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Snapshot
  • A 58-year-old man presents to the emergency department with transient vision loss in both eyes. His symptoms are associated with a throbbing right frontal headache. He endorses an unintentional 25 pound loss over the course of 3 months. Physical examination is notable for bilateral papilledema. An MRI brain with and without contrast demonstrates a right frontal intra-axial mass concerning for malignancy.
Introduction
  • Overview
    • optic disc swelling secondary to increased intracranial pressure
  • Pathophysiology
    • raised intracranial pressure is transmitted to the optic nerve sheath
      • this disrupts axoplasmic nerve flow, leading to leakage of intracellular contents, and subsequently resulting in optic disc swelling
  • Associated conditions
    • intracranial mass
    • cerebral edema
    • idiopathic intracranial hypertension
    • obstructive hydrocephalus
    • obstructive venous flow (e.g., venous sinus thrombosis)
Presentation
  • Symptoms
    • transient vision loss
      • with changes in head position or spontaneously
  • Physical exam 
    • typically bilateral findings
    • loss of venous pulsation
    • obliteration of the optic nerve cup
    • optic disc swelling
      • disc margins become obscured
Imaging
  • Brain imaging
    • indication
      • initial step in the evaluation of increased intracranial pressure suggested by papilledema
    • modality
      • MRI brain with contrast is preferred
Studies
  • Lumbar puncture
    • indication
      • in patients with papilledema with normal neuroimaging
      • to assess opening pressure
  • Visual field testing
    • indication
      • to monitor 
        • visual side effects of papilledema
        • response to treatment
Differential
  • Optic neuritis
    • differentiating factors
      • typicailly unilateral
      • relative afferent pupillary defect in unilateral cases
      • pain associated with eye movements
Treatment
  • Treatment is aimed at the underlying cause of papilledema
    • e.g., tumor resection in patients with a brain malignancy
Complications
  • Blindness

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