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Mathkour M, Scullen T, Kilgore MD, Gouveia EE, Chu J, Abou-Al-Shaar H, Tubbs RS, Khan F, Bui CJ. Complete ophthalmoplegia secondary to idiopathic intracranial hypertension managed successfully with dural sinus stenting: A case and systematic review. Clin Neurol Neurosurg 2021; 209:106910. [PMID: 34560385 DOI: 10.1016/j.clineuro.2021.106910] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2020] [Revised: 08/15/2021] [Accepted: 08/18/2021] [Indexed: 10/20/2022]
Abstract
Idiopathic Intracranial Hypertension (IIH) typically occurs in obese (BMI >30 kg/m2) females of childbearing age in the absence of any apparent intracranial space-occupying lesion. Patients typically present with headache, nausea, vomiting, tinnitus, and blurry vision secondary to increased intracranial pressure, with more severe cases involving cranial neuropathies and ophthalmological manifestations. Complete ophthalmoplegia is a rare event in IIH. In such cases, aggressive management with pharmacological, endovascular, and surgical intervention is essential to hasten recovery and limit long-term neurological and visual deficits. Herein, we present a rare case of a patient with IIH associated with third, fourth, and sixth cranial nerve palsies, resulting in complete unilateral ophthalmoplegia, who underwent dural sinus stenting and 2.5-year follow-up revealed complete resolution with full extraocular movements. We also perform a systematic literature review of complete and partial ophthalmoplegia secondary to IIH, highlighting the associated presentations, pathophysiology, management, and outcomes.
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Affiliation(s)
- Mansour Mathkour
- Ochsner Health System, Department of Neurosurgery, Ochsner Neuroscience Institute, Ochsner Clinic Foundation, New Orleans, LA; Tulane Medical Center, Department of Neurosurgery, New Orleans, LA, USA.
| | - Tyler Scullen
- Ochsner Health System, Department of Neurosurgery, Ochsner Neuroscience Institute, Ochsner Clinic Foundation, New Orleans, LA; Tulane Medical Center, Department of Neurosurgery, New Orleans, LA, USA.
| | - Mitchell D Kilgore
- Tulane Medical Center, Department of Neurosurgery, New Orleans, LA, USA.
| | - Edna E Gouveia
- Ochsner Health System, Department of Neurosurgery, Ochsner Neuroscience Institute, Ochsner Clinic Foundation, New Orleans, LA.
| | - Julie Chu
- Tulane Medical Center, Department of Neurosurgery, New Orleans, LA, USA.
| | - Hussam Abou-Al-Shaar
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA.
| | - R Shane Tubbs
- Ochsner Health System, Department of Neurosurgery, Ochsner Neuroscience Institute, Ochsner Clinic Foundation, New Orleans, LA; Tulane Medical Center, Department of Neurosurgery, New Orleans, LA, USA.
| | - Fawad Khan
- The McCasland Family Comprehensive Headache Center, Ochsner Neuroscience Institute, Ochsner Clinic Foundation, New Orleans, LA.
| | - Cuong J Bui
- Ochsner Health System, Department of Neurosurgery, Ochsner Neuroscience Institute, Ochsner Clinic Foundation, New Orleans, LA; Tulane Medical Center, Department of Neurosurgery, New Orleans, LA, USA.
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Chen BS, Newman NJ, Biousse V. Atypical presentations of idiopathic intracranial hypertension. Taiwan J Ophthalmol 2021; 11:25-38. [PMID: 33767953 PMCID: PMC7971435 DOI: 10.4103/tjo.tjo_69_20] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2020] [Accepted: 09/11/2020] [Indexed: 11/05/2022] Open
Abstract
Idiopathic intracranial hypertension (IIH) is a disorder of unknown etiology that results in isolated raised intracranial pressure. Classic symptoms and signs of IIH include headache, papilledema, diplopia from sixth nerve palsy and divergence insufficiency, and pulsatile tinnitus. Atypical presentations include: (1) highly asymmetric or even unilateral papilledema, and IIH without papilledema; (2) ocular motor disturbances from third nerve palsy, fourth nerve palsy, internuclear ophthalmoplegia, diffuse ophthalmoplegia, and skew deviation; (3) olfactory dysfunction; (4) trigeminal nerve dysfunction; (5) facial nerve dysfunction; (6) hearing loss and vestibular dysfunction; (7) lower cranial nerve dysfunction including deviated uvula, torticollis, and tongue weakness; (8) spontaneous skull base cerebrospinal fluid leak; and (9) seizures. Although atypical findings should raise a red flag and prompt further investigation for an alternative etiology, clinicians should be familiar with these unusual presentations.
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Affiliation(s)
- Benson S. Chen
- Department of Ophthalmology, Emory University School of Medicine, Atlanta, GA, United States
- Department of Neurology, Auckland City Hospital, Auckland, New Zealand
| | - Nancy J. Newman
- Department of Ophthalmology, Emory University School of Medicine, Atlanta, GA, United States
- Department of Neurology, Emory University School of Medicine, Atlanta, GA, United States
- Department of Neurological Surgery, Emory University School of Medicine, Atlanta, GA, United States
| | - Valérie Biousse
- Department of Ophthalmology, Emory University School of Medicine, Atlanta, GA, United States
- Department of Neurology, Emory University School of Medicine, Atlanta, GA, United States
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Interlandi E, Pellegrini F, De Luca M, Cerullo G, De Falco A, De Marco R, Tortori A, Lee AG. Complete bilateral ophthalmoplegia in malignant intracranial hypertension in a child. Eur J Ophthalmol 2020; 32:1120672120966562. [PMID: 33081535 DOI: 10.1177/1120672120966562] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
PURPOSE To describe a case of fulminant idiopathic intracranial hypertension (IIH) in a child with "malignant" presentation. CASE REPORT A 16-year-old, previously healthy, girl presented with bilateral visual loss and bilateral global limitation of eye movements in the absence of headache. Extensive laboratory evaluation for infectious, inflammatory, autoimmune, and neoplastic conditions was negative. Magnetic resonance imaging (MRI) of the brain and lumbar puncture findings were consistent with a diagnosis of IIH. Extraocular motility improved in the next few days as well as optic disc edema but visual acuity remained poor. CONCLUSION The authors believe that the acute, severe, and fulminant ("malignant") presentation with markedly elevated intracranial pressure may produce the unique presentation of severe vision loss and bilateral complete ophthalmoplegia. Interestingly, there was no headache. To our knowledge this is the first such case to be reported in the English language ophthalmic literature.
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Affiliation(s)
- Emanuela Interlandi
- Department of Ophthalmology, "Ospedale del Mare", ASL Napoli 1-Centro, Naples, Campania, Italy
| | | | - Marco De Luca
- Department of Ophthalmology, "Ospedale del Mare", ASL Napoli 1-Centro, Naples, Campania, Italy
| | - Giovanni Cerullo
- Department of Neurology, "Ospedale del Mare", ASL Napoli 1-Centro, Naples, Campania, Italy
| | - Arturo De Falco
- Department of Neurology, "Ospedale del Mare", ASL Napoli 1-Centro, Naples, Campania, Italy
| | - Rocco De Marco
- Department of Ophthalmology, "Ospedale del Mare", ASL Napoli 1-Centro, Naples, Campania, Italy
| | - Achille Tortori
- Department of Ophthalmology, "Ospedale del Mare", ASL Napoli 1-Centro, Naples, Campania, Italy
| | - Andrew G Lee
- Department of Ophthalmology, Blanton Eye Institute, Houston Methodist Hospital, Houston, TX, USA
- Departments of Ophthalmology, Neurology, and Neurosurgery, Weill Cornell Medicine, New York, NY, USA
- Departments of Ophthalmology, The University of Texas Medical Branch (UTMB), Galveston, TX, USA
- The University of Texas MD Anderson Cancer Center, Houston, TX, USA
- Texas A&M College of Medicine, College Station, TX, USA
- Baylor College of Medicine, Center for Space Medicine, Houston, TX, USA
- University of Iowa Hospitals and Clinics, Iowa City, IA, USA
- University at Buffalo, Buffalo, NY, USA
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Wall-eyed Bilateral Internuclear Ophthalmoplegia (WEBINO) in a Patient With Idiopathic Intracranial Hypertension. Neurologist 2018; 23:157-159. [PMID: 30169368 DOI: 10.1097/nrl.0000000000000192] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
INTRODUCTION Wall-eyed bilateral internuclear ophthalmoplegia (WEBINO) is a variant syndrome of internuclear ophthalmoplegia, consisting of primary gaze exotropia, adduction impairment, nystagmus of the abducting eye, and vertical gaze-evoked nystagmus. It seems to be most frequently associated with multiple sclerosis, although other etiologies such as brainstem ischemia or hydrocephalus have also been described. CASE REPORT We report the case of a 25-year-old woman who presented with subacute progressive oculomotor disturbances, resulting in the development of a WEBINO over a few days. Fundoscopy showed papilledema first in the right and afterwards also in the left eye. Brain magnetic resonance imaging was normal. Lumbar puncture demonstrated an opening pressure of 38 cm H2O, without pleiocytosis and with normal protein. As no other cause of intracranial hypertension could be identified by imaging or extensive biochemical testing, the patient was treated with acetazolamide for idiopathic intracranial hypertension. As there was further progression despite increase of acetazolamide dosing, more aggressive therapy was pursued, and a ventriculoperitoneal shunt was placed by our neurosurgeons. Clinical follow-up showed progressive recovery of normal oculomotor function and disappearance of papilledema over the course of 6 weeks. CONCLUSIONS To our knowledge this is the first case description of a patient with WEBINO and idiopathic intracranial hypertension. The diagnosis is supported by the very high opening pressure, the absence of neuroimaging abnormalities, the papilledema, and the response to ventriculoperitoneal drainage.
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Wright HE, Brodsky MC, Chacko JG, Ramakrishnaiah RH, Phillips PH. Diplopia is better than no plopia! Surv Ophthalmol 2017; 62:875-881. [DOI: 10.1016/j.survophthal.2017.03.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2017] [Accepted: 03/29/2017] [Indexed: 12/17/2022]
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Wani IY, Verma S, Wani M, Asimi R, Sheikh S, Wani M, Sheikh N, Shah I, Mushtaq M. Complete ophthalmoplegia: A rare presentation of idiopathic intracranial hypertension. Ann Indian Acad Neurol 2015; 18:468-70. [PMID: 26713027 PMCID: PMC4683894 DOI: 10.4103/0972-2327.160087] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/05/2022] Open
Abstract
Idiopathic intracranial hypertension (IIH) is a disorder defined by clinical criteria that include signs and symptoms isolated to those produced by increased intracranial pressure (ICP; e. g., headache, papilledema, and vision loss), elevated ICP with normal cerebrospinal fluid (CSF) composition, and no other cause of intracranial hypertension evident on neuroimaging or other evaluations. The most common signs in IIH are papilledema, visual field loss, and unilateral or bilateral sixth cranial nerve palsy. Here we report a case of IIH presenting as headache with vision loss, papilledema, complete ophthalmoplegia with proptosis in one eye, and sixth cranial nerve palsy in the other eye. Patient was managed with acetazolamide, topiramate, and diuretics. Symptoms remained static and she was planned for urgent CSF diversion procedure.
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Affiliation(s)
- Irfan Yousuf Wani
- Department of Neurology, Sher-I-Kashmir Institute of Medical Sciences, Soura, Srinagar, Jammu and Kashmir, India
| | - Sawan Verma
- Department of Neurology, Sher-I-Kashmir Institute of Medical Sciences, Soura, Srinagar, Jammu and Kashmir, India
| | - Mushtaq Wani
- Department of Neurology, Sher-I-Kashmir Institute of Medical Sciences, Soura, Srinagar, Jammu and Kashmir, India
| | - Ravouf Asimi
- Department of Neurology, Sher-I-Kashmir Institute of Medical Sciences, Soura, Srinagar, Jammu and Kashmir, India
| | - Saleem Sheikh
- Department of Neurology, Sher-I-Kashmir Institute of Medical Sciences, Soura, Srinagar, Jammu and Kashmir, India
| | - Maqbool Wani
- Department of Neurology, Sher-I-Kashmir Institute of Medical Sciences, Soura, Srinagar, Jammu and Kashmir, India
| | - Nawaz Sheikh
- Department of Neurology, Sher-I-Kashmir Institute of Medical Sciences, Soura, Srinagar, Jammu and Kashmir, India
| | - Irfan Shah
- Department of Neurology, Sher-I-Kashmir Institute of Medical Sciences, Soura, Srinagar, Jammu and Kashmir, India
| | - Mudasir Mushtaq
- Department of Neurology, Sher-I-Kashmir Institute of Medical Sciences, Soura, Srinagar, Jammu and Kashmir, India
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Abstract
We describe seven patients with idiopathic intracranial hypertension (IIH), a disorder, mostly in young women, characterized by papilledema, elevated cerebrospinal fluid (CSF) pressure, normal CSF composition, and normal neuroradiologic studies. Obesity, the most consistent etiologic association, was present in two of our patients. Hypothalamic compression in IIH may induce increased appetite and result in weight gain. Use of trimethoprim/sulfamethoxazole has been reported to be associated with IIH and was seen in one of our patients. IIH is an important diagnostic consideration in the differential diagnosis for a patient with headache, visual disturbances, and papilledema.
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Affiliation(s)
- N Jain
- Department of Medicine, Queens Hospital Center, Jamaica, New York 11432
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