Idiopathic Intracranial Hypertension

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Idiopathic Intracranial Hypertension - Dr James Beatty

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Idiopathic Intracranial Hypertension

  1. 1. Idiopathic Intracranial Hypertension By J Beatty
  2. 2. Introduction  Common cause of disc swelling.  Most common cause of papillodema.  NB because papilloedema can = mass lesion.  NB because IIH can lead to significant visual loss.
  3. 3. Modified Dandy Criteria  Signs and symptoms of raised intracranial pressure  Normal neuro exam, except 6th nerve palsy  Elevated CSF pressure with normal constituents  Normal neuroimaging
  4. 4. Demographics and General Info  Typical = early adult, women, overweight or recent weight gain.  Cause and mechanism unclear (? decreased CSF absorption from dysfunctional arachnoid villi). Numerous other postulations.
  5. 5. Clinical Presentation  Headache. – 90% of patients (most common). – 60% pulsatile intracranial noise.  Visual symptoms. – Transient visual obscurations (TVOs), 72%. – Blurred vision. – Enlarged blind spot or other visual field loss. – Diplopia.
  6. 6. Associated Conditions  Before examination, think!?  Very long list of conditions to consider in the differential diagnosis.  Need to exclude cranial venous conditions, mass lesions and specific known causes of elevated intracranial pressure.
  7. 7.  Venous thrombosis or obstruction. – Pseudotumor like appearance, difficult to exclude. – Cerebral dural venous sinus thrombosis > increased venous pressure >decreased CSF absorbtion. – Seriously effected patients develop cortical vein thrombosis and cerebral infarction. – Also thrombosis of transverse and sigmoid sinus. – Cause of clot formation:
  8. 8.  Dural Arteriovenous malformations  Apnea
  9. 9. Neuro-ophthalmic Examination – Insidious visual or field loss. – Sever loss (chronic papilloedema, RD, Hx, macular exudate). – Peripheral field defects, enlarged blind spot. – Colour and pupil normal. – 50% abnormal contrast sensitivity. – 6th nerve palsy.
  10. 10.  Papilloedema – Usually bilatereal – Pantons lines – Vascular changes (2nd to compression) – Loss of spontaneous venous pulsation – Acute vs chronic
  11. 11.  Pseudopapilloedema – Congenital, harmatoma, mylinated nerve fibers, drusen – Serial examinations – Optic disc drusen  Defect in axonal metabolism  1-2% of population, often bilat, inherited  Examination, u/s, CT – Other causes
  12. 12. Diagnostic Evaluation  MRI better than CT – Empty sella, dilation optic nerve sheath, flat post globe, elevation of optic disc, slit like ventricles  LP – >25mm H20
  13. 13. Management  No visual loss – Weight reduction – Acetazolamide (500-2000 mg/day)  Mild to moderate visual loss – Acetazolamide (up to 2-3 gms/day) – Or furosemide (40-80mg daily) – Weight reduction
  14. 14.  Sever or progressive visual loss. – Optic nerve sheath fenestration. – High-dose IV steroids and acetazolamide. – Lumboperitoneal shunt for failed ONSF or intractable headache.
  15. 15. Outcome  Mild and moderate do well  Sever can have decreased vision and field defects. Devestating 5%

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