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Grand Ward Round

Grand Ward Round. 28/6/07 Jamie Ng. 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. 0. R. L. 0. 0.

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Grand Ward Round

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  1. Grand Ward Round 28/6/07 Jamie Ng

  2. 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

  3. 0 R L 0 0 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

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

  6. 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

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

  9. Idiopathic Intracranial Hypertension • Modified Dandy Criteria • 1. Raised ICP >25cm H2O • 2. No localising signs except a CN6 palsy • 3. Normal CSF composition • 4. Normal to slit ventricles on imaging with no intracranial mass

  10. Pathogenesis • Vasogenic extracellular brain edema • Low conductance of CSF outflow • Characteristics and Risk factors:5 • 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 (>100,000 U/d)/retinoic acid. • Cushing’s, hypothyroid, hypoparathyroid

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

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

  13. 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

  14. Optic nerve sheath fenestration1,2 • Via lateral orbitotomy app • Window of dura and arachnoid made • Arachnoid excised • CSF allowed to drain

  15. 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

  16. 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 15;112(2):177-85. • Pseudotumor cerebri and optic nerve sheath decompression.Banta T, Farris BK. Ophthalmology. 2000 Oct;107(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 Mar;30(3):391-5. • Factors affecting visual loss in benign intracranial hypertension.Orcutt JC, Page NG, Sanders MD. Ophthalmology. 1984 Nov;91(11):1303-12. • Idiopathic intracranial hypertension. A prospective study of 50 patients.Wall M, George D. Brain. 1991 Feb;114 ( Pt 1A):155-80.

  17. The End!

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