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  • 1. An interesting case of headache G.Balaji med.pg Prof.Dr.G.sundharamurthy’s unit
  • 2. history
    • 35 year old female presented with c/o headache of 2 weeks duration.
    • Headache -generalised throbbing pain present through out the day.
    • Aggravated by bending forward , coughing and sneezing. Pain reduced by NSAIDs but not completely absent.
    • Headache associated with nausea and vomiting occasionally.
  • 3.
    • No h/o loc, seizures, fever, altered sensorium, weakness of limbs, hard of hearing ,tinnitus.
    • H/o blurring of vision for both distant and near objects. No h/o double vision, deviation of eyes to one side.
    • No h/o trauma, head injury, falls.
    • No h/o any drug in take.
  • 4.
    • Past history:
    • not a known case of type 2 dm, sht, ihd, pulmonary tb.
    • no chronic drug intake.
    • No similar episodes in the past.
    • No h/o any hospitalisation.
  • 5.
    • Personal history :
    • Nil addictions.
    • bowel and bladder habits normal.
    • Menstrual& marital history :
    • Married with 2 children. Last child birth 7 years ago. Underwent sterilisation after birth of 2 child
    • Menstrual cycles regular.
  • 6. On examination
    • Patient conscious, oriented, afebrile.
    • pulse- 80/ min
    • Bp- 110/70 mm hg.
    • No pallor, icterus, lymphadenopathy, cyanosis, clubbing.
    • Cvs –S1,S2 heard, no murmurs.
    • Rs – nvbs heard, no added sounds.
    • Per abdomen- soft, no organomegaly. No mass.
  • 7.
    • Cns:
    • Pt is conscious, oriented ,
    • No cranial nerve palsies
    • Motor- no weakness of limbs. Reflexes normal.
    • No sensory deficit
    • No cerebellar signs.
    • No signs of meningeal irritation.
    • Fundus- bilateral papilledema.
  • 8.
    • Provisional diagnosis-
    • intra cranial hypertension.
    • cause?
  • 9. investigations
    • Complete blood count- normal
    • RFT – normal.
    • Chest x ray- normal
    • ECG– normal.
    • CT brain – no mass ,bleeding .
    • MRI brain- normal .
  • 10.
    • Ophthal examination-
    • Bilateral papilledema.
    • Enlarged blind spot, peripheral constriction of visual field.
    • Lumbar puncture-
    • opening pressure was high.(more than 250 mm water).
    • Cell count, cytology, gram stain -normal
  • 11. Final diagnosis
    • Idiopathic intracranial hypertension
  • 12. Idiopathic intracranial Hypertension
    • Pseudotumor Cerebri
    • Benign Intracranial Hypertension
  • 13. Definition
    • Clinical features of raised intracranial pressure (ICP)
    • Absence of space-occupying lesion (SOL) on brain imaging
    • Exclusion of other causes
  • 14. Physiology of raised ICP
  • 15. Epidemiology
    • General population = 1 / 100,000 / yr
    • Women aged 15 – 44 = 3.5 / 100,000 / yr
    • Women BMI >29 = 20 / 100,000 / yr
  • 16. Clinical features of Idiopathic Intracranial Hypertension
    • Headache
    • Vomiting
    • Visual symptoms / signs
      • Transient visual obscurations
      • Diplopia (VIth Nerve palsy)
        • “ false localising sign”
      • Enlarged blind-spot
    • Papilledema on fundus examination
    • Rest of neurological examination should be normal
  • 17. LUMBAR PUNCTURE
    • Measure CSF opening pressure with pt lyig in left lateral position.
    • If opening pressure elevated, remove enough CSF to decrease closing pressure to about 150 mm H2O.
    • Send for cell count, protein, glucose, cultures (bacterial, viral, and fungal), and cytology.
  • 18. NEUROIMAGING
    • MRI preferred over CT
    • Possible MRI Findings
      • Empty sella – 70%
      • Flattening of posterior sclera – 80%
      • Enhancement of prelaminar optic nerve – 50%
      • Distention of perioptic subarachnoid space – 45%
      • Vertical tortuosity of orbital optic nerve – 40%
      • Intraocular protrusion of prelaminar optic nerve – 30%
    • Consider Magnetic Resonance Venography to r/o cerebral venous thrombosis
  • 19.  
  • 20. Identifying papilledema Normal Papilledema
  • 21.  
  • 22.  
  • 23. Conditions to Exclude
    • SOL
    • Hydrocephalus
    • Venous Sinus Thrombosis
    • Chronic Meningitis
        • Infective
        • Inflammatory / granulomatous
        • Neoplastic (Carcinomatous / lymphomatous)
    • “ Medical causes”
      • CO 2 retention
      • Malignant hypertension
  • 24. IMPLICATED ETIOLOGIC MEDS
    • NSAIDS
    • Tetracycline
    • OCPs
    • Nitrofurantoin
    • Isotretinoin
    • Minocycline
    • Tamoxifen
    • Nalidixic Acid
    • Lithium
    • Steroids (stopping or starting them)
  • 25. DIAGNOSIS OF PSEUDOTUMOR CEREBRI
    • Based on modified Dandy criteria
      • Awake, alert pt.
      • Signs and symptoms of increased ICP
      • Absence of localized neurological findings, except for CN VI paresis
      • Normal CSF fluid findings except for increased pressure
      • Absence of deformity, displacement, and obstruction of ventricular system
      • No other identifiable cause of ICP,SOL
  • 26. How do we make the diagnosis?
    • Clinical features of raised ICP without apparent cause
    • Normal brain imaging
    • Normal imaging of venous system
    • LP (serves 3 purposes):
      • Checks pressure – establishes diagnosis
      • CSF analysis – excludes infectious, inflammatory and neoplastic etiologies
      • Symptomatic improvement
  • 27. Associated Factors
    • Female > Male
    • Obesity
    • Drugs
      • Tetracyclines
      • Vitamin A
    • Iron Deficiency Anemia
    • Endocrine abnormalities
      • Hypothyroidism
      • Hypoparathyroidism
      • PCOS (probably independent of obesity, acne treatment)
  • 28. Treatment
    • Treat risk factors
      • Weight loss
      • Correct endocrine abnormalities
      • Stop offending medication
    • Medical ( decrease CSF production)
      • Carbonic anhydrase inhibitors
      • Furosemide
    • Surgical
      • CSF diversion procedures
      • Optic nerve sheath fenestration
  • 29. “ Benign Intracranial Hypertension?” - No longer!
    • May lead to irreversible visual loss
    Normal Optic atrophy
  • 30. Follow up
    • Symptoms of raised ICP
    • Neuro-opthalmological assessment
        • Visual Field Testing
        • Fundus Examination
  • 31. treatment
    • T. acetaolamide 250 mg tds
    • T.furesamide- 40 mg od.
    • Lumbar puncture- about 30 ml of csf drained till 200 mm water pressure reached.
    • Patietnt improved with above therapy and was discharged with t.acetazolamide 250 mg tds. To review after 15 days.
  • 32. British medical bulletin-june 2006. pg 233-244
    • Idiopathic intracranial hypertension and
    • visual function
    • James F. Acheson*
    • Department of Neuro-Ophthalmology, National Hospital for Neurology and Neurosurgery, London,
    • and Neuro-Ophthalmology and Strabismus Service, Moorfields Eye Hospital, London, UK
  • 33.
    • THANK YOU