GRAND ROUND GRAND ROUND

Cc. Headache of 04 months

- globbal,dullaching,inc. in severity

- Sts. awaken her from sleep

- temporal improv’t with analgesics ass’d nausea and vomiting diplopia and blurring of vision of 2 months tinnitus but no dizziness or vertigo

Ctd.Ctd.

no similar history in the past no abnormal body mov’t or weakness of

extremitis no history of fever no chronic cough;no intake of drugs increase 8kg of wt. Over 1yr no chronic illnesses in the past

ctdctd

has regular menses single and lives with her family

P\E

GA:healthy looking

BP=100\80 PR=80 RR=16 BMI=24.7no pallor , NISno LAP

ctdctd

Chest,Cvs,Abdomen/NAD CNS:conscious,oriented to TPP

- language,memory,attention/Intact

-cranial nerves: Normal findings

-Fundoscopy:swollen disc with blurred

disc marigin

-visual acuity:6/6

CNS exam’n ctdCNS exam’n ctd

Visual field-normal by confront’n method motor and sensory :normal findingsr reflexes:2/4 allover plantar-downgoing bilaterally cerebellar signs-absent

summarysummary

24 yrs old female patient with 04 months

history of headache and 02 months history

of visual complaints

Fundoscopy showing evidence of papilledema

Differential DiagnosisDifferential Diagnosis

Intracranial mass

Hydrocephalus

Meningeal process(infectious,inflammatory,

neoplastic)

Inc’d venous press./Cerbral venous thromb.

Idiopathic intracranial HPNm

Lab. ResultsLab. Results

• WBC=4500 Hgb=14.8gm/dl Plt=76000• ESR=45mm/hr serum VDRL-NR• CT scan of brain-Normal CT findings• LP-opening press. >300mm of water

clear CSF

No cell,glucose 70mg/dl,protein0.2gm/l

CSF VDRL-NR,gram s.and AFB-No organism.

Idiopathic intracranial HPNIdiopathic intracranial HPN

also called pseudotumor cerebri,benign ICHa disorder of unknown etiologyprimary problem is chronically inc. ICPmost important neurologic manifestation is

papilledema

PathophysiologyPathophysiology

Unclear multiple studies with conflicting results some of proposed mechanisms

increased CSF production;decd. absorp’n

cerebral edema

elevated cerebral venous pressure role of obesity

FrequencyFrequency

variable from country to country Annual incidence at Mayo clinic(1976-90)

0.9/100000 pop’n 1.6/100000 women

3.3/100000 females aged 15-44 yrs

7.9/100000 obese women aged 15-44 yrs F:M=8:1

obese women of child bearing age

Clinical FindingsClinical Findings

Symptoms of increased ICP -headache,pulsatile tinnitus,diplopia symptoms of papilledema -transient visual obscursions,progressive

-loss of vision,blurring of vision

-sudden visual loss There are pts. with IIH without papilledema -In one study of 65 adults with refractory migrane,12(18% had IIH without papilledema

Cont’dCont’d

Visual function testing -fundoscopy,visual field,visual acuity

-color vision,ocular motility characteristics,Sxs,Sns in pts. with IIH - pt. Characterstics - symptoms female(65-95%) Headache(75-99%) Age peak:21-34yrs Visual dist.(30-68%) obesity (44-94%) diplopia (20-38%) Intracranial noises(0-80%)

Cont’dCont’d

Signs - papilledema(98-100%) -VF defects (3-51%)

- abducent palsy(14-35%) -Dec’d VA (2-25%)

Risk Factors

Conditions Endocrine diseases female sex Addisons disease Reproductive age gp. Cushing’s disease Obesity Hypoparathyroidism

Recent weight gain Hypothyroidism

Risk Factors cont’dRisk Factors cont’d

Miscellaneous diseases

CRF,SLE,Anemia,Hypervitaminosis A,Dural AV malf.

Medications - Multivitamines(vit. A),steroids and steroid withdrwal

TTC,sulfa Abics.,cimetidine,naldixic acid,nitrofurantoin

amiodarone,tamoxifen,cyclosporine,lithium carbonate

DiagnosisDiagnosis

a dignosis of exclusion Based on modified Dandy criteria 1.signs and symptoms of raised ICP

2.No localizing neurologic signs,in an alert patient, other than abducens n. palsy 3.Normal neuroimaging studies,except for small ventricles and empty sella 4.Documented inc’d opening pressure(>250mm of water) but normal CSF composition 5.Primary structural or systemic causes of elevated intracranial venous sinus pressure excludedM

Diagnosis cont’dDiagnosis cont’d

Neuroimaging - for structural abns. or mass lesions

- Brain MRI with gadolinium enhancement

- MRI venography,CT scan LP Orbital ultrasonography Other lab tests

- CBC,ESR,ACLA,ANA,Full procoagulant profile

TreatmentTreatment

Joint Mx with ophthalmologist and neurologist Treatment goals to detect and prevent visual loss to reduce ICP to relieve headache Medical and surgical options

Medical therapyMedical therapy

Treatment of associated condition

- withdrawal of offending agent

- treatment of obesity

as low as 6%loss of wt. results in dec’d ICP and papilledema

Diuretics - Acetazolamide-first line medical therapy

-250mg po qid or 500mg po bid

- Loop diuretics,Eg. Furesemide: as an adjunct to acetazolamide

Medical therapy cont’dMedical therapy cont’d

Corticosteroids

-rapidly lower ICP

-long term use not recommended

-for patients who continue to have visual loss

Repeated LP

-in patients with infrequent exacerbations of symptoms

Surgical therapySurgical therapy

When visual function is severly impaired To those with incapacitating headache Options

-optic nerve sheath decompression (fenestration)

-lumboperitoneal or ventriculoperitoneal shunting

PrognosisPrognosis

Encouraging in early intervetionPrognosis for visual loss,varied in d/f series

-studies of 1960’s and 1970’s ,<25% of pts. Had significant blindness

-recent study ,visual dysfunction in close to ½ of patients