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Papilledema (ReelDx)

VIDEO-CASE-PRESENTATION-REEL-DX

56 y/o with intermittent loss of vision in the right eye

Patient will present as → a 57-year-old male with a history of hypertension who complains of an acute onset of intermittent headaches and blurred vision of the right eye.

Papilledema is swelling of the optic disk secondary to increased intracranial pressure → classically bilateral but (as in the video example) may be unilateral

  • Optic disk swelling resulting from causes that do not involve increased intracranial pressure (eg, malignant hypertension, thrombosis of the central retinal vein) is not considered papilledema.
  • There are no early symptoms, although vision may be disturbed for a few seconds. Papilledema requires an immediate search for the cause

Diagnosis is by ophthalmoscopy with further tests, usually brain imaging and sometimes subsequent lumbar puncture, to determine the cause

  • MRI or CT scan of the head looking for a cause. Focus on finding intracranial pathology = tumor or bleed, cerebral edema, CSF outflow obstruction or overproduction
  • Increased opening pressure with lumbar puncture confirms increased intracranial pressure

Causes include the following:

  • Brain tumor or abscess
  • Cerebral trauma or hemorrhage
  • Meningitis
  • Arachnoidal adhesions
  • Cavernous or dural sinus thrombosis
  • Encephalitis
  • Idiopathic intracranial hypertension (pseudotumor cerebri), a condition with elevated CSF pressure and no mass lesion

Urgent treatment of the underlying disorder is indicated to decrease intracranial pressure.

  • If intracranial pressure is not reduced, secondary optic nerve atrophy and vision loss eventually occur, along with other serious neurologic sequelae.

Picmonic
Increased Intracranial Pressure (ICP)

Intracranial pressure (ICP) is a measure of the hydrostatic pressure in the brain. Three elements contribute to ICP: brain tissue, blood, and cerebrospinal fluid (CSF). While these elements usually remain in balance, factors such as an increased body temperature or increased arterial or venous pressures can cause the ICP to fluctuate. The Monro-Kellie doctrine states, that if one component of ICP (brain tissue, blood, CSF) increases, one of the other components will decrease to maintain a constant pressure. When this balance is disrupted or when compensatory mechanisms fail, increased ICP can result. Signs and symptoms of increased ICP include a change in the level of consciousness, headache, irregular respirations, widening pulse pressure, bradycardia, projectile vomiting, abnormal pupils, and decerebrate or decorticate posturing.

Increased Intracranial Pressure (ICP) Assessment
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Increased Intracranial Pressure (ICP) Interventions
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Question 1
A 45-year-old woman with a history of chronic headaches presents with transient visual obscurations and pulsatile tinnitus. Fundoscopic examination reveals bilateral optic disc swelling with blurred margins. This finding is most indicative of which underlying condition?
A
Acute angle-closure glaucoma
Hint:
Typically presents with painful, red eye and vision loss.
B
Diabetic retinopathy
Hint:
Causes microvascular changes in the retina, not optic disc swelling.
C
Increased intracranial pressure
D
Hypertensive retinopathy
Hint:
Characterized by retinal vascular changes, not typically optic disc swelling.
E
Central retinal vein occlusion
Hint:
Usually unilateral and presents with sudden vision loss.
Question 1 Explanation: 
Papilledema, characterized by bilateral optic disc swelling, is most commonly indicative of increased intracranial pressure. The patient's symptoms of transient visual obscurations, pulsatile tinnitus, and chronic headaches further support this diagnosis.
Question 2
A 19-year-old woman presents to the clinic with a history of worsening headaches over the past two weeks. The headaches are generalized, progressively intensifying, and unresponsive to over-the-counter analgesics. She also reports recent episodes of blurred vision and occasional double vision. Her medical history is notable for obesity and she has been on isotretinoin for acne and oral contraceptives. On examination, bilateral papilledema is noted, but her visual acuity is 20/30. An MRI of the brain is unremarkable. What is the most appropriate next step in management?
A
Order a CT scan of the head
Hint:
This is typically performed to rule out intracranial pathology, but an MRI has already been done and is more sensitive.
B
Perform a lumbar puncture
C
Initiate therapy with high-dose prednisone
Hint:
Corticosteroids are not the first-line treatment for IIH and are typically reserved for cases with severe vision loss or other complications.
D
Conduct a stat cerebral arteriogram
Hint:
This would be indicated if there was suspicion of a vascular abnormality, which is not suggested by the current findings.
E
Provide reassurance and schedule a follow-up in 6 months
Hint:
Given the presence of papilledema and the potential risk for permanent vision loss, immediate action is required rather than mere reassurance and delayed follow-up.
Question 2 Explanation: 
The patient's symptoms of headache, blurred vision, diplopia, and the finding of bilateral papilledema, in the context of a normal brain MRI, are suggestive of idiopathic intracranial hypertension (IIH), also known as pseudotumor cerebri. IIH is particularly suspected in young, obese females and can be associated with the use of certain medications, including isotretinoin and oral contraceptives. A lumbar puncture is indicated to measure cerebrospinal fluid (CSF) pressure and to rule out other causes of increased intracranial pressure.
Question 3
A 30-year-old woman is diagnosed with idiopathic intracranial hypertension (IIH) presenting with papilledema. She has no visual field loss. What is the most appropriate initial management for her condition?
A
Acetazolamide
B
Topical beta-blockers
Hint:
Used in the treatment of glaucoma, not indicated for IIH.
C
Surgical optic nerve sheath decompression
Hint:
Considered in cases with severe or progressive vision loss.
D
Systemic corticosteroids
Hint:
Not the first-line treatment for IIH.
E
Weight loss and lifestyle modification
Hint:
Important adjunctive measures, especially in overweight patients, but acetazolamide is the primary initial treatment.
Question 3 Explanation: 
Acetazolamide (a carbonic anhydrase inhibitor) is the first-line treatment for idiopathic intracranial hypertension (IIH) presenting with papilledema. It works by reducing the production of cerebrospinal fluid (CSF), thereby lowering intracranial pressure (ICP) and improving papilledema
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References: Merck Manual · UpToDate

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