Presentation Title

“It’s Not a Tumor”: MRI for Initial Diagnosis of Pseudotumor Cerebri

Speaker Credentials

MD

Format

Poster

Start Date

6-11-2020 10:30 AM

End Date

6-11-2020 10:45 AM

Abstract

Introduction Idiopathic Intracranial Hypertension (IIH), also known as pseudotumor cerebri, is a clinical condition characterized by increased intracranial pressure without underlying cerebral spinal fluid or anatomic abnormalities. Patients suffer disabling, sometimes positional headaches and risk of permanent vision loss [1]. Currently, the incidence of IIH is 1-2 for every 100,000 patients, with highest incidence between the ages of 15-44 years old, more than 90% of whom are obese women [2-4]. Several pathophysiological theories have implicated impaired venous outflow; however, no studies to date have been conclusive [5-7] Case Presentation We present a 32-year-old female with a past medical history of anemia and morbid obesity who has been referred to the emergency department by her optometrist due to papilledema. The patient reports having intermittent occipital headaches, dizziness, and occasional blurry vision for the past month. Magnetic resonance imaging (MRI) of the brain without contrast demonstrated a partially empty sella, mild flattening of the posterior sclera bilaterally, dilated CSF spaces around the optic nerves and subtle protrusion of the optic papilla into the posterior globes. A lumbar puncture as a confirmatory test revealed increased opening pressure, diagnostic of IIH. Patient was discharged home and advised to follow up with ophthalmology for optical coherence tomography and visual field testing. Discussion: The case highlights the utility of MRI for a noninvasive, relatively fast, and accurate diagnosis of IIH based on pathognomonic features of brain MRI findings. Exclusion of venous sinus thrombosis requires specialized MRV sequences, which can be readily added to a standard MRI protocol. Overall, MRI is an invaluable study for patients with headaches with atypical features, such as those associated with optic disc edema and neurologic deficits.

References 1. Friedman DI, Jacobson DM. Diagnostic criteria for idiopathic intracranial hypertension. Neurology 2002; 59:1492. Durcan FJ, Corbett JJ, Wall M. The incidence of pseudotumor cerebri. Population studies in Iowa and Louisiana. Arch Neurol 1988; 45:875. Radhakrishnan K, Ahlskog JE, Cross SA, et al. Idiopathic intracranial hypertension (pseudotumor cerebri). Descriptive epidemiology in Rochester, Minn, 1976 to 1990. Arch Neurol 1993; 50:78. Kesler A, Gadoth N. Epidemiology of idiopathic intracranial hypertension in Israel. J Neuroophthalmol 2001; 21:12. Johnston I, Kollar C, Dunkley S, et al. Cranial venous outflow obstruction in the pseudotumour syndrome: incidence, nature and relevance. J Clin Neurosci 2002; 9:273. Lee AG, Brazis PW. Magnetic resonance venography in idiopathic pseudotumor cerebri. J Neuroophthalmol 2000; 20:12. Higgins JN, Tipper G, Varley M, Pickard JD. Transverse sinus stenoses in benign intracranial hypertension demonstrated on CT venography. Br J Neurosurg 2005; 19:137.

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Nov 6th, 10:30 AM Nov 6th, 10:45 AM

“It’s Not a Tumor”: MRI for Initial Diagnosis of Pseudotumor Cerebri

Introduction Idiopathic Intracranial Hypertension (IIH), also known as pseudotumor cerebri, is a clinical condition characterized by increased intracranial pressure without underlying cerebral spinal fluid or anatomic abnormalities. Patients suffer disabling, sometimes positional headaches and risk of permanent vision loss [1]. Currently, the incidence of IIH is 1-2 for every 100,000 patients, with highest incidence between the ages of 15-44 years old, more than 90% of whom are obese women [2-4]. Several pathophysiological theories have implicated impaired venous outflow; however, no studies to date have been conclusive [5-7] Case Presentation We present a 32-year-old female with a past medical history of anemia and morbid obesity who has been referred to the emergency department by her optometrist due to papilledema. The patient reports having intermittent occipital headaches, dizziness, and occasional blurry vision for the past month. Magnetic resonance imaging (MRI) of the brain without contrast demonstrated a partially empty sella, mild flattening of the posterior sclera bilaterally, dilated CSF spaces around the optic nerves and subtle protrusion of the optic papilla into the posterior globes. A lumbar puncture as a confirmatory test revealed increased opening pressure, diagnostic of IIH. Patient was discharged home and advised to follow up with ophthalmology for optical coherence tomography and visual field testing. Discussion: The case highlights the utility of MRI for a noninvasive, relatively fast, and accurate diagnosis of IIH based on pathognomonic features of brain MRI findings. Exclusion of venous sinus thrombosis requires specialized MRV sequences, which can be readily added to a standard MRI protocol. Overall, MRI is an invaluable study for patients with headaches with atypical features, such as those associated with optic disc edema and neurologic deficits.

References 1. Friedman DI, Jacobson DM. Diagnostic criteria for idiopathic intracranial hypertension. Neurology 2002; 59:1492. Durcan FJ, Corbett JJ, Wall M. The incidence of pseudotumor cerebri. Population studies in Iowa and Louisiana. Arch Neurol 1988; 45:875. Radhakrishnan K, Ahlskog JE, Cross SA, et al. Idiopathic intracranial hypertension (pseudotumor cerebri). Descriptive epidemiology in Rochester, Minn, 1976 to 1990. Arch Neurol 1993; 50:78. Kesler A, Gadoth N. Epidemiology of idiopathic intracranial hypertension in Israel. J Neuroophthalmol 2001; 21:12. Johnston I, Kollar C, Dunkley S, et al. Cranial venous outflow obstruction in the pseudotumour syndrome: incidence, nature and relevance. J Clin Neurosci 2002; 9:273. Lee AG, Brazis PW. Magnetic resonance venography in idiopathic pseudotumor cerebri. J Neuroophthalmol 2000; 20:12. Higgins JN, Tipper G, Varley M, Pickard JD. Transverse sinus stenoses in benign intracranial hypertension demonstrated on CT venography. Br J Neurosurg 2005; 19:137.