Idiopathic Intracranial Hypertension in Pregnant Women

Transcription

1 Azza A. Ghali et al. Idiopathic Intracranial Hypertension in Pregnant Women Azza Abass Ghali, Ehab El-Seidy, Tarek Ragaiey Hussein 2, Manal Mostfa 3 Departments of Neuropsychiatry, Ophthalmology 2, Obstetrics and Gynecology 3, Tanta University ABSTRACT Objectives: When pregnancy is complicated by Idiopathic intracranial hypertension (IIH) the management and treatment of the disorder can be problematic. So, the aim of this work is to evaluate the course, management of pregnant IIH patients and the visual and pregnancy outcomes. Subjects and Methods: Case series of 3 pregnant women diagnosed with IIH. IIH symptoms, neuro-ophthalmological findings, IIH management, visual and pregnancy outcomes were documented. Results: This study included thirteen pregnant females with clinical diagnosis of IIH. Their age ranged from 23 to 38 years (mean 28.±4.2). The gestation age at the time of IIH diagnosis ranged from 6-24 weeks (mean 2.4±5.4). Ten patients were obese. The main presenting symptoms were headache (84.6%), transient visual obscuration (77 %), dizziness (38.5%), diplopia, pulsatil tinnitus, nausea and vomiting (30.8%), and blurred vision (23.%). On examination, four patients had bilateral six nerve palsy. Fundus examination of these patients at the time of presentation revealed that six patients (i.e., twelve eyes) had early papilledema and seven patients had established papilledema. All patients had visual field changes in the first examination. Ten patients were treated by serial lumbar puncture. Not all the patients adhered to the diet, eight patients accepted to be on diet control. Five patients were taking acetazolamide after the first trimester. After intervention, visual function improved in all cases. There were full term pregnancies with normal delivery in 9 patients. Conclusions: IIH appears to present during the first two trimesters of pregnancy with typical symptoms and findings. Visual outcome is similar as for non-pregnant women. Treatment should be oriented towards dietary control, without ketosis. Repeated lumbar puncture, and acetazolamide if needed after the first trimester, can be helpful. (Egypt J. Neurol. Psychiat. Neurosurg.,, 46(): 4-50) INTRODUCTION Idiopathic intracranial hypertension (IIH) is defined as a syndrome of signs and symptoms of increased intracranial pressure without causative lesions on magnetic resonance imaging (MRI) or computed tomography. It occurs with a frequency of 9.3 per 00,000 in obese women of childbearing age 2. The terms pseudotumour cerebri and pseudotumour syndrome are also used, but the term benign intracranial hypertension is now obsolete, reflecting current awareness of the major risks to vision from papilloedema.,2 Symptoms and signs of IIH should be attributable to raised CSF pressure. Common symptoms are headache, pulsatile tinnitus, nausea, transitory visual obscurations, diplopia and blurred vision. The presenting symptom is often headache, although other symptoms including asymptomatic papilloedema are also seen 3. The pathogenesis of IIH remains unknown and it may not be a syndrome with a single causative factor. In theory, IIH may be attributed to the Correspondence following factors; Azza Abass parenchymal Ghali, edema, azzaghali_4@hotmail.com. increased Contact number: cerebral blood volume, excessive CSF production, compromised CSF resorption, and venous outflow obstruction 2.The major morbidity is visual loss, with blindness reported in 0% of patients 4. An association between IIH and obesity has been recognized, especially in individuals with a history of recent weight gain, including children. 5 Idiopathic intracranial hypertension is reported only occasionally during pregnancy 6. Both pregnancy and exogenous estrogens are thought to promote IIH or worsen it. It can occur in any trimester during pregnancy, therapeutic abortion to limit its progression is not indicated, and subsequent pregnancies do not increase the risk of recurrence 7. Pregnant and non-pregnant patients with IIH are managed similarly, but the use of imaging and drug contraindications during pregnancy account for some differences in management between the 2 4

2 groups 7. The aim of treatment is to preserve vision and improve symptoms. Treatments include weight control by diet, analgesics, diuretics, steroids, and serial lumbar punctures. When medical therapy fails, surgical procedures need to be considered 7. The two main surgical procedures are optic nerve sheath fenestration and lumboperitoneal shunt. Anesthetic considerations in the pregnant patient are an additional factor when surgeries are contemplated 8. When pregnancy is complicated by IIH the management and treatment of the disorder can be problematic. So, the aim of this work is to evaluate the course, management of pregnant IIH patients and the visual and pregnancy outcomes. 42 SUBJECTS AND METHODS Thirteen pregnant women with clinical diagnosis of IIH were selected from the Outpatient Clinic of Neurology, Ophthalmologic Departments, and Department of Obstetrics and Gynecology Tanta University Hospital. Their age ranged from years. The clinical diagnosis of IIH was done according to the criteria of the International Headache Society s (IHS) classification of headache disorders (2 nd edition). 3 All subjects were submitted to the following: ) Complete history taking including; age of the patient, the presenting symptoms (headache, diplopia, visual blurring, transitory visual obscuration, nausea, vomiting, tinnitus etc), onset, duration, and course of symptoms.. History of drug intake that are associated with IIH especially vitamin A supplement. 2) Neuro-ophthalmological evaluation: since the most worrisome feature of IIH is visual loss, patients were followed throughout their pregnancy to monitor their vision. All patients were submitted to the following: a. Thorough neurological examination to exclude focal neurological signs. b. Visual acuity was measured using the Landolt Brocken rings. c. Extra-ocular muscle (EOM) examination as regard limitation of EOM with especial attention to lateral rectus muscle to detect sixth cranial nerve paresis. d. Fundus examination was done using both direct ophthalmoscope and the slit lamp on dilated Vol. 46 () - Jan pupil using 78 D Volk lens for stereroscopic view of the optic disc, peripapillary nerve fiber layer and the macula. e. Fundus disc photography using Topcon camera f. Visual field examination: for every patient, automated static perimetry with Humphery visual field analyzer was done using fastpac central 30-2 threshold program with white color stimulus test size III. Visual field examination was done for the first time when the clinical diagnosis of IIH was established for the detection of optic nerve function and then visual field was repeated for the evaluation of visual field function in response to treatment. 3) Obstetric evaluation: including obstetric history and examination. Patients were followed clinically till the delivery. Documentation of pregnancy outcome included normal pregnancy, fetal loss, and congenital malformations. Patients were followed during pregnancy every month. 4) General examination: with special consideration to the body mass index. 5) Brain MRI and MRV were done to exclude secondary causes of intracranial hypertension as sinus thrombosis. 6) Laboratory tests:. To exclude conditions mimicking idiopathic intracranial hypertension as complete blood count, hemoglobin level, erythrocyte sedimentation rate, K and Na level, TSH, T3, T4.etc 2. Measurements of opening lumbar pressure were done prior to CSF tapping. CSF pressure greater than 250 mmh 2 O is consistent with the diagnosis, less than 200 mm H 2 O is normal, and 20 to 249 mm H 2 O is non diagnostic 9. Also, CSF analysis was done 7) Protocol of management of IIH during pregnancy was applied according to Huna-Baron and Kupersmith 6 who outlined that treatment is determined by symptoms, visual function and optic disc appearance. Headaches were treated with paracetamol. Patients presented by early papilledema treated by diet control and serial lumbar puncture. Patients presented by established papilledema were treated by diet control, serial lumbar puncture, and acetazolamide especially if the patients not in the first trimester.

3 Azza A. Ghali et al. Patients were advised to avoid excessive weight gain with guidance from their obstetrician. Lowcalorie diets and weight reduction were not recommended. Limiting vitamin A consumption, salt restriction, and a low tyramine diet were recommended. RESULTS This study included thirteen pregnant females with clinical diagnosis of IIH. Their age ranged from 23 to 38 years (mean 28.±4.2). Ten patients were obese; their body mass index was more than 30. The main presenting symptom was headache which was reported by eleven patients (84.6%) followed by transient visual obscuration in 0 patients (77%). Five patients had dizziness (38.5%). Four patients complained of diplopia (30.8%). Also four patients (30.8%) had pulsatil tinnitus. Furthermore, nausea and vomiting were present in four patients (30.8%). Three patients had blurred vision (23.%). By examination, four patients had bilateral six nerve palsy (30.8%) (Table ). The gestation age at the time of IIH diagnosis ranged from 6-24 weeks (mean 2.4±5.4). All the patients were affected by IIH after the onset of their pregnancies. During the study, two patients had spontaneous abortions (5.4%). Eleven patients continue their pregnancy till the full term. All had normal vaginal delivery except two who had caesarian section due to breech presentation and premature rupture of membrane. No patient worsened during delivery. No one of patients had a child with congenital malformations. Also, the manifestations of IIH were improved during the course of the pregnancy, no one continue treatment till the time of labor. After improvement, no patient had recurrence of IIH during the course of pregnancy. The neuro-ophthalmological findings included visual acuity which ranged from 6/6 to 6/36 in both eyes of twelve women. Only one woman had severe loss of visual acuity in one eye to 2/60 and the other eye had reduction to 6/60. At the last visit, visual acuity ranged from 6/6 to 2/60. Totally, out of 26 (42.3%) eyes of the patients of the study had a stable visual acuity throughout the follow-up period while 5 out of 26 (57.7%) eyes had improvement of visual acuity at the last follow up visit (Table 3). Fundus examination of these patients at the time of presentation revealed that six patients (i.e., twelve eyes) had early papilledema and six patients had established papilledema (Table 3). Only one case had papilledema with optic atrophy on both eyes. At the end of the study, fundus became normal except for two eyes which showed postpapilledemic optic atrophy. Visual field changes were enlarged blind spot with nasal defect in 0 out of 26 eyes (38.5%), enlarged blind spot alone in 9 eyes (34.6%), double arcuate defect in 3 eyes (.5 %), upper arcuate defect alone in 2 eyes (7.7%), large blind spot with paracentral defect in eye (3.9%) and lower nasal defect alone in eye (3.9%). On the last visit, 3 out of 26 (.5%) eyes had stable visual field while the remaining 23 eyes (88.5%) had improvement of the visual field (Fig. ). In out of 23 (47.8%) eyes of improved visual field, the field returned back to normal. Regarding the treatment received by the patients, the most common line of treatment was lumbar puncture which was used in ten women. Not all the patients adhered to the diet, eight patients accepted to be on diet control. Five patients were taking acetazolamide; all of them started it after the first trimester. It was given in dose of mg/day. Patients who had severe headache were treated by paracetamol which was enough to control headache (Table 2). Table. Clinical data of the studied patients. Clinical Data Results Age Range: years; Mean: 28.± 4.2 Headache /3 (84.6%) TVO 0/3 (77 %) Obesity (BM I > 30) 0/3 (77%) Dizziness 5/3 (38.5%) Diplopia 4/3 (30.8%) Tinnitus 4/3 (30.8%) Nausea and vomiting 4/3 (30.8%) Blurred vision 3/3 (23.%) Bilateral 6 th nerve palsy 4/3 (30.8%) 43

4 Vol. 46 () - Jan Total number = 3 patients. TOV: transient visual obscuration. BMI: body mass index. 44

5 Azza A. Ghali et al. Table 2. Obstetrical data and treatment. Patient. NO Gestational age (week) Duration of pregnancy Type of delivery Treatment 6 Full term Vaginal delivery Serial lumbar puncture 2 8 Full term Caesarian delivery Serial lumbar puncture Diet control 3 2 Full term Vaginal delivery Serial lumbar puncture acetazolamide 4 20 Full term Vaginal delivery acetazolamide 5 4 Full term Vaginal delivery Diet control Serial lumbar puncture Acetazolamide 6 6 abortion Diet control Serial lumbar puncture 7 2 Full term Vaginal delivery Diet control Serial lumbar puncture 8 24 Full term Vaginal delivery acetazolamide 9 0 Full term Vaginal delivery Diet control Serial lumbar puncture 0 8 Full term Vaginal delivery Serial lumbar puncture 2 Full term Vaginal delivery Serial lumbar puncture Diet control 2 6 Full term Caesarian delivery Diet control Serial lumbar puncture Acetazolamide 3 6 abortion Diet control Serial lumbar puncture Table 3. Ophthalmologic findings and outcome. Ophthalmic data No of eyes at presentation No of eyes at Last visit Visual acuity Visual field changes Fundus Examination 6/6 6/9 6/2 6/24 6/36 6/60 2/60 Normal field Large BS with nasal defect Large BS Double arcuate defect Upper arcuate defect Nasal defect Large BS with paracentral defect Early papilledema Established papilledema Postpapilledemic optic atrophy

6 BS: blind spot Vol. 46 () - Jan 46

7 Azza A. Ghali et al. Fig. (): Overview of 3 consecutive control 30-2 threshold visual fields of right and left eye of the same patient showing enlarged blind spot with lower nasal bundle defect improving over follow up period. Fig. (): Continuous 47

8 Vol. 46 () - Jan DISCUSSION 48

9 With obscure etiology, confusing terminology, and controversial management, idiopathic intracranial hypertension (IIH) remains a common and challenging clinical problem of the general and neurological practice. IIH occurs most commonly in reproductive age women who are obese. The incidence is approximately /00 000/year rising to 3/00 000/ year in women between 20 and 44 years who are 0% above ideal body weight and 9/00 000/ year in those 20% above ideal body weight. Although pregnancy is not considered an independent risk factor for IIH, the disease may start or worsen during pregnancy 9. Since Quincke 0 first related menstrual irregularity and pregnancy to IIH over a century ago, 3 a number of isolated case reports and a few larger series have described patients who developed IIH during pregnancy. In this study, among the IIH pregnant patients 0 (77%) were obese (BMI > 30). Obesity is a known significant risk factor for non-pregnant women to develop IIH,2,3. Obesity predisposes to IIH, and the mechanism proposed is that central obesity raises intra-abdominal pressure, which increases pleural pressure and cardiac filling pressures, which in turn impedes venous return from the brain and leads to increased intracranial venous pressure and increased intracranial pressure,7. Dietary management and weight loss are timehonored treatments, supported by several observational studies 9. In this study, patients are advised to avoid excessive weight gain with guidance from their obstetrician. In prior case reports 4,5, the onset of IIH is present in the first half of pregnancy, which is similar to our results. On the other hand, Huna- Baron and Kupersmith 6 reported that IIH in their series can occur at any trimester. In this study, IIH symptoms and findings were not different from those experienced by nonpregnant women with this disorder as reported by Bagga et al. 7 and Schiffman et al. 0. All the patients were reported manifestations of IIH during their pregnancies, not before. Evans and Friedman 6 explained the association between pregnancy and IIH by that weight gain, fluid retention, and hormonal fluctuation are common to both conditions. Also, Bagga et al. 7, reported that both pregnancy and exogenous estrogens are thought Vol. 46 () - Jan to promote IIH or worsen it. It has also been speculated that polycystic ovarian disease (PCOS) associated with obesity and extreme obesity can promote IIH. The associated thrombophiliahypofibrinolysis and subsequent thrombosis lead to reduced CSF resorption in the arachnoid villi of the brain. Thrombophilia and hypofibrinolysis are often exacerbated by thrombophilic exogenous estrogens, pregnancy, or the paradoxical hyperestrogenemia of PCOS and all of these are considered as treatable causal factors for IIH 7. In addition, vitamin A toxicity may play a role in the pathogenesis of IIH 8. Regarding the obstetric outcome, two patients had spontaneous abortions. Eleven patients continued their pregnancy till the full term. All had normal vaginal delivery except two who had caesarian section due to breech presentation. No patient worsened during delivery. No one of the patients had a child with congenital malformations. Huna-Baron and Kupersmith 6 reported that IIH does not have a major negative impact on the outcome of the pregnancy. Monitoring visual function is mandatory, and it is important to appreciate that uncontrolled raised intracranial pressure and persistent papilloedema can result in blindness. Fundus examination of our patients at the time of presentation revealed that six patients (i.e., tweleve eyes) had early papilledema and six patients had established papilledema. Only one case (case 5) had started optic atrophy on both eyes. The ophthalmoscopic appearances of papilloedema reflect the severity of raised intracranial pressure and associated central retinal vein obstruction. However, measuring degrees of disc swelling by ophthalmoscopy or by disc imaging techniques and blind spot size measurement are unreliable markers of visual field loss, and quantitative serial perimetry is mandatory for monitoring clinical progress 0. Visual field examination was done for the first time when the clinical diagnosis of IIH was established for the detection of optic nerve function and then visual field was repeated for the evaluation of visual function in response to treatment. Enlarged blind spot with nasal defect was the most common field defect in this study (38.5%) followed by enlarged blind spot alone in (34.6%), double arcuate defect (.5%), upper arcuate defect 48

10 Azza A. Ghali et al. (7.7%), large blind spot with paracentral defect (3.9%) and lower nasal defect alone in one eye (3.9%). These visual field findings are in agreement with Hung et al. study 9, who have found that the visual field defects in their IIH patients (who were non-pregnant sample) were enlargement of the blind spot, concentric constrictions, inferior nasal defects, central, paracentral and centrocecal scotomas, arcuate defects, and altitudinal defects. The most common types of visual field defect in their study were constriction and inferonasal loss. Visual acuity in patients of our study was ranged from 6/6 to 2/60 at the last visit. Totally, out of 26 (42.3%) eyes of the patients of the study had a stable visual acuity throughout the follow-up period while 5 out of 26 (57.7%) eyes had improvement of visual acuity at the last follow up visit. Huna-Baron and Kupersmith 6 in 2 women with IIH with pregnancy have found that visual acuity improved in all cases with prior reduction in visual acuity. So, visual outcome is similar to that of non-pregnant patients as reported by Schiffman, et al. 0 and Hung et al. 9. Too little of the pathophysiological mechanisms in IIH is known for the treatment to be causal. The treatment is symptomatic focusing on lowering the CSF pressure, thus preventing visual defect development and disabling headaches 3. Treatment should not base on the appearance of optic disc alone, since many patients have residual optic disc elevation after their intracranial pressure normalizes. So, during the course of the disease, treatment efficiency was evaluated with regular automated perimetry testing in order to assure stable visual function 20. In this study, patients were advised to avoid excessive weight gain with guidance from their obstetrician. Low-calorie diets and weight reduction are not recommended. Limiting vitamin A consumption, salt restriction, and a low tyramine diet were recommended. Not all the patients adhered to the diet, eight patients accepted to be on diet control. Five patients were taking acetazolamide; all of them started it after the first trimester. It was given in dose of mg/day. The carbonic anhydrase inhibitor, acetazolamide, is usually the first-line drug in treatment and probably acts by reducing the CSF production and thus ICP. The effective dose is individualized 9. The clinical need for the use of acetazolamide during pregnancy for IIH is a relatively common decision. Although many review articles on IIH suggest that acetazolamide to be avoided in pregnancy, especially in the first trimester, there is little clinical evidence to support this recommendation. 2 Digre and associates 5 reported on patients with IIH during pregnancy. Of these, 3 received acetazolamide. In patient the acetazolamide was discontinued after the pregnancy was discovered. One patient had a spontaneous abortion at 2 weeks, and 2 patients had normal pregnancy outcomes. These authors reviewed the literature on cases of IIH in pregnancy and found that 3 additional patients had received acetazolamide with no adverse pregnancy outcome. Moreover, Lee et al. 2 in their 2 IIH pregnant women receiving acetazolamide, found that there were no minor or major malformations noted either at delivery or at the well baby visits, and all pregnancy outcomes were within normal which is in agreement with our result. Friedman and Jacobson 9 and Evans and Friedman 6 advised repeated lumbar puncture as a mode of therapy in pregnant IIH patients. In this study, ten patients were treated with repeated lumbar puncture with satisfactory results regarding to the headache and visual function. From this study, it can be concluded that IIH appears to present during the first two trimesters of pregnancy with typical symptoms and findings. Visual outcome is similar as for non-pregnant women. Treatment should be oriented towards dietary control, without ketosis. Repeated lumbar puncture, and acetazolamide if needed after the first trimester, can be helpful. The prognosis for individuals who develop IIH during pregnancy is excellent as long as the appropriate clinical monitoring and medical interventions are followed in a timely fashion to prevent visual failure. Without this approach, total blindness can ensue from postpapilledemic optic atrophy. A team approach involving the patient, her obstetrician, an appropriate eye care professional, and a neurologist is often the key to success. Communication and awareness of the possible complications can avoid any adverse outcome. 49

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