Idiopathic intracranial hypertension

Case contributed by Dr Bruno Di Muzio

Presentation

Headache. Bilateral papilledema.

Patient Data

Age: 31-year-old
Gender: Female

CT Brain + CT venogram

CT

Findings: Asymmetry of the lateral ventricles mild bulkiness to the left thalamus. No definite mass identified. A vessel traversing the inferior right frontal lobe extending to the anterior horn of the right lateral ventricle in keeping with a developmental venous anomaly. The optic nerves are distended bilaterally with associated proptosis. This could be further evaluated with MRI.

The venous sinuses enhance normally without evidence of dural venous sinus thrombosis. No intra or extra-axial hemorrhage is seen.

MRI Brain

MRI

 

Findings: Asymmetric lateral ventricles again noted without any underlying abnormality or abnormal signal; no "slit ventricles". No intra or extra-axial collection, mass or focal abnormality.

No restricted diffusion. No evidence of previous infarction or hemorrhage. No abnormal contrast enhancement.

Dilatation and mild tortuosity of both extra-cranial optic nerve sheaths. No abnormal T2/STIR or post contrast enhancement of the optic nerve. Partially empty sella. Increased nuchal fat noted.

MRV - no evidence of venous sinus thrombosis but typical and marked focal narrowing of the transverse sinuses laterally.

Lumbar Puncture guided by fluoroscopy

Fluoroscopy

Technique: The procedure was explained to the patient and informed consent obtained. Prone position. Aseptic technique. Administration of local anesthetic (Lignocaine 1%) to the skin. Under fluoroscopy guidance, a 22 gauge spinal needle was directed to the L4/L5 space. Clear CSF was obtained and 5 samples were sent for routine pathology. Opening pressure was 24cm H20. Procedure was well tolerated by the patient and there were no immediate complications.

Conclusion: Mildly elevated opening CSF pressure and an uncomplicated L4/5 lumbar puncture.

 

Case Discussion

Dilatation and tortuosity of both extra-cranial optic nerves, partially empty fossa, pinched transverse sinuses and increased subcutaneous fat are typical imaging features of idiopathic intracranial hypertension. Correlation with CSF opening pressures was recommended and then performed under fluoroscopic guidance, showing mildly elevated values. 

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