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Pseudotumor Cerebri

by Carlo Raj, MD
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    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 ICH.

    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.

    02:12 Why? I have no freaking clue, but make sure you know that these are possible causes or medications that may result as an adverse effect of pseudotumor cerebri.

    02:27 Diagnosis: Imaging initially to rule out a mass lesion because there is no mass.

    02:32 Lumbar puncture to document -- document -- opening pressure.

    02:38 elevated at 250 to 450 millimeters, the water pressure in lateral decubitus.

    02:46 It is important that you know the specifics for opening pressure, please.

    02:52 CSF should otherwise be normal.

    02:56 Formal visual field testing because of papilledema.

    02:59 Early defect is enlargement of blind spot and slight peripheral field constriction.

    03:06 Remember, there is prominent papilledema in these patients, so early on, you would find such defects.

    03:14 Management: Well, here, lumbar puncture to make sure that you’ve figured out what that opening pressure is, weight loss, carbonic anhydrase inhibitors, Diamox, shunt, optic nerve fenestrations.

    03:29 You do want to relieve some of that pressure that’s taking place with idiopathic intracranial hypertension, AKA, pseudotumor cerebri.

    03:42 Summary of pseudotumor cerebri: Female, early, young, obese.

    03:48 Preventive medicine: Weight loss.

    03:50 Signs and symptoms: Blurred vision, headache.

    03:53 The differentials include, if you remember, we talked about venous sinus thrombosis during pregnancy.

    03:58 Please be very careful, because during pregnancy with estrogen, it may result in the thrombus formation in the sagittal or the transverse sinus.

    04:06 I even showed you an image where the transverse sinus was absent.

    04:11 That’s venous sinus thrombosis.

    04:14 Here, we have pseudotumor, mass lesion, migraines as being differentials.

    04:21 Diagnostic: Lumbar puncture.

    04:22 We talked about earlier, specifically the pressure of 250 to 450 millimeters of mercury.

    04:29 Treatment: Weight loss, carbonic anhydrase inhibitors, and shunting.


    About the Lecture

    The lecture Pseudotumor Cerebri by Carlo Raj, MD is from the course Headache.


    Included Quiz Questions

    1. A headache is usually sudden in onset and often progressive.
    2. Horizontal diplopia is a symptom.
    3. Papilledema is usually prominent.
    4. Blurred vision is commonly seen.
    5. A headache aggravates on lying down.
    1. Valproic acid
    2. All-trans retinoic acid
    3. Tetracycline
    4. Dexamethasone
    5. Pregnancy
    1. 250 to 450 mmH2O in lateral decubitus position
    2. 150 to 250 mmH20 elevated position
    3. 150 to 250 mmH20 in lateral decubitus position
    4. 250 - 450 mmH20 in elevated position
    5. 30mmHg in elevated position
    1. Weight loss
    2. Use of carbonic anhydrase inhibitors
    3. Shunting of CSF
    4. Optic nerve fenestration
    5. Lumbar puncture

    Author of lecture Pseudotumor Cerebri

     Carlo Raj, MD

    Carlo Raj, MD


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