Pseudotumor cerebri

Question 1

Papilledema is an indication for . . .

Answer 1

. . . emergent head CT with contrast

Question 2

Who tends to be affected by pseudotumor cerebri?

Answer 2

Obese women between ages 20-40

Question 3

Papilledema on exam

Answer 3

Question 4

Hydrocephalus

Answer 4

Abnormal excessive accumulation of CSF in the brain

Question 5

Pathophysiology of papilledema

Answer 5

Results from axoplasmic flow stasis

Increased intracranial pressure is transmitted to the subarachnoid space, and in turn to the optic nerve and sheath. As pressure increases, the sheath is compressed around the axon, preventing normal axoplasmic transport.

The result is accumulation of axonal transport components resulting in edema of the nerve and the optic disc.

Question 6

When might a clinician perform a high volume tap?

Answer 6

When the opening pressure is greather than 20 mL water

High volume tap is removal of ~30-40 mL of CSF

Question 7

The longer papilledema goes on. . .

Answer 7

. . . the more nerves are damaged

Papilledema can cause irreversible damage to nerve axons and loss of peripheral vision.

All patients with significant papilledema require ophthalmologic examination for visual fields.

Question 8

Diagnostic criteria for pseudotumor cerebri

Answer 8

• Findings of increased intracranial pressure (papilledema)
• Nonfocal neurologic signs (exception of 6th nerve palsy)
• Normal imaging studies (exception slit-like ventricles)
• Normal CSF studies (exception increased opening pressure)

Question 9

Venous return theory of pseudotumor cerebri

Answer 9

Obesity leads to increased intra-abdominal pressure

This raises cardiac filling pressures

This leads to impaired venous return from the brain

Question 10

Classic features of pseudotumor cerebri

Answer 10

• Headache (diffuse, worse in the morning, worsens with Valsalva)
• Transient visual obscuration exacerbated by bending over or standing up quickly
• N/V
• Pulsatile tinnitus
• 6th nerve palsy

Question 11

Discontinuation of ___ has been associated with the development of pseudotumor cerebri

Answer 11

Discontinuation of corticosteroids has been associated with the development of pseudotumor cerebri

Question 12

Treatment of pseudotumor cerebri

Answer 12

• Acute:
  
  • Large-volume LP
• Chronic:
  
  • Weight management (essential to control of disease, bariatric surgery should be considered)
  • Carbonic anhydrase inhibitors (acetazolomide, topiramate)
  • Furosemide (alone or in combination with above)
• Medically refractory:
  
  • VP shunt
  • LP shunt
• Rapid or progressive vision loss:
  
  • Optic nerve sheath fenestration

Question 13

Papilledema in the presence of normal opening pressure suggests. . .

Answer 13

. . . optic nerve trauma

Question 14

Medications that may induce pseudotumor cerebri

Answer 14

• vitamin A analogs
• Tetracyclines