An Observational Study on Idiopathic Intracranial Hypertension (IIH) in a Tertiary Care Hospital in Bangladesh

Background: Among the risk factors of cardiovascular diseases, hypertension is one of the major reason. Intracranial hypertension (IIH) is a pressure buildup around the brain. It can happen unexpectedly, as a result of a severe head injury, stroke, or brain abscess could be occurred. It could also be a chronic, long-term condition, known as IIH. It results in the signs and symptoms of a brain tumor. Which is also known as benign intracranial hypertension. Cerebrospinal fluid, or CSF, is the fluid that surrounds the spinal cord and brain. CSF can accumulate if too much fluid is produced or not enough is reabsorbed. This can induce symptoms similar to a brain tumor. Intracranial Hypertension can be classified into three categories, they are Acute, Chronic and Idiopathic. IIH is recognized when the increased intracranial pressure cannot be explained by any other underlying cause.Aim: The aim of the study was to observe idiopathic intracranial hypertension patients in a select tertiary care hospital of Bangladesh.Methods:This cross-sectional observational study was conducted at the Department of Neurosurgery, Sylhet M. A. G. Osmani Medical College Hospital, Sylhet, Bangladesh. The study duration was from January 2012 to December 2020. A total number of 47 participants had been recruited as study population.Results:Male: female ratio was 1:10.75, and 91% of the total participants were female. 40.43% of the participants were aged between 21-30 years. 46.81% were overweight and 34.04% were obese. Most common symptom was nausea, followed by visual impairment and double vision.Conclusion:The prevalence of Idiopathic Intracranial Hypertension is much higher among the female. Female and high BMI are significant risk factors of IIH. It is more prevalent among young adults, and results on various vision related symptoms.

Benign Intracranial Hypertension Due to Hypoparathyroidism: A Case Report

Objective: The objective of this study is to present the rare case of a young girl with idiopathic intracranial hypertension secondary to hypoparathyroidism.Background: Idiopathic intracranial hypertension is a neurological syndrome characterized by elevated intracranial pressure (> 25 cmH2O) in the absence of intracerebral abnormalities or hydrocephalus. The pathophysiology of idiopathic intracranial hypertension is unknown, and rare cases of idiopathic intracranial hypertension secondary to hypoparathyroidism have been described. It is supposed that hypocalcemia causes decrease in the absorption of cerebrospinal fluid in arachnoidal granulations.Methods: The workup of the girl with idiopathic intracranial hypertension and hypoparathyroidism included physical examination, blood tests, diagnostic imaging, and lumbar puncture.Results: We present a 9-year-old female patient who was hospitalized for headache associated with nausea and vomiting for 3 weeks. She underwent an ophthalmologic examination that revealed papilledema. Lumbar puncture revealed an opening pressure of 65 cm H2O; cerebrospinal fluid analysis and brain computed tomography scan were normal. The patient started taking acetazolamide. Blood tests revealed hypocalcemia associated with high phosphorus level and undetectable PTH hormone, which led us to suspect hypoparathyroidism. She had never had cramps, paraesthesias, or tetany. Chvostek's and Trousseau's signs were positive. In the neck ultrasonography, parathyroids were not visible. Oral supplementation with calcitriol and calcium was started. Headache, nausea, and vomiting immediately disappeared after the lumbar puncture, and the papilledema improved gradually.Conclusions: Several anecdotal cases of idiopathic intracranial hypertension secondary to hypoparathyroidism have been described. However, our case report is of particular interest, since the child did not present with typical neurological hypoparathyroidism symptoms. Therefore, we recommend that hypoparathyroidism should be included in diagnostic investigations on children with clinical findings of idiopathic intracranial hypertension, because clinical manifestations of hypoparathyroidism are variable and may involve almost all organ systems.

Sixth Nerve Palsy in Children Etiology, Long-Term Course, and a Diagnostic Algorithm

Background Acute onset strabismus is worrisome for parents and physicians. This condition is sometimes attributed to sixth cranial nerve palsy, which may be secondary to various etiologies. Debate still exists about the appropriate diagnostic approach. Objective The objective of this study was to describe the common etiologies of sixth nerve palsy in our pediatric population and to suggest a clear, implementable diagnostic algorithm. Methods The authors conducted an electronic medical review of files of patients admitted to the pediatric department at Emek Medical Center between January 2014 and April 2020. They reviewed the medical records from the study period of patients with the following diagnoses according to the International Classification of Diseases 9: sixth nerve palsy, acute infective polyneuritis, Guillain-Barré syndrome, benign intracranial hypertension, malignant neoplasm of the brain, strabismus, myasthenia gravis, and multiple sclerosis. The authors extracted information regarding clinical presentation, previous history, and diagnostic work-up, including serological testing, cerebrospinal fluid testing, and neuroimaging. Final diagnosis and clinical follow-up were assessed. Results Seventeen patients with sixth nerve palsy were identified. The most common etiologies were increased intracranial hypertension and anti-GQ1B syndrome (3 patients each). Conclusions This is a retrospective study of patients diagnosed in one medical center. The suggested algorithm was not validated on a prospective study. The etiologies of sixth nerve palsy in children are variable. The authors suggest performing neuroimaging in all patients and considering serum and cerebrospinal fluid testing in selected patients. Initial neuroimaging combined with laboratory testing is useful and provides rational tools for proper diagnosis.

Neurological complications in pediatric patients with SARS-CoV-2 infection: a systematic review of the literature

Objectives To describe clinical characteristics, laboratory tests, radiological data and outcome of pediatric cases with SARS-CoV-2 infection complicated by neurological involvement. Study design A computerized search was conducted using PubMed. An article was considered eligible if it reported data on pediatric patient(s) with neurological involvement related to SARS-CoV-2 infection. We also described a case of an acute disseminated encephalomyelitis (ADEM) in a 5-year-old girl with SARS-CoV-2 infection: this case was also included in the systematic review. Results Forty-four articles reporting 59 cases of neurological manifestations in pediatric patients were included in our review. Most (32/59) cases occurred in the course of a multisystem inflammatory syndrome in children (MIS-C). Neurological disorders secondary to cerebrovascular involvement were reported in 10 cases: 4 children with an ischemic stroke, 3 with intracerebral hemorrhage, 1 with a cerebral sinus venous thrombosis, 1 with a subarachnoid hemorrhage, 1 with multiple diffuse microhemorrhages. Reversible splenial lesions were recognized in 9 cases, benign intracranial hypertension in 4 patients, meningoencephalitis in 4 cases, autoimmune encephalitis in 1 girl, cranial nerves impairment in 2 patients and transverse myelitis in 1 case. Five cases had Guillain-Barré syndrome (GBS) and two, including ours, had ADEM. Radiological investigations were performed in almost all cases (45/60): the most recurrent radiological finding was a signal change in the splenium of the corpus callosum. The presence of SARS-CoV-2 viral nucleic acid in the cerebrospinal fluid was proved only in 2 cases. The outcome was favorable in almost all, except in 5 cases. Conclusions Our research highlights the large range of neurological manifestations and their presumed pathogenic pathways associated with SARS-CoV-2 infection in children. Nervous system involvement could be isolated, developing during COVID-19 or after its recovery, or arise in the context of a MIS-C. The most reported neurological manifestations are cerebrovascular accidents, reversible splenial lesions, GBS, benign intracranial hypertension, meningoencephalitis; ADEM is also a possible complication, as we observed in our patient. Further studies are required to investigate all the neurological complications of SARS-CoV-2 infection and their underlying pathogenic mechanism.

Benign intracranial hypertension associated with inhaled corticosteroids in a child with asthma

A 13-year-old male asthmatic presented to the general paediatric clinic with papilloedema identified following a check-up with his optician due to blurred vision. His asthma was well controlled on a moderate dose of inhaled corticosteroid and there had been no recent increase or decrease in the dose. A diagnosis of benign intracranial hypertension (BIH) was made based on a raised cerebrospinal fluid opening pressure, papilloedema, a normal neurological examination and normal neuroimaging. The only associated risk factor was his inhaled corticosteroids. He was commenced on acetazolamide and the inhaled corticosteroid dose was reduced, resulting in resolution of his papilloedema. This case serves to highlight that steroid side effects including BIH may occur at moderate doses of inhaled corticosteroids and that inhaled corticosteroid dose should be regularly reviewed and decreased to the lowest dose that maintains asthma control.

Clinical treatment of Idiopathic Benign Intracranial Hypertension (IIH): case report

Introduction: Headache is one of the most common complaints in medicine, being divided into primary or secondary. Idiopathic Benign Intracranial Hypertension (IBIH) is one of the causes of secondary headache, where there is an increase in intracranial pressure in the absence of an expansive process. Goals: To present the management of IBIH refractory to conventional treatment. Methodology: Clinical evaluation of the patient, review of her medical record and review of literature related to the topic. Case report: RMC, female, 55 years old, short stature, BMI 48, presented in 2018 repetitive pictures of severe headache, without improvement factors, associated with visual disturbances that evolved to amausore, sporadic loss of balance and slowing pupillary reflexes, mood disorders and easy cry. Magnetic resonance and fundscopy were inconclusive, and CSF puncture found an opening pressure of 20 cm of water. After CSF puncture, the patient showed instantaneous vision improvement, and therapy with Acetazolamide was introduced, which controlled and kept her ophthalmological symptoms stable. Angina conditions were only resolved with the introduction of Lamotrigine. RESULTS: The most commonly prescribed medication for IBIH, Acetazolamide, controlled the reported patient’s ophthalmological condition, but not the pain episodes. When this medication alone cannot control the condition, the association of other medications or surgical conduct is indicated. The association of Acetazolamide with Lamotrigine was extremely important to solve the patient’s pain episodes, making her clinical management positive. Conclusion: The combination of Lamotrigine and Acetazolamide has been shown to be an excellent form of outpatient treatment for IBIH.

Transtemporal Venous Decompression for Idiopathic Venous Pulsatile Tinnitus

Objective To evaluate the clinical characteristics and present surgical outcomes of transtemporal venous decompression technique in the treatment of pulsatile tinnitus (PT). Study Design This is a prospective cohort study. Setting This study was done at the tertiary private neurotologic skull base clinic. Participants The primary author, between March 2012 and February 2013, evaluated 55 patients with the complaint of PT. Seven out of the 55 patients were diagnosed with severe, unrelenting idiopathic pulsatile tinnitus (IPT), and were placed into the study. These seven patients had temporal bone computed tomography, magnetic resonance imaging, arteriogram, videonystagmography, electrocochleography, and lumbar puncture based on the symptoms. All the seven patients underwent transtemporal venous decompression surgery. Main Outcome Measure Resolution of PT was determined as the primary outcome measure. Results Six out of seven patients had complete resolution of their PT immediately after surgery and at 3 to 4 years follow-up. One patient developed intracranial hypertension after 3 months requiring ventriculoperitoneal shunt, which resolved PT as well. No complications occurred. Conclusion A significant subset of the PT patient population has known reversible causes. The more common includes conductive hearing loss, superior canal dehiscence, benign intracranial hypertension, jugulosigmoid venous anomalies, stapedial myoclonus, etc. There exists a subset of patients who have IPT. Transtemporal venous decompression is a surgical technique that can be employed to give patients with IPT long-term relief.