2011/04/17

Pseudotumor Cerebri Treatment

Pseudotumor cerebri or idiopathic intracranial hypertension treatments
Medical care
- Patients without visual loss most often are treated with carbonic anhydrase inhibitor to lower intracranial pressure (ICP).
- In patients with severe symptoms, early visual field loss, or poor response to standard medical therapy, some clinicians utilize a short course of high-dose corticostreroids.
- When new visual field loss is documented, medical management should be coupled with plans for emergency surgical intervention if the visual function continues to deteriorate or does not improve immediately with corticosteroid treatment.
Surgical Care
For patients with Pseudotumor Cerebri or Idiopathic Intracranial Hypertension who have progressive visual field loss, currently 2 general surgical approaches can be considered: Cerebrospinal Fluid (CSF) shunting procedures or optic nerve sheath fenestrain.
a. Neurosurgical Operations
- Lumboperitoneal shunt is the traditional method for providing prompt reduction of ICP in patients with IIH.
- Some neurosurgeons prefer ventriculoperitoneal or ventriculoatrial shunts over lumboperitoneal shunting.
- The reason for this preference is that venticular shunts can be monitored for function using an extracranial subcutaneous compressible bulb and one - way valve (intracranial to abdominal flow) in series with the intracranial and abdominal ends of the shunt.
- The bulb will resist digital compression if the distal (abdominal or atrial) end obstructed.
- The bulb will collapse under digital pressure but will fail to re-inflate if the intracranial end is obstructed.
- Other neurosurgeons are reluctant to place ventricular shunts in patients with IIH because the ventricles are small and difficult to cannulate with radiographic guidance.
b. Ophthalmic Approa ch - Optic nerve sheath fenestration
- The ophthalmic surgical approach to managing patients with progressive vision loss and pappiledema involves cutting slits or rectangular patches in the dura surrounding the optic nerve immediately behind the globe.
- This allows egress of CSFdirectly into the orbital fat where it is absorbed into the venous circulation.
- Lumber puncture following this procedure does not consistently not reliably relieved by this approach.
- Despite general lack of an ICP-lowering effect, papilledema in both eyes may regress following fenestration of one optic nerve.
Consultations :
- Diagnosis and long term management of patients with Pseudotumor Cerebri ( Idiopathic Intracranial Hypertension) requires the performance of lumbar puncture, typically performed by neurologists or internists, and careful monitoring of visual status (most importantly peripheral visual field and fundus photography). Vision examination and fundus photography are in the domain of ophthalmologists, and neuro ophthalmologists are especially expert in examining visual field.
- Neurosurgical consultation is required when patients are losing visual field and medical management does not arrest or reverse the process promptly
Diet :
On initial diagnosis, a weight reduction, diet coupled with an exercise program should be strongly advised to all patients with IIH. Some recent evidence suggests that weight loss is associated with improvement of papilledema in these patients. Often, a formal weight-loss program is required.
Activity :
No activity restriction is required in this disease. In fact, exercise programs are strongly recommended along with a weight reduction diet.

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