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Idiopathic Intracranial Hypertension: A Case Report
Abstract: Idiopathic intracranial hypertension can cause significant vision loss if not diagnosed and
treated in a timely manner. This case illustrates the management of severe papilledema in a patient
unable to tolerate acetazolamide.
I.
Case History

Patient Demographics: 37 year old, overweight, African American female

Chief complaint: headaches for several years with whooshing sound in ears, having trouble
adjusting from dark to light room

Ocular history: no previous surgeries or trauma, last eye exam in October 2013 was normal.

Medical history: Hypertension, Otis Externa, Agoraphobia with panic disorder

Medications: Amlodipine, Propanol , Losartan, Linzess, Protnoix

Social History: Massage therapist, non-smoker, denies alcohol use, has gained 20 lbs this year
without any changes to diet or appetite
II. Pertinent Findings
 Clinical:
BCVA
OD: 20/20
OS: 20/20
EOMs: full range of motion OU, reports pressure with movement, denies
diplopia
Pupils: 5 mm in dark, 3 mm in light, equally reactive, no APD OU
CVF: FTFC OD, OS
IOP: 15 mm Hg OD, 16 mm HG
Color vision (Ishihara plates):
OD: 14/14
OS: 14/14
Slit lamp examination: normal OU
Fundus examination: Grade 4 papilledema OU

Physical:
Height: 5’7”
Weight: 205.5 lbs
BP: 144/80
BMI: 32

Laboratory studies:
Lumbar puncture shows elevated open pressure of 38 cm H2O.

Radiology studies:
-MRI with and without contrast: normal without optic nerve sheath
dilation.
-MR Venography with and without contrast: no venous sinous thrombosis
III. Differential diagnosis
-Idiopathic Intracranial Hypertension
-Neuromyelitis optica
-Malignant Hypertension
-Diabetic papillopathy
-Optic disc drusen
-Meningitis
IV. Diagnosis and discussion
Idiopathic Intracranial hypertension (IIH) is a neurological condition where there is
elevated intracranial pressure in the absence of a tumor or other diseases. The most
common symptoms are persistent headaches and transient episodes of visual loss. IIH
occurs predominantly in overweight females in their third decade of life. Upon
examination, bilateral optic disc edema is almost always present. To diagnose this
condition, a MRI/MRV of the orbit and brain must be obtained to rule out an intracranial
mass or venous sinus thrombosis. Subsequently, a lumbar puncture is then performed and
the opening pressure must be elevated.
V. Treatment and management
There are a variety of treatments for idiopathic intracranial hypertension. Weight loss is
always recommended along with a low sodium diet. If a patient requires medical therapy,
acetazolamide or furosemide is commonly prescribed. Topiramate may also be prescribed
to alleviate the headaches associated with this condition. If medical therapy or weight loss
is unsuccessful, there are a few surgical therapies such as optic nerve sheath decompression
surgery or a ventriculoperitoneal or lumboperitoneal shunt. Patients with IIH should be
monitored every month if there is a visual field loss and then every three months,
depending on the response to treatment.
VI. Clinical Pearls
-Ask the patient if there has been any recent weight loss or weight gain
-Ask the patient, if female, if she is taking oral contraceptives
-Always obtain an MRI/MRV before a lumbar puncture
-A normal MRI and elevated opening pressure (>25 mm H2O) must be present to
diagnose IIH