Pseudotumor Cerebri

Posted On December 29, 2021

AKA Idiopathic Intracranial hypertension (IHH)
Pseudo = False
- False or mimic a tumor in the brain
- No brain tumor but has increased intracranial pressure
Main symptoms:
- Headache 90%
- Transient visual obscurations (blurring, lasting seconds) 70%
- Intracranial noises (pulsatile tinnitus) 60%
- Photopsia (floaters): 50%
- Back pain 50%
- Retrobulbar pain 40%
- Diplopia 30%, typically from sixth nerve palsy
- Sustained visual loss 30%
- Neck pain 40%
Exam: may show papilledema, visual field loss, 6th nerve palsy
Imaging:
- MRI head: may show empty sella, posterior flattening of globe
- MRV with co0ntrast: rule out venous thrombosis
Lumbar puncture: opening pressure over 25 cm water
- poor relaxation may elevated CSF pressure
- CSF cell count, protein normal
Ophthalmic exam: papilledema, visual field loss
Treatment:
- General:
  - Stop tetracycline
  - Weight loss
  - Treat anemia if present
- No visual loss
  - Above plus
  - Acetazolamide 500 mg bid to lower CSF production
  - or Topiramate start at 25 mg bid
  - or Furosemide 20 to 40 mg qd
- Mild visual loss:
  - above plus
  - Methylprednisolone 250 mg qid for 5 days with oral taper
  - Serial LP
  - Consider optic nerve sheath fenestration
  - Sleep study
- Severe visual loss:
  - Above
  - Optic nerve sheath fenestration: vision symptoms improve > 90%
  - Last resort: VP shunt
Further reading and References
- Eye Rounds
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