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  • Updated 04.18.2023
  • Released 03.30.1994
  • Expires For CME 04.18.2026

Idiopathic intracranial hypertension



Idiopathic intracranial hypertension is a disorder of increased intracranial pressure that is most commonly seen in obese women of childbearing age. The pathophysiology remains under investigation. Symptoms include headache, transient visual obscurations, and pulsatile tinnitus. Papilledema is the hallmark sign of this disorder. Untreated, it can result in optic nerve injury, consequent visual field defects, and blindness. It continues to be a diagnostic and therapeutic challenge, and the incidence is rising as obesity becomes more prevalent. This update reviews the clinical features of idiopathic intracranial hypertension in adults and children, conditions with which it can be confused, diagnostic evaluation and criteria, and current therapeutic options.

Key points

• Headaches, transient visual obscurations, and pulsatile tinnitus are the most frequent early manifestations of idiopathic intracranial hypertension in adults.

• Obese women of childbearing age are most commonly affected by idiopathic intracranial hypertension, but the syndrome may occur in children, nonobese patients, and those over 45 years of age.

• Diagnosis of exclusion and careful history, examination, and work-up (neuroimaging, CSF examination) are required to rule out other etiologies.

• Visual acuity reduction or significant visual field loss at presentation is an ominous sign, requiring aggressive intervention.

• The Idiopathic Intracranial Hypertension Treatment Trial (IIHTT) provides evidence-based therapy for patients who have mild visual loss.

• A team approach to management is ideal, and a team leader (generally a neurologist or neuro-ophthalmologist) is critical.

Historical note and terminology

In 1897, Quincke first described a syndrome of elevated intracranial pressure and bilateral papilledema due to impaired cerebrospinal fluid circulation. Seven years later, Nonne recognized that this group of conditions mimicked an intracranial tumor and named them "pseudotumor cerebri." In 1937, Dandy suggested that pseudotumor cerebri resulted from increased cerebral blood volume. In 1955, Foley popularized the term "benign intracranial hypertension." Recognition of visual loss as a possible complication resulted in substitution of the descriptor "idiopathic" for "benign" in 1982 (24). The diagnostic criteria were updated in 2002 to reflect advances in neuroimaging techniques and to incorporate atypical presentations (44). Revised criteria in 2013 defined the diagnosis of pseudotumor cerebri syndrome in adults and children, including criteria for those in whom papilledema is absent (45). “Idiopathic intracranial hypertension” is the term applied when no secondary cause is found.

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