Fire Frog's

Intra Cranial Hypertension
Information Page

(Also called Pseudotumor Cerebri, Idiopathic Intracranial Hypertension
and Benign Intracranial Hypertension.)

NOTE: everything in red has been added in by me.

Spinal Taps - Leaks.

Diagnoses of a leak.
Why Blood patches sometimes only work for a short time.

These headaches can be of mild, moderate, or severe intensity. They are located, ... more commonly in the forehead...temples, or occiput ...either alone or in various combinations. In some patients, the headache location was stable, while in others it was not.

Most headaches after LPs begin within 24 hours of the LP. Some begin within minutes and others not until a few days later. The great majority disappear within a week, but durations of weeks and even months have been reported.

Loss of CSF from the... brain and spinal cord results in downward displacement of the brain when patients are seated or standing. This movement is painful because it stretches arteries and veins supplied with pain fibres. The double vision often present in postural headaches is from stretching of the 6th cranial nerve...

The great majority of LP headaches... need no more treatment than bed rest. Those that last longer and especially those that adversely affect the person's life situation can generally be alleviated by an epidural blood patch, which is a slow injection of 10-20 ml of ...blood into the site of the Lumbar Puncture.

About 90% of patients with LP headaches experience immediate relief from headache. Those unrelieved generally are relieved by a second later patch. The immediate relief is believed due not to sealing the hole, but from pressure of the blood on the lumbar dural sac, thus increasing the volume of cerebral CSF.

Info found at
http://www.upstate.edu/neurology/haas/hpcsf.htm

** 

Post-op meningitus (brain infection) is more likely to occur after a CSF leak, so professional observation is necessary.

Found at a random LP site.

**

Benign Intracranial Hypertension Symptoms

  • Everyone is different. Some people just have
    one symptom, others show them all.
    Headaches
    Visual Disturbances
    Dizziness
    Back Pain
    Neck Pain
    Memory Problems
    Tinnitus
    Photophobia
    (eyes sensitive to bright light)
    Nausea and Vomiting
    Disorientation
    Depression

These are some of the ways BIH can be diagnosed

*An examination of the eyes may show swelling of the optic disc (papilloedema)

*A Lumber Puncture will show the measurement of cerbrospinal fluid (under pressure). Normal CSF pressure is 70mm to 200mm. In BIH it is elevated to between 250mm and 600mm. *Note, reading measurements vary. In Australia for instance the measure is done in cmH2O. Elsewhere it is in mmH2O. The average pressure reading in Australia is 15 to 17cmH2O, anything over is considered too high.

*A CT (cat scan) or MRI scan will be performed to rule out the possibility of a brain tumor.

*Visual Field Test. This is performed (by an optician) to determine if the sight has been affected. (i.e. to look for loss of peripheral vision or an enlarged blind spot.)

Treatment and Monitoring

*Lumber Puncture - A lumber puncture is performed to see if the CSF is raised. If it is, the excess will be drained off and the level brought down to normal. These may be performed at regular intervals to keep the condition under control.

*Weight Loss - Research shows that this does not stop the disease but helps reduce papilleodema.

*Medication - Acetazolomide (Diamox) is the most popular choice of medication. Frusemide may also be used. These are both diuretics and they reduce the amount of fluid. Sometimes a short course of steroids may be enough to re-open venous pathways and help relieve BIH.

*Shunt Insertion - A shunt maybe surgically inserted to relieve abnormal fluid pressure. These are only carried out if medication and repeated Lumber Punctures are not relieving severe symptoms.

*Optic Nerve Fenestration - As sight can deteriorate quickly leading to blindness this operation may be performed to allow the fluid to drain away and prevent further deterioration of sight.

Info found at
http://www.angelfire.com/hi5/bihuk/

**

Idiopathic Intracranial Hypertension

Raised ICP without explanation
usually obese young women
occasional males, older females

  • symptoms:
    headache, nausea, vomiting, visual obscurations signs: papilloedema, VI nerve palsies
    (Loss of lateral eye movement... horizontal double vision when looking left... Common complaint is difficulty when reading)

Treatment

MEDICAL
1. Discontinue causative medication
2. Weight loss
3. Acetazolamide
4. Systemic steroids

SURGICAL
5. Optic nerve decompression
6. Lumboperitoneal shunt
7. Repeat LPs

See web page for excellent pictures of affected optic nerves at the back of an eye.
http://www.angelfire.com/retro/michaelpoon168/benign_intracranial_hypertension%20case%20study.htm

**
Intracranial Hypertension

Primary or Idiopathic Intracranial Hypertension (IIH), ... is often difficult to diagnose because it is a disease of "absence." There is no brain tumor, trauma or causative signs found on a brain scan, no abnormalities of the CSF and no localizing findings on neurological examination. This very lack of obvious medical clues is what distinguishes IIH. And it's further complicated by the fact that an individual patient may not exhibit all the telltale symptoms, like tinnitus or papilledema.

Secondary Intracranial Hypertension is IH with an identifiable, causative agent, such as another underlying disease, an intracranial blood clot (dural sinus thrombosis), a secreting brain tumour, or certain drugs.

Signs & Symptoms

The most common symptom is an unbearably painful headache that is not relieved by any medication...
The second most common symptom is transient altered vision particularly on movement, followed by intracranial noise (pulse synchronous tinnitus). Other symptoms can include stiff neck, back pain, double vision, pain behind the eyes, and exercise intolerance.

Treatments

Carbonic anhydrase inhibitors are very difficult to tolerate. Used for ... blocking the carbonic anhydrase enzyme system...(which produces the Cerebral Spinal Fluid - CSF)

Optic nerve fenestration, a small opening is made in the sheath around the optic nerve to relieve swelling.

Neurosurgical shunts are surgically implanted internal tubes that are used to drain the CSF into another area such as the abdominal cavity.
Surgical treatments often require repeat operations and can produce a new set of complications, including blindness and other conditions that can be life threatening.

Info found at the Intracranial Hypertension Research Foundation site.
http://www.ihrfoundation.org/

**

Increased Intracranial Pressure.

Increased intracranial pressure means that the pressure inside the skull is abnormally high, which may cause damage to the brain. What is going on in the body?

There is normally a small amount of pressure inside the skull. This pressure can become elevated from various conditions. An increased pressure in the skull can put too much pressure on the brain and decrease blood flow to the brain. Increased pressure can also force the brain downward onto the brainstem. This area controls vital functions like breathing, so this is a potentially fatal problem.

What are the signs and symptoms of the condition? The symptoms of increased intracranial pressure may include: headache ringing in the ears nausea and vomiting vision problems, such as blurry vision or double vision feeling tired and wanting to sleep painful eye movements neck pain hearing loss unsteadiness while standing or walking, known as ataxia weakness, which may occur in only certain parts of the body or throughout the whole body

What are the causes and risks of the condition? Increased intracranial pressure may be caused by: brain tumors bleeding inside the skull, such as intracerebral hemorrhage infection inside the skull, such as encephalitis blood clots, known as hematomas certain medications head injury or trauma

There are other causes, and in some cases the cause is not known.

Info found at
http://health.discovery.com/diseasesandcond/encyclopedia/1584.html

**

What are the common signs and symptoms of Idiopathic Intracranial Hypertension? Most patients with IIH experience headache. The headache may be aggravated by changes in position. There may be a ringing or a "whooshing" sound in the ear. A patient may experience double vision.

In this disorder, it is common to have momentary loss of vision known as "transient obscurations of vision". Other visual symptoms are a central blind spot, blurred vision, or loss of peripheral vision in one or both eyes. The visual loss may be mild to severe. If severe and untreated, it can result in blindness. The optic nerves are usually swollen in appearance.

Info found at
http://www.djo.harvard.edu/meei/PI/pseudotcereb.html

**

The symptoms most commonly reported by IIH patients followed by their frequency are:

  • headache (94%)
  • transient visual obscurations or blurring (68%)
  • pulse synchronous tinnitus or "wooshing noise" in the ear (58%)
  • pain behind the eye (44%)
  • double vision (38%)
  • visual loss (30%)
  • pain with eye movement (22%)

Headache
Headache is present in nearly all patients with IIH and is the usual symptom for which patients seek medical attention. The headaches of the IIH patient are usually severe and daily; they are are often throbbing. They are different from previous headaches, may awaken the patient and usually last hours. Nausea is common and vomiting less so. The headache is often the worst head pain ever experienced. Although uncommon, the presence of pain behind the eyeball that is worsened movements of the eyes can occur.

Transient visual obscurations
Visual obscurations are episodes of transient blurred vision that usually last less than 30 seconds and are followed by full recovery of vision. Visual obscurations occur in about 3/4 of IIH patients. The attacks may be involve one or both eyes. They are not correlated with the degree of intracranial hypertension or with the extent of optic nerve swelling. Visual obscurations do not appear to be associated with poor visual outcome.

Pulsatile intracranial noises
Pulsatile intracranial noises or pulse-synchronous tinnitus is common in IIH. The sound is often unilateral. In patients with intracranial hypertension, compression of the jugular vein on the side of sound abolishes it. The periodic compressions were thought to convert the laminar blood flow to turbulent.

Visual loss
The most serious problem patients have is vision loss. About 5% of patients go blind in at least one eye. These are usually patients who do not return for follow-up evaluation.

Info found at
http://webeye.ophth.uiowa.edu/dept/iih/pc_3.htm

**

NOTE: By now you should have noticed the difference in symptom lists. As I have mentioned, these really do change from person to person, so take care, and make sure your doctors take notice too!

**
Tetracyclines and Benign Intracranial Hypertension

BIH has been documented in association with a variety of medicines, particularly the tetracyclines.

The common presenting feature of BIH is headache. The signs are papilloedema and sometimes sixth nerve palsy. Raised intracranial pressure confirms the diagnosis. If associated with a medicine, the condition may resolve totally on stopping it. Treatment includes therapeutic lumbar punctures and acetazolamide.

BIH is associated with various medical conditions and medicines

Benign intracranial hypertension (also known as pseudotumor cerebri, or idiopathic intracranial hypertension) is a rare condition of unknown cause with an annual incidence of 0.9/100,000 in the general population. It is likely that there is a genetic predisposition.

It is significantly more common in adolescent and young adult women, but can occur in children. In case control studies, obesity and weight gain have been demonstrated as risk factors for BIH. Other medical conditions linked to BIH include migraine, thyroid and parathyroid disorders, Addison's and Cushing's diseases, systemic lupus erythematosis, and sarcoidosis.

Medicines reported to be associated with BIH include vitamin A analogues, tetracyclines, steroids (especially in withdrawal), nalidixic acid, sulphonamides, lithium, thyroxine, growth hormone, amiodarone and tamoxifen... doxycycline... isotretinoin... Minocycline is most frequently reported in the literature...used to treat acne.

Info found at
http://www.medsafe.govt.nz/Profs/PUarticles/bih.htm#BIH

**

Benign Intracranial Hypertension
Symptoms and signs include headache of varying severity (often mild) and papilledema in a patient who otherwise appears healthy. Partial or complete monocular visual loss--the only serious neurologic sign--occurs in about 5% of patients, and the normal blind spots are commonly enlarged. CT and MRI scans generally are normal or show a somewhat small ventricular system. EEG is normal. CSF pressure is increased, but the fluid is normal.

A similar picture can result from occlusion of an intracranial venous sinus affecting the posterior 1/3 of the sagittal sinus or one of the transverse or sigmoid sinuses; from increased intracranial pressure secondary to chronic CO2 retention and hypoxemia in pulmonary disease; or, occasionally, from less well-established abnormalities, including iron-deficiency anemia and hypoparathyroidism.

Info from
http://www.merck.com/mrkshared/mmanual/section14/chapter177/177c.jsp

**

Ventriculoperitoneal Shunts Referral Guideline

Diagnosis/Definition

  • Shunt dependency is a condition of multiple etiology in which the spinal fluid produced in the ventricles of the brain is not absorbed in a normal fashion. This, in turn, causes enlargement of the ventricular system, which generally results in intracranial hypertension or increase in head size in children. VP shunts are designed to relieve this abnormality by redirecting flow of the CSF to the peritoneal cavity.

Initial Diagnosis and Management

  • The initial management of this is placement of a shunt diversion system (generally from the ventricles to the abdominal cavity). Alternatively, the shunt can be placed into the atrium of the heart or the pleural cavity, but these are much less common. Once a shunt is in place, yearly follow-up and examination by the PCP is recommended. These patients should also be examined by a neurosurgeon every 2 years primarily to make sure the child is not outgrowing the length of the shunt tubing.

Info found at Ventriculoperitoneal Shunts Referral Guideline
http://www.mamc.amedd.army.mil/Referral/guidelines/dev_ped_ventricul.htm

**

ICP (Inter Cranial Pressure)

symptoms ... commonly include headache, visual disturbances, photophobia, vomiting, problems with balance and spatial awareness, disorientation, loss of short-term memory (sometimes long-term memory loss), "pins and needles" or loss of sensation in hands.

In some cases, CSF leaks down the nose. It is important to exclude cerebral tumour as a cause of the symptoms. People with raised ICP may find it difficult to cope with previously learnt everyday tasks, eg handling money or using the telephone. They may be unable to find their way around a previously familiar town: traffic is confusing, they can be unaware of kerb height (sometimes afraid to step off the kerb in case they step into space); crossing the road can be a nightmare.

Some people need repeated lumbar punctures to remove excess CSF, or the excess CSF may need to be diverted by means of a surgically inserted shunt. In theory, a lumbar peritoneal shunt is the shunt of choice. In practice, the patient may undergo frequent shunt revision, including changing to a ventriculo-peritoneal shunt, or insertion of a lumbar reservoir.

Shunt Risks

Once a shunt is in place, the patient is at risk of those complications sometimes associated with shunting - for whatever reason the procedure is performed. The risks include infection, blockage, and, most commonly in BIH, over-drainage.

Back pain and sciatica or arachnoiditis may occur after lumbar peritoneal (lumbar=lower back, peritoneal=belly) shunting.

Surgery should be considered only if there is a deterioration in vision, despite drug therapy or diet; inability to tolerate medication or non-compliance with taking medicines; or severe headaches which are proved to be associated with raised CSF.

Info found at
http://www.asbah.org/bih.html

**
Diamox Side Effects:

Tablets or capsules of acetazolamide (Diamox) increase the production of urine, may cause tingling of the fingers and toes and occasionally cause indigestion and lassitude. In long term use predisposed patients may develop kidney stones.

Info found at
http://www.iga.org.uk/SimpFact/sf001.htm

**

Chat room info.

Diamox is a carbonic anhydrase inhibitor, so it affects CO2 balance in the body. That causes increased respiration.

Tiredness, impaired concentration, confusion and dizziness can be symptoms of BIH and of Diamox.

Diamox is best taken a little at a time. Ie 1/4 then 1/3 then 1/2 then a full tablet, adjusting to each new dose before starting the next. This lessens the tingle/tiredness and odd taste side effects.

A disorder of the facial nerve caused by it being stretched may result in twitching, weakness or paralysis of the face, dryness of the ear or the mouth, loss of taste, increased sensitivity to loud sound and pain in the ear.

**

SYMPTOMS OF METASTATIC BRAIN TUMORS HEADACHE:
Why the headaches aren't just about pain...
PS, note, this article is about cancer tumours (metastatic tumours), but can be applied in part to ICH as well.

Headache is caused by stretching of sensitive structures such as blood vessels or nerves due to edema, spinal fluid obstruction or tumor growth, or by injury to the brain caused by the tumor. Initially, the headache comes and goes, and is usually more common in the morning, just after awakening. It gradually increases in duration and frequency.

MUSCLE WEAKNESS:

Localized (focal) weakness or weakness on one side of the body (hemiparesis) may occur. That is caused by irritation or injury to specific areas of the brain by the tumor.

BEHAVIORAL CHANGES:

Common behavioral changes include changes in judgment, reasoning, behavior; impaired memory; emotional changes such as rapid mood shifts; and confusion. Those symptoms are caused by edema and increased intracranial pressure.

PHYSICAL CHANGES:

Physical changes include changes in vision, language disturbances (dysphasia [Dysphasia is the impairment of the ability to speak or write, to understand speech or written words. Dysphasia may be moderate or severe.]), sensory loss, and gait disorders (ataxia [Ataxia refers to a clumsy, uncoordinated walk and problems with balance.]). Those changes are due to increased intracranial pressure or brain irritation.

Ataxia is more common in people with spinal fluid obstruction, or with tumors involving the cerebellum. Cerebellar tumors often cause dizziness and vomiting.

Seizures [Seizures are convulsions. They are due to temporary disruption in the electrical activity of the brain.] Seizures are caused by brain irritation or increased intracranial pressure. They may be the first indication of brain metastases, particularly in people with melanoma.

Papilledema (swelling of the optic nerve)

Papilledema is due to increased intracranial pressure.

SYMPTOMS OF INCREASED INTRACRANIAL PRESSURE

The common symptoms of increased intracranial pressure are listlessness, confusion, and headache.

Info found at Metastatic Tumors to the Brain and Spine
http://neurosurgery.mgh.harvard.edu/abta/mets.htm#SYMPTOMS_3

**

Diamox What side effects may occur?

  • More common side effects may include:
    Change in taste
    (notably soda can taste metallic), diarrhea, increase in amount or frequency of urination, loss of appetite, nausea, ringing in the ears, tingling or pins and needles in face, hands or feet, vomiting
  • Less common or rare side effects may include:
    Anemia, black or bloody stools, blood in urine, confusion, convulsions, drowsiness, fever, hives, liver dysfunction, nearsightedness, paralysis, rash, sensitivity to light, severe allergic reaction, skin peeling

This drug is considered to be a sulfa drug because of its chemical properties. Although rare, severe reactions have been reported with sulfa drugs. If you develop a rash, bruises, sore throat, or fever contact your doctor immediately.

Be very careful about taking high doses of aspirin if you are also taking Diamox. Effects of this combination can range from loss of appetite, sluggishness, and rapid breathing to unresponsiveness; the combination can be fatal.

If Diamox is taken with certain other drugs, the effects of either could be increased, decreased, or altered. It is especially important to check with your doctor before combining Diamox with the following:
Amitriptyline (Elavil)
Amphetamines such as Dexedrine
Aspirin
Cyclosporine (Sandimmune)
Lithium (Lithonate)
Methenamine (Urex)
Oral diabetes drugs such as Micronase
Quinidine (Quinidex)

Info found at
http://www.healthsquare.com/newrx/dia1131.htm

**

Alas, a tumour can give rise to pressures in the brain which may impact on personality and on ability to reason, qualities which are under stress in any case when you have a worrisome diagnosis. (This may make it harder for the patient to reason; carers' capacities to think through issues may also be troubled - counselling may be something for the carer to consider for her or himself).

Brain tumours may tend not to cause pain, compared with other forms of cancer, but they can muddle perception (including perception of reality), behaviour and thought more insidiously. And because aggressive tumours can cause sudden, not just gradual, changes in circumstance, it may be wise not to delay discussing basic issues - it may suddenly be too late.

Some treatments have insidious effects too.

There is a need for two other common kinds of treatment - anti-oedema and anti-seizure.

(i) Anti-oedema medication: Tumours do damage not only when they themselves grow but also if they produce oedema (fluid build-up); oedema also creates destructive pressure. The standard treatment for oedema, but one which can provide only temporary relief, is dexamethosone (marketing name in Australia is Dexmethsone; in the United States Decadron).

This is a very powerful corticosteroid, which has very unpleasant side effects if used for a long time (and some may arise particularly, particularly psychological symptoms, in some patients), and withdrawal from which takes time and may itself produce some adverse symptoms, including adrenal insufficiency, causing great weakness.

Info found at the now non working link to
OzBrain Tumours Notes.

 Links

Intracranial Hypertension (Pseudotumor Cerebri)
http://www.djo.harvard.edu/meei/PI/pseudotcereb.html

Pseudotumor Cerebri - suffers research page.
http://members.hometown.aol.com/_ht_a/wellbarnca/myhomepage/

The UIHC Ophthalmology and Visual Sciences
Idiopathic Intracranial Hypertension
(Pseudotumor Cerebri)
 
http://webeye.ophth.uiowa.edu/dept/iih/pc_index.htm

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