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Letters

Idiopathic intracranial hypertension: need to rule out cerebral venous sinus thrombosis

Aravind Ganesh
CMAJ October 07, 2019 191 (40) E1109; DOI: https://doi.org/10.1503/cmaj.72955
Aravind Ganesh
Neurology resident, Department of Clinical Neurosciences, University of Calgary, Calgary, Alta.; associate fellow, Centre for Prevention of Stroke and Dementia, University of Oxford, Oxford, UK
MD DPhil
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I thank Drs. Micieli and Micieli for their report on fulminant idiopathic intracranial hypertension, which highlighted the importance of promptly considering interventions like optic nerve sheath fenestration or shunting in the setting of vision loss, rather than just standard medical therapy with acetazolamide.1 However, a key caveat in the diagnostic process for idiopathic intracranial hypertension that is worth noting is the need to rule out secondary causes of intracranial hypertension, the most important one being cerebral venous sinus thrombosis, which can exactly mimic the clinical symptoms and examination findings of idiopathic intracranial hypertension. There are critical implications for management, as patients with cerebral venous sinus thrombosis require anticoagulation.

Consequently, the diagnostic criteria for idiopathic intracranial hypertension require a normal neuroimaging result, including venography with no evidence of abnormal meningeal enhancement or venous thrombosis.2 This can be accomplished using computed tomography or magnetic resonance imaging with venography, but the latter has the added advantage of also potentially showing supportive features of idiopathic intracranial hypertension such as flattening of the posterior globes, tortuous optic nerves, enlargement of the pre-optic optic subarachnoid space, empty sella turcica, or narrowing of the transverse venous sinuses.

The presence of 3 or more of these findings is required to make the diagnosis of suspected idiopathic intracranial hypertension in the absence of papilledema or sixth nerve palsy, although idiopathic intracranial hypertension without papilledema is a controversial entity.3

Footnotes

  • Competing interests: None declared.

References

  1. ↵
    1. Micieli A,
    2. Micieli JA
    . Recovery of vision in fulminant idiopathic intracranial hypertension. CMAJ 2019;191:E639.
    OpenUrlFREE Full Text
  2. ↵
    1. Friedman DI,
    2. Liu GT,
    3. Digre KB
    . Revised diagnostic criteria for the pseudotumor cerebri syndrome in adults and children. Neurology 2013;81:1159–65.
    OpenUrlCrossRefPubMed
  3. ↵
    1. Markey KA,
    2. Mollan SP,
    3. Jensen RH,
    4. et al
    . Understanding idiopathic intracranial hypertension: mechanisms, management, and future directions. Lancet Neurol 2016;15:78–91.
    OpenUrlCrossRefPubMed
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Canadian Medical Association Journal: 191 (40)
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Vol. 191, Issue 40
7 Oct 2019
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Idiopathic intracranial hypertension: need to rule out cerebral venous sinus thrombosis
Aravind Ganesh
CMAJ Oct 2019, 191 (40) E1109; DOI: 10.1503/cmaj.72955

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Idiopathic intracranial hypertension: need to rule out cerebral venous sinus thrombosis
Aravind Ganesh
CMAJ Oct 2019, 191 (40) E1109; DOI: 10.1503/cmaj.72955
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