mm CSF.

METHODS

This retrospective study involved IIH patients based on the modified Dandy criteria from two tertiary medical centers in Taiwan. Clinical manifestations were retrieved from electronic medical records, and findings on ophthalmologic examination and magnetic resonance images (MRIs) were reviewed.

RESULTS

A total of 102 patients (71 F/31 M, mean age 33.4 ± 12.2 years, mean CSF pressure 282.5 ± 74.5 mm CSF) were identified, including 46 (45.1%) with obesity (body-mass index ≥ 27.5), and 57 (62.6%) with papilledema. Overall, 80 (78.4%), 55 (53.9%), 51 (50.0%), and 58 (56.9%) patients met the Second and Third Edition of International Classification of Headache Disorders, Friedman, and Korsbæk criteria, respectively. Patients in the 200-250 mm CSF group (n = 40) were less likely to have papilledema (48.5% vs. 70.7%, p = 0.035), transient visual obscuration (12.5% vs. 33.9%, p = 0.005), and horizontal diplopia (10.0% vs. 30.6%, p = 0.006), and had fewer signs on MRIs (2.2 ± 1.3 vs. 2.8 ± 1.0, p = 0.021) when compared with those with CSF pressures > 250 mm CSF (n = 62). However, the percentages of patients with headache (95.0% vs. 87.1%, p = 0.109) at baseline, chronic migraine at six months (31.6% vs. 25.0%, p = 0.578), and visual field defect (86.7% vs. 90.3%, p = 0.709) were similar.

CONCLUSIONS

It was found that obesity and papilledema were less common in Asian IIH patients when compared with Caucasian patients. Although patients with CSF pressures of 200-250 mm CSF had a less severe phenotype, the risks of having headache or visual loss were comparable to those in the > 250 mm CSF group. It is possible that a diagnostic cutoff of > 200 mm CSF could be more suitable for Asians, although further studies are still needed.

Clinical Characteristics of Idiopathic Intracranial Hypertension in Older Adults

BACKGROUND

Idiopathic intracranial hypertension (IIH) is a condition that classically affects obese women of child-bearing age. However, it is sometimes encountered in older patients. The purpose of this study was to help clinicians better understand how this disease can present differently in these age groups.

METHODS

This is a retrospective chart review from a single academic center of baseline characteristics of adult patients diagnosed with IIH based on the modified Dandy criteria. The patients were divided into 2 groups: (1) those 18-44 years old and (2) those older than 45 years at diagnosis.

RESULTS

One hundred sixty-seven patients were identified; 135 in the younger group and 32 in the older group. The younger group had a higher rate of headaches (90% vs 63%, P = 0.0004), higher body mass index (38.9 vs 36.1, P = 0.046), higher opening pressure (38 vs 31 cm H2O, P = 0.005), and thicker peripapillary retinal nerve fiber layer average thickness (right eye 178 vs 131 μm, P = 0.02; left eye 184 vs 136 μm, P = 0.045). The older group had higher rates of empty sella (90% vs 62%, P = 0.0039). In addition in the younger group, there was a trend toward higher rates of pulsatile tinnitus (63% vs 45%, P = 0.08), transient visual obscurations (50% vs 32%, P = 0.07), and lower rates of spontaneous cerebrospinal fluid leak (4% vs 13%, P = 0.08). Sex, rates of obesity, other MRI findings typical of elevated intracranial pressure, frequency and Frisen grading of papilledema, and visual field loss were not statistically different between the groups.

CONCLUSIONS

The older age group had milder signs and symptoms of IIH and a higher prevalence of empty sella than the younger group, but otherwise had typical characteristics. These findings suggest that IIH in the older age group may represent milder chronic disease that was previously undiagnosed.

The idiopathic intracranial hypertension prospective cohort study: evaluation of prognostic factors and outcomes

BACKGROUND

There are limited longitudinal data evaluating outcomes in idiopathic intracranial hypertension (IIH). We aimed to evaluate the long-term outcomes in a real-world cohort of patients with IIH and sought to establish the prognostic factors.

METHODS

A longitudinal prospective cohort study was conducted over 9 years (2012-2021). Data included demographics and disease status. All consenting patients with IIH were recruited. Visual outcomes included visual acuity, Humphrey visual field and optical coherence tomography (OCT) imaging measurements. Headache frequency, severity, and impact were noted. We analysed the key variables impacting visual and headache outcomes.

RESULTS

The cohort contained 490 patients with a confirmed IIH diagnosis. 98% were female with a mean body mass index (BMI) of 38 kg/m². Those with the highest OCT retinal nerve fibre layer had the worst visual outcomes. We noted a delayed decline, in the visual field and OCT ganglion cell layer after 12 months. In the medically managed cohort (n = 426), we found that disease duration and change in BMI had the greatest influence on visual outcomes. There was a high burden of headache, with a daily headache at presentation and prior migraine history influencing long-term headache prognosis.

CONCLUSIONS

There is a delayed decline in visual outcomes in those with the most severe papilloedema. Disease duration and change in BMI were the key visual prognostic factors, therefore those with the more acute disease may require closer monitoring. Improving prognosis in IIH should focus on the potentially modifiable factor of weight management.

Efficacy of Dural Sinus Quantitative Measurements in Idiopathic Intracranial Hypertension : A Practical Diagnostic Feature

BACKGROUND AND PURPOSE

This study aimed to investigate the potential contribution of quantitative measurements of dural venous sinuses to the diagnosis of idiopathic intracranial hypertension (IIH) and the relationship between IIH and dural venous sinus dimensions on 3D post-gadolinium T1-weighted magnetic resonance (MR) images.

MATERIAL AND METHODS

A total of 129 individuals (57 IIH patients and 72 controls) who complained of headache and underwent both magnetic resonance venography (MRV) and precontrast/postcontrast 3D T1-weighted MR imaging between 2018 and 2021 were included in this retrospective study. Dural venous sinus and jugular vein diameters were measured in all cases using post-gadolinium 3D T1 TFE images. The presence of transverse sinus (TS) hypoplasia and occipital sinus variation, the number and size of arachnoid granulations in the TS, and the presence of brain parenchymal herniation were also evaluated. Cut-off values that maximized accurate diagnosis of IIH were established on the receiver operating characteristic curve. The sensitivity and specificity of the diagnosis of IIH based on quantitative measurements of the dural sinus were calculated.

RESULTS

The ratios of the maximum to minimum TS diameters and the minimum TS diameters to minimum sigmoid sinus (SS) diameters were significantly higher in IIH patients than in the control group (p < 0.001). The diagnostic sensitivity and specificity values of TS_max/TS_min and TS_{min sum}/SS_{min sum} parameters for the detection of IIH were 84.2%, 84.7% and 83.3%, 84.2%, respectively.

CONCLUSION

Practical measurements from multiplanar T1 sequences can be useful for both quantitative assessment and overcoming misinterpretation due to anatomical variation.

Interventional and surgical management of internal jugular venous stenosis: a narrative review

BACKGROUND

A small subset of patients with presumed idiopathic intracranial hypertension are found to have isolated internal jugular vein stenosis (IJVS).

OBJECTIVE

To review the current interventions used in patients who present with intracranial hypertension secondary to IJVS.

METHODS

In December 2020, we performed a literature search on Pubmed/Medline and Scopus databases for original articles studying surgical and endovascular interventions used for intracranial hypertension in the setting of internal jugular vein stenosis. No date, patient population, or study type was excluded.

RESULTS

All studies that included at least one case in which a surgical or endovascular intervention was used to treat IJVS were included. Selection criteria for patients varied, most commonly defined by identification of compression of the internal jugular vein. The 17 studies included in this review ranged from case reports to large single-center cohort studies. The most used surgical intervention was styloidectomy. Styloidectomy had an overall better outcome success rate (79%) than angioplasty/stenting (66%). No complications were recorded in any of the surgical cases analyzed. Outcome measures varied, but all studies recorded clinical symptoms of the patients.

CONCLUSION

Few current large cohort studies analyze surgical and endovascular interventions for patients with IJVS. Notably, the most common intervention is styloidectomy, followed by internal jugular vein stenting. By understanding the trends and experience of interventionalists and surgeons, more focused and larger studies can be performed to determine effective strategies with the best clinical outcomes.

Extent of transverse sinus stenosis does not predict visual outcomes in idiopathic intracranial hypertension

BACKGROUND

We aimed to investigate whether the degree of transverse sinus stenosis (TSS) on magnetic resonance venography (MRV) can predict visual outcomes in patients with idiopathic intracranial hypertension (IIH).

METHODS

A chart review identified IIH patients followed for at least 6 months. Mean deviation (MD) on visual field (VF) testing at initial and last follow-up visits, best corrected visual acuity (BCVA), patients' age, body mass index, and lumbar puncture opening pressure were recorded. MRV was used to grade TSS on a scale of 0-8 using the grading scheme proposed by Farb et al., whereby a lower score indicates a greater degree of stenosis. Linear regression analysis was used to test for association between above variables and MD on VF, including change in MD over time.

RESULTS

44 female patients were followed for a median of 26 months. All patients had unilateral or bilateral TSS on MRV. The median TSS score was 3/8. The median BCVA was 0.06 logMAR at baseline. The median VF MD was -3.02 dB at baseline and -1.96 dB at final follow-up. There was no significant association between the degree of TSS and either baseline MD (P-value = 0.34) or the change in MD on VF over the course of follow-up (P-value = 0.54). Baseline BCVA (P = 0.045) and baseline MD (P < 0.001) were the only significant predictors of changes in MD on VF over follow-up.

CONCLUSIONS

Baseline BCVA and MD on VF were the only significant predictors of visual outcome in IIH patients. While all patients demonstrated TSS on MRV, the degree of TSS did not correlate with visual prognosis.

Idiopathic Intracranial Hypertension and Multiple Sclerosis

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

Vision treatment strategy for acute blindness in adolescent female with diffuse leptomeningeal glioneuronal tumor

Diffuse leptomeningeal glioneuronal tumor with the first symptom of acute rapid blindness in both eyes are rare in adolescents. We present a case of an adolescent female without a history of cancer who developed a dramatic loss of vision and eventually blindness, and was diagnosed as diffuse leptomeningeal glioneuronal tumor by cerebrospinal fluid cytology and enhanced MRI. In order to save vision, under the condition of ineffective dehydration treatment, timely emergency surgery to implant Ommaya sac drainage cerebrospinal fluid. According to the pathophysiological mechanism of cerebral edema, we added Edaravone to scavenge oxygen free radicals, Alprostadil to improve microcirculation, Monosialotetrahexosylganglioside nutrient nerve, Butylphthalide to promote collateral circulation, combined with hyperbaric oxygen and acupoint injection of Anisodine. Finally, the patient's vision returned to normal. Conclusion: when dehydration treatment is ineffective, timely surgery to reduce intracranial pressure, combined with comprehensive treatment, can effectively save vision.

Long-Term Follow-up of Pseudotumor Cerebri Syndrome in Prepubertal Children, Adolescents, and Adults

PURPOSE

Pseudotumor cerebri syndrome can have a recurrent course. We compared the long-term disease course, recurrences, and final visual outcomes in prepubertal children, adolescents, and adults.

METHODS

In this retrospective observational study, patients were divided into prepubertal children (group A) adolescents (group B), and adults (group C).

RESULTS

Sixty-five patients (56 females, nine males) were included, 26.2% in group A, 24.6% in group B, and 49.2% in group C. Age at diagnosis was 8.6 ± 2.0 years, 14.3 ± 1.5 years, and 31.9 ± 9.7 years for the prepubertal children, adolescents, and adults, respectively. Medical treatment duration was similar (2.4 to 3.3 years, P > 0.05). Recurrences were observed in 23.5% of prepubertal children, 50% of adolescents, and 28.1% of adults. Recurrences occurred within 1.3 ± 0.6 years from treatment cessation in the prepubertal group compared with 3.8 ± 5.1 years in adolescents and 2.7 ± 2.0 years in adults (P = 0.267). Optic neuropathy was evident in 41% of group A, 31% of group B, and 87.5% of group C (P < 0.001). Obesity and cerebrospinal fluid opening pressures were unassociated with either relapsing rates or final visual outcomes in all groups.

CONCLUSIONS

Pseudotumor cerebri syndrome exhibits a relapsing course in a third of cases. Recurrences tend to occur within one year after treatment cessation in prepubertal children, and within three years in older patients, revealing the importance of longer follow-up, especially in adults. Optic neuropathy was more common in adults along with a tendency for visual decline. Longer treatment times were associated with fewer recurrences.

Headaches Due to Low and High Intracranial Pressure

PURPOSE OF REVIEW

Headache disorders attributed to low and high intracranial pressure are commonly encountered in specialty headache practices and may occur more frequently than realized. While the headaches resulting from intracranial pressure disorders have what are conventionally thought of as defining characteristics, a substantial minority of patients do not manifest the "typical" features. Moreover, patients with intracranial pressure disorders may also have a preexisting primary headache disorder. Heightening the complexity of the presentation, the headaches of intracranial pressure disorders can resemble the phenotype of a primary disorder. Lastly, patients with so-called intracranial "hypotension" often have normal CSF pressure and neuroimaging studies. Thus, a high index of suspicion is needed. The published literature has inherent bias as many types of specialists evaluate and treat these conditions. This article reviews the key points to emphasize the history, examination, and laboratory evaluation of patients with intracranial pressure disorders from a neurologist's perspective.

RECENT FINDINGS

Lumbar puncture opening pressure in patients with spontaneous intracranial hypotension was low enough to meet diagnostic criteria (≤60 mm CSF) in only 34% of patients in one study. Most patients had an opening pressure in the low normal to normal range, and 5% had an opening pressure of 200 mm CSF or more. Diskogenic microspurs are a common cause of this syndrome. The Idiopathic Intracranial Hypertension Treatment Trial found that most participants had a headache phenotype resembling migraine or tension-type headache. No "typical" or characteristic headache phenotype was found, and headache-related disability was severe at baseline. Headache disability did not correlate with the lumbar puncture opening pressure at baseline or at the 6-month primary outcome period. Although participants who were randomly assigned to acetazolamide had a lower mean CSF opening pressure at 6 months, headache disability in that group was similar to the group who received placebo.

SUMMARY

Significant overlap is seen in the symptoms of high and low CSF pressure disorders and in those of primary headache disorders. Neurologists are frequently challenged by patients with headaches who lack the typical clinical signs or imaging features of the pseudotumor cerebri syndrome or spontaneous intracranial hypotension. Even when characteristic symptoms and signs are initially present, the typical features of both syndromes tend to lessen or resolve over time; consider these diagnoses in patients with long-standing "chronic migraine" who do not improve with conventional headache treatment. While the diagnostic criteria for pseudotumor cerebri syndrome accurately identify most patients with the disorder, at least 25% of patients with spontaneous intracranial hypotension have normal imaging and over half have a normal lumbar puncture opening pressure. Detailed history taking will often give clues that suggest a CSF pressure disorder. That said, misdiagnosis can lead to significant patient morbidity and inappropriate therapy.

Pattern of Idiopathic Intracranial Hypertension in Indian Population

Objective

To evaluate the clinical and demographic profile, laboratory parameters and outcomes of Idiopathic Intracranial hypertension (IIH) patients from Indian subpopulation.

Materials and method

We did a prospective study on patients who fulfilled the revised diagnostic criteria for Primary pseudotumor cerebri syndrome in adults and children, proposed by Friedman et al in 2013. All patients were examined for BMI, papilloedema, extraocular muscle movement, opening CSF pressure and underwent MRI, MR venography of brain and perimetry. Patients were followed up for a minimum period of 6 months, upto 2 years, with the outcomes monitored being visual acuity, visual field, headache, diplopia and optic disc changes.

Results

We evaluated 33 patients (31 female and 2 male). 25 patients had BMI less than 25. Commonest clinical presentation was headache. 7 patients showed normal CSF opening pressure. The most common MRI finding was flattening of posterior aspect of globe and was found in 90.90% (30). 25 patients showed either unilateral or bilateral transverse sinus stenosis. Most common finding in perimetry was enlarged blind spot. 4 patients recovered spontaneously and rests were treated with acetazolamide (1gm/day). All showed favorable outcome when followed up.

Conclusion

Obesity may not be a dominant risk factor for development of IIH in the Indian subcontinent. Non obese IIH have better prognosis and tend to have a good response to medical management alone.

Trigeminal Hyperexcitability in Idiopathic Intracranial Hypertension: A Blink Reflex Study

PURPOSE

To compare blink reflex examination findings in patients with idiopathic intracranial hypertension (IIH) with migraineurs and controls and to investigate the role of blink reflex data in the follow-up by evaluating their relationship with clinical symptoms.

METHODS

We included 23 patients with IIH, 15 migraineurs, and 16 controls. Blink reflex was studied with bilateral paired stimulations, and the 2R2/1R2 and 2R2c/1R2c area ratios, 1R2, 2R2, 1R2c, and 2R2c latencies were compared (R2:ipsilateral R2 response, R2c:contralateral R2 response).

RESULTS

2R2/1R2 area ratios at 200, 300, and 500 ms interstimulus intervals were significantly higher in the IIH group compared with the controls, and significantly higher 2R2/1R2 area ratio at 200 ms interstimulus interval was also detected in the IIH group compared with the migraine group. Significantly shorter 2R2 latencies were found at 500 and 800 ms interstimulus intervals in IIH group compared with the migraine group and controls. Significantly higher 2R2/1R2 area ratios at 500, 800 ms, and 2R2c/1R2c area ratios at 300, 500, and 800 ms were detected in patients with IIH in remission compared with patients with attacks.

CONCLUSIONS

The significant increase in R2 recovery rates in patients with IIH in remission suggests that there is an increased excitability in the trigeminal pathways. Our findings may provide a new perspective for IIH mechanism related to trigeminal hyperexcitability and evaluating new management strategies.

Living with Hypertension: A Qualitative Research

BACKGROUND

Hypertension affects many aspects of the patients' life. Factors such as attitudes, beliefs and experiences, and social and cultural conditions of patients have effective roles in hypertension treatment process. The aim of this research was to explore perspectives and experiences of patients with hypertension while living with this disease.

METHODS

This is a qualitative research using content analysis approach. 27 hypertensive patients who referred to hospitals affiliated to Tehran University of Medical Sciences were selected based on purposive sampling, and semi-structured interviews were carried out. Graneheim and Lundman's approach was used for analysis of data and Lincoln and Guba's criteria were used to confirm the trustworthiness of the study's findings.

RESULTS

Experiences of the participants were divided into three main categories as follows: (1) disease shadow; (2) dual understanding of the effect of drug therapy consisting of two sub-categories known as ''perceived benefits,'' ''negative consequences''; and (3) facing the disease that includes the two subcategories of ''Compatibility'' and ''Negligence and denial''.

CONCLUSION

Based on the findings, patients with hypertension had experienced many physical, psychological, social, familial and spiritual problems due to the disease and their cultural context. These patients obtained positive experiences following the compatibility with hypertension. Comprehensive planning tailored to the cultural, social context and their beliefs is necessary to solve problems in these patients.

Acetazolamide lowers intracranial pressure and modulates the cerebrospinal fluid secretion pathway in healthy rats

Acetazolamide is one of the most widely used drugs for lowering intracranial pressure (ICP) and is believed to reduce cerebrospinal fluid (CSF) secretion via its action on the choroid plexus (CP). In the CP the main driving force for CSF secretion is primarily active transport of Na⁺ ions facilitated by the Na/K ATPase. Transmembrane water channels, known as aquaporins (AQP), are also present in the CP and play an important role in the movement of water. In the present study, we investigated the effect of a single dose acetazolamide on the activity of the Na/K ATPase and ICP. Furthermore, we investigated the expression of Na/K ATPase, AQP1 and AQP4 in the CP tissue following acetazolamide treatment. 12 female Sprague Dawley rats were randomized into two groups; one group received 200mg acetazolamide and the other vehicle treatment. All animals were subjected to ICP recordings and the CP tissue was collected for qPCR and western blot analysis. The effect of acetazolamide on the Na/K ATPase activity was evaluated in an in vitro assay of primary CP epithelial cells isolated from rats. Acetazolamide significantly lowered ICP within 10min of injection compared to the vehicle group (P<0.05), reaching a maximum reduction at 55min 66±4% (P<0.00001). Acetazolamide also significantly decreased the activity of the Na/K ATPase in CP epithelial cells compared to vehicle (P=0.0022). Acetazolamide did not change the AQP1, AQP4 or Na/K ATPase mRNA content in the CP tissue. However, we did record an increase in the amount of AQP1 (p=0.0152) and Na/K ATPase (p=0.0411) protein in the membrane fraction of the CP, but not AQP4 (p=0.0649). A single dose of acetazolamide lowers ICP and modulates the CSF secretion pathway in healthy rats - Firstly, by inhibiting the Na/K ATPase to slow the CSF production, secondly, by increasing AQP1 and Na/K ATPase protein in the membrane of the CP epithelial cells.

Idiopathic Intracranial Hypertension – Pathophysiology Based on Case Series

According to the definition, idiopathic intracranial hypertension (IIH) is a pathological state characterized by an increase in intracranial pressure; however, there are no obvious intracranial pathological processes. The pathophysiology of this disorder is not clear, although there are many reports related to it.

We present an overview of possible etiopathogenetic mechanisms, clinical presentations and therapeutic interventions from a series of patients hospitalized with the clinical picture and final diagnosis of idiopathic intracranial hypertension (IIH). All data were collected from the moment of IIH diagnosis as well as three months later.

The obtained data showed that IIH is a disease that primarily affects obese women in early and midlife. The positive correlation between values of cerebrospinal fluid pressure and body mass index was observed. The disorders of sexual hormones were identified as a possible etiology for IIH female patients. Headache, papilloedema, decreased visual acuity, vertigo and cranial nerve palsy were identified as the most prevalent IIH clinical presentations. The existence of stenosis and hypoplasia of the sigmoid and transverse sinus were confirmed only in one third of IIH patients. Pharmacotherapy combined with weight loss was efficacious in a large number of patients. In this series, there were no short-term consequences of IIH.

The results suggest the importance of early and accurate looking for IIH in obese early and midlife women with any hormonal imbalances having a variety of neurological expression, mostly presented as headaches and visual disturbances. Early detection of IIH might influence the timely treatment and prevent far-reaching and severe clinical consequences.

Increased Prevalence of Optic Disc Drusen after Papilloedema from Idiopathic Intracranial Hypertension: On the Possible Formation of Optic Disc Drusen

This is a 25-year observational retrospective review of 372 consecutive participants with optic disc drusen or resolved papilloedema from idiopathic intracranial hypertension. The prevalence of optic disc drusen at 19% among eyes with resolved papilloedema was approximately 10 times higher and significantly increased (p < 0.001) as compared with the occurrence in the general population. Eyes with both resolved papilloedema and optic disc drusen had similar visual acuity and visual field outcome as compared with resolved papilloedema alone. Eyes with exposed drusen had significantly worse visual acuity and visual field outcome (p < 0.001) than buried drusen. The high prevalence of optic disc drusen after papilloedema has resolved suggests a non-coincidental relationship. Optic disc drusen formation can be a sequela of papilloedema.

Neurogenic vision loss: Causes and outcome. An experience from a tertiary center in Northern India

INTRODUCTION

Vision loss can be a consequence of numerous disorders of eye and neural pathway conveying visual input to brain. A variety of conditions can affect visual pathway producing neurogenic vision loss. The presentation and course of vision loss depends on the site of involvement and underlying etiology. We conducted this unprecedented study to evaluate the characteristics and outcome of various diseases of the visual pathway.

MATERIALS AND METHODS

In this prospective cohort study, we evaluated 64 patients with neurogenic visual impairment. Ophthalmological causes were excluded in all of them. Their presentation, ophthalmological characteristics and investigation findings were recorded. These patients were followed up till 6 months.

RESULTS

Out of 69 patients evaluated, 5 were excluded as they had ophthalmological abnormalities. The remaining 64 cases (113 eyes) were enrolled. 54 cases were due to diseases of anterior visual pathway and rest 10 had cortical vision loss. The etiologic distribution is as follows: Isolated optic neuritis- 12 (19%), multiple sclerosis- 4 (6.3%), neuromyelitis optica- 5 (7.9%), tubercular meningitis- 15 (23.8%), non-arteritic ischemic optic neuropathy, ischemic optic neuropathy complicating cavernous sinus thrombosis, cryptococcal meningitis, malignant infiltration of optic nerve, Crouzon's syndrome, calvarial thickening and traumatic occipital gliosis- 1 (1.6%) case each, idiopathic intracranial hypertension, pituitary adenoma, acute disseminated encephalomyelitis, posterior reversible leukoencephalopathy- 3 (4.8%) cases each, cortical venous thrombosis 5 (7.9%), subacute scleroing panencephalitis- 4 (6.3%) cases.

CONCLUSIONS

The diseases of anterior visual pathway were much more common than cortical vision loss. A majority of our patients had severe impairment of vision at presentation.

Idiopathic intracranial hypertension

Background

Idiopathic intracranial hypertension or pseudotumour cerebri is primarily a disorder of young obese women characterised by symptoms and signs associated with raised intracranial pressure in the absence of a space-occupying lesion or other identifiable cause.

Summary

The overall incidence of idiopathic intracranial hypertension is approximately two per 100,000, but is considerably higher among obese individuals and, given the global obesity epidemic, is likely to rise further. The pathophysiology of this condition is poorly understood, but most theories focus on the presence of intracranial venous hypertension and/or increased cerebrospinal fluid outflow resistance and how this relates to obesity. A lack of randomised clinical trials has resulted in unsatisfactory treatment guidelines and although weight loss is important, especially when used in conjunction with drugs that reduce cerebrospinal fluid production, resistant cases remain difficult to manage and patients invariably undergo neurosurgical shunting procedures. The use of transverse cerebral sinus stenting remains contentious and long-term benefits are yet to be determined.

Conclusion

An understanding of the clinical features, diagnostic work-up and therapeutic options available for patients with idiopathic intracranial hypertension is important both for neurologists and ophthalmologists as visual loss maybe permanent if untreated.