Idiopathic Intracranial Hypertension

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.