IIH Flashcards
IIH triad ( MCCC in )
Female , childerbeering age , BMI > 30 or recent gain weight ,+
polycystic ovarian syndrome
PTCS pseudotumor cerebri syndrome diagnostic criteria
papilledema
○ ICP elevation ≥ 25 cm CSF LP
○ normal CSF analysis
No neurological deficit except VI nerve palsy
Imaging ; no intracranial mass except ;
1- slit-like ventricles
2-findings associated with increased intracranial pressure;
- Empty sella
- transverse sinus stenosis
-intraorbital; flattening of the posterior globe, dilated optic nerve sheath, toruchous of optic nerve
…Other enlarged Meckle cave
pseudotumor cerebri syndrome without papilledema PTCSWOP ( variant)
variant with less risk to vision and more refractory H/A.
Complication
Risk of blindness correlate»_space; progressive visual field constriction (enlarging blind spot is characteristic) » diagnosed on visual field testing
Work up
✔ brain MRI (without and with coyntrast) to include ++craniocervical junction (to R/O Chiari malformation) :
Slit v
Tonsillar ectopia (Chiari I)> 5mm
Most findings are those of 🔼ICP (not specific just for PTCS):
empty sella
dural sinuses stenosis: (MRV is more sensitive)
Meckel’s cave enlargement
👀5 ; flattening of the posterior globe/sclera, protrusion/enhancement of the prelaminar optic nerve, optic nerve sheath distended or tourchous.
○ ✔ brain MRV to r/o dural sinuses indication; for patients who are male or not obese, or who have progression of visual deficit despite treatment , sequence MIP + gladinume
○ ✔ LP: measure opening pressure (OP) >25cm in and send CSF at a minimum for cell count, protein and glucose, cytology and culture (aerobic, anaerobic, fungal, and TB)
○ ✔ BP (blood pressure) to R/O hypertensive encephalopathy
○ ophthalmologic eval. Priorities: ✔ visual fields Perimetry perimetric mean deviation (PMD ++ ✔ fundoscope r/o papilledema
Secondarily: acuity, color vision, intraocular pressure, EOM testing for abducens palsy
Condition asso IIH
obstructive sleep apnea, no proven study > high co2 > high ICP
hypervitaminosis A or use of retinoids
, iron deficiency anemia…
Biography venous stenosis epiphenomena (e.g., venous hypertension may be due to compression of the transverse sinuses by high ICP
Conditions that may be related by virtue of increased pressure in the dural sinuses (see below):
1. otitis media with petrosal extension (so-called otitic hydrocephalus)
2. radical neck surgery with resection of the jugular vein
3. hypercoagulable states
Mangment
Medical;
weight loss: 6-15% weight loss usually resolves papilledema.
Dietary consultation and/or bariatric surgery may help
○ medical management: provides modest improvement. Acetazolamide (Diamox®) is initial drug of choice. Alternative: Topamax ,lasix
Surgery :
procedural interventions: not recommended unless»_space; 👀 vision threatened.
Primarily:
○ optic nerve sheath fenestration (ONSF): best for» 👀visual loss without H/A
○ CSF shunt: better than ONSF for refractory H/A 🤯associated with visual loss 👀
- stenting for bilateral focal transverse sinus stenosis: controversial. Requires antiplatelet drugs X ≈ 6 m ❌ can’t do other surgical option after»_space;
indications: a gradient > 8 mmHg (some say 5) across the stenosis in the presence of refractory increased ICP
Other terms of IIH
1-otic HC
2- pseudotumor cerebri broad term **
3-idiopathic intracranial hypertension (IIH)
4-benign intracranial hypertension🚫»_space; loss of vision and reduced quality of life from debilitating headaches are not benign)
Pseudotumor cerebri syndrome (PTCS) def
A group of conditions characterized by»_space; increased intracranial pressure with no 🚫 evidence of intracranial mass, hydrocephalus, infection (e.g., meningitis, especially chronic ones such as fungal meningitis), or hypertensive encephalopathy
Involve ;
Primary or IIH ; patients with obesity🐘👨👩👧👦, recent weight gain🤰🏼, polycystic ovarian syndrome and thin children
2ry; w/ papilloedema 👀 or PTCSWOP w/o without papilledema
Peak age of IIH
3rd decade 1-55
37% children
90% 5-15
If age < 3 or > 60 r/o other cause of high ICP
% visual loss
% of sever visual deficit IIH = 4-12%
%papiloedema= 15%
% of permanent 👀 loss =2-24% ( depending on criteria used + degree to which it is sought)
Diagnostic criteria
For PTCS pic
PTCSWOP ;
1-Low OP on LP
2-High photophobia 📸
3-High non-physiologic visual field constriction/not progressive
4-normal visual fields on presentation
5-H/A refractory to tx
6-Low incidence 6th palsy
7-preserved venous pulsation on funduscopy
Hx PTCS
1- MCC H/ A ; tension / migraine
🔼ICP and 🔽ICP > indpendent RF
🚫BMI , OP , Papiloedema grade or use of acetzolmied
2- PT unilateral ; 🔼 ICP and 🔽 ICP > comp JV or head rotation same side
3- visual loss;
70% TVO; transient visual obscurations (TVO): graying or blacking out of vision. Lasts ≈ 1 second. Uni- or bilateral
Bulrred 30% > injury affrent
4- H diopopia👀 > 6CN palsy
Medication overuse headache (MOH)
1-H/A occurring ≥ 15 days/month + 💊 over use 10 days/month (for opioids, combined preparations, ergotamines or triptans) or ≥ 15 days/month (for NSAIDs, APAP, ASA)
2- 💊 overuse for > 3 months
3- no other DDX
4- H/A improved after DC 💊
Exam finding VF
DC in PTCS
Suboccpital or
subremporal( old 🧓🏼) ;
Risk of seizure, painful bulging site
Indication slit ventricle , LP shunt not feasible
F/ u PTCS
MRI 2 ys to r/o occult tumors
