A SIGHT-THREATENING PAPILLOEDEMA MIMIC: POLYPOIDAL CHOROIDAL VASCULOPATHY

A 44-year-old woman from Guyana was referred to the neurology services with headache and blurred vision. The ophthalmology services had made the referral following discovery of apparent bilateral papilloedema and a right retinal haemorrhage. A CT venogram reported enlarged optic nerve sheaths, empty sella and asymmetrical lateral sinuses. The initial lumbar puncture revealed a normal opening pressure of 14 cm H2O and clinical headache assessment suggested migraine. Further ophthalmology advice was sourobight. Having excluded drusen by B-scan ultrasound, a second lumbar puncture was performed and revealed opening pressure 23 cm H2O. Despite extensive investigation, diagnostic uncertainty persisted until the patient presented to Eye Casualty with acute deterioration in right eye visual acuity. A large retinal haemorrhage was noted and fluorescein angiography revealed multiple choroidal vascular polyps. A diagnosis of peripapillary polypoidal choroidal vasculopathy (PCV) was made. Treatment with intraocular anti-VEGF injections and photodynamic therapy successfully avoided permanent visual loss. Caution is advised when interpreting CT findings consistent with idiopathic intracranial hypertension, as PCV is an important differential diagnosis in unexplained papilloedema, which if left untreated can lead to irreversible blindness.

SUNCT, SUNA and pituitary tumors: Clinical characteristics and treatment

Background Short-lasting unilateral neuralgiform headache attacks with conjunctival injection and tearing (SUNCT) and short-lasting unilateral neuralgiform headache attacks with cranial autonomic symptoms (SUNA) are rare types of trigeminal autonomic cephalalgias (TACs). Objective To describe a series of patients with SUNCT and SUNA including relationship to pituitary tumors. Method All patients diagnosed with SUNCT or SUNA in the Calgary Headache Assessment and Management Program were reviewed. Results Six patients (five SUNCTs and one SUNA) were identified. The pain was severe, sharp, showed fixed-laterality, involved mainly the orbito-fronto-temporal region and was associated with autonomic symptoms. Attack duration ranged from 3 to 300 seconds and frequency was 1–200 paroxysms/day. MRI showed ipsilateral pituitary adenomas to the pain in five out of five of the SUNCT patients. Patients with adenomas underwent surgery. Pathology included three prolactinomas, and one mixed adenoma and gangliocytoma. One patient has remained headache free for 4 years after surgery. One was pain free for a year, and then headaches returned with tumor recurrence. Another had major improvement, and two have not improved. Patients were generally refractory to medications. Conclusion All five of our patients with typical SUNCT had pituitary tumors, with headache ipsilateral to the pituitary tumors in all cases. Tumor removal provided major improvement in three out of five patients. Medical treatment was only partially effective.