scholarly journals Visual loss in HIV-associated cryptococcal meningitis: A case series and review of the mechanisms involved

2015 ◽  
Vol 16 (1) ◽  
Author(s):  
Anand Moodley ◽  
William Rae ◽  
Ahmed Bhigjee
Keyword(s):  
Optic Nerve ◽  
Intracranial Pressure ◽  
Cryptococcal Meningitis ◽  
Visual Loss ◽  
Fluid Pressure ◽  
Case Series ◽  
Aggressive Management ◽  
Pressure Lowering ◽  
Treatment Measures ◽  
Preventable Complication

Permanent visual loss is a devastating yet preventable complication of cryptococcal meningitis. Early and aggressive management of cerebrospinal fluid pressure in conjunction with antifungal therapy is required. Historically, the mechanisms of visual loss in cryptococcal meningitis have included optic neuritis and papilloedema. Hence, the basis of visual loss therapy has been steroid therapy and intracranial pressure lowering without clear guidelines. With the use of high-resolution magnetic resonance imaging of the optic nerve, an additional mechanism has emerged, namely an optic nerve sheath compartment syndrome (ONSCS) caused by severely elevated intracranial pressure and fungal loading in the peri-optic space. An improved understanding of these mechanisms and recognition of the important role played by raised intracranial pressure allows for more targeted treatment measures and better outcomes. In the present case series of 90 HIV co-infected patients with cryptococcal meningitis, we present the clinical and electrophysiological manifestations of Cryptococcus-induced visual loss and review the mechanisms involved.

Optic Nerve Sheath Decompression

2011 ◽  
Author(s):  
Thomas N. Hwang ◽  
Timothy J. McCulley
Keyword(s):  
Optic Nerve ◽  
Intracranial Pressure ◽  
Conservative Management ◽  
Weight Control ◽  
Visual Loss ◽  
Surgical Intervention ◽  
Case Series ◽  
Optic Nerve Sheath ◽  
Nerve Sheath ◽  
Csf Shunting

Optic nerve sheath decompression (ONSD) or fenestration refers to a surgical technique that creates a window through the dural and arachnoid meningeal layers of the retrobulbar optic nerve sheath to release pressure on the optic nerve. ONSD for treatment of visual loss secondary to refractory papilledema was first described by DeWecker in 1872. Later that century, Carter and Müller published the second case series of optic nerve sheath fenestrations. However, despite these and several additional reports, the clinical benefit of performing this procedure was still questioned. In addition, alternative cerebrospinal shunting procedures were developed for patients with increased intracranial pressure. Renewed interest arose in 1964 when Hayreh demonstrated the effectiveness of ONSD in relieving experimental papilledema in rhesus monkeys. Various supporting clinical publications have since followed, starting with Smith, Hoyt, and Newton’s description in 1969 of relief of chronic papilledema by ONSD. Surgical intervention is considered for patients with progressive visual loss secondary to elevated intracranial pressure (ICP) in whom conservative management, such as medications (acetazolamide and furosemide) and weight control, has failed. Occasionally surgery is used primarily in patients whose visual function has already reached a critical level. Examples include patients in whom vision has declined to a disabling level in hopes that rapid papilledema resolution will result in some visual return. Surgery is also considered primarily in those with little remaining vision, in whom any further visual loss would carry substantial functional impact should conservative management fail. Once surgical intervention is deemed necessary, ONSD is one of several options. Cerebrospinal fluid (CSF) shunting in the form of ventricular–peritoneal (VP) or lumbar–peritoneal (LP) shunting can be considered. A deciding factor for some is the presence of headache, which is more effectively managed with VP or LP shunting. Comparative trials of ONSD and other CSF shunting procedures are lacking. Consequently, some medical centers opt for ONSD as the first-line surgical option, while others recommend alternative shunting procedures. At present, the only uniformly accepted therapeutic indication for ONSD is management of visual loss related to elevated ICP. The most common setting for ONSD is idiopathic intracranial hypertension.

scholarly journals Accuracy of Noninvasive Intraocular Pressure or Optic Nerve Sheath Diameter Measurements for Predicting Elevated Intracranial Pressure in Cryptococcal Meningitis

2014 ◽  
Vol 1 (3) ◽  
Author(s):  
Henry W. Nabeta ◽  
Nathan C. Bahr ◽  
Joshua Rhein ◽  
Nicholas Fossland ◽  
Agnes N. Kiragga ◽  
...  
Keyword(s):  
Intraocular Pressure ◽  
Optic Nerve ◽  
Intracranial Pressure ◽  
Cryptococcal Meningitis ◽  
Optic Nerve Sheath Diameter ◽  
Diagnostic Value ◽  
Optic Nerve Sheath ◽  
Increased Intracranial Pressure ◽  
Nerve Sheath ◽  
Immunodeficiency Virus

Abstract Background.  Cryptococcal meningitis is associated with increased intracranial pressure (ICP). Therapeutic lumbar puncture (LP) is recommended when the initial ICP is >250 mm H2O, yet the availability of manometers in Africa is limited and not always used where available. We assessed whether intraocular pressure could be a noninvasive surrogate predictor to determine when additional therapeutic LPs are necessary. Methods.  Ninety-eight human immunodeficiency virus-infected Ugandans with suspected meningitis (81% Cryptococcus) had intraocular pressure measured using a handheld tonometer (n = 78) or optic nerve sheath diameter (ONSD) measured by ultrasound (n = 81). We determined the diagnostic performance of these methods for predicting ICP vs a standard manometer. Results.  The median ICP was 225 mm H2O (interquartile range [IQR], 135–405 mm H2O). The median intraocular pressure was 28 mm Hg (IQR, 22–37 mm Hg), and median ultrasound ONSD was 5.4 mm (IQR, 4.95–6.1 mm). ICP moderately correlated with intraocular pressure (ρ = 0.45, P < .001) and with ultrasound ONSD (ρ = 0.44, P < .001). There were not discrete threshold cutoff values for either tonometry or ultrasound ONSD that provided a suitable cutoff diagnostic value to predict elevated ICP (>200 mm H2O). However, risk of elevated ICP >200 mm H2O was increased with an average intraocular pressure >28 mm Hg (relative risk [RR] = 3.03; 95% confidence interval [CI], 1.55–5.92; P < .001) or an average of ONSD >5 mm (RR = 2.39; 95% CI, 1.42–4.03; P = .003). As either intraocular pressure or ONSD increased, probability of elevated ICP increased (ie, positive predictive value increased). Conclusions.  Noninvasive intraocular pressure measurements by tonometry or ultrasound correlate with cerebrospinal fluid opening pressure, but both are a suboptimal replacement for actual ICP measurement with a manometer.

scholarly journals Pediatric Idiopathic Intracranial Hypertension: A not so Rare and Benign Condition

2014 ◽  
Vol 7 (1) ◽  
pp. 5-9
Author(s):  
Manish Modi ◽  
Karan Gupta
Keyword(s):  
Optic Nerve ◽  
Intracranial Hypertension ◽  
Idiopathic Intracranial Hypertension ◽  
Vision Loss ◽  
Fluid Pressure ◽  
Case Series ◽  
Invasive Procedure ◽  
Positive Outcome ◽  
Benign Condition ◽  
Work Up

ABSTRACT Objective Pediatric idiopathic intracranial hypertension is an underdiagnosed entity with catastrophic presentations. High index of suspicion with early diagnosis and prompt treatment is the key to successful management. Trans-nasal trans-sphenoid Endoscopic Optic Nerve Fenestration is an effective surgical modality for the reversal of vision loss in pediatric idiopathic intracranial hypertension (IIH). Materials and methods This is a single center observational prospective case series. Five diagnosed pediatric patients of IIH satisfying the modified Dandy criteria and reported to the out-patient services of otolaryngology, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India in the year 2012 were included in this study. All children underwent thorough clinical examination, complete Neuro-ophthalmological work-up including Visual acuity (V/A), Visual field charting (V/F), Fundus venogram and Radiological work-up with MRI for special optic nerve sections in sagittal reconstruction. Cerebro-Spinal Fluid pressure (CSF) measured preoperatively for all children. Standard endoscopic optic nerve Sheath Fenestration was performed on all children. visual improvement was assessed by comparing preoperative ophthalmological findings. Results Improvement in vision was taken as a positive outcome. Vision improved in all except one child, who had pre-existing optic nerve atrophy. Conclusion Endoscopic optic nerve fenestration is an effective minimally invasive procedure to revert visual loss in pediatric idiopathic intracranial hypertension. How to cite this article Gupta AK, Gupta K, Modi M, Gupta A. Pediatric Idiopathic Intracranial Hypertension: A not so Rare and Benign Condition. Clin Rhinol An Int J 2014;7(1):5-9.

scholarly journals Retinal Vein Changes as a Biomarker to Guide Diagnosis and Management of Elevated Intracranial Pressure

2021 ◽  
Vol 12 ◽  
Author(s):  
Heather E. Moss
Keyword(s):  
Optic Nerve ◽  
Intracranial Pressure ◽  
Optic Nerve Head ◽  
Venous Pressure ◽  
Fluid Pressure ◽  
Elevated Intracranial Pressure ◽  
Venous Outflow ◽  
Non Invasive ◽  
Clinical Measurements ◽  
Cerebral Venous Pressure

Retinal vein changes, which can be observed on clinical exam or ophthalmic imaging, are promising non-invasive biomarkers for elevated intracranial pressure (ICP) as a complement to other markers of high ICP including optic nerve head swelling. Animal and human studies have demonstrated increase in retinal vein pressure associated with elevated ICP mediated by increase in cerebral venous pressure, compression of venous outflow by elevated cerebral spinal fluid pressure in the optic nerve sheath, and compression of venous outflow by optic nerve head swelling. Retinal vein pressure can be estimated using ophthalmodynamometry. Correlates of retinal vein pressure include spontaneous retinal venous pulsations, retinal vein diameter, and retinal vein tortuosity. All of these have potential for clinical use to diagnose and monitor elevated ICP. Challenges include diagnostic prediction based on single clinical measurements and accurate assessment of retinal vein parameters in cases where optic nerve head swelling limits visualization of the retinal veins.

scholarly journals Optic nerve sonographic examination to predict raised intracranial pressure in idiopathic intracranial hypertension: The cut-off points

2018 ◽  
Vol 31 (5) ◽  
pp. 490-495 ◽  
Author(s):  
Nirmeen A Kishk ◽  
Asmaa M Ebraheim ◽  
Amal S Ashour ◽  
Nashwa M Badr ◽  
Mohamed A Eshra
Keyword(s):  
Optic Nerve ◽  
Intracranial Pressure ◽  
Intracranial Hypertension ◽  
Idiopathic Intracranial Hypertension ◽  
Fluid Pressure ◽  
Area Under The Curve ◽  
Raised Intracranial Pressure ◽  
Sonographic Examination ◽  
Linear Probe ◽  
Significant Difference

Purpose Monitoring of raised intracranial pressure (ICP) in patients with idiopathic intracranial hypertension (IIH) is required to prevent secondary optic nerve damage. Sonographic measurement of the optic nerve sheath diameter (ONSD) is a noninvasive method to evaluate intracranial hypertension. Different ONSD cut-off values have been reported probably due to ethnic variations. Our aim was to determine optic nerve sonographic examination cut-off points to predict raised ICP in IIH patients. Methods This case-control study was conducted on 99 IIH post-pubertal female patients (both probable and definite) and 35 age- and sex-matched healthy volunteers. Sonographic ONSD and optic nerve diameter (OND) were obtained 3 mm behind the posterior edge of the globe in a horizontal plane via a 7–13 MHz linear probe. Lumbar puncture was then carried out on the patients. Results The opening cerebrospinal fluid pressure documented in the patient group was 279.64 ± 65.97 mm H2O. A statistically significant difference was found between IIH patients and controls regarding ONSD. The best ONSD cut-off value indicating raised ICP was 6.05 mm with an area under the curve of 0.850 (95% confidence interval 0.805 to 0.894, 73.2% sensitivity and 91.4% specificity). Regarding OND/ONSD ratio, there was an insignificant difference between both groups. Conclusion Sonographic ONSD but not OND/ONSD ratio could offer a bedside adjunct or alternative indicator of elevated ICP in IIH patients. Ethnic differences, however, should be noted when using this parameter.

scholarly journals Ultrasonic measurement of optic nerve sheath diameter: a non-invasive surrogate approach for dynamic, real-time evaluation of intracranial pressure

2018 ◽  
Vol 103 (4) ◽  
pp. 437-441 ◽  
Author(s):  
Li-min Chen ◽  
Li-juan Wang ◽  
Yang Hu ◽  
Xiao-han Jiang ◽  
Yu-zhi Wang ◽  
...  
Keyword(s):  
Optic Nerve ◽  
Intracranial Pressure ◽  
Real Time ◽  
Vertical Section ◽  
Fluid Pressure ◽  
Correlation Coefficients ◽  
Optic Nerve Sheath Diameter ◽  
Ultrasonic Measurement ◽  
Optic Nerve Sheath ◽  
Nerve Sheath

The current study aimed to identify whether ultrasonographic measurements of optic nerve sheath diameter (ONSD) could dynamically and sensitively evaluate real-time intracranial pressure (ICP). ONSD measurements were performed approximately 5  min prior to and after a lumbar puncture (LP). A total of 84 patients (mean±SD age, 43.5±14.7 years; 41 (49%) men; 18 patients with elevated ICP) were included in the study. The Spearman correlation coefficients between the two observers were 0.779 and 0.703 in the transverse section and 0.751 and 0.788 in the vertical section for the left and right eyes, respectively. The median (IQR) change in ONSD (ΔONSD) and change in ICP (ΔICP) were 0.11 (0.05–0.21) mm and 30 (20–40) mmH2O, respectively, for all participants. With a reduction in cerebrospinal fluid pressure, 80 subjects (95%) showed an immediate drop in ONSD; the median (IQR) decreased from 4.13 (4.02–4.38) mm to 4.02 (3.90–4.23) mm (p<0.001). Significant correlations were found between ONSD and ICP before LPs (r=0.482, p<0.01) and between ΔONSD and ΔICP (r=0.451, p<0.01). Ultrasonic measurement of ONSD can reflect the relative real-time changes in ICP.

Quantitative Electroencephalography for Early Detection of Elevated Intracranial Pressure in Critically Ill Children: Case Series and Proposed Protocol

2021 ◽  
pp. 088307382110150
Author(s):  
Arnold J. Sansevere ◽  
Melissa L. DiBacco ◽  
Phillip L. Pearl ◽  
Alexander Rotenberg
Keyword(s):  
Intracranial Pressure ◽  
Suppression Ratio ◽  
Case Series ◽  
Quantitative Eeg ◽  
Interquartile Range ◽  
Critically Ill Children ◽  
Quantitative Electroencephalography ◽  
Increased Intracranial Pressure ◽  
Continuous Eeg ◽  
Pressure Lowering

Objective: To describe quantitative EEG (electroencephalography) suppression ratio in children with increased intracranial pressure comparing acute suppression ratio changes to imaging and/or examination findings. Methods: We retrospectively reviewed the suppression ratio from patients with neuroimaging and /or examination findings of increased intracranial pressure while on continuous EEG. The time of the first change in the suppression ratio was compared to the time of the first image and/or examination change confirming increased intracranial pressure. Results: Thirteen patients with a median age of 3.1 years(interquartile range 1.8-6.3) had a rise in the suppression ratio with median time from identification to acute neuroimaging or examination of increased intracranial pressure of 3.12 hours (interquartile range 2.2-33.5) after the first increase in the suppression ratio. Conclusions: Acute suppression ratio increase is seen prior to imaging and/or examination findings of increased intracranial pressure. With further study, the suppression ratio can be targeted with intracranial pressure–lowering agents to prevent morbidity and mortality associated with increased intracranial pressure.

Sign in / Sign up

Export Citation Format

Share Document