Case report: Association between PTEN-gene variant and an aggressive case of multiple dAVFs

Introduction

Mutations of the phosphatase and tensin homolog (PTEN) gene have been associated with a spectrum of disorders called PTEN hamartoma tumor syndrome, which predisposes the individual to develop various types of tumors and vascular anomalies. Its phenotypic spectrum includes Cowden syndrome (CS), Bannayan-Riley-Ruvalcaba syndrome (BRRS), Proteus syndrome, autism spectrum disorders (ASD), some sporadic cancers, Lhermitte-Duclos disease (LDD), and various types of associated vascular anomalies.

Clinical presentation

A previously healthy 27-year-old woman was experiencing visual scintillating scotomas and mild chronic headaches for the past 2 years. The initial computed tomographic (CT) and magnetic resonance imaging (MRI) scans did not reveal any abnormalities, but the possibility of pseudotumor cerebri was considered. Furthermore, a cerebral angiogram showed a posterior fossa dural arteriovenous fistula (dAVF), which was initially treated through embolization. However, in spite of proper treatment, this patient experienced multiple recurrent dAVFs in different locations, requiring multiple embolizations and surgeries. Despite exhibiting altered cerebral perfusion and hemodynamics, the patient did not display any significant symptoms until she experienced a sudden stroke resulting from deep venous thrombosis, which was not associated with any medical procedures or medication use. A comprehensive analysis was performed due to the aggressive nature of the dAVFs. Surprisingly, exome sequencing of a blood sample revealed a PTEN gene variant in chromosome 10, indicative of Cowden syndrome. However, no tumors or other vascular lesions were detected in other systems that would constitute Cowden syndrome.

Conclusion

The rapid formation of multiple and complex dAVFs, coupled with not meeting the criteria for any other PTEN-related syndrome, unequivocally leads to the presentation of a novel phenotype of the PTEN germline variant.

Idiopathic intracranial hypertension and obstetric and neonatal outcomes: A 1:20 matched study from a population database

OBJECTIVE

Idiopathic intracranial hypertension (IIH), also known as pseudotumor cerebri, is a common pathology in reproductive-aged women, although data regarding pregnancy outcomes are scarce. In the present study, we aimed to compare pregnancy and perinatal outcomes between women who suffered from IIH to those who did not.

METHODS

A retrospective cohort study using the Healthcare Cost and Utilization Project, Nationwide Inpatient Sample. All pregnant women who delivered or had a maternal death in the US (2004-2014) were included. Women with an ICD-9 diagnosis of IIH before or during pregnancy were matched to controls without IIH according to age, race, insurance type, and income quartile, in a 1:20 ratio. Pregnancy, delivery, and neonatal outcomes were compared between the two groups.

RESULTS

Overall, 9 096 788 deliveries were identified. Of these, 1454 women (0.016%) had a diagnosis of IIH (study group) and were compared to 29 080 women without IIH (control group). Women with IIH, compared to those without, were more likely to be obese (body mass index >30 kg/m2) and suffer from pregestational diabetes mellitus and chronic hypertension (P < 0.001, all). After adjusting for confounders, patients in the IIH group, compared to those without, had a higher rate of pregnancy-induced hypertension (aOR 1.82, 95% CI: 1.57-2.1, P < 0.001), pre-eclampsia (aOR 1.98, 95% CI: 1.61-2.45, P < 0.001), preterm delivery (aOR 1.88, 95% CI: 1.59-2.23, P < 0.001), CD (aOR 2.41, 95% CI: 2.12-2.73, P < 0.001), wound complications (aOR 3.2, 95% CI: 1.89-5.42, P < 0.001), and congenital anomalies (aOR 2.18, 95% CI: 1.4-3.4, P < 0.001).

CONCLUSION

Women with IIH had a higher incidence of obstetrical complications, including preterm deliveries, hypertensive disorders of pregnancy, and congenital anomalies.

Spontaneous Cerebrospinal Fluid Leak in a Patient with Asymptomatic Idiopathic Intracranial Hypertension

BACKGROUND

Spontaneous cerebrospinal fluid (CSF) leaks occur when there is a tear in the dura mater. Spontaneous CSF leaks are rare, and often associated with conditions like intracranial hypertension, connective tissue disorders, or congenital defects in the dura mater.

CASE REPORT

The patient was a 66-year-old woman who presented to the Emergency Department with clear, positional nasal discharge from her left nostril for 1 week. She had a history of chronic headaches, which seemed to have been relieved around the time of onset of her rhinorrhea. Diagnostic imaging, including computed tomography and magnetic resonance imaging scans, confirmed the presence of a CSF leak and a left temporal meningoencephalocele. The patient subsequently underwent surgical repair of the leak and ventriculoperitoneal shunt placement, and was discharged home in stable condition. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Early detection of CSF leaks require a thorough history and physical examination, and is crucial in preventing potentially life-threatening complications such as meningitis and intracranial abscesses.

Navigating the Enigma: A Comprehensive Review of Idiopathic Intracranial Hypertension

An unidentified source of increased intracranial pressure is a hallmark of idiopathic intracranial hypertension (IIH), also referred to as pseudotumor cerebri. It mainly affects young, obese women, yet it can happen to anyone, regardless of age, gender, or weight. IIH presents with symptoms such as headaches, visual disturbances, and pulsatile tinnitus and can lead to severe complications, including vision loss, if left untreated. Diagnosis involves clinical evaluation, neuroimaging, and lumbar puncture, while management options include medical interventions and surgical procedures. This review provides a comprehensive overview of IIH, including its etiology, clinical presentation, epidemiology, complications, management approaches, and challenges. Increased awareness among healthcare professionals, standardized diagnostic criteria, and further research efforts are essential for improving outcomes and quality of life for individuals with IIH.

Assessment of glymphatic dysfunction in pediatric idiopathic intracranial hypertension: insights from quantitative diffusivity and perivascular spaces analysis-a case-control study

Background

The impaired drainage of cerebrospinal fluid through the glymphatic system is thought to play a role in the idiopathic intracranial hypertension (IIH) pathophysiology. Limited data exist regarding the glymphatic system's involvement in pediatric patients with IIH. Therefore, the study's objective was to quantitatively evaluate alterations in parenchymal diffusivity and magnetic resonance imaging (MRI)-visible dilated perivascular spaces (PVS) as imaging indicators of glymphatic dysfunction in pediatric patients with IIH.

Methods

Patients diagnosed with IIH in 2017-2022 in a single tertiary center (Sheba Medical Center, Israel) were retrospectively reviewed. Twenty-four pediatric patients were enrolled. All patients underwent clinical 3-T brain MRI. The control group included 24 age- and gender-matched healthy subjects with a normal-appearing brain on imaging. We used automatic atlas-based diffusion-weighted imaging analysis to determine regional diffusivity of the thalamus, caudate, putamen, globus pallidus, hippocampus, amygdala, and brain stem. PVS were evaluated using a semi-quantitative rating scale on T2-weighted images. Variables were compared using the Mann-Whitney test. Multivariate analysis of covariance was used to test for differences between controls and IIH patients.

Results

No significant differences in regional brain diffusivity were observed between individuals with IIH and healthy controls (P=0.14-0.91 for various brain regions). The number of visible PVS was comparable between patients with IIH and the control group across all evaluated sites (P=0.12-0.74 for various brain regions).

Conclusions

Pediatric IIH patients exhibited similar patterns of parenchymal diffusivity and PVS compared to age-matched controls. These findings do not support the hypothesis that the glymphatic system may play a role in the pathophysiology of pediatric IIH, although previously postulated. However, employing more sophisticated magnetic resonance (MR) techniques could enhance the sensitivity in uncovering underlying glymphatic dysfunction. Further research is warranted to validate and explore this association in larger cohorts and investigate the underlying mechanisms involved in IIH.

Effect of General Anesthesia on MR Optic Nerve Sheath Diameter in the Pediatric Population

BACKGROUND

Papilledema is thought to be the hallmark sign of increased intracranial pressure (ICP). Distension of the subarachnoid space within the optic nerve sheath is also commonly reported in MR studies as an indirect sign of increased ICP.

HYPOTHESIS

General anesthesia and positive pressure ventilation might result in changes in optic sheath diameter (OSD) observed on clinical brain MRI.

STUDY TYPE

Retrospective.

POPULATION

One hundred forty-five  patients (154 MRI scans, 7.3 years ± 5.1); 97 studies in the anesthesia group (4.4 years ± 3.4) of which 22 had papilledema, and 57 in the non-anesthesia group (12.3 years ± 3.2), of which 28 had papilledema.

FIELD STRENGTH/SEQUENCE

1.5T or 3.0T volumetric T2 images. T2 images were obtained from different vendors.

ASSESSMENT

OSD, optic nerve diameter (OND), and peri-optic cerebrospinal fluid (CSF) were measured manually on T2-weighted MR images for various population subgroups (with and without anesthesia; with or without papilledema). The correlation between these measurements and the clinical diagnosis of papilledema was evaluated via receiver operating characteristic (ROC) analysis.

STATISTICAL TESTS

Chi-square test; Mann-Whitney Test; Spearman's test and ROCs; Interclass correlation coefficient, P = 0.05.

RESULTS

General anesthesia resulted in significantly larger mean OSD in patients with or without papilledema (7.3 ± 1.0 mm vs. 6.1 ± 1.1 mm and 6.7 ± 1.0 mm vs. 5.4 ± 0.9 mm, respectively). In the non-anesthesia group, the average OSD values (6.1 ± 1.1 mm) were significantly higher in papilledema patients compared to non-papilledema patients (5.4 ± 0.9 mm), with larger peri-optic CSF rim (1.6 ± 0.4 mm vs. 1.3 ± 0.3 mm). In the anesthesia group, OND was significantly larger in papilledema patients (3.4 ± 0.4 mm vs. 3.1 ± 0.5 mm), though the average peri-optic CSF rim did not reach a significance in papilledema compared with non-papilledema patients (2.0 ± 0.3 mm vs. 1.8 ± 0.4 mm, P = 0.06). In patients with general anesthesia, peri-optic CSF rim had a limited correlation with increased ICP.

DATA CONCLUSION

In the pediatric population, imaging findings of increased OSD on brain MRI might be related to general anesthesia rather than increased ICP. The interpretation of optic nerve sheath distention should be reported cautiously in conjunction with anesthesia status, especially in the pediatric population.

EVIDENCE LEVEL

4 Technical Efficacy: 5.

Cranial decompression and expansion surgery for the treatment of refractory idiopathic intracranial hypertension: case report and systematic review

OBJECTIVE

The purpose of this study is to systematically review the literature on the clinical outcomes following different surgical techniques in patients with refractory idiopathic intracranial hypertension (IIH).

BACKGROUND

IIH is a condition characterised by increased cranial pressure (ICP) in the absence of an intracranial lesion that does not adequately respond to different medical and surgical therapies. Cranial decompression or expansion surgeries are a last resort therapy for patients with refractory IIH.

METHODS

A systematic literature search of the databases of PubMed, Embase and Medline from inception to 2019 was performed. Searches were limited to the English language and to clinical studies. Studies were included if clinical outcomes following different cranial decompression or expansion techniques were reported. We also add one case of our own experience with performing a bilateral frontoparietal expansion craniotomy and subtemporal craniectomy.

RESULTS

Five manuscripts, describing 38 procedures, met the inclusion criteria. Thirty-one patients were female (82%). The mean age was 26.2 years. The techniques studied included subtemporal craniectomy (27/38, 71%), internal cranial expansion (10/38, 26%), and cranial morcellation decompression (1/38, 3%). Thirty-five patients presented with headaches of which 17 noted postoperative improvement or resolution (49%). Visual deficits were documented in 30 patients and 25 reported postoperative improvement (83%). Papilledema disappeared in 23 of 32 patients with this sign at presentation (72%). In our patient, symptoms completely resolved postoperatively and a 6% increase in intracranial volume was measured.

CONCLUSIONS

Cranial vault decompression or expansion surgeries may be an effective last resort therapy for patients with refractory IIH. These surgeries expand the intracranial volume, and thus may normalise ICP, leading to clinical improvement.

Clinical Course and Ophthalmologic Findings in Idiopathic Intracranial Hypertension and Pregnancy

Idiopathic intracranial hypertension (IIH) has its highest prevalence among women of childbearing age and therefore frequently coincides with pregnancy. This retrospective cohort study aimed to explore the impact of pregnancy on the clinical course, ophthalmologic findings and on the therapeutic management of IIH patients. Individual patient records were reviewed for neuro-ophthalmologic findings, treatment strategy, adherence to therapy and pregnancy complications. Sixteen patients with 19 documented pregnancies were identified. The visual acuity, visual field defects and the grade of papilledema at baseline and after pregnancy were compared. The visual acuity and visual field mean deviation at baseline and at follow-up after pregnancy did not significantly differ. Papilledema at baseline was more pronounced in patients who had been diagnosed with IIH during pregnancy than in patients with established IIH. In this cohort, the visual acuity and the visual field were not lastingly impacted by pregnancy. The adherence to therapy was low, with 69% discontinuing treatment or medication.

Determining the role of novel metabolic pathways in driving intracranial pressure reduction after weight loss

Idiopathic intracranial hypertension, a disease classically occurring in women with obesity, is characterized by raised intracranial pressure. Weight loss leads to the reduction in intracranial pressure. Additionally, pharmacological glucagon-like peptide-1 agonism reduces cerebrospinal fluid secretion and intracranial pressure. The potential mechanisms by which weight loss reduces intracranial pressure are unknown and were the focus of this study. Meal stimulation tests (fasted plasma sample, then samples at 15, 30, 60, 90 and 120 min following a standardized meal) were conducted pre- and post-bariatric surgery [early (2 weeks) and late (12 months)] in patients with active idiopathic intracranial hypertension. Dynamic changes in gut neuropeptides (glucagon-like peptide-1, gastric inhibitory polypeptide and ghrelin) and metabolites (untargeted ultra-high performance liquid chromatography-mass spectrometry) were evaluated. We determined the relationship between gut neuropeptides, metabolites and intracranial pressure. Eighteen idiopathic intracranial hypertension patients were included [Roux-en-Y gastric bypass (RYGB) n = 7, gastric banding n = 6 or sleeve gastrectomy n = 5]. At 2 weeks post-bariatric surgery, despite similar weight loss, RYGB had a 2-fold (50%) greater reduction in intracranial pressure compared to sleeve. Increased meal-stimulated glucagon-like peptide-1 secretion was observed after RYGB (+600%) compared to sleeve (+319%). There was no change in gastric inhibitory polypeptide and ghrelin. Dynamic changes in meal-stimulated metabolites after bariatric surgery consistently identified changes in lipid metabolites, predominantly ceramides, glycerophospholipids and lysoglycerophospholipids, which correlated with intracranial pressure. A greater number of differential lipid metabolites were observed in the RYGB cohort at 2 weeks, and these also correlated with intracranial pressure. In idiopathic intracranial hypertension, we identified novel changes in lipid metabolites and meal-stimulated glucagon-like peptide-1 levels following bariatric surgery which were associated with changes in intracranial pressure. RYGB was most effective at reducing intracranial pressure despite analogous weight loss to gastric sleeve at 2 weeks post-surgery and was associated with more pronounced changes in these metabolite pathways. We suggest that these novel perturbations in lipid metabolism and glucagon-like peptide-1 secretion are mechanistically important in driving a reduction in intracranial pressure following weight loss in patients with idiopathic intracranial hypertension. Therapeutic targeting of these pathways, for example with glucagon-like peptide-1 agonist infusion, could represent a therapeutic strategy.

Post-operative weight loss in venous sinus stenting patients: A multi-center review, systematic review, and meta-analysis

INTRODUCTION

Idiopathic intracranial hypertension (IIH) can result in headaches, pulsatile tinnitus, papilledema, and other neurological symptoms. Weight loss can alleviate some symptoms of IIH. This study aims to investigate the effect of venous sinus stenting on post-operative weight and body mass index (BMI) changes among IIH patients. The secondary objective is to investigate the relationship between post-operative weight changes and papilledema resolution.

METHODS

Patients with papilledema undergoing venous sinus stenting for IIH were retrospectively reviewed from two comprehensive North American cerebrovascular centers. Patient demographics, surgical course, post-operative outcomes, and weight were analyzed. A systematic review and meta-analysis of post-operative weight in stented IIH patients was conducted.

RESULTS

Twenty-eight patients with a diagnosis of IIH and papilledema who underwent venous sinus stenting were identified across two institutions. Patients had a mean pre-operative weight of 103.2 kg, which decreased to 101.5 kg at 3-month follow up (p = 0.0757). Patients at 6-month follow-up saw a weight decrease to 97.4 kg (p = 0.0066). Patients who saw papilledema resolution saw a mean greater decrease in weight (-4.5%) at 6-month follow up than those whose papilledema did not resolve (-1.7%), although this was insignificant (p = 0.1091). A total of 41 patients were included in the meta-analysis. Patients had an average of 1.1 increase in BMI at 3-month follow up.

CONCLUSIONS

This study shows that venous sinus stenting leads to modest weight reduction in IIH patients, and those with resolved papilledema experience slightly greater weight loss. Further research is necessary to determine the clinical significance of these findings.

Successful Electroconvulsive Therapy in Idiopathic Intracranial Hypertension With Mood Disorder and Partial Empty Sella Syndrome

ABSTRACT

Patients with idiopathic intracranial hypertension (IIH) often experience significant burden from psychiatric comorbidities. Mood disorders are present in up to half of all patients with IIH, and they are often refractory to treatment by psychopharmacologic agents. Electroconvulsive therapy (ECT) is the criterion standard for treatment of patients with the most severe psychiatric burden but has relative contraindications in those possessing pathologies that raise intracranial pressure (ICP). There is a growing body of literature that a multidisciplinary care model would allow for patients with elevated ICP to receive ECT safely. Despite the high prevalence of mood disorders in patients with IIH, there are only 2 published case reports describing ECT delivery to patients from this cohort. We report our own case of a patient with IIH and major depressive disorder who received 38 bitemporal treatments with a positive response and no change in baseline ICP. Her positive response, along with the absence of elevation of ICP, aligns with the prior reports; however, her IIH symptoms have not responded as reported in the 2 cases-despite receiving more than 4 times the amount of treatments. Moreover, our patient possessed unique imaging for a partial empty sella syndrome, which has recently been found to be the only significant finding in patients who had a mood disorder before IIH diagnosis, versus a mood disorder developing after IIH diagnosis. This case serves to provide evidence of the safety and success of ECT in patients with IIH, relying on multidisciplinary care from psychiatry, neurology, and neuro-ophthalmology.

A Case Report of Pseudotumor Cerebri Syndrome with a Huge Retroperitoneal Cyst

Background: Aside from primary pseudotumor cerebri syndrome (PTCS) with an unknown etiology (i.e., idiopathic intracranial hypertension), which typically occurs in association with obesity, several conditions including cerebral venous abnormalities, drug use, and hormonal imbalance may be a secondary cause of PTCS. However, a focal space-occupying lesion outside of the brain as a cause of PTCS has rarely been reported. Case Presentation: A previously healthy 34-year-old man presented with blurred vision for three weeks. The patient had a three-month preceding history of worsening headache. On admission, he was hypertensive (160/90 mmHg) and underweight with a body mass index of 18.4 kg/m2. Fundus examination documented papilledema in both eyes. Neurological examination was unremarkable except for mild nuchal rigidity, and results of routine serologic testing were normal. Gadolinium-enhanced brain magnetic resonance imaging revealed bilateral posterior scleral flattening, suggesting intracranial hypertension. There was no other abnormal brain parenchymal lesion or meningeal enhancement. Cerebrospinal fluid (CSF) assay showed a markedly increased opening pressure (30.0 cmH2O) with normal CSF composition. A tentative diagnosis of PTCS was made based on ophthalmological, neuroradiological, and laboratory findings. During differential diagnosis, abdomen computed tomography demonstrated a huge benign cystic lesion (14.7 × 10.6 × 16.4 cm) in the right retroperitoneal space, which originated from the mesentery and resulted in hydronephrosis and renovascular hypertension due to external compression of the right kidney. Other evaluations were unremarkable. After successful surgical removal of the cyst, clinical symptoms such as headache, blurred vision, and papilledema on fundus examination were markedly improved, and blood pressure was normalized during the three-month follow-up period. Conclusions: A large retroperitoneal cyst that can increase intra-abdominal pressure could be a rare cause of PTCS. Therefore, meticulous evaluation is warranted for patients with PTCS, especially those without known risk factors.

Benign Intracranial Hypertension: A Rare Manifestation of Neurosarcoidosis

Sarcoidosis is an immune-mediated disease that can involve multiple systems. Sarcoidosis of the nervous system or neurosarcoidosis may present as cranial mononeuropathy, hypothalamic involvement, aseptic meningitis, granulomatous inflammation in the brain parenchyma or spinal cord, peripheral neuropathy, and, in rare cases, as myopathy and benign intracranial hypertension. The most common cranial nerve involvement is the facial nerve, which can present as unilateral or bilateral facial nerve palsy, often with recurrent episodes. Involvement of other cranial nerves such as the second and eighth cranial nerves has also been reported. Granulomatous inflammation in the spinal cord presents as myelopathy or radiculopathy. Peripheral neuropathy can manifest as mononeuropathy, mononeuritis multiplex, or generalized sensory-motor neuropathy. Carpal tunnel syndrome is more common in patients with sarcoidosis compared to the general population. Here, we describe the case of a 40-year-old female who presented with heaviness of the head and blurred vision, with a prior history of left-sided Bell's palsy. Bilateral papilledema was observed during the fundus examination. MRI of the brain revealed signs suggestive of benign intracranial hypertension. The cerebrospinal fluid (CSF) opening pressure was measured at 40 cmH2O. Biopsy of bilateral hilar lymphadenopathy indicated granulomatous inflammation consistent with sarcoidosis. The patient was started on steroids and acetazolamide, and she had a dramatic improvement in symptoms.

Asymptomatic idiopathic intracranial hypertension: Prevalence and prognosis

BACKGROUND

Little is known about the presentation and prognosis of asymptomatic idiopathic intracranial hypertension (IIH). Papilloedema can be found incidentally on routine fundus examination, with many of these patients actually having symptoms on direct questioning. The aim was to evaluate visual and headache outcomes in people with IIH who present with or without symptoms.

METHODS

Prospective observational cohort study, between 2012 and 2021, 343 people with confirmed IIH diagnosis were enrolled in the IIH:Life database. Outcomes such as vision (LogMAR); Humphrey visual field perimetric mean deviation (PMD) and optical coherence tomography (OCT) and headache were evaluated using LOESS (locally weighted scatterplot smoothing) graphs and regression analysis.

RESULTS

One hundred and twenty-one people had incidentally found papilloedema, with 36 people with completely asymptomatic presentations. Those with asymptomatic IIH at diagnosis had similar visual prognosis compared to those with symptomatic disease. Sixty-six percent of the asymptomatic cohort became symptomatic during follow-up, and of these the predominant symptom was headache (96%). Headache frequency during follow-up was lower in the asymptomatic cohort.

CONCLUSIONS

The prognosis of those with IIH who present with or without symptoms is similar.

Optic nerve sheath fenestration: A second lease at sight

Purpose

To study the safety and efficacy of optic nerve sheath fenestration surgery in patients with optic disc edema due to different etiologies.

Methods

Records of 18 eyes of 15 patients who underwent optic nerve sheath fenestration for vision threatening optic disc edema were reviewed retrospectively, and results were analyzed. Improvement of visual acuity was the main measure of outcome. Improved visual fields, resolution of optic disc edema, diplopia, and headache were other benefits that were observed.

Results

Fifteen patients between 13 and 54 years of age were included in the study. Three patients underwent successive bilateral surgery. Idiopathic intracranial hypertension was the most common cause for optic disc edema and was found in 80% of the patients. Mean preoperative logMAR acuity was -1.9789 ± 1.46270, which improved to -0.9022 ± 1.23181 (p < 0.005) in the operated eye, and mean logMAR acuity of contralateral eye improved from -1.3378 ± 1.50107 to -1.0667 ± 1.33813 (p < 0.05).

Conclusion

Early optic nerve sheath fenestration is an effective modality for treating optic disc edema due to a wide myriad of causes and helps resolve the associated symptoms.

High CCL2 Levels Detected in CSF of Patients with Pediatric Pseudotumor Cerebri Syndrome

Pseudotumor cerebri (PTC) is a disorder characterized by increased intracranial pressure in the absence of a structural lesion or other identifiable cause. Cytokines, which are involved in the regulation of immune responses and inflammation, have been implicated in the pathogenesis of PTC. In a prospective, cross-sectional study at three centers in Israel, we analyzed cerebrospinal fluid (CSF) samples from 60 children aged 0.5-18 years, including 43 children with a definitive diagnosis of PTC and a control group of 17 children. Levels of IL-4, IL-10, IL-17, CCL2, CCL7, CCL8, CCL13, BDNF, and IFN-γ were measured using ELISA kits. Levels of CCL2 were significantly higher in the PTC group compared to the control group (p < 0.05), with no other significant differences in the measured cytokines between the two groups. The groups did not differ significantly in clinical presentation, imaging, treatment, or ophthalmic findings. Our findings provide preliminary evidence that CCL2 may be involved in the pathogenesis of PTC and may serve a potential target for therapy in PTC.

Papilledema in childhood for diagnosis of pseudotumor cerebri or late hydrocephalus: a case report

Abstract

A case of hydrocephalus is presented in a 13-year-old female with transient loss of vision from 1 week and papilledema, previous ophtalmological history was negative. Visual field was performed, and neurogical examination proved to be hydrocephalus. In literature few cases of Papilledema in adolescent children with hydrocephalus has been reported. The aim of this case report is to decode the signs, symptoms and factors associated with papilledema in children with hydrocephalus at an early stage in order to prevent a poor visual-functional residual (permanent low vision).

Is Lumbar Puncture Needed? - Noninvasive Assessment of ICP Facilitates Decision Making in Patients with Suspected Idiopathic Intracranial Hypertension

PURPOSE

 Idiopathic intracranial hypertension (IIH) usually occurs in obese women of childbearing age. Typical symptoms are headache and sight impairment. Lumbar puncture (LP) is routinely used for both diagnosis and therapy (via cerebrospinal fluid drainage) of IIH. In this study, noninvasively assessed intracranial pressure (nICP) was compared to LP pressure (LPP) in order to clarify its feasibility for the diagnosis of IIH.

MATERIALS AND METHODS

 nICP was calculated using continuous signals of arterial blood pressure and cerebral blood flow velocity in the middle cerebral artery, a method which has been introduced recently. In 26 patients (f = 24, m = 2; age: 33 ± 11 years), nICP was assessed one hour prior to LPP. If LPP was > 20 cmH₂O, lumbar drainage was performed, LPP was measured again, and also nICP was reassessed.

RESULTS

 In total, LPP and nICP correlated with R = 0.85 (p < 0.001; N = 38). The mean difference of nICP-LPP was 0.45 ± 4.93 cmH₂O. The capability of nICP to diagnose increased LPP (LPP > 20 cmH₂O) was assessed by ROC analysis. The optimal cutoff for nICP was close to 20 cmH₂O with both a sensitivity and specificity of 0.92. Presuming 20 cmH₂O as a critical threshold for the indication of lumbar drainage, the clinical implications would coincide in both methods in 35 of 38 cases.

CONCLUSION

 The TCD-based nICP assessment seems to be suitable for a pre-diagnosis of increased LPP and might eliminated the need for painful lumbar puncture if low nICP is detected.

Efficacy of Optic Nerve Sheath Fenestration in Patients with Increased Intracranial Pressure

Objectives

To evaluate the effectiveness of optic nerve sheath fenestration (ONSF) on visual functions in patients with increased intracranial pressure (İİP).

Materials and Methods

The medical records of 24 eyes of 17 patients who had İİP due to idiopathic intracranial hypertension, cerebral venous sinus thrombosis, or intracranial cyst and underwent ONSF surgery to prevent visual loss were evaluated. Pre- and postoperative visual acuity, optic disc images, and visual field findings were reviewed.

Results

The mean age of the patients was 30.4±8.5 years, and 88.2% were female. The patients' mean body mass index was 28.67±6.1 kg/m². The mean follow-up time was 24±12.1 months (range: 3-44). At postoperative 3 months, the mean best-corrected distance visual acuity had improved in 20 eyes (83.3%) and stabilized in 4 eyes (16.7%) compared to preoperative values. In visual field mean deviation, an improvement was observed in 10 eyes (90.9%), while 1 eye (9.1%) eye remained stable. Optic disc edema decreased in all patients.

Conclusion

This study indicates that ONSF has beneficial effects on visual function in patients with rapidly progressive visual loss caused by increased intracranial pressure.

Prospective, Cross-Sectional Study Finds No Common Viruses in Cerebrospinal Fluid of Children with Pseudotumor Cerebri

Pseudotumor cerebri (PTC) in children is a rare condition whose underlying cause remains largely unknown. No study has yet systematically examined viral infection as a cause of PTC. The current study aimed to characterize PTC in children and investigate the possible role of acute viral infection of the central nervous system in its pathogenesis. A prospective, cross-sectional study was conducted in three centers in Israel. Participants were 50 children aged 0.5-18 years, of whom 27 had a definitive diagnosis of pseudotumor cerebri (the study group) and 23 comprised a control. Data collected included clinical presentation, imaging, treatment, ophthalmic findings, and cerebrospinal fluid (CSF) analysis. Using the ALLPLEX^TM meningitis panel, real-time polymerase chain reaction (PCR) was used to test for the presence of 12 common viruses. PTC patients (mean age 12 ± 4.3 years; 14 males, 13 females) had mean opening pressure of 41.9 ±10.2 mmH2O. All PTC patients had papilledema, and 25 (93%) had PTC symptoms. No viruses were found in the PTC group, while in the control group, one patient tested positive for Epstein-Barr virus and another for human herpesvirus type 6. Overall, in our study, PTC was not found to be associated with the presence of viruses in CSF.

Leber Mitochondrial Optic Neuropathy in Pediatric Females With Focus on Very Early Onset Cases

The aim of this study was to describe the phenotype of Leber hereditary optic neuropathy occurring in pediatric females. This disease generally affects young adult males, but it can occur also in females, and research data in this population is lacking. The very early onset can challenge the diagnosis and delay treatment. We searched PubMed through February 2021 and identified 226 pediatric females with genetically confirmed Leber hereditary optic neuropathy and added a new case of a 3-year-old female. The male-female ratio was 1.8:1; the mean onset age in females was 11 years with the onset at 3 years of age occurring in 3 females only. Acute onset with mild visual impairment was the most common presentation, associated with optic disc edema in 16%. Differential diagnoses are pseudotumor cerebri, optic nerve drusen and optic neuritis. The outcome is poor with partial recovery in 50%, despite some receiving Idebenone therapy.

Co-morbid Polycystic Ovarian Syndrome with Idiopathic Intracranial Hypertension

The link between polycystic ovarian syndrome (PCOS) and idiopathic intracranial hypertension (IIH) has long been debated. Historically, there is a wide range of reported occurrence of both conditions, being between 15% and 64%. Both conditions share a common phenotype. The awareness that in a new large data study that there is a 1.5-fold increased prevalence of diagnosed PCOS in participants with IIH as compared to the controls is important. Assessment for the potential of co-morbid PCOS in women with IIH is important as this may enable optimisation of weight and fertility management.

Idiopathic Intracranial Hypertension following Levothyroxine Replacement Therapy: Systematic Review and a Case Report

The data on the characteristics of patients with idiopathic intracranial hypertension (IIH) following levothyroxine (LT4) replacement are limited. Here, we report a case and systematically review published cases of idiopathic intracranial hypertension (IIH) following levothyroxine (LT4) replacement. The systematic review was performed as per the PRISMA guidelines. Our patient is a 46-year-old lady with hypothyroidism (thyrotropin: 319 mIU/L, free thyroxine: 0.04 ng/dl), treated with 100 μg.d of LT4 and presented a month later with headache, visual diminution, bilateral lateral rectus palsies, and papilledema. Cerebrospinal fluid (CSF) pressure was 32 cmH2O. Drainage of CSF, oral acetazolamide, and modification of LT4 dose resulted in prompt symptomatic improvement and complete reversal of IIH. In the systematic review (n = 21), the median age of patients (7 males) was 13 (IQR: 8.8- 26.5) years. The median duration of hypothyroid symptoms was 4 (n = 10, IQR: 0.44-6.25) years whereas that from initiation of LT4 replacement to the diagnosis of IIH was 2 (n = 20, IQR: 1.17-4) months. Initial median serum thyrotropin and thyroxine were 100 (n = 14, IQR: 72.5-421.6) mIU/L, and 1.13 (n = 12, IQR: 1.0-2.45) μg/dl which changed to 2.2 (n = 7; IQR: 0.23-3.40) mIU/L and 8.90 μg/dl (n = 8, IQR: 6.43-14.85 μg/dl), respectively at diagnosis of IIH after LT4 treatment with median daily LT4 doses of 0.89 (n = 8, IQR: 0.60 - 1.17) times the maximum recommended dose for age. To conclude, we report an adult woman with IIH following LT4 replacement for primary hypothyroidism, a rare entity. Pediatric age, prolonged symptom duration, and use of higher LT4 replacement dose may be associated with IIH following LT4 replacement.

Cerebrospinal fluid levels of sortilin-1, lipocalin-2, autotaxin, decorin and interleukin-33 in patients with idiopathic intracranial hypertension

BACKGROUND

Idiopathic intracranial hypertension (IIH) is characterized by increased cerebrospinal fluid (CSF) pressure of unknown cause. It has been suggested that the inflammatory process plays a role in the pathophysiology of the disease. Sortilin-1, lipocalin-2, autotaxin, decorin, and interleukin-33 (IL-33) are among the factors involved in inflammatory processes.

OBJECTIVE

To investigate the CSF levels of sortilin-1, lipocalin-2, autotaxin, decorin, and IL-33 in patients with IIH.

METHODS

A total of 24 IIH patients and 21 healthy controls were included in the study. Demographic characteristics of the patients and of the control group as well as CSF pressures were evaluated. Sortilin-1, lipocalin-2, autotaxin, decorin and IL-33 levels in the CSF were measured.

RESULTS

The CSF levels lipocalin-2, sortilin-1, autotaxin, IL-33 and CSF pressure were significantly higher in the patients group compared with the control group (p < 0.001). Decorin levels were reduced in patients (p < 0.05). There was no correlation between the autotaxin and IL-33 levels and age, gender, CSF pressure, and body mass index. The results of our study showed that inflammatory activation plays an important role in the development of the pathophysiology of IIH. In addition, the fact that the markers used in our study have never been studied in the etiopathogenesis of IIH is important in explaining the molecular mechanism of this disease.

CONCLUSION

Studies are needed to evaluate the role of these cytokines in the pathophysiology of the disease. It is necessary to evaluate the effects of these molecules on this process.

Evaluation of Clinical Findings with MRI Venography in Patients with Idiopatic Intracranial Hypertension

OBJECTIVES

To evaluate clinical data and Magnetic Resonance Venography (MRV) findings together in patients with idiopathic intracranial hypertension (IIH).

MATERIALS AND METHODS

In this retrospective study between January 2009 and February 2021, conventional MRI and MRV examinations were performed on 30 patients who were admitted to the neurology service of Erciyes University Medical Faculty with the pre-diagnosis of IIH, cerebrospinal fluid (CSF) pressure was measured in these patients to confirm the diagnosis of IIH. Transverse Sinus Stenosis Ratio (TS SR), Superior Sagittal Sinus (SSS) diameter, Sinus Rectus (SR) diameter, Stenosis Segment Length (SSL) were studied.

RESULTS

High CSF pressure was detected in 22 of 30 patients with IIH pre-diagnosis. CSF pressure was normal in 8 cases. TS SR was compared in all groups, right TS SR 0.63 ± 0.16, Left TS SR 0.55 ± 0.16 in the patient group with IIH, right TS SR 0.55 ±0.16 in the CSF pressure normal patient group, Right TS SR 0.28 ± 0.07 Left TS SR 0.31 ± 0.07 in the control group Right TS SR It was 0.28 ± 0.09, Sol TS SR was 0.30 ± 0.07.

CONCLUSION

Before LP, the cranial venous system must be monitored. TS SR and CSF pressure are directly proportional. The stenosis rate is important for IIH rather than SSL.

Idiopathic intracranial hypertension: Evaluation of births and fertility through the Hospital Episode Statistics dataset

OBJECTIVE

Idiopathic intracranial hypertension (IIH) predominantly affects women of reproductive age with obesity, and these women have a distinct profile of hyperandrogenism and insulin resistance. Polycystic ovary syndrome (PCOS) has an established adverse fertility phenotype that typically affects obese women. As IIH may impact reproductive health, we sought to evaluate fertility, gestational complications and pregnancy outcome in IIH.

DESIGN

Prospective cohort study from English Hospital Episode Statistics dataset.

SETTING

English hospitals, UK.

POPULATION

Women aged 18-45 years seen in English hospitals between 1 April 2002 and 31 March 2019. Patients were required to have an IIH diagnosis and were compared with those with PCOS and general population female controls.

MAIN OUTCOME MEASURES

Pregnancies resulting in live births, complications of gestational diabetes and pre-eclampsia, and method of delivery.

RESULTS

Data was collected from 17 587 IIH, 199633 PCOS and 10 947 012 women in the general population. The live birth rate, adjusted for age, was significantly lower among women with IIH (54.1%) than PCOS (67.9%), p < 0.0001 and the general population (57.7%), p < 0.0001. Pre-eclampsia and gestational diabetes risks were higher following a diagnosis of IIH (5.3-fold and 2.7-fold, respectively, p < 0.0001) compared with the general population controls. Following a diagnosis of IIH, elective caesarean section rates were more than twice that of general population (odds ratio [OR] 2.4) and prior to a diagnosis of IIH (OR 2.2).

CONCLUSIONS

These data indicate there are lower age-adjusted total pregnancy rates, increased risk of pre-eclampsia and gestational diabetes, and a doubling of elective caesarean section rates in those with a diagnosis of IIH.

Pregnancy and Childbirth in Women With Idiopathic Intracranial Hypertension

Background Idiopathic intracranial hypertension affects many women of childbearing age. However, the literature is sparse regarding pregnancy outcomes for these women. The goal of this study is to investigate the relationship between pregnancy outcomes in patients with a diagnosis of idiopathic intracranial hypertension. Methodology The TriNetX Research Network database was used to query 57 healthcare organizations for patients with idiopathic intracranial hypertension while pregnant (cohort 1) versus those who were pregnant without idiopathic intracranial hypertension (cohort 2). Cohorts were propensity-score matched for confounders related to pregnancy outcomes. The primary outcomes of interest were ectopic or molar pregnancy, cesarean section, abortion, preterm labor, depression, pre-eclampsia or eclampsia, and mortality. Chi-square analysis and logistic analysis were used on categorical variables. Results Ectopic/molar pregnancy was seen in 106 (1.75%) versus 117 (1.93%) (odds ratio (OR) 0.904, 95% confidence interval (CI) (0.694, 1.179), p = 0.4572) patients in cohorts 1 and 2, respectively. Cesarean section was seen in 785 (12.94%) versus 886 (14.59%) (OR 0.869, 95% CI (0.784, 0.964), p = 0.0078) patients, abortion in 536 (8.83%) versus 682 (11.24%) (OR 0.765, 95% CI (0.679, 0.862), p < 0.0001), preterm labor in 498 (8.206%) versus 668 (11.01%) (OR 0.723, 95% CI (0.640, 0.816), p < 0.0001), depression in 1,057 (17.42%) versus 1,061 (17.48%) (OR 0.995, 95% CI (0.906, 1.093), p = 0.9238), and pre-eclampsia/eclampsia in 501 (8.26%) versus 492 (8.11%) (OR 0.1.02, 95% CI (0.896, 1.161), p = 0.7657). Mortality was seen in 68 patients in cohort 1 versus 13 patients in cohort 2 (OR 5.279, 95% CI (2.913, 9.564), p < 0.0001). Conclusions This retrospective study examined pregnancy outcomes for pregnant women with a diagnosis of idiopathic intracranial hypertension. Women with idiopathic intracranial hypertension do not have an increase in rates of abortion, ectopic/molar pregnancy, cesarean section, preterm labor, or depression when compared to women without idiopathic intracranial hypertension. The mortality rate was higher in the idiopathic intracranial hypertension cohort, but still very low. This study demonstrates that pregnancy is generally well tolerated in the idiopathic intracranial hypertension population.

Visual recovery after unilateral optic nerve sheath fenestration for pseudotumor cerebri syndrome

PURPOSE

To evaluate the effect of optic nerve sheath fenestration (ONSF) on the rate of visual function improvement in patients with pseudotumor cerebri syndrome (PTCS).

METHODS

Retrospective chart review of patients with PTCS who underwent ONSF between 1998 and 2017. Visual function was evaluated by evaluating visual field (VF), mean deviation (MD), retinal nerve fiber layer (RNFL) thickness, papilledema grade, and visual acuity (VA) prior to and after ONSF.

RESULTS

Seventeen female patients aged 17 to 36 years underwent unilateral ONSF. Follow-up averaged 40.1 months. VF MD improved steadily in both eyes up to 12 months. Average RNFL thickness improved in the operated eye from 347 ± 166 mm to 92 ± 27 mm (p < .001) and the non-operated eyes from 306 ± 165 mm to 109 ± 46 mm (p < .001). The grade of papilledema improved in the operated eye from 3.3 ± 1.3 to 0.3 ± 0.7 and the non-operated eye from 3.0 ± 1.6 to 0.18 ± 0.4. There was an exponential rate of improvement in papilledema and RNFL thickness, with the greatest improvement occurring within the first 30 days. Average visual acuity remained intact in both eyes before and after surgery.

CONCLUSIONS

ONSF in appropriately selected patients leads to rapid improvement in papilledema and a steady recovery in VF.

Management of idiopathic intracranial hypertension in pregnancy

Idiopathic intracranial hypertension is more common among women of reproductive age and is often encountered in pregnancy, either pre-existing and exacerbated by pregnancy-associated weight gain and hormonal changes or arising de novo. We report the case of a 33-year-old woman with progressive visual loss and intractable headache from 20 weeks' gestation requiring ventriculoperitoneal shunting during pregnancy. The risk of permanent maternal vision loss raises complex management dilemmas, when this must be balanced with the fetal and neonatal risks of treatment and possible premature delivery.

Increased Incidence of Pseudotumor Cerebri Syndrome Among Users of Tetracycline Antibiotics

BACKGROUND

To determine whether the use of a tetracycline-class antibiotic is associated with an increased risk of developing pseudotumor cerebri syndrome (PTCS).

METHODS

We identified patients in the University of Utah Health system who were prescribed a tetracycline-class antibiotic and determined what percentage of those individuals were subsequently diagnosed with PTCS secondary to tetracycline use. We compared this calculation to the number of patients with PTCS unrelated to tetracycline use.

RESULTS

Between 2007 and 2014, a total of 960 patients in the University system between the ages of 12 and 50 were prescribed a tetracycline antibiotic. Among those, 45 were diagnosed with tetracycline-induced PTCS. We estimate the incidence of tetracycline-induced PTCS to be 63.9 per 100,000 person-years. By comparison, the incidence of idiopathic intracranial hypertension (IIH) is estimated to be less than one per 100,000 person-years (Calculated Risk Ratio = 178).

CONCLUSIONS

Although a causative link between tetracycline use and pseudotumor cerebri has yet to be firmly established, our study suggests that the incidence of pseudotumor cerebri among tetracycline users is significantly higher than the incidence of IIH in the general population.

Case Report of Idiopathic Intracranial Hypertension in Pregnancy

Idiopathic intracranial hypertension (IIH) is a disease of increased intracranial pressure with an unknown cause that is seen most often in women during their childbearing years. Women can be under care for IIH when they become pregnant, or it may occur during pregnancy. In the past, women with IIH who became pregnant were often counseled to terminate their pregnancies, to give birth early, and even to be sterilized to prevent future pregnancies. Today, multiple therapeutic options are available. In this case report, I describe the case of a woman with IIH who was treated with a cerebral spinal fluid shunt and gave birth to two sets of twins. This case report adds new information to the limited nursing literature currently available on this disease.

Cerebral Venous Outflow Implications in Idiopathic Intracranial Hypertension-From Physiopathology to Treatment

In this review, we provide an update on the pathogenesis, diagnosis, and management of adults with idiopathic intracranial hypertension (IIH) and implications of the cerebral venous system, highlighting the progress made during the past decade with regard to mechanisms of the venous outflow pathway and its connection with the cerebral glymphatic and lymphatic network in genesis of IIH. Early diagnosis and treatment are crucial for favorable visual outcomes and to avoid vision loss, but there is also a risk of overdiagnosis and misdiagnosis in many patients with IIH. We also present details about treatment of intracranial hypertension, which is possible in most cases with a combination of weight loss and drug treatments, but also in selected cases with surgical interventions such as optic nerve sheath fenestration, cerebral spinal fluid (CSF) diversion, or dural venous sinus stenting for some patients with cerebral venous sinus stenosis, after careful analysis of mechanisms of intracranial hypertension, patient clinical profile, and method risks.

Headaches and obesity

Obesity and headache disorders are two very common conditions in the general population that have been increasing in incidence over the last decades. Recent studies have shown a significant relationship between obesity and headaches, particularly migraine, with an important role in whether the disease is chronic. On the other hand, no such association was found with tension-type headaches. Studies showing an overlapping of hunger-control pathways and those involved in the pathophysiology of migraine may justify the close association between obesity and migraine. Moreover, a secondary headache for which obesity is a strong risk factor is idiopathic Intracranial Hypertension (pseudotumor cerebri), with several studies showing the impact of weight reduction/bariatric surgery in the treatment of the disease. In conclusion, since obesity is a modifiable risk factor, it is important for physicians treating patients with headaches, and particularly migraine, to be aware of the association between these two disorders.

Update on Idiopathic Intracranial Hypertension Management

BACKGROUND

Idiopathic Intracranial Hypertension (IIH) is a secondary headache with a steadily growing incidence. Currently, there is little evidence to guide the treatment of IIH.

OBJECTIVE

To review the pathophysiology of IIH, with focus on the role of obesity as a risk factor, and the implications for new therapeutic perspectives.

METHODS

in this narrative review, we summarized the current knowledge on treatment options highlighting available evidence for managing intracranial hypertension, obesity, and headache.

RESULTS

Clinical Presentation: headache is the most common symptom and a significant cause of quality-of-life impairment. Visual loss is common in the diagnosis. Pathophysiology: there is no unified theory able to explain all symptoms and the evolution of the disease. There is growing data pointing to metabolic changes and obesity with a central role in IIH pathophysiology. Treatment: most published data on IIH treatment is related to pressure control and protection from visual loss. Acetazolamide and cerebrospinal fluid diversion are the best options available. Optic nerve sheath fenestration might be useful to temporally control the pressure over the optic nerve and thus protect from visual deterioration. Recently, venous sinus stenting has proven to be a safe option in selected cases. Finally, bariatric surgery has proven to effectively control elevated intracranial pressure.

CONCLUSION

IIH is a potential cause of high disability. Early recognition is important, and treatment should be tailored to the needs of each case. There is a lack of research on headache management, which might persist after ICP control.

Why don't ventricles dilate in pseudotumor cerebri? A circuit model of the cerebral windkessel

OBJECTIVE

Pseudotumor cerebri is a disorder of intracranial dynamics characterized by elevated intracranial pressure (ICP) and chronic cerebral venous hypertension without structural abnormalities. A perplexing feature of pseudotumor is the absence of the ventriculomegaly found in obstructive hydrocephalus, although both diseases are associated with increased resistance to cerebrospinal fluid (CSF) resorption. Traditionally, the pathophysiology of ventricular dilation and obstructive hydrocephalus has been attributed to the backup of CSF due to impaired absorption, and it is unclear why backup of CSF with resulting ventriculomegaly would not occur in pseudotumor. In this study, the authors used an electrical circuit model to simulate the cerebral windkessel effect and explain the presence of ventriculomegaly in obstructive hydrocephalus but not in pseudotumor cerebri.

METHODS

The cerebral windkessel is a band-stop filter that dampens the arterial blood pressure pulse in the cranium. The authors used a tank circuit with parallel inductance and capacitance to model the windkessel. The authors distinguished the smooth flow of blood and CSF and the pulsatile flow of blood and CSF by using direct current (DC) and alternating current (AC) sources, respectively. The authors measured the dampening notch from ABP to ICP as the band-stop filter of the windkessel.

RESULTS

In obstructive hydrocephalus, loss of CSF pathway volume impaired the flow of AC power in the cranium and caused windkessel impairment, to which ventriculomegaly is an adaptation. In pseudotumor, venous hypertension affected DC power flow in the capillaries but did not affect AC power or the windkessel, therefore obviating the need for adaptive ventriculomegaly.

CONCLUSIONS

In pseudotumor, the CSF spaces are unaffected and the windkessel remains effective. Therefore, ventricles remain normal in size. In hydrocephalus, the windkessel, which depends on the flow of AC power in patent CSF spaces, is impaired, and the ventricles dilate as an adaptive process to restore CSF pathway volume. The windkessel model explains both ventriculomegaly in obstructive hydrocephalus and the lack of ventriculomegaly in pseudotumor. This model provides a novel understanding of the pathophysiology of disorders of CSF dynamics and has significant implications in clinical management.

Idiopathic Intracranial Hypertension - Challenges and Pearls

Idiopathic intracranial hypertension (IIH) is defined as a syndrome of raised intracranial pressure with normal imaging of the brain and cerebrospinal fluid (CSF) composition. There is a rising incidence and prevalence of this disease related to the increased prevalence of obesity. It typically affects women of working age, and headache is the predominant morbidity in over 90%. The disease is also more prevalent in young males. There are many controversies and myths that surround IIH. There are currently few treatment options for IIH, management is typically medical with those experiencing progressive visual loss undergoing surgical procedures. Weight loss and venous sinus stenting are a few therapies directed at the etiology.

COINCIDENCE OF IDIOPATHIC INTRACRANIAL HYPERTENSION AND LEBER HEREDITARY OPTIC NEUROPATHY. A CASE REPORT

GOAL

This paper describes a case of a long-term monitoring of a patient with optic nerve swelling on the ocular background (papilledema), accompanied by symptoms of intracranial hypertension, on whom a genetic examination was performed as part of differential diagnosis, confirming Leber Hereditary Optic Neuropathy with the m.3460G&gt;A mutation. Casuistry: During the examination of a 5-year-old patient after an alleged head injury at a bouncy castle, an optic nerve papilla with unclear boundaries was described on the ocular background of both eyes. Neurological examination, including brain Magnetic Resonance Imaging, was indicated to rule out possible intracranial hypertension. Both examinations yielded a finding within the norm. After eight years of regular follow-up, the patient attended to our clinic with acute problems in terms of sudden visual impairment during baseball training. The performed eye examination revealed a deterioration of the vision of the right eye on counting fingers to 50 cm, vision of the left eye to 0.4 naturally, a slowed photoreaction of the right pupil, prominent optic nerve papilla with unclear boundaries on both eyes, dilated and more coiled vessels with a crossing phenomenon, the retinal periphery shows no focal changes. Due to the swelling of the papilla, acute deterioration of the vision and the suspected intracranial hypertension, the patient was immediately referred for neurological examination and subsequent hospitalization. There, the patient underwent computer tomography of the brain, venography of the dural venous sinuses and an initial laboratory examination that showed no pathology. There was increasing headache, nausea and vomiting throughout the period. A lumbar puncture was performed. The cerebrospinal fluid pressure before sampling was 285 mmH2O and 100 mmH2O after sampling. The biochemistry of the fluid was normal with negative microbiology. Evoked visual potentials had bilaterally prolonged latencies, which corresponds to optic nerve compression. An ophthalmological examination ruled out a drusen papilla. Using Optical Coherence Tomography, a 600 &#956;m edema was detected. The patient underwent two relieving lumbar punctures, which led to a subjective improvement without objective improvement. Finally, the neurosurgeon referred the patient for ventriculoperitoneal drainage. Due to the impaired vision and lack of response to the therapy induced, a genetic test was performed, which confirmed Leber Hereditary Optic Neuropathy with the mutation of m.3460G&gt;A.

CONCLUSION

Despite the substantially improved identification of the Leber Hereditary Optic Neuropathy, the diagnosis may still be significantly delayed. The variability of initial findings, the rare incidence of the disease and few well-defined symptoms of the disease lead to significant diagnostic difficulties and late commencement of treatment. It is not possible to say whether there was a coincidence of IIH and LHON or whether the signs of IIH are a possible concomitant of the acute phase of LHON.

Elusive Neck Carcinoma Simulating Idiopathic Intracranial Hypertension Due to Jugular Venous Outflow Obstruction - Case Report

Few cases have been reported of extra-cranial tumours in the neck causing intracranial hypertension due to jugular vein compression and consequent outflow obstruction. We present a case of a patient presenting with transient vision loss due to intracranial hypertension of unidentifiable cause on initial imaging workup. Upon further evaluation, the patient was found to have a neck tumour compressing the right jugular vein with stenosis of the ipsilateral transverse sinus - both contributing to his intracranial hypertension. Atypical patients presenting with symptoms concerning for intracranial hypertension may benefit from imaging below the level of the head to evaluate for extra-cranial causes.

Multisystem Inflammatory Syndrome in Children Presenting With Pseudotumor Cerebri and a Review of the Literature

Multisystem inflammatory syndrome in children (MIS-C) is a rare but life-threatening inflammatory immune response associated with severe acute respiratory syndrome coronavirus 2 infection. The majority of patients have been presented with hypotension, shock, gastrointestinal, cardiovascular and mucocutaneous symptoms. The incidence of neurologic symptoms in MIS-C is of rising concern as they are not well described and reported in fewer patients. An 8-year-old boy was admitted to the hospital with headache, fever, conjunctivitis, and hyperinflammatory findings diagnosed as MIS-C. Fundus examination performed with complaints of headache, vomiting, and conjunctivitis showed bilateral papilledema. Pseudotumor cerebri is a rare manifestation of MIS-C that can lead to vision loss and may not only be resolved with the standard treatment for MIS-C. We report a case of MIS-C presented with neurologic symptoms due to pseudotumor cerebri and successfully treated with intravenous immunoglobulin and acetazolamide.

Levothyroxine-Induced Pseudotumor Cereberi

Rise in intracranial tension (ICT) has varied clinical presentation which can range from subtle disturbances like headache to frank neurologic impairment. An important aspect is rapidity of rise of ICT. Pseudotumor cerebri is associated with many syndromes, toxication, and drugs. Our case is a unique one given the rarity of eltroxin, which is otherwise relatively safe drug and commonly used in this part of the world, induced Pseudotumor cerebri. Our patient had dramatic response to discontinuation of levothyroxine.

Optic nerve sheath decompression saves sight in severe papilloedema: results from 81 eyes in 56 patients with pseudotumor cerebri

PURPOSE

To report the outcome of optic nerve sheath decompression (ONSD) for papilloedema in a teaching hospital in western Turkey.

METHODS

The charts of 56 patients who had ONSD surgery between April 2007 and September 2019 were collated; and a total of 81 operated and 31 fellow eyes were included. Pre- and postoperative ophthalmologic examination including best-corrected visual acuity (BCVA), colour vision (CV), visual field (VF) analysis, fundoscopic examination and demographic and medical characteristics of the patients were noted and outcomes after surgery were investigated.

RESULTS

Of all study eyes, 49 (43.7%) eyes had BCVA 0.2 or less and 62 (55.3%) eyes had mean deviation (MD) below - 20.0 dB. 62 (55.3%) eyes had Frisen grade 4 or 5 papilloedema. Almost half of the eyes had severe vision loss. After ONSD, BCVA, CV and MD in both operated and fellow non-operated eyes improved significantly (p < 0.001, p = 0.009 and p < 0.001 for operated, p < 0.001, p = 0.007 and p < 0.001 for fellow eyes, respectively). Earlier surgery and higher cerebrospinal fluid opening pressure were related to better outcomes. None of the patients had major operative complications.

CONCLUSION

Optic nerve sheath decompression can safely improve vision not only of the operated but also of the non-operated eye, even in cases with severe vision loss from severe bilateral papilloedema. Regardless of initial VA and VF, patients may benefit from ONSD; the earlier it is done the more likely the better outcome.

Renal Involvement and Its Treatment in Pediatric Patients With Proteinase-3 Anti-Neutrophil Cytoplasmic Antibody Positive Granulomatosis With Polyangiitis: A Case Series

We describe three pediatric patients between the ages of 10 and 14 years old who were diagnosed with granulomatosis with polyangiitis (GPA) between 2014 and 2019. Each case involves variations in presentation, symptomatology, diagnostics, and induction and maintenance therapy regimens. Patient 1 presented with significant renal involvement, hypertensive emergency, and focal alveolar hemorrhage, a rare presentation of GPA that causes up to 60% mortality.Patient 2 presented with minimal renal involvement and a diffuse petechial rash, which is the most common cutaneous presentation of GPA. Finally, patient 3 presented with significant renal involvement and later on with symptoms of idiopathic intracranial hypertension (IIH), a unique and rare presentation associated with GPA. Despite the heterogeneity of these cases, the similar therapy regimens used in each case successfully achieved induction and maintenance of disease remission, providing an evidentiary basis for these treatment regimens even in severe and unusual pediatric GPA cases.

Optic nerve sheath diameter measurement: a means of detecting increased intracranial pressure in pseudotumor cerebri patients

BACKGROUND

Pseudotumor cerebri (PTC) occurs when the pressure inside the skull increases for no obvious reason. The aim of this study was to investigate three different methods: the optic nerve sheath diameter (ONSD) method, ONSD/eyeball transverse diameter (ETD) index, and ONSD/orbital transverse diameter (OTD) index for the initial detection of elevated ICP in patients with PTC.

MATERIALS AND METHODS

A retrospective study of MR data from adult PTC patients (n=42) and control group (n=40) was performed. ONSD and OTD measurements were made 3mm and 10mm posterior to the globe, after intracranial pressure was measured with lumbar puncture. The sensitivity, specificity, and overall accuracy of the findings on MRI were calculated.

RESULTS

The optic nerve sheath was enlarged in the PTC group compared with the control group. It showed 97%sensitivity and 100% specificity and 79% sensitivity and 87.5% specificity for 3mm and 10mm, respectively. The ONSD/ETD and ONSD/OTD indices were increased in the PTC group compared with the control group. For 3mm posterior to the globe, the ONSD/ETD index had 90.5% sensitivity and 92% specificity, and the ONSD/OTD index had 86% sensitivity and 95% specificity. For 10mm posterior to the globe, the sensitivity and specificity of the ONSD/ETD and ONSD/OTD indices were 86% and 80% and 74% and 82.5%, respectively.

CONCLUSIONS

According to our study, the ONSD method and the ONSD/ETD and ONSD/OTD indices are reliable diagnostic markers for PTC. These noninvasive techniques may be useful in monitoring the invasive intracranial catheter and have wide potential clinical applications in district hospitals, emergency departments and intensive care units.

Neuroimaging Features of Intracranial Hypertension in Pediatric Patients With New-Onset Idiopathic Seizures, a Comparison With Patients with Confirmed Diagnosis of Idiopathic Intracranial Hypertension: A Preliminary Study

A cutoff value of 6.0 mm for optic nerve sheath dilation may be used as a screening imaging marker to suspect elevated opening pressure with specificity of 88% in pediatric patients with new-onset idiopathic seizures.

Pseudotumor Cerebri Syndrome as a Neurologic Involvement of Multisystem Inflammatory Syndrome in Children: A Case Report

BACKGROUND

Coronavirus disease 2019 may have neurological manifestations including meningitis, encephalitis, post-infectious brainstem encephalitis and Guillain-Barre syndrome. Neuroinflammation has been claimed as a possible cause. Here, we present a child with multisystem inflammatory syndrome in children (MIS-C) who developed pseudotumor cerebri syndrome (PTCS) during the disease course.

CASE

A 11-year-old girl presented with 5 days of fever, headache and developed disturbance of consciousness, respiratory distress, conjunctivitis and diffuse rash on her trunk. Immunoglobulin M and G antibodies against severe acute respiratory syndrome coronavirus 2 were positive in her serum. She was diagnosed with MIS-C. On day 10, she developed headache and diplopia. Left abducens paralysis and bilateral grade 3 papilledema were observed. Brain magnetic resonance imaging revealed optic nerve head protrusion, globe flattening. She was diagnosed with secondary PTCS. Papilledema and abducens paralysis improved under acetazolamide and topiramate. Neurological examination became normal after 2 months.

CONCLUSION

PTCS may emerge related to MIS-C.

External lumbar drainage in progressive pediatric idiopathic intracranial hypertension

OBJECTIVE

Pediatric idiopathic intracranial hypertension (IIH) is characterized by increased intracranial pressure despite normal cerebrospinal fluid and neuroimaging findings. Initial management is typically medical; however, nearly 10% of children will eventually require surgery for persistent headache and/or vision loss. External lumbar drainage, which is a considerably safer treatment option, has not been adequately analyzed in children with medically refractory IIH.

METHODS

The authors conducted a single-institution retrospective analysis of children with medically refractory IIH who had undergone external lumbar drain (ELD) placement because of worsening papilledema, reflected as increased retinal nerve fiber layer (RNFL) thickness on optical coherence tomography (OCT) testing. The main outcome measures were effects of external lumbar drainage on papilledema resolution, symptoms, and vision.

RESULTS

The authors analyzed the medical records of 13 children with IIH (11 girls, mean age 15.0 ± 2.3 years) whose mean CSF opening pressure was 45.5 ± 6.8 cm H2O. In all children, the average global RNFL thickness in both eyes significantly increased at ELD placement (right eye 371.8 ± 150.2 μm, left eye 400.3 ± 96.9 μm) compared with presentation thickness (right eye 301.6 ± 110.40 μm, left eye 350.2 ± 107.7 μm) despite acetazolamide medical therapy (20-30 mg/kg/day), leading to ELD placement after 9.5 ± 6.9 days (range 3-29 days). After ELD insertion, there was headache resolution, gradual and continuous improvement in optic disc thickness, and preservation of good vision.

CONCLUSIONS

ELD placement in children with medically refractory IIH who demonstrated worsening papilledema with increased RNFL thickening on OCT testing typically results in symptom relief and disc edema resolution with good visual outcome, often preventing the need for additional definitive surgeries that carry greater failure and morbidity risks.

Herpes Simplex Virus-2 Meningitis Masquerading as Pseudotumor Cerebri

We report a case of a 27-year-old obese female presenting with headache, blurry and double vision. She was found to have bilateral papilledema by an ophthalmologist and sent to the emergency department (ED). Cerebrospinal fluid (CSF) analysis showed elevated opening pressure and lymphocytic pleocytosis. Symptoms improved significantly after lumbar puncture (LP). Subsequently, polymerase chain reaction (PCR) for herpes simplex virus-2 (HSV-2) came back positive. This case represents an unusual presentation of HSV-2 meningitis, where the clinical picture was suggestive of pseudotumor cerebri or idiopathic intracranial hypertension (IIH), but CSF analysis revealed HSV-2. Papilledema and elevated intracranial pressure has not previously been described in association with HSV-2. Therefore, patients presenting with typical signs and meeting all diagnostic criteria for IIH in the presence of CSF pleocytosis may represent a distinct group of viral-induced intracranial hypertension. In these cases, an investigation of viral etiologies should be conducted.

Abnormal Intracranial Pulse Pressure Amplitude Despite Normalized Static Intracranial Pressure in Idiopathic Intracranial Hypertension Refractory to Conservative Medical Therapy

Idiopathic intracranial hypertension (IIH) incorporates symptoms and signs of increased intracranial pressure (ICP) and is diagnosed by increased lumbar cerebrospinal fluid pressure. However, our knowledge about the characteristics of ICP abnormality, e.g., changes in pulsatile versus static ICP, remains scarce. This study questioned how overnight pulsatile ICP (mean ICP wave amplitude, MWA) associates with static ICP (mean ICP) in IIH patients who were refractory to conservative medical treatment. The material included 80 consecutive IIH patients undergoing ICP monitoring prior to shunt, as part of work-up for failed conservative medical therapy. In this group, the overnight mean ICP was normalized in 52/80 patients, but with abnormal overnight MWA in 45 of the 52 patients. Even though there was a positive correlation between MWA and mean ICP at group level and within individual ICP recordings, the levels of MWA were abnormal in a high proportion of patients despite normalized mean ICP. Taken together, the present results disclosed lasting abnormal pulsatile ICP despite normalized static ICP in IIH patients refractory to conservative medical therapy, which may reflect the underlying pathophysiology. It is tentatively suggested that abnormal pulsatile ICP in IIH may reflect alterations at the glia-neurovascular interface, resulting in impaired astrocytic pulsation absorber mechanisms.

The diagnostic dilemma of bilateral optic neuritis and idiopathic intracranial hypertension coexistence in a patient with recent COVID-19 infection

Owing to autoantibody production and thrombophilic disorders in COVID-19, physicians must have low threshold to investigate secondary IIH and demyelinating disorders in patients with headache and decreased vision following recent COVID-19 infection.

Idiopathic intracranial hypertension with juvenile idiopathic arthritis-associated uveitis: A case report

A 14-year-old girl with juvenile idiopathic arthritis (JIA)-associated uveitis who also had optic disc edema, was later diagnosed with Idiopathic intracranial hypertension (IIH). To our knowledge, this is the fifth case of the coexistence of uveitis and IIH among children, and the only one with no obvious risk factors for IIH.