IIH - dont miss it !!!

1. INTERESTING CASE
PRESENTATION
Presented by : Dr Shaz Pamangadan
Chair : Prof . Sudeep .K

2. • 40/F
• Housewife
• presenting complaints :
Headache - 3 days
Difficulty in closing right eye – 3 days

3. • Her headache started insidiously, had a
progressive course, squeezing nature , mainly
bifrontal distribution and was associated with
nausea, vomiting, dizziness, transient visual
disturbances in her right eye, and a feeling of
both her ears being clogged.
• A day prior to the presentation, she started to
feel numbness and weakness of the right side of
her face, along with an inability to close her right
eye properly.

4. • No h/o diplopia, loss of vision, photophobia,
tinnitus, or any feeling of weakness,
numbness, or tingling in other locations of her
body.
• She had no history of migraine headaches, tick
bite, or any recent illness or fever, trauma .
• She was not taking oral contraceptive pills at
the time.

5. Past History
• History of Obesity, BMI  of 32
• Systemic Hypertension  10 years
• No h/o T2dm , dyslipidemia or significant
medical or surgical history in the past .

6. Family history
• No significant illnesses in family

7. Personal history
• Mixed diet.
• Normal bowel bladder.
• No addictions.
• Sleep and appetite adequate.

8. To summarize …

9. On examination
• Conscious , oriented , co-operative .
• BP – 140/90 mmHg
• PR – 88/mt regular .
• T – Afebrile
• RR – 18/mt
• GRBS- 97mg/dl.

10. General examination
• No pallor ,icterus , cyanosis , clubbing , lymph
node enlargement , oedema .
• Skin , hair , nails appear normal .
• No thyroid swelling

11. CNS Examination
• HMF  fully alert and oriented, fluent speech
and intact comprehensive abilities.
• CN  3–4 mm pupils, PEARL & Accommodation;
intact extra-ocular movements, no nystagmus,
saccadic movement or skew, full visual fields.
• No signs of abducent nerve palsy were present.
• There was facial asymmetry evident by right
lower facial droop, weaker right eye closure, and
limited ability to raise the right eyebrow.

12. • Facial sensation  equal on both sides, with a
strong jaw opening and a midline tongue of
good power. shoulder shrug was symmetrical,
and hearing was intact.
• A fundus examination revealed bilateral grade
I–II papilledema.
• No signs of meningeal irritation.
• motor function, sensation, gait analysis, skull
and spine -wnl

13. Other systems
• CVS – S1S2 heard . No murmur
• RS – NVBS b/l . No added sounds
• P/A – soft ; No HSM

14. investigations
• Blood r/e ,
• lft ,
• rft ,
• se ,rbs
• ur/e ,
• cxr-pa view ,
• ecg ,
• s.ca , s.mg , s.ph , s.uric acid  normal

15. Eventually ???
• She underwent a computed tomography (CT)
scan of her head that showed right-sided
pontomedullary hypodensity.
• Brain magnetic resonance imaging (MRI) with
magnetic resonance venography (MRV)
revealed a stenosis in the lateral aspect of the
transverse sinus, a partially empty sella
turcica, and a picture of mild papilledema.

16. Lumbar puncture :
• opening pressure  28 cm of csf
• The cytological and chemical findings of the LP
WBCs  2
• lymphocytes 100%
• protein 24
• RBCs 13
• Glucose 58
• c/s ,gram stain, ada , normal

17. Differential diagnosis
• Migraine variants.
• Meningitis/meningoencephalitis.
• Subarachnoid hemorrhage.
• Intracranial hemorrhage .
• Hydrocephalus.
• Intracranial epidural abscess.
• Lymes disease.
• Pseudotumour cerebri.

18. Diagnosis ???
• Pseudotumour cerebri
Or
• Benign intracranial hypertension
Or
• Idipathic intracranial hypertension.

19. • She was started on prednisone 60 mg daily
for 5 days and 500 mg of acetazolamide twice
daily.
• Two days later, she reported a dramatic
improvement in both the headache and the
facial nerve palsy. A week later, right facial
nerve examination was done, which was
completely normal.

36. In our patient …?
• Why seventh nerve palsy ??? Not sixth ???

39. Thank you .