Transcript GRAND ROUND - Selam Higher Clinic

GRAND ROUND
 Cc.
Headache of 04 months
- globbal,dullaching,inc. in severity
- Sts. awaken her from sleep
- temporal improv’t with analgesics
 ass’d nausea and vomiting
 diplopia and blurring of vision of 2 months
 tinnitus but no dizziness or vertigo
Ctd.
 no
similar history in the past
 no abnormal body mov’t or weakness of
extremitis
 no history of fever
 no chronic cough;no intake of drugs
 increase 8kg of wt. Over 1yr
 no chronic illnesses in the past
ctd
 has
regular menses
 single and lives with her family
P\E
GA:healthy looking
BP=100\80 PR=80 RR=16 BMI=24.7
 no pallor , NIS
 no LAP
ctd

Chest,Cvs,Abdomen/NAD
 CNS:conscious,oriented to TPP
- language,memory,attention/Intact
-cranial nerves: Normal findings
-Fundoscopy:swollen disc with blurred
disc marigin
-visual acuity:6/6
CNS exam’n ctd
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Visual field-normal by confront’n method
motor and sensory :normal findingsr
reflexes:2/4 allover
plantar-downgoing bilaterally
cerebellar signs-absent
summary
24 yrs old female patient with 04 months
history of headache and 02 months history
of visual complaints
Fundoscopy showing evidence of
papilledema
Differential Diagnosis
Intracranial mass
Hydrocephalus
Meningeal process(infectious,inflammatory,
neoplastic)
Inc’d venous press./Cerbral venous thromb.
Idiopathic intracranial HPNm
Lab. Results
•
WBC=4500 Hgb=14.8gm/dl Plt=76000
• ESR=45mm/hr serum VDRL-NR
• CT scan of brain-Normal CT findings
• LP-opening press. >300mm of water
clear CSF
No cell,glucose 70mg/dl,protein0.2gm/l
CSF VDRL-NR,gram s.and AFB-No organism.
Idiopathic intracranial HPN
also called pseudotumor cerebri,benign ICH
a disorder of unknown etiology
primary problem is chronically inc. ICP
most important neurologic manifestation is
papilledema
Pathophysiology
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Unclear
 multiple studies with conflicting results
 some of proposed mechanisms
increased CSF production;decd. absorp’n
cerebral edema
elevated cerebral venous pressure
 role of obesity
Frequency
 variable
from country to country
 Annual incidence at Mayo clinic(1976-90)
0.9/100000 pop’n 1.6/100000 women
3.3/100000 females aged 15-44 yrs
7.9/100000 obese women aged 15-44 yrs
 F:M=8:1
obese women of child bearing age
Clinical Findings
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Symptoms of increased ICP
-headache,pulsatile tinnitus,diplopia
 symptoms of papilledema
-transient visual obscursions,progressive
-loss of vision,blurring of vision
-sudden visual loss
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There are pts. with IIH without papilledema
-In one study of 65 adults with refractory
migrane,12(18% had IIH without papilledema
Cont’d
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Visual function testing
-fundoscopy,visual field,visual acuity
-color vision,ocular motility
characteristics,Sxs,Sns in pts. with IIH
- pt. Characterstics - symptoms
female(65-95%)
Age peak:21-34yrs
obesity (44-94%)
Headache(75-99%)
Visual dist.(30-68%)
diplopia (20-38%)
Intracranial noises(0-80%)
Cont’d
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Signs
- papilledema(98-100%) -VF defects (3-51%)
- abducent palsy(14-35%) -Dec’d VA (2-25%)
Risk Factors
Conditions
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Endocrine diseases
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female sex
Reproductive age gp.
Obesity
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Recent weight gain
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Addisons disease
Cushing’s disease
Hypoparathyroidism
Hypothyroidism
Risk Factors cont’d
 Miscellaneous
diseases
CRF,SLE,Anemia,Hypervitaminosis A,Dural AV malf.
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Medications
- Multivitamines(vit. A),steroids and steroid withdrwal
TTC,sulfa Abics.,cimetidine,naldixic acid,nitrofurantoin
amiodarone,tamoxifen,cyclosporine,lithium carbonate
Diagnosis
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a dignosis of exclusion
Based on modified Dandy criteria
1.signs and symptoms of raised ICP
2.No localizing neurologic signs,in an alert patient, other
than abducens n. palsy
3.Normal neuroimaging studies,except for small ventricles
and empty sella
4.Documented inc’d opening pressure(>250mm of water)
but normal CSF composition
5.Primary structural or systemic causes of elevated intracranial venous
sinus pressure excludedM
Diagnosis cont’d
 Neuroimaging
- for structural abns. or mass lesions
- Brain MRI with gadolinium enhancement
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- MRI venography,CT scan
LP
Orbital ultrasonography
Other lab tests
- CBC,ESR,ACLA,ANA,Full procoagulant profile
Treatment
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Joint Mx with ophthalmologist and neurologist
 Treatment goals
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to detect and prevent visual loss
to reduce ICP
to relieve headache
Medical and surgical options
Medical therapy
 Treatment of
associated condition
- withdrawal of offending agent
- treatment of obesity
as low as 6%loss of wt. results in dec’d ICP and papilledema
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Diuretics
- Acetazolamide-first line medical therapy
-250mg po qid or 500mg po bid
- Loop diuretics,Eg. Furesemide: as an adjunct to acetazolamide
Medical therapy cont’d
 Corticosteroids
-rapidly lower ICP
-long term use not recommended
-for patients who continue to have visual loss
 Repeated
LP
-in patients with infrequent exacerbations of symptoms
Surgical therapy
 When
visual function is severly impaired
 To those with incapacitating headache
 Options
-optic nerve sheath decompression (fenestration)
-lumboperitoneal or ventriculoperitoneal shunting
Prognosis
 Encouraging in
early intervetion
 Prognosis for visual loss,varied in d/f series
-studies of 1960’s and 1970’s ,<25% of pts. Had
significant blindness
-recent study ,visual dysfunction in close to ½ of patients