Fall 2014: Week 8: Neuro: Papilledema

Question 1

Signs to look for ONH Edema

1. What are the 2 things to look for to tell if there is ONH Edema?
2. Other signs?

Answer 1

1. a. Is nerve elevated
   b. Edema surrounding the RNFL
2. Indistinct borders; Hyperemia of ON; Vessel Obscuration; Dilated/Engorged Vessels; Flame HEMES; Lack of SVP; High Water Marks; Circumferential Retinal Folds around the Disc (PATON’s LINES)

Question 2

1. Are Optic Disc Edema or Optic Atrophy a DIAGNOSIS?

Answer 2

1. NO! They’re Findings!

Question 3

History

1. Ophthalmic Symptoms?
2. Neurologic

Answer 3

1. Blurred vision; Transient Vision; Photopsia; Double Vision; Change in Color vision perception
2. HAs; Pulsatile Tinnitus; Paresthesia or weakness; Personality Changes; Loss of Consciousness; Nausea; Nuchal Rigidity

Question 4

Papilledema

1. Define
2. Optic Nerve Sheaths are an Extension of what that surrounds the brain?
3. CSF if found where?
4. If CSF pressure increases in the brain, what does it do?

Answer 4

1. Optic Nerve SWELLING due to PROVEN ELEVATED ICP!
2. of the DURA
3. in the Subarachnoid Spaces of the ON sheaths and of the brain
4. Increases pressure in the nerve sheaths on the ONs.

Question 5

CSF

1. Made in what?
2. Path thru brain?
3. Reabsorbed by what?

Answer 5

1. Choroid Plexus
2. Lateral Ventricles –> 3rd Ventricle –>(Sylvian aqueduct) 4th Ventricle –> Brain and Spinal Cord
3. Cerebral Venous Drainage System

Question 6

Pressure Gradient

1. Is pressure in the eye usually higher than pressure in the brain?
   a. Purpose?
   b. What happens when pressure in the brain goes up?

Answer 6

1. YES
   a. Keeps flow of Axoplasmic Material going towards the Brain (ORTHOGRADE)

b. Get a Reversal of the Pressure gradient and the AXOPLASMIC MATERIAL BACKS UP INTO THE EYE!

Question 7

Early Papilledema

1. “Sick”
   a. Optic Nerve Fibers?
   b. ONH looks how?
   c. VA?
   d. VF?
   e. Can it be reversed?
2. Chronic Papilledema (“Dead”)
   a. Due to what?
   b. Optic Nerve function?
   c. Pallor?
   d. VA?
   e. VF?
   f. Reversible?

Answer 7

1. They still work ok.
   b. Looks HYPEREMIC
   c. NORMAL
   d. Enlarged Blind Spots
   e. Yes
2. a. Chronic or severely elevated ICP
   b. Dead…
   c. Increased
   d. Reduced
   e. RNFL Pattern Defects, Diffuse Constriction
   f. NOPE

Question 8

Papilledema: SYMPTOMS

1. HAs:
   a. When are they worse?
   b. They Intensify when?
2. Transient Visual Obscurations
   a. How long do they last?
   b. U/L or B/L?
   c. How often do they occur?
3. What other two symptoms?

Answer 8

1. a. Morning, and can wake Pt from thier sleep.
   b. When bending over or w/Valsalva
2. a. a couple of seconds
   b. Either
   c. rarely or several times a day
3. Nausea and vomiting; Diplopia (Horizontal due to a CN6 palsy)

Question 9

Causes of Papilledema

1. 7 of them

Answer 9

1. Chiari Malformation
2. Hydrocephalus
3. Idiopathic Intracranial Hypertension
4. Infection (Meningitis)
5. Malignant Hypertension
6. Space Occupying Lesion
7. Venous Sinus Thrombosis

Question 10

Papilledema: Malignant Hypertension

1. Systolic?
2. Diastolic?
3. Other signs?

Answer 10

1. > 200 mmHg
2. > 130 mmHg
3. Hemes, CWS, Hard Exudates, Macular Edema

Question 11

Papilledema: Space Occupying Lesion

1. Mass Lesions?
2. Cerebral Hemorrhage

Answer 11

1. ~1/4 of Pts w/Brian Tumors present w/Papilledema

2. Terson Syndrome

Question 12

Papilledema: Space Occupying Lesion: Terson Syndrome

1. What is it?
2. Mechanism?

Answer 12

1. Subarachnoid Heme + Intraocular Heme
2. Severe, Sudden rise in ICP causes an ACUTE DECREASE in Venous Drainage from the Retina, causing VENOUS STASIS and Intraocular Hemorrhaging

Question 13

Dural Venous Sinus Thrombosis

1. Mechanism?
2. causes (3)
3. Diagnosis?
4. Tx?

Answer 13

1. Obstruction of 1 of the Major dural venous sinuses by a CLOT causes decreased drainage of CSF from the Subarachnoid Space
2. Hypercoagulable Conditions, Infections, Neoplasm
3. MRV
4. Urgent Anticoagulation Therapy, Tx of the underlying Cause

Question 14

Papilledema: Meningitis

1. Acute or Chronic?
2. Causes? (5)
3. Symptoms? (3)
4. MRI?
5. LP?
6. Tx?
   a. Infectious?
   b. Carcinomatous?

Answer 14

1. Either
2. Bacterial, Carcinomatous, Fungal, Lyme, or Viral
3. Fever, HA, Nuchal Rigidity
4. Meningeal Enhancement
5. CSF Analysis
6. a. High-Dose IV Abs + Surgical procedures to decrease ICP
   b. Radiotherapy or Chemotherapy
   * Pt can present w/HA, Altered Mental Status, Phonophobia/Photophobia, Stiffness in the Neck, High Fever, Muscus membranes (Petechiae)

Question 15

Papilledema: Hydrocephalus

1. What is it?
2. Congenital or acquired?

Answer 15

1. Obstruction to normal Flow of CSF w/in the Cranial Cavity

2. Either (Expansion of the skull occurs in infants)

Question 16

Papilledema: Chiari Malformation

1. What is it?

Answer 16

1. Congenital. Anatomic Anomalies of the Cerebellum, Brainstem, Craniocervical Junction, with Downward Displacement of the Cerebellum (thru the Foramen Magnum)

Question 17

Foster Kennedy Syndrome

1. What is seen?
2. Main cause?
3. Pseudo-Foster Kennedy Syndrome: OTher causes?

Answer 17

1. Disc Pallor in one eye and Papilledema in the OTHER EYE (Dead nerve can’t Swell!)
2. Frontal Lobe Tumor compressing Ipsilateral ON AND INCREASING ICP causing Papilledema in the CONTRALATERAL EYE
3. Old NAION in one eye and ACUTE NAION in the other eye

Question 18

Management of Papilledema

1. Malignant Hypertension
2. B/L Swollen Nerves:?

Answer 18

1. Urgent referral to ER
2. Urgent referral to a Neuro-Ophthalmologist or;
   a. Urgent MRI/MRV
   b. LP if MRI/MRV are normal
   c. Blood tests/Chest x-ray if necessary

Question 19

Lumbar Puncture

1. Measure Opening Pressure
   a. Normal?
2. Check CSF for what?
3. Temporarily therapeutic: why?

Answer 19

1. a. 100 mmH20 -250mmH20
2. for infection or malignancy
3. Lowers ICP

Question 20

Idiopathic Intracranial Hypertension

1. Usually found in whom?

Answer 20

1. Obese Females and of child bearing age (90%)
   * Often associated w/HAs (94%)

• Transient Vision Obscurations (68%)
• Tinnitus (60%)

Photopsia (54%)

Diplopia (38%) (CN 6 palsy in 10-20%)

Vision loss: Some degree of permanent visual loss (86%). Severe vision loss (10%)

Question 21

Idiopathic Intracranial Hypertension: Criteria REQUIRED for Dx!! (KNOW!)

1. Modified Dandy Criteria
   a. Signs and Symptoms of what?
   b. Elevated what?
   c. CSF Analysis?
   d. CT/MRI and MRV Normal?
   e. Localizing Neurological signs?

Answer 21

1. a. Increased ICP
   b. ICP (>250 mm of H20)
   c. Normal
   d. Normal
   e. None except CN 6

Question 22

Idiopathic Intracranial Hypertension: Pathogenesis

1. What is it?
2. Impaired CSF Absorption by what?
3. Increased Intra-Abdominal Pressure due to Obesity may increase what?
4. Prognosis?

Answer 22

1. Endocrine basis maybe…
2. by Arachnoid Villi of the Venous Sinuses
3. Pleural Pressure and Cardiac filling pressure, which can lead to increased intracranial venous pressure and ICP
4. 86% have some degree of permanent visual Loss with 10% having severe visual loss

Question 23

Idiopathic Intracranial Hypertension: Treatment

1. 3 things

Answer 23

Weight Loss

Medical

Surgical

Question 24

Idiopathic Intracranial Hypertension: Tx: Weight Loss

1. % of Body weight?
2. Only Permanent what?
3. What does it improve?
4. Referral to whom?
5. Surgery?

Answer 24

1. 10%
2. Cure
3. HAs and Papilledema
4. to a nutritionist
5. Bariatric Sx

Question 25

Idiopathic Intracranial Hypertension: Medical Tx 1. Drug? a. Type of Tx line? b. Mechanism? c. CIs? d. Side-Effects? 2. Other Drug? a. Second line if Diamox is intolerable c. Mechanism? d. Dose?

Answer 25

1. Acetazolamide (Diamox): ORAL CAI a. 1st line b. Decreases CSF production by the cells lining the ventricles by inhibiting Carbonic Anhydrase c. Sulfa Allergy, Pregnancy, Liver, or Renal Failure d. Metallic Tase, Nausea, Paresthesia 2. Furosemide (Lasix): Diuretic b. Decreases total amt of fluid in the body c. 20-40 mg

Question 26

Idiopathic Intracranial Hypertension: Surgical 1. 2 things?

Answer 26

1. Nerve Sheath Fenestration 2. CSF Shunt a. Ventriculoperitoneal b. Lumboperitoneal

Question 27

Idiopathic Intracranial Hypertension: Nerve Sheath Fenestration 1. When is it indicated? 2. How is it done? 3. Long term fix?

Answer 27

1. when vision is threatened, but no HA or mild HAs. 2. Blade creates a slit in the ON Sheath so CSF can escape 3. Temporary Fix

Question 28

Idiopathic Intracranial Hypertension: Neurosurgical Shunt Insertion 1. CSF is drained by what?

Answer 28

1. an implanted tube from the LATERAL VENTRICLE or LUMBAR SUBARACHNOID SPACE into the peritoneal cavity in the abdomen where it's absorbed

Question 29

Papilledema Grades 1. Grade 1 2. Grade 2 3. 3 4. 4 5. 5

Answer 29

1. C-Shaped Halo w/a Temporal Gap 2. Halo becomes Circumferential 3. Loss of major vessels as they leave the disc 4. Loss of major vessels on the disc 5. Partial/Total Obscuration of all vessels of the disc.