Examination: Idiopathic Raised intracranial Pressure - Papilloedema

Casebank Combined
1

Candidate instructions

Where you are:
You are a FY2 in the GP surgery

Who the patient is:
Ella Williams, aged 30, has made an appointment to see you

Other information you have about the patient:
None

What you must do:
Talk to the patient and address the concern

Patient informations

  • 30-year-old woman
  • Headache for 3-4 months
  • Throbbing, boring, constant headache
  • Worse with bending forward, sneezing and coughing
  • Also worse in the morning
  • Relieved when she stands up
  • Has been taking oral contraceptives pills for the papt 10 years
  • Her weight is on the higher side
  • Has also been experiencing blurring of vision for the past 3-4 months

Approach

  • GRIPS
  • History of headache
    – SOCRATES
    – What medications have you tried
    – Which medications helped?

Symptoms

  • a constant throbbing headache which may be worse in the morning, or when coughing or straining; it may improve when standing up
  • temporary loss of vision – your vision may become dark or “greyed out” for a few seconds at a time; this can be triggered by coughing, sneezing or bending down
  • feeling and being sick
  • feeling sleepy
  • feeling irritable
  • finding it difficult or painful to look at bright lights (photophobia)
  • hearing a pulsing rhythmic noise in your ears (pulsatile tinnitus)
  • problems with co-ordination and balance
  • mental confusion
  • loss of feeling or weakness
  • History of Taking COCPs

Differential diagnosis

  • Migraine
  • Tension headache
  • Brain tumor
  • Idiopathic intracranial hypertension
  • Cluster headache
  • CO poisoning
  • Medication overuse headache
  • Giant cell arteritis

Raised intracranial pressure symptoms:

  • Worst on bending forward
  • Worst in the morning
  • Worst with sneezing and coughing
  1. DD- Idiopathic raised intracranial pressure aka Benign raised intracranial pressure

Typical symptoms

  • Young female patient
  • Obese
  • Risk factors include: obesity, irregular periods, postpartum period or first trimester of pregnancy
  • Coincide with recent weight gain
  1. DD- Brain tumor
  • Middle age or older patient
  • Progressive, constant headache
  • Focal neurological symptoms e.g. weakness, hyperreflexia, reduced power unilaterally
  • Other symptoms of raised intracranial pressure like headache: worse in the morning and bending forward, and blurring of vision due to papilloedema

Other history

  • PMAFTOSA
  • ICE
  • Effect of symptoms on the patient’s life
  • Summary

Effect of symptoms

  • What do you do for your living?
  • Have the headaches affected your work?
  • Have they affected your daily life? Sleep?

Examination

  • Visual acuity- reduced bilaterally
  • Fundoscopy- papilloedema bilaterally
  • Cranial nerve examination- normal or 6th nerve palsy
  • Neurological examination of lower limbs and upper limbs: normal
  • Visual field examination- enlarged blind spot bilaterally

Papilloedema

Figure a Figure b
Papilledema
Papilledema277Ă—266 29.7 KB
patons-lines
patons-lines357Ă—210 10.2 KB
Figure c
688482.png
688482.png1185Ă—571 109 KB

Findings:

  • The optic disc is swollen (or elevated) and disc margin has disappeared.
  • Veins are congested: Venous engorgement (dilated & tortuous vessels), hyperemia
  • Paton’s Lines: (figure b) circumferential retinal folds

Diagnosis

  • It is caused by overproduction of fluid in the brain. The fluid is called cerebral fluid.
  • The cause of which is unknown
  • Risk factors: obese, use of contraceptive pills
  • High pressure in the brain leads to headaches and damage to the optic nerve (Nerve responsible for vision) which in turn causes blurring of vision

Management

  • Routine Investigations: FBC, U&E, LFT, ESR, Iron studies, Antinuclear antibodies, clotting screen
  • MRI scan of the brain.
  • Symptomatic treatment: Pain killers for headache
  • Refer to ophthalmologist for further visual field assessment.
  • Referral to neurologist for disease management.
  • Safety net (Neurological symptoms, chest pain, driving…).
  • Give a leaflet for Idiopathic raised intracranial pressure.

Treatment

  • Lose weight
  • Offer alternative if there correlation with weight gain.
  • If heavy menstrual history present, offer Mirena
  • Acetazolamide medication
  • Surgical options
  • Intracranial venous sinus stenting (placement of stent in one of the veins in the brain)
  • CSF shunting

Note: Recent studies have shown that COCPs don’t have any link with Idiopathic raised intracranial pressure.

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Shouldn’t this patient be referred for admission for possible lumbar puncture and other brain scans, and also the acetazolamide treatment?

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