00:01
Our topic continues with
subacute and chronic headache.
00:04
Here, we’ll take a look
at pseudotumor cerebri.
00:07
Who’s your patient?
Patient comes in with
this chronic headache,
also called idiopathic
intracranial hypertension.
00:14
In other words, this is your IIH.
00:18
Now, idiopathic because we don’t
know exactly as to what causes it.
00:21
We do know that there’s a particular drug
that you should be extremely familiar with
that might be a possible etiology, and
that’s your ATRA, all-trans retinoic acid.
00:31
Well, pseudotumor cerebri, as the
name implies, pseudo means false,
a tumor-like lesion,
or should I say
tumor-like manifestation.
00:41
By that, we mean there’s
a headache taking place.
00:43
You’ll find papilledema on
fundoscopic examination but
absolutely no evidence of a tumor.
00:50
Described as diffuse,
dull, ache, pressure.
00:53
Remember, this is
chronic headache.
00:55
Onset is a gradual but
often progressive.
00:57
Headache is often worsened by laying
down and by physical activity.
01:02
Blurred vision is common.
01:04
Horizontal diplopia is occasionally seen,
and bilateral cranial nerve VI
abducens palsy can be seen.
01:12
So this will be a good time
to review quickly, please,
the functions of your
abducens cranial nerve VI,
And papilledema is
quite prominent.
01:20
Keep that in mind.
01:22
What does papilledema
mean to you?
You do a fundoscopic examination
and you find there around optic
disc, it looks like sun rays.
01:29
Very bright, huh?
That’s your papilledema.
01:32
Now, with that papilledema,
you would think that,
“Oh my goodness, that
must be prominent.”
You’re worried about intracranial
pressure being increased,
and that is not a good thing.
01:41
So, keep that in mind.
01:43
We’ll take a look at epidemiology
of pseudotumor cerebri.
01:47
75% of your patients
will be females.
01:49
That’s where your
focus should be.
01:51
She,
will be in her reproductive
age between 20 to 40.
01:55
Vast majority of these
females are obese,
more common during pregnancy,
also seen with steroid therapy,
vitamin A toxicity, which I
was referring to earlier,
your ATRA, all-trans retinoic acid,
and maybe perhaps, even
tetracycline antibiotics.
02:13
Make sure you know that
these are possible causes
or medications that may result as an
adverse effect of pseudotumor cerebri.
02:24
Diagnosis: Imaging initially to rule out
a mass lesion because there is no mass.
02:29
Lumbar puncture to document --
document -- opening pressure.
02:35
elevated at 250 to 450 millimeters,
the water pressure in
lateral decubitus.
02:43
It is important that you know the
specifics for opening pressure, please.
02:49
CSF should otherwise be normal.
02:53
Formal visual field testing
because of papilledema.
02:56
Early defect is enlargement of blind spot
and slight peripheral field constriction.
03:04
Remember, there is prominent
papilledema in these patients,
so early on, you would
find such defects.
03:11
Management:
Well, here, lumbar puncture, weight loss,
carbonic anhydrase
inhibitors, Diamox,
shunt,
optic nerve fenestrations.
03:23
You do want to relieve some of
that pressure that’s taking place
with idiopathic intracranial
hypertension, AKA, pseudotumor cerebri.
03:36
Summary of pseudotumor cerebri:
Female,
early, young, obese.
03:41
Preventive medicine: Weight loss.
03:44
Signs and symptoms:
Blurred vision, headache.
03:47
The differentials include, if you remember,
we talked about venous sinus
thrombosis during pregnancy.
03:53
Please be very careful,
because during pregnancy with estrogen,
it may result in the thrombus formation
in the sagittal or the transverse sinus.
03:59
I even showed you an image where
the transverse sinus was absent.
04:05
That’s venous sinus thrombosis.
04:08
Here, we have pseudotumor, mass lesion,
migraines as being differentials.
04:15
Diagnostic: Lumbar puncture.
04:16
We talked about earlier,
specifically the pressure of 250
to 450 millimeters of water.
04:22
specifically the pressure of 250
to 450 millimeters of water.
04:22
Treatment: Weight loss, carbonic
anhydrase inhibitors, and shunting.