Current Neurology and Neuroscience Reports

, Volume 4, Issue 5, pp 398–409

Medical and surgical management of idiopathic intracranial hypertension in pregnancy

  • Rosa A. Tang
  • E. Ulysses Dorotheo
  • Jade S. Schiffman
  • Hasan M. Bahrani
Article

Abstract

Idiopathic intracranial hypertension (IIH) is a syndrome of increased intracranial pressure without hydrocephalus or mass lesion with elevated cerebrospinal fluid (CSF) pressure but otherwise normal CSF composition. It has been found that pregnancy occurs in IIH patients at about the same rate as in the general population, that IIH can occur in any trimester of pregnancy, that patients have the same spontaneous abortion rate as the general population, and that the visual outcome is the same as for nonpregnant patients with IIH. Although it is also stated that pregnant patients with IIH should be managed and treated the same way as any other patient with IIH, the use of imaging and drug contraindications do make a difference between the two groups. The treatment has two major goals, which are to preserve vision and to improve symptoms. The medical therapy includes weight control, nonketotic diet, serial lumbar punctures, diuretics, steroids, and certain analgesics. When medical therapy fails, surgical procedures should be considered. The two main procedures are optic nerve sheath fenestration and lumboperitoneal shunt. Anesthetic considerations in the pregnant patient are an additional factor when surgeries are contemplated. It is also noted that therapeutic abortion to limit progression of disease is not indicated and that subsequent pregnancies do not increase the risk of recurrence.

Preview

Unable to display preview. Download preview PDF.

Unable to display preview. Download preview PDF.

References and Recommended Reading

  1. 1.
    Friedman DI, Jacobson DM: Diagnostic criteria for idiopathic intracranial hypertension. Neurology 2002, 59:1492–1495. The authors describe updated diagnostic criteria for IIH since the Modified Dandy Criteria articulated in 1985.PubMedCrossRefGoogle Scholar
  2. 2.
    Alderson TL: Nonrecurrent pseudotumor cerebri in pregnancy: report of case. J Am Osteopath Assoc 1983, 82:728–731.PubMedGoogle Scholar
  3. 3.
    Koontz WL, Herbert WNP, Cefalo RC: Pseudotumor cerebri in pregnancy. Obstet Gynecol 1983, 62:324–327.PubMedGoogle Scholar
  4. 4.
    Kassam SH, Hadi HA, Fadel HE, et al.: Benign intracranial hypertension in pregnancy: current diagnostic and therapeutic approach. Obstet Gynecol Surv 1983, 36:314–321.CrossRefGoogle Scholar
  5. 5.
    Shekleton P, Fidler J, Grimwade J: A case of benign intracranial hypertension in pregnancy. Br J Obstet Gynecol 1980, 87:354–347.Google Scholar
  6. 6.
    Gupta HL, Venkateswar N, Prakash SK: Benign intracranial hypertension in pregnancy. J Indian Med Assoc 1980, 75:93–94.PubMedGoogle Scholar
  7. 7.
    Henry SD, Jacques S: Benign intracranial hypertension in pregnancy. J Am Coll Emer Med 1979, 8:323–325.Google Scholar
  8. 8.
    Caroscio JT, Pellmar M: Pseudotumor cerebri: occurrence during the third trimester of pregnancy. Mt Sinai J Med 1978, 45:539–541.PubMedGoogle Scholar
  9. 9.
    Powell JL: Pseudotumor cerebri and pregnancy. Obstet Gynecol 1972, 40:713–718.PubMedGoogle Scholar
  10. 10.
    Nickerson CW, Kirk RF: Recurrent pseudotumor cerebri in pregnancy. Report of 2 cases. Obstet Gynecol 1965, 26:811–813.PubMedGoogle Scholar
  11. 11.
    Digre KB, Varner MW, Corbett JJ: Pseudotumor cerebri and pregnancy. Neurology 1984, 34:721–729.PubMedGoogle Scholar
  12. 12.
    Thomas E: Recurrent benign intracranial hypertension associated with hemoglobin SC disease in pregnancy. Obstet Gyncecol 1986, 67:7S-9S.Google Scholar
  13. 13.
    Katz VL, Peterson R, Cefalo RC: Pseudotumor cerebri and pregnancy. Am J Perinatol 1989, 6:442–445.PubMedGoogle Scholar
  14. 14.
    Ireland B, Corbett JJ, Wallace RB: The search for causes of idiopathic intracranial hypertension: a preliminary case-control study. Arch Neurol 1990, 47:315–320.PubMedGoogle Scholar
  15. 15.
    Giuseffi V, Wall M, Siegel PZ, et al.: Symptoms and disease associations in idiopathic intracranial hypertension (pseudotumor cerebri): a case-control study. Neurology 1991, 41:239–244.PubMedGoogle Scholar
  16. 16.
    Huna-Baron R, Kupersmith MJ: Idiopathic intracranial hypertension in pregnancy. J Neurol 2002, 249:1078–1081. Among 240 female patients diagnosed with IIH, 12 women aged 21 to 35 years had 16 pregnancies. Visual acuity was markedly decreased in one patient and markedly affected in three other patients. Visual field loss was reported in four women. Visual symptoms and visual loss improved for the duration of the pregnancy after diagnostic lumbar puncture and salt-restricted diet in three patients. Two additional women were treated with continuous spinal drainage for two days. In this series, there were 10 full-term normal deliveries, three missed abortions, one therapeutic abortion, and two intrauterine fetal deaths. The authors concluded that IIH appears to present during the first two trimesters of pregnancy. They also found that no patient worsened during delivery and that the papilledema in all patients was persistent during each pregnancy. As shown in the literature, IIH symptoms, findings, and visual outcome were similar to those of nonpregnant women with IIH.PubMedCrossRefGoogle Scholar
  17. 17.
    Pearlman RL, Riser JB, Riser ES: Pseudotumor cerebri mimicking hyperemesis gravidarum. Int J Gynecol Obstet 1991, 37:52.CrossRefGoogle Scholar
  18. 18.
    Koppel BS, Kaunitz AM, Tuchman AJ: Pseudotumor cerebri following eclampsia. Eur Neurol 1990, 30:6–8.PubMedGoogle Scholar
  19. 19.
    Greer M: Benign intracranial hypertension. III. Pregnancy. Neurology 1963, 13:670–672.PubMedGoogle Scholar
  20. 20.
    Evans RW, Friedman DI: Expert opinion: the management of pseudotumor cerebri during pregnancy. Headache 2000, 40:495–497.PubMedCrossRefGoogle Scholar
  21. 21.
    Chung SM: Safety issues in magnetic resonance imaging. J Neuro-ophthalmol 2002, 22:35–39.CrossRefGoogle Scholar
  22. 22.
    Brazis PW: Pseudotumor cerebri. Curr Neurol Neurosci Rep 2004, 4:111–116. The author reviews the idiopathic and secondary causes of pseudotumor cerebri and its clinical features and treatment.PubMedCrossRefGoogle Scholar
  23. 23.
    Digre KB, Corbett JJ: Practical Viewing of the Optic Disc. Boston: Butterworth-Heinemann; 2002.Google Scholar
  24. 24.
    Lacy CF: Drug Information Handbook. Cleveland, OH: Lexi Comp; 2001.Google Scholar
  25. 25.
    Goodwin J: Medical management of idiopathic intracranial hypertension. Paper presented at 18th annual North American Neuro-Ophthalmology Society Meeting. San Diego, CA, 1992.Google Scholar
  26. 26.
    Della-Giustina K, Chow G: Medications in pregnancy and lactation. Emer Med Clin North Am 2003, 21:585–613. The authors review medications commonly considered for use by pregnant and breast-feeding patients, as well as the physiology and other factors to consider when prescribing these medications.CrossRefGoogle Scholar
  27. 27.
    Weiner CP, Buhimschi C: Drugs for Pregnant and Lactating Women. New York: Churchill Livingstone; 2004. The authors provide mechanisms of action, indications, adverse effects, fetal and maternal considerations, and breast-feeding safety on hundreds of drugs used by pregnant and lactating patients.Google Scholar
  28. 28.
    Cunningham FG: Drugs commonly used in pregnancy. In Williams Obstetrics, edn 21. Edited by Seils A. New York: McGraw-Hill; 2001:1020–1031.Google Scholar
  29. 29.
    Paterson R, DePasquale N, Mann S: Pseudotumor cerebri. Medicine 1961, 140:85–99.Google Scholar
  30. 30.
    Weisberg LA: Benign intracranial hypertension. Medicine 1975, 54:197–207.PubMedCrossRefGoogle Scholar
  31. 31.
    Samples JR, Meyer SM: Use of ophthalmic medications in pregnant and nursing women. Am J Ophthalmol 1988, 106:616–623.PubMedCrossRefGoogle Scholar
  32. 32.
    Noronha A: Neurologic disorders during pregnancy and the puerperium. Clin Perinatol 1985, 12:695–713.PubMedGoogle Scholar
  33. 33.
    Lee AG, Brazis PW: Optic disc swelling and papilledema. In Clinical Pathways in Neuro-ophthalmology, an Evidence-Based Approach. New York: Thieme; 1998:106–120.Google Scholar
  34. 34.
    Burde RM: Surgical therapy of idiopathic intracranial hypertension. Paper presented at the 18th Annual North American Neuro-Ophthalmology Society Meeting. San Diego, CA, 1992.Google Scholar
  35. 35.
    Manno NJ, Uihlein A, Kernohan JW: Intraspinal epidermoids. J Neurosurg 1962, 19:754–765.PubMedGoogle Scholar
  36. 36.
    Shapiro S, Yee R, Brown H: Surgical management of pseudotumor cerebri in pregnancy: case report. Neurosurgery 1995, 37:829–831.PubMedCrossRefGoogle Scholar
  37. 37.
    Hayreh SS: Pathogenesis of oedema of the optic disc (papilloedema): a preliminary report. Br J Ophthalmol 1964, 48:522–543.PubMedGoogle Scholar
  38. 38.
    Banta JT, Farris BK: Pseudotumor cerebri and optic nerve sheath decompression. Ophthalmology 2000, 107:1907–1912.PubMedCrossRefGoogle Scholar
  39. 39.
    Plotnik JL, Kosmorsky GS: Operative complications of optic nerve sheath decompression. Ophthalmology 1993, 100:683–690.PubMedGoogle Scholar
  40. 40.
    Goh KY, Schatz NJ, Glaser JS: Optic nerve sheath fenestration for pseudotumor cerebri. J Neuro-Ophthalmol 1997, 17:86–91.CrossRefGoogle Scholar
  41. 41.
    Keltner JL, Miller NR, Gittinger JW, et al.: Pseudotumor cerebri. Surv Ophthalmol 1979, 23:315–322.PubMedCrossRefGoogle Scholar
  42. 42.
    Landwehr JB, Isada NB, Pryde PG, et al.: Maternal neurosurgical shunts and pregnancy outcome. Obstet Gynecol 1994, 83:134–137.PubMedGoogle Scholar
  43. 43.
    Magram G: Cerebrospinal fluid shunt management. Neurologist 1996, 2:274–287.Google Scholar
  44. 44.
    Perez-Lopez C, Duran P, Isla-Guerrero A, et al.: Cerebrospinal fluid shunting and pregnancy. Rev Neurol 2003, 36:872–876.PubMedGoogle Scholar
  45. 45.
    Yu JN: Pregnancy and extracranial shunts: case report and review of the literature. J Fam Pract 1994, 38:622–626.PubMedGoogle Scholar
  46. 46.
    Luciano M: The treatment of neuro-hydrodynamic disorders: indications and methods. Paper presented at the 30th Annual North American Neuro-Ophthalmology Society Meeting. Orlando, FL, 2004.Google Scholar
  47. 47.
    Cardona-Bonet LL, Cortes A: Management of perioperative infectious complications in the neurologic patient. Neurol Clin North Am 2004, 22:329–345.Google Scholar
  48. 48.
    Abouleish E, Ali V, Tang RA: Benign intracranial hypertension and anesthesia for cesarean section. Anesthesiology 1985, 63:705–707.PubMedCrossRefGoogle Scholar
  49. 49.
    Peterson CM, Kelly JV: Pseudotumor cerebri in pregnancy. Case reports and review of literature. Obstet Gynecol Surv 1985, 40:323–329.PubMedCrossRefGoogle Scholar
  50. 50.
    Kim K, Orbegozo M: Epidural anesthesia for cesarean section in a parturient with pseudotumor cerebri and lumboperitoneal shunt. J Clin Anesth 2000, 12:213–215.PubMedCrossRefGoogle Scholar
  51. 51.
    Bedard JM, Richardson MG, Wissler RN: Epidural anesthesia in a parturient with a lumboperitoneal shunt. Anesthesiology 1999, 90:621–623.PubMedCrossRefGoogle Scholar
  52. 52.
    Bray RS, Lynch R, Grossman RG, et al.: Management of neurosurgical problems in pregnancy. Clin Perinatol 1987, 14:243–257.PubMedGoogle Scholar
  53. 53.
    Stevens E: Pregnancy in women with cerebrospinal shunts: a literature review and case report. J Perinatol 1996, 16:374–380.PubMedGoogle Scholar
  54. 54.
    Littleford JA, Brockhurst NJ, Bernstein EP, et al.: Obstetrical anesthesia for a parturient with a ventriculoperitoneal shunt and third ventriculostomy. Can J Anaesth 1999, 46:1057–1063.PubMedGoogle Scholar
  55. 55.
    Liakos AM, Bradley NK, Magram G, et al.: Hydrocephalus and the reproductive health of women: the medical implications of maternal shunt dependency in 70 women and 138 pregnancies. Neurol Res 2000, 22:69–88.PubMedGoogle Scholar
  56. 56.
    Foley J: Benign forms of intracranial hypertension: "toxic" and "otitic" hydrocephalus. Brain 1955, 78:1–41.PubMedCrossRefGoogle Scholar
  57. 57.
    Zuidema GD, Cohen SJ: Pseudotumor cerebri. J Neurosurg 1954, 11:433–441.PubMedGoogle Scholar
  58. 58.
    Greer M: Benign intracranial hypertension. III. Pregnancy. Neurology (Minneapolis) 1963, 13:670–672.Google Scholar
  59. 59.
    Elian M, Ben-Tovim N, Bechar M, et al.: Recurrent benign intracranial hypertension (pseudotumor cerebri) during pregnancy. Obstet Gynecol 1968, 31:685–688.PubMedCrossRefGoogle Scholar
  60. 60.
    Guidetti B, Guiffre R, Gambacorta D: Follow-up study of 100 cases of pseudotumor cerebri. Acta Neurochir (Wien) 1968, 18:259–267.CrossRefGoogle Scholar
  61. 61.
    Benini A: Pseudotumor cerebri. Schweiz Med Wochenschr 1973, 103:921–926.PubMedGoogle Scholar
  62. 62.
    Meythaler H, Meythaler-Radek B: Zur frage des pseudotumors cerebri. Klin Monatabl Augenheilkd 1973, 163:200–204.Google Scholar
  63. 63.
    Johnston I, Paterson A: Benign intracranial hypertension. Brain 1974, 97:289–300.PubMedCrossRefGoogle Scholar
  64. 64.
    Jefferson A, Clark J: Treatment of benign intracranial hypertension by dehydrating agents with particular reference to the measurement of the blind spot area as a means of recording improvement. J Neurol Neurosurg Psychiatry 1976, 39:627–639.PubMedGoogle Scholar
  65. 65.
    Traviesa DC, Schwartzman RJ, Glaser JS, Savino P: Familial benign intracranial hypertension. J Neurol Neurosurg Psychiatry 1976, 39:420–423.PubMedCrossRefGoogle Scholar
  66. 66.
    Bulens C, DeVries WA, Van Crevel H: Benign intracranial hypertension. J Neurol Sci 1979, 40:147–157.PubMedCrossRefGoogle Scholar
  67. 67.
    Palop R, Choed-Amphai E, Miller R: Epidural anesthesia for delivery complicated by benign intracranial hypertension. Anesthesiology 1979, 50:159–160.PubMedCrossRefGoogle Scholar
  68. 68.
    Rush J: Pseudotumor cerebri. Mayo Clin Proc 1980, 55:541–546.PubMedGoogle Scholar

Copyright information

© Current Science Inc 2004

Authors and Affiliations

  • Rosa A. Tang
    • 1
  • E. Ulysses Dorotheo
  • Jade S. Schiffman
  • Hasan M. Bahrani
  1. 1.University of Texas Medical Branch, Galveston, TexasHoustonUSA

Personalised recommendations