prasannakumar
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An 18-year-old girl comes to the office due to a three-week history of headaches that has been disturbing her daily activities, including her sleep. She describes these headaches as pulsatile, diffuse, and occasionally results in vomiting. Her school grades have deteriorated over the past 3 months. She complains of double vision when she looks sideways. Her family history is significant for migraine. She is afebrile. Her neurologic examination is significant for sixth cranial nerve palsy. The pupils are equal, and reactive to light and accommodation. There is no sinus tenderness. Fundoscopy reveals bilateral papilledema. MRI of the brain reveals an empty sella. What is the most appropriate next step in the management of this patient?
A) Lumbar puncture
B) Sinus imaging
C) Refractive testing of the eye
D) Trial of prednisone
E) Start sumatriptan
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| ssrpk
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D) Trial of prednisone???
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| usmlestud
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A...increased ICT in pseudotumor cerebri
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| Hotobhaga
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Empty sella in itself does not require any treatment. What is more disconcerting is papilledema and 6th nerve palsy. pailledema with normal MRI could mean psudotumor creribri. Now this has no relation to 6th nerve palsy. So I cannot corelate these three symptoms. Anybody with better answers?
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| Justice
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A) Lumbar puncture
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| ssrpk
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hey lumbar puncture should not be performed when there is papilledema.
i am suspecting some condition with cavernous sinus....both papilledema and VI CN palsy fits.
anyone?
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| Aashi
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Hotobhaga wrote:
Empty sella in itself does not require any treatment. What is more disconcerting is papilledema and 6th nerve palsy. pailledema with normal MRI could mean psudotumor creribri. Now this has no relation to 6th nerve palsy. So I cannot corelate these three symptoms. Anybody with better answers?
The diplopia seen in patients with ICH/Pseudo.t.cerebri is invariably due to unilateral or bilateral sixth nerve palsy, and these cranial nerve palsies will disappear with the lowering of the ICP.From the hx it looks like a case of ICH until proven otherwise..Empty sella can be seen in cases of ICH/pseudo.T.c
T/T for ICH----->surgical and medical
Surgical----->1) optic nerve sheath fenestration---->reduces the edema around the optic nerve and 2nd) is ventriculoperitoneal or lumboperitoneal SHUNTS---->to reduce the ICH
Medical---->1) DOC---->azetazolmide, diuretics like furosemide and corticosterioids as a alternative for azatozolmide used in ppl esp with severe papillaedema comprimising visual function and also used for increased ICP caused by inflammatory conditions.
L.P is C.I coz the risk of herniation cannot be ignored and rest of the choices are not used in the t/t of ICH except Corticosteroids----->So i would go for D
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| young_doc
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Good Question 
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| sprint123
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Steroids are helpful in Pseudotumor cerebri
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| ssrpk
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good job aashi....excellent explanation.
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| ssrpk
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can you please elaborate on pseudotumor cerebri little bit more especially regarding etiology and pathogenesis
thanks
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| prasannakumar
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The most likely diagnosis is benign/idiopathic intracranial hypertension (pseudotumor cerebri). The risk factors include use of medications (e.g., corticosteroids, oral contraceptive pills), trauma and increased weight. Pertinent physical findings may include visual loss, papilledema on fundoscopy and abducent nerve palsy. Idiopathic intracranial hypertension is a diagnosis of exclusion. Neuroimaging is always performed first to rule out a mass-occupying lesion. Most patients with pseudotumor cerebri have an empty sella seen on neuroimaging; this is probably caused by the downward herniation of arachnocele due to the high CSF pressure. Once neuroimaging excludes space-occupying lesions, lumbar puncture is indicated.
Lumbar puncture (LP) reveals normal CSF findings, except for an increased opening pressure. Sufficient CSF should be removed during the LP to decrease the intracranial pressure to 150 mm H2O.
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| dr in trouble
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Good Q and explanations.
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| usmlestud
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so is the answer A ??
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| young_doc
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Answer should be LP, because IIH is NOT a clinical diagnosis, and so we can't just start treating it. We have to comfirm it first with a LP.
(there is no increased risk of herniation when doing an LP in IIH, as long as we first rule out a mass lesion with CT/MRI)
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| khorshid
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nice q
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| ssrpk
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blue prinit nerology says noth steroids as well as serial lumbar puncture can be used.
but which one is prerferred?
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| ssrpk
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http://www.revoptom.com/HANDBOOK/SECT53a.HTM
that explains pretty much everything
preferred treatment modality is lumbar puncture
good work guyz
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| young_doc
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ssrpk wrote:
preferred treatment modality is lumbar puncture
LP is a diagnostic modality not a treatment modality!! From the same website you mentioned, LP is part of the 4 criteria needed to diagnose IIH:
-increased ICP demonstrated by LP
-no space-occupyling lesions as demostrated by CT/MRI
-normal CSF analysis
-S/S of increased ICP (like Papilledema)
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| ssrpk
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sorry ... lack of sleep
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| dr in trouble
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so what is the answer--lumber puncture????
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| ssrpk
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yes lumbar puncture
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| cirus
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Guys, the quest doesn ask about the ttt, its asking about the next step which has to be a lumbar punct to confirm the diag..High openning pr & a decrease in the severity of sympt ( Together with empty sella turcica) is highly suggestive even before fluid examinat that would confirm by absolutely normal fluid content..
ttt is supposed to be surgical (treatment of choice) with a shunt but untill then or if surgery is CI for a specific reason, acetazolamide is the drug of choice
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