Grand Ward Round

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Grand Ward Round

• 28/6/07
• Jamie Ng

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Case presentation

• 33/Chinese/Female
• Past hx ?Migraine
• c/o LE BOV since episode of conjunctivitis 2/12
  ago
• a/w mild headaches and 1 episode of vomiting
• No known trauma
• No OCP/antibiotic tx
• Been taking TCM for past few yrs

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Case presentation

• O/E VR 6/7.5 VL 6/9-2
• No RAPD
• Ishihara OU 15/15
• Red desaturation vaguely reduced in left
  inferior hemifield

0
4

• Visual field by confrontation full BE
• GAT OU 10mmHg
• Anterior segment normal

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Differential diagnosis

• Papilloedema due to raised ICP
• Malignant hypertension
• Pseudo-papilloedema Drusens
• Less likely Bilateral inflammatory/infiltrative
  ON, Toxic ON, AION, optic neuritis

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Further work-up

• BP normal
• Urgent CT Brain and AVP
• No SOL noted, no compressive lesion in AVP
• Ventricles not dilated
• Neurology referral made
• MRI brain and MRV
• No evidence of intracranial hypertension,
  enhancing intracranial masses or hydrocephalus
  demonstrated. No venous sinus thrombosis is
  identified.

7

• LP performed in lateral position
• Opening pressure 26mmHg
• CSF studies normal
• HVF no visual field defects

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• Diagnosis Idiopathic Intracranial Hypertension
• Treatment T. Diamox 250mg bd
• Reviewed 4/7 later nasal margins still blurred
  but swelling decreased in BE

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Idiopathic Intracranial Hypertension

• Modified Dandy Criteria
• 1. Raised ICP gt25cm H2O
• 2. No localising signs except a CN6 palsy
• 3. Normal CSF composition
• 4. Normal to slit ventricles on imaging with no
  intracranial mass

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• Pathogenesis
• Vasogenic extracellular brain edema
• Low conductance of CSF outflow
• Characteristics and Risk factors5
• Young female
• Obese
• Medications amiodarone, antibiotics (penicillin,
  tetracycline), levodopa, corticosteroids,
  cyclosporine, growth hormone, indomethacin,
  ketoprofen, lead, acetate, levonorgestrel
  implants, lithium, oral contraceptives, oxytocin,
  perhexiline, phenytoin, and vitamin A (gt100,000
  U/d)/retinoic acid.
• Cushings, hypothyroid, hypoparathyroid

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• Symptoms
• Headache 90
• Visual obscurations transient(70) or
  persistent (30)
• Tinnitus 60
• Photopsia
• Retrobulbar pain
• Diplopia

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• Poor Prognostication Factors4
• Older age
• Raised IOP
• Systemic hypertension
• DM
• Weight gain during first year prior to diagnosis
• Anaemia
• High myope

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• Management
• Indications to tx visual loss, high ICP and
  patient is symptomatic
• Encourage weight loss
• Medical Diamox and steroids
• LP diagnostic and therapeutic
• ON sheath fenestration
• Ventriculo peritoneal shunt or lumbar peritoneal
  shunts

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Optic nerve sheath fenestration1,2

• Via lateral orbitotomy app
• Window of dura and arachnoid made
• Arachnoid excised
• CSF allowed to drain

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Recommendations1,2,3

• Studies have quoted that VA stabalized or
  improved in 94 -97 of patients
• Suggests that acute papilloedema and visual loss
  should be offered primary ONSF
• Safe and effective to repeat in recurrences
• All patients should be routinely followed-up with
  perimetery

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References

• Treatment of pseudotumor cerebri by primary and
  secondary optic nerve sheath decompression. Spoor
  TC, Ramocki JM, Madion MP, Wilkinson MJ. Am J
  Ophthalmol. 1991 Aug 15112(2)177-85.
• Pseudotumor cerebri and optic nerve sheath
  decompression.Banta T, Farris BK. Ophthalmology.
  2000 Oct107(10)1907-12.
• Optic nerve decompression surgery improves visual
  function in patients with pseudotumor
  cerebri.Kelman SE, Heaps R, Wolf A, Elman MJ.
  Neurosurgery. 1992 Mar30(3)391-5.
• Factors affecting visual loss in benign
  intracranial hypertension.Orcutt JC, Page NG,
  Sanders MD. Ophthalmology. 1984
  Nov91(11)1303-12.
• Idiopathic intracranial hypertension. A
  prospective study of 50 patients.Wall M, George
  D. Brain. 1991 Feb114 ( Pt 1A)155-80.

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The End!