Abstract
Objective: We report that lumbar puncture (LP) with removal of cerebrospinal fluid (CSF) induced rebound intracranial hypertension with increased papilledema as monitored by optical coherence tomography (OCT). Background: Severe papilledema causes visual field loss and central vision damage if untreated. Fundoscopy is a key to diagnose papilledema, but is not sensitive enough to monitor therapeutic effects. Methods: OCT was applied to follow a 24-year-old woman with headache, visual dysfunction, severe bilateral papilledema, and elevated CSF opening pressure. She was first treated with serial LP, which led to symptom deterioration, increased CSF pressure, and increased the retinal nerve fiber layer (RNFL) thickness. She was then successfully treated with acetazolamide and furosemide. Results: OCT showed reduction of RNFL thickness directly after LP with CSF removal, accompanied with reduced CSF pressure. Increased RNFL thickness accompanied with worsened headache, visual dysfunction, and increased CSF pressure was observed on the next day after LP. Less than 24 h after start of medication, the symptoms had reversed and RNFL thickness was reduced. The patient was symptom-free 2 weeks after starting on medical treatment. Papilledema had vanished on fundoscopy 6 weeks after the therapy, and RNFL thickness was normalized at 3 months of follow-up. Conclusion: This case provides evidence that OCT is an objective and sensitive tool to monitor papilledema and its response to therapy, and thereby important to help in correct clinical decision-making.
Highlights
Papilledema refers to optic disc swelling caused only by elevated intracranial pressure (ICP) [1]
We report a patient with papilledema and high ICP secondary to meningoencephalitis who was monitored with optical coherence tomography (OCT) during the treatment
ICP is not treated in time, it can lead to irreversible damage to the optic disc with larger scotomas and visual loss [9]
Summary
Papilledema refers to optic disc swelling caused only by elevated intracranial pressure (ICP) [1]. Acute elevated ICP with bilateral, symmetric papilledema is often linked to, e.g., intracranial space-occupying lesions, meningitis/encephalitis, cerebral venous sinus thrombosis, or idiopathic intracranial hypertension (IIH) [2]. Numerical quantitative models might be more accurate and sensitive to monitor papilledema [6]. Optical coherence tomography (OCT) provides direct in vivo real-time, noninvasive, sensitive measurements of the retina [7]. With the help of OCT, optic disc pathology can be demonstrated and monitored both qualitatively and quantitatively at few-micrometer levels [8]. We report a patient with papilledema and high ICP secondary to meningoencephalitis who was monitored with OCT during the treatment. Carbonic anhydrase inhibitor combined with loop diuretics rapidly reversed the acute rebound intracranial hypertension (IH) secondary to lumbar puncture (LP) with CSF removal
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