Severe Papilledema Research Articles

Automatic detection of papilledema through fundus retinal images using deep learning

Papilledema is a syndrome of the retina in which retinal optic nerve is inflated by elevation of intracranial pressure. The papilledema abnormalities such as retinal nerve fiber layer (RNFL) opacification may lead to blindness. These abnormalities could be seen through capturing of retinal images by means of fundus camera. This paper presents a deep learning-based automated system that detects and grades the papilledema through U-Net and Dense-Net architectures. The proposed approach has two main stages. First, optic disc and its surrounding area in fundus retinal image are localized and cropped for input to Dense-Net which classifies the optic disc as papilledema or normal. Second, consists of preprocessing of Dense-Net classified papilledema fundus image by Gabor filter. The preprocessed papilledema image is input to U-Net to achieve the segmented vascular network from which the vessel discontinuity index (VDI) and vessel discontinuity index to disc proximity (VDIP) are calculated for grading of papilledema. The VDI and VDIP are standard parameter to check the severity and grading of papilledema. The proposed system is evaluated on 60 papilledema and 40 normal fundus images taken from STARE dataset. The experimental results for classification of papilledema through Dense-Net are much better in terms of sensitivity 98.63%, specificity 97.83%, and accuracy 99.17%. Similarly, the grading results for mild and severe papilledema classification through U-Net are also much better in terms of sensitivity 99.82%, specificity 98.65%, and accuracy 99.89%. The deep learning-based automated detection and grading of papilledema for clinical purposes is first effort in state of art.

Superior Ophthalmic Vein Flow Patterns as a Marker of Venous Sinus Stenosis and Hypertension in Idiopathic Intracranial Hypertension: A Case of Emergent Transverse Sinus Stenting as Treatment of Fulminant Idiopathic Intracranial Hypertension

Fulminant idiopathic intracranial hypertension (IIH) can cause rapid vision loss. Transverse sinus stenosis is a finding commonly associated with IIH, and transverse sinus stenting has been used to rapidly reduce intracranial pressure and improve visual symptoms. Our objective was to describe a case of immediate alteration in reversed superior ophthalmic vein (SOV) flow in a fulminant IIH patient who underwent venous sinus stenting. All charts, imaging, and notes spanning from the initial presentation to the post-intervention follow-up were reviewed and summarized for inclusion. A 24-year-old woman presented with several weeks of severe headaches and progressive vision loss. She was found to have severe papilledema and the opening pressure on lumbar puncture (LP) was 70 mm Hg. Computed tomography (CT) and magnetic resonance imaging demonstrated findings consistent with elevated intracranial pressure, and CT venography revealed stenosis of the right transverse sinus. She underwent an uncomplicated diagnostic cerebral angiogram, right venous sinus manometry, and right transverse to sigmoid sinus stenting procedure. Prior to deployment of the stent, a trans-stenotic pressure gradient of 12 mm Hg was observed within the right transverse-sigmoid junction, and flow through the bilateral SOVs was retrograde. Following stent placement, the pressure gradient normalized, and SOV flow was bidirectional. She subjectively reported improved vision, and there was improving papilledema. Repeat LP yielded an opening pressure of 21.6 mm Hg. This case demonstrates reversed SOV flow should be considered an indicator of severe venous sinus stenosis, and restoration to normal or near normal state following stenting for IIH is likely indicative of procedural success.

Prophylactic lumboperitoneal shunt in cases of cerebral venous sinus thrombosis with papilledema

Background: Although the mainstay of cerebral venous sinus thrombosis treatment is medical, rarely surgical intervention is warranted. We aimed to determine the role of prophylactic lumbo-peritoneal (LP) shunt in cases of CVST with papilledema.Methods: This is a retrospective review of 70 cases of CVST managed between November 2019 to April 2020. Indications for surgical management included poor response to medical management and severe vision impairment.Results: The mean age of the patients included in the study was 39.44±4.76 years. The most common presenting complaint was headache (83%) and nausea/vomiting (69%). On examination, the common findings were papilledema (57%), blurred vision (31%), double vision (21%) and hemiparesis (11%). Two cases had sudden loss of vision, who underwent emergency LP shunt surgery. Of the 40 cases with papilledema, 8 had severe papilledema. Based on MRI venography, transverse sinus was involved in half of all patients, superior sagittal sinus was involved in 29% and 21% had both the sinuses involved, while 7% had cortical vein thrombosis. Anticoagulants was the first line of therapy for the patients. Papilledema was present in 40 cases, of which 10 showed complete resolution of symptoms, 15 cases had reduced severity of symptoms and symptoms persisted in rest of the 15 cases. The 10 cases who had complete resolution of symptoms included two patients who underwent LP shunt. There were no deaths.Conclusions: We recommend that a LP shunt insertion in a patient with severe papilledema with superior sagittal sinus thrombosis can prevent disease progress, preserve vision and facilitate re-canalisation.

Accuracy of a Deep Learning System for Classification of Papilledema Severity on Ocular Fundus Photographs.

To evaluate the performance of a deep learning system (DLS) in classifying the severity of papilledema associated with increased intracranial pressure on standard retinal fundus photographs. A DLS was trained to automatically classify papilledema severity in 965 patients (2,103 mydriatic fundus photographs), representing a multiethnic cohort of patients with confirmed elevated intracranial pressure. Training was performed on 1,052 photographs with mild/moderate papilledema (MP) and 1,051 photographs with severe papilledema (SP) classified by a panel of experts. The performance of the DLS and that of 3 independent neuro-ophthalmologists were tested in 111 patients (214 photographs, 92 with MP and 122 with SP) by calculating the area under the receiver operating characteristics curve (AUC), accuracy, sensitivity, and specificity. Kappa agreement scores between the DLS and each of the 3 graders and among the 3 graders were calculated. The DLS successfully discriminated between photographs of MP and SP, with an AUC of 0.93 (95% confidence interval [CI] 0.89-0.96) and an accuracy, sensitivity, and specificity of 87.9%, 91.8%, and 86.2%, respectively. This performance was comparable with that of the 3 neuro-ophthalmologists (84.1%, 91.8%, and 73.9%, p = 0.19, p = 1, p = 0.09, respectively). Misclassification by the DLS was mainly observed for moderate papilledema (Frisén grade 3). Agreement scores between the DLS and the neuro-ophthalmologists' evaluation was 0.62 (95% CI 0.57-0.68), whereas the intergrader agreement among the 3 neuro-ophthalmologists was 0.54 (95% CI 0.47-0.62). Our DLS accurately classified the severity of papilledema on an independent set of mydriatic fundus photographs, achieving a comparable performance with that of independent neuro-ophthalmologists. This study provides Class II evidence that a DLS using mydriatic retinal fundus photographs accurately classified the severity of papilledema associated in patients with a diagnosis of increased intracranial pressure.

Optic nerve sheath decompression saves sight in severe papilloedema: results from 81 eyes in 56 patients with pseudotumor cerebri.

To report the outcome of optic nerve sheath decompression (ONSD) for papilloedema in a teaching hospital in western Turkey. The charts of 56 patients who had ONSD surgery between April 2007 and September 2019 were collated; and a total of 81 operated and 31 fellow eyes were included. Pre- and postoperative ophthalmologic examination including best-corrected visual acuity (BCVA), colour vision (CV), visual field (VF) analysis, fundoscopic examination and demographic and medical characteristics of the patients were noted and outcomes after surgery were investigated. Of all study eyes, 49 (43.7%) eyes had BCVA 0.2 or less and 62 (55.3%) eyes had mean deviation (MD) below - 20.0dB. 62 (55.3%) eyes had Frisen grade 4 or 5 papilloedema. Almost half of the eyes had severe vision loss. After ONSD, BCVA, CV and MD in both operated and fellow non-operated eyes improved significantly (p<0.001, p=0.009 and p<0.001 for operated, p<0.001, p=0.007 and p<0.001 for fellow eyes, respectively). Earlier surgery and higher cerebrospinal fluid opening pressure were related to better outcomes. None of the patients had major operative complications. Optic nerve sheath decompression can safely improve vision not only of the operated but also of the non-operated eye, even in cases with severe vision loss from severe bilateral papilloedema. Regardless of initial VA and VF, patients may benefit from ONSD; the earlier it is done the more likely the better outcome.

Recurrent Cerebellar Hemangioblastoma with Obstructive Hydrocephalus in Pregnancy: Challenges in Management—a Case Report

Hemangioblastoma is a rare brain tumor seen in pregnancy. Its management can be challenging due to the physiological changes of pregnancy. We discuss the challenges of managing such patients during pregnancy and review the literature regarding the management of cerebellar hemangioblastoma during pregnancy. We report a case of recurrent cerebellar hemangioblastoma who presented in pregnancy with a repeated history of severe headache and papilledema at 36 weeks. She was diagnosed to have obstructive hydrocephalus which did not respond to conservative management. Cesarean delivery along with cerebrospinal fluid diversion, ventriculoperitoneal shunt procedure, and excision of posterior fossa cyst was done, which resulted in good maternal and neonatal outcome. The risk of newborn and maternal mortality can be minimized by knowing the challenges and their appropriate management.

Clinical and demographic differences between idiopathic intracranial hypertension patients with mild and severe papilledema.

PURPOSE:The purpose of this study was to evaluate whether papilledema severity is associated with specific demographic or clinical factors in patients with idiopathic intracranial hypertension (IIH).MATERIALS AND METHODS:A retrospective cohort study of consecutive IIH patients seen at one tertiary care institution between 1989 and March 31, 2017 was performed. IIH patients were classified as mild (Frisén Grade 1 or 2) or severe (Frisén Grade 4 or 5) based on grading of fundus photographs obtained at first presentation. Demographic and clinical variables including age, body mass index (BMI), gender, visual acuity, Humphrey visual field mean deviation, and cerebrospinal fluid (CSF) opening pressure were extracted from patient medical records for statistical analyses.RESULTS:A total of 239 patients were included in the study: 152 with mild papilledema and 87 with severe papilledema. There was no difference in age, race, BMI, or male gender between the mild and severe papilledema groups. CSF opening pressure was significantly higher in the severe papilledema group (41.89 cm of water vs. 33.69, 95% confidence interval [CI]: −10.79–−5.62, P < 0.0001). There was a significant difference in the Humphrey mean deviation (−6.38 dB compared to − 3.25 dB, 95% CI: −4.82–−1.44 dB, P < 0.001) and average logarithm of the minimum angle of resolution visual acuity at final follow-up (0.21 vs. 0.045, 95% CI: −0.299–−0.040 , P = 0.01).CONCLUSION:Age, race, sex, and BMI were similar in IIH patients with mild versus severe papilledema, emphasizing the importance of a dilated fundus examination to reliably stratify patients. Patients with severe papilledema are at higher risk of visual acuity and visual field loss at final follow-up.

Neurofilament light chain as biomarker in idiopathic intracranial hypertension.

Damage of the optic nerve is the major complication of idiopathic intracranial hypertension. A biomarker indicative for optic nerve damage would help identifying high-risk patients requiring surgical procedures. Here, we studied the potential of cerebrospinal fluid neurofilament to predict idiopathic intracranial hypertension-induced optic nerve damage. In two centers, serum and cerebrospinal fluid of 61 patients with clinically suspected idiopathic intracranial hypertension were prospectively collected. Neurofilament concentrations were measured and related to ophthalmological assessment. The average cerebrospinal fluid neurofilament concentration in patients with moderate and severe papilledema was increased compared to patients with minor and no papilledema (1755 ± 3507 pg/ml vs. 244 ± 102 pg/ml; p < 0.001). Cerebrospinal fluid neurofilament concentrations correlated with the maximal lumbar puncture opening pressure (r = 0.67, p < 0.001). In patients fulfilling the Friedman criteria for idiopathic intracranial hypertension with or without papilledema (n = 35), development of bilateral visual field defects and bilateral atrophy of the optic nerve were associated with increased average age-adjusted cerebrospinal fluid neurofilament concentrations. At last follow-up (n = 30), 8/13 of patients with increased, but only 3/17 with normal, cerebrospinal fluid neurofilament had developed bilateral visual field defects and/or bilateral optic nerve atrophy resulting in a sensitivity of 72.7% and a specificity of 73.7% of cerebrospinal fluid neurofilament to detect permanent optic nerve damage. Cerebrospinal fluid neurofilament is a putative biomarker for optical nerve damage in idiopathic intracranial hypertension.

MON-342 Severe Hypocalcemia and Psuedotumor Cerebri: Old, Still Not so Well Known Relationship

Introduction:Severe headaches with nonspecific characteristics raise concern for idiopathic intracranial hypertension (IIH) in a young adult female patient. Clinical features of severe headache, vision loss, and papilledema; normal neuroimaging and elevated opening pressure on lumbar puncture are diagnostic of IIH or pseudotumor cerebri. Etiology is often attributed to obesity in young female patients. We present a rare case of Pseudotumor cerebri in a non-obese female patient with severe hypocalcemia.Case:A 26 year old Hispanic female patient with past medical history of hypocalcemia, but off her medications, presented to ER for worsening headache for over a month. Without any specific triggers, she began having headaches in her bitemporal region. The pain was continuous, pressure-type, and 9/10 intensity at its worst. It was associated with nausea and blurring of vision and was refractory to ibuprofen. Patient endorsed severe muscle cramps on review of systems. Physical examination demonstrated mild distress due to the headache, positive Trousseau’s sign, and bilateral papilledema. Laboratory studies revealed serum total calcium level of 4.8 mg/dL, albumin 3.5 g/dL, ionized calcium 0.71 mmol/L, serum phosphate 5.3 mg/dL, intact PTH 300.1 pg/mL, 25-OH Vitamin D 14.3 ng/mL and 1, 25-Dihydoxy Vitamin D 14.1 pg/mL, alkaline phosphatase 131 IU/L, 24-hour urinary calcium 48mg/d and 24 hour urinary calcium/creatinine ratio 50 mg/g. Her MRI brain and MR venogram were unremarkable. Lumbar puncture had elevated opening pressure of 46 cm of H2O. The patient was started on Acetazolamide, oral calcium, and calcitriol without resolution of headaches and hypocalcemia. Acetazolamide was discontinued when she developed severe hypokalemia. With diagnosis of pseudohypoparathyroidism, the dose of elemental calcium was doubled and calcitriol dose increased to 1 mcg BID with improvement of serum calcium, symptoms, and papilledema.Discussion:While IIH could be associated with certain medications and systemic conditions, obesity or recent weight gain are the most commonly cited causes of IIH. Severe hypocalcemia is a rare and less known etiology of IIH. Cases of adult patients are reported with a variety of etiologies of severe hypocalcemia. Severe hypocalcemia leading to hypersecretion of cerebrospinal fluid is postulated as a possible mechanism but evidence is lacking in literature. Chronic, rather than acute, severe hypocalcemia is likely to precipitate IIH. Visual symptoms, headache and papilledema are difficult to resolve with conventional medical therapy without correction of underlying severe hypocalcemia. We conclude that before considering surgical interventions for cases which are refractory to medical therapy, rare underlying conditions like severe hypocalcemia must be investigated and treated optimally.

Visual Field Mean Deviation at Diagnosis of Idiopathic Intracranial Hypertension Predicts Visual Outcome.

A robust predictor of visual outcome in idiopathic intracranial hypertension (IIH) would be useful in management, but there is limited information on this point. The purpose of this study was to ascertain whether visual field mean deviation on standard static perimetry performed at diagnosis in a large patient cohort is a reliable predictor of visual outcome. We retrospectively reviewed the automated visual field mean deviations at diagnosis and at final encounter in 79 patients with IIH examined in the neuro-ophthalmology clinics at a single academic medical center from 1999 to 2015. Of the 79 study patients, 66 (84%) entered with visual field mean deviations of -7 dB or better. Of those 66 patients, 59 (89%) had final mean deviations of -4 dB or better and 33 (56%) had final mean deviations of -2 dB or better. The single patient who had an initial mean deviation of -7 dB or better and a poor final mean deviation (-32 dB) was nonadherent to prescribed medication. Of the 13 (21%) patients who entered with mean deviations worse than -7 dB, 11 (85%) ended up with poor visual outcomes, their final mean deviations ranging from -5 dB to -32 dB. Over half of those 13 patients had required surgery for IIH, often within 3 weeks of diagnosis, owing to severe papilledema and visual dysfunction at the time of diagnosis. Based on this retrospective study, patients with IIH who have relatively mild visual dysfunction at diagnosis are likely to have a favorable visual outcome, provided they are adherent to recommended treatment. Many of those with poor visual function at diagnosis will have unfavorable visual outcomes despite aggressive treatment.

Recent developments in neuro-ophthalmology

Some recent advances in neuro-ophthalmology including clinical trials, diagnostic testing and newly elucidated disease entitites were summarized in present paper, such as neuromyelitis optica spectrum disorder.The review goes into great detail regarding recent clinical trials in neuro-ophthalmology.These trials have investigated the management of idiopathic intracranial hypertension as well as treatment of Leber hereditary optic neuropathy and optic nerve glioma.The potential gene therapy for Leber hereditary optic neuropathy seems very promising and may have a significant clinical impact within the next few years.This review also includes an extensive discussion about the application of optical coherence tomography (OCT) and OCT-angiography (OCTA) in neuro-ophthalmology.OCT has important clinical relevance not only for the diagnosis and management of optic neuropathies, such as optic neuritis, ischemic optic neuropathy and chiasmal compression, but also for retro-chiasmal injury.In terms of OCTA, recent studies have demonstrated increased vessel density in acute stage of ischemic optic neuropathy (NAION) and optic neuritis, but decreased vessel density in severe papilloedema and late stage of optic atrophy of any cause.These serve as the potential foundation for future clinical applications.Ophthalmologists should pay more attentions to these recent progress in neuro-ophthalmology. Key words: Neuro-ophthalmology; Clinical trials, intracranial hypertension; Leber's optic neuropathy; Optical coherence tomography; Optical coherence tomography angiography; Optic neuritis; Ischemic optic neuropathy

Pseudotumour cerebri associated with mycoplasma pneumoniae infection and treatment with levofloxacin: a case report

BackgroundIdiopathic intracranial hypertension (IIH), also known as pseudotumour cerebri syndrome (PTCS), is characterized by the presence of signs and symptoms of raised intracranial pressure without evidence of any intracranial structural cause and with normal cerebrospinal fluid microscopy and biochemistry.Obesity, various systemic diseases and endocrine conditions, and a number of medications are known to be risk factors for PTCS. The medications commonly associated with PTCS are amiodarone, antibiotics, corticosteroids, cyclosporine, growth hormone, oral contraceptives, vitamin A analogues, lithium, phenytoin, NSAIDs, leuprolide acetate, and some neuroleptic drugs. In relation to antibiotics, quinolones may cause intracranial hypertension, and most reported cases of quinolone-induced intracranial hypertension were associated with nalidixic acid, ciprofloxacin, ofloxacin, or pefloxacin. Literature reports of levofloxacin-induced PTCS are rare. Some authors recently hypothesized that Mycoplasma pneumoniae may trigger PTCS.Case presentationWe report on a 14-year-old overweight White Italian boy who suffered headache, diplopia, and severe bilateral papilloedema after a Mycoplasma pneumoniae infection, exacerbated on levofloxacin intake. A spontaneous improvement in headache and a reduction in diplopia was seen during hospitalisation. Oral acetazolamide therapy led to the regression of papilloedema in about five months. No permanent eye damage has been observed in our patient to date.ConclusionsPTCS pathophysiology may be multifactorial and its specific features and severity may be a consequence of both constitutional and acquired factors interacting synergistically. It may be useful for paediatricians to know that some antibiotics may have the potential to precipitate PTCS in patients who already have an increased CSF pressure due to a transitory imbalanced CSF circulation caused by infections such as Mycoplasma pneumoniae, with headache being the first and most sensitive, but also the least specific, symptom.

Severe preeclampsia with HELLP syndrome with Wilson's disease.

Severe Preeclampsia is characterized by systolic blood pressure ≥ 160 mmHg or diastolic pressure >110 mmHg, protein excretion >5 gm/24 hour or 3+ or more on random samples, oliguria <500 ml/24 hr, platelet count <1,00,000/mm3, hemolysis, elevated alanine aminotransferase and aspartate aminotransferase, cerebral and visual disturbance, persistent severe epigastric pain, retinal hemorrhages, exudates and papilledema, intrauterine growth restriction of the fetus and pulmonary edema. HELLP (Hemolysis, elevated liver enzymes and low platelets) syndrome is the variant of preeclampsia. Definitive treatment of HELLP syndrome is delivery of the baby. Wilson's disease is autosomal recessive disorder of copper metabolism. It is characterized by the toxic accumulation of copper mainly in liver and brain but also in cornea and kidney due to defective biliary excretion of copper. It is one of the major causes of cirrhosis of liver. Excess copper levels are associated with the disorder of the menstrual cycle and infertility. Increased copper levels are also associated with the preeclampsia, intrauterine growth restriction and neurologic damages in the fetus. However Pregnancy is not contraindicated in well treated Wilson's disease. A case of decompensated cirrhosis due to Wilson's disease, presented in third trimester of pregnancy, with Preeclampsia and HELLP syndrome is discussed.

Use of A-scan Ultrasound and Optical Coherence Tomography to Differentiate Papilledema From Pseudopapilledema.

Differentiating papilledema from pseudopapilledema reflecting tilted/crowded optic discs or disc drusen is critical but can be challenging. Our study suggests that spectral-domain optical coherence tomography (OCT) peripapillary retinal nerve fiber layer thickness and retrobulbar optic nerve sheath diameter (ONSD) measured by A-scan ultrasound provide useful information when differentiating the two conditions. To evaluate the use of A-scan ultrasound and spectral-domain OCT retinal nerve fiber layer thickness (RNFLT) in differentiating papilledema associated with idiopathic intracranial hypertension from pseudopapilledema. Retrospective cross-sectional analysis included 23 papilledema and 28 pseudopapilledema patients. Ultrasound-measured ONSD at primary gaze, percent change in ONSD at lateral gaze (30° test), and peripapillary RNFLT were analyzed. Receiver operating characteristic curves were constructed using one eye from each subject. Compared with pseudopapilledema, papilledema eyes showed larger mean ONSD (5.4 ± 0.6 vs. 4.0 ± 0.3 mm, P < .0001), greater change of ONSD at lateral gaze (22.4 ± 8.4% vs. 2.8 ± 4.8%, P < .0001), and thicker retinal nerve fiber layer (219.1 ± 104.6 vs. 102.4 ± 20.1 μm, P < .0001). Optic nerve sheath diameter and 30° test had the greatest area under the receiver operating characteristic curve, 0.98 and 0.97, respectively; followed by inferior quadrant (0.90) and average RNFLT (0.87). All papilledema eyes with Frisén scale greater than grade II were accurately diagnosed by ONSD, 30° test, or OCT. In mild papilledema (Frisén scale grades I and II, n = 15), area under the receiver operating characteristic curve remained high for ONSD (0.95) and 30° test (0.93) but decreased to 0.61 to 0.71 for RNFLT. At 95% specificity, sensitivities for ONSD, 30° test, and RNFLT were 91.3%, 91.3%, and 56.5%, respectively, for the entire papilledema group and 80.0%, 86.7%, and 13.3% for the mild papilledema subgroup. Retinal nerve fiber layer thickness can potentially be used to detect moderate to severe papilledema. A-scan may further assist differentiation of mild papilledema from pseudopapilledema.

Decision Support System for Detection of Papilledema through Fundus Retinal Images.

A condition in which the optic nerve inside the eye is swelled due to increased intracranial pressure is known as papilledema. The abnormalities due to papilledema such as opacification of Retinal Nerve Fiber Layer (RNFL), dilated optic disc capillaries, blurred disc margins, absence of venous pulsations, elevation of optic disc, obscuration of optic disc vessels, dilation of optic disc veins, optic disc splinter hemorrhages, cotton wool spots and hard exudates may result in complete vision loss. The ophthalmologists detect papilledema by means of an ophthalmoscope, Computed Tomography (CT), Magnetic Resonance Imaging (MRI) and ultrasound. Rapid development of computer aided diagnostic systems has revolutionized the world. There is a need to develop such type of system that automatically detects the papilledema. In this paper, an automated system is presented that detects and grades the papilledema through analysis of fundus retinal images. The proposed system extracts 23 features from which six textural features are extracted from Gray-Level Co-occurrence Matrix (GLCM), eight features from optic disc margin obscuration, three color based features and seven vascular features are extracted. A feature vector consisting of these features is used for classification of normal and papilledema images using Support Vector Machine (SVM) with Radial Basis Function (RBF) kernel. The variations in retinal blood vessels, color properties, texture deviation of optic disc and its peripapillary region, and fluctuation of obscured disc margin are effectively identified and used by the proposed system for the detection and grading of papilledema. A dataset of 160 fundus retinal images is used which is taken from publicly available STARE database and local dataset collected from Armed Forces Institute of Ophthalmology (AFIO) Pakistan. The proposed system shows an average accuracy of 92.86% for classification of papilledema and normal images. It also shows an average accuracy of 97.85% for classification of already classified papilledema images into mild and severe papilledema. The proposed system is a novel step towards automated detection and grading of papilledema. The results showed that the technique is reliable and can be used as clinical decision support system.

Pediatric pseudotumor cerebri.

Recent findings in the literature regarding the epidemiology, diagnosis, and treatment of pediatric pseudotumor cerebri (PTC) are described. In the past, children with PTC have been treated like adult cases; however, the literature highlights important differences between children and adults with PTC. Revised diagnostic criteria define an opening cerebrospinal fluid pressure greater than 28 cm water as elevated in the pediatric population. Obesity is an important risk factor for primary and secondary PTC in post-pubertal children. Magnetic resonance imaging shows findings suggestive of elevated intracranial pressure in children with PTC, similar to those of adults with PTC. Diamox and weight loss are effective treatments for PTC patients with mild visual field loss. Severe papilledema, decreased vision, and optical coherence tomography measures at presentation identify patients at increased risk for subsequent visual loss. Findings summarized in the recent literature may change practice patterns in the diagnosis and treatment of pediatric PTC. Although there are many similarities between the adult and pediatric populations, the differences should be considered when managing children with PTC.

New frontiers in venous sinus stenting: Illustrative cases

Idiopathic intracranial hypertension (IIH) occurs rarely, with severe patients recalcitrant to pharmacologic management often requiring cerebrospinal fluid diversion. We report two patients with variant IIH successfully treated with venous sinus stenting: 1) A 65-year-old man with severe vision loss, papilledema, and cognitive decline treated with four telescoped stents across a long, severely stenotic transverse-sigmoid system, and 2) a 58-year-old woman with headaches, vision loss, and papilledema secondary to a jugular paraganglioma causing severe jugular bulb stenosis that required contralateral venous sinus stenting. At 3-month and 1-month follow-up, respectively, ophthalmologic examinations showed vision improvement. The first patient also had improved cognition, and the second patient also had improved headaches.

The Optic Canal Size Is Associated With the Severity of Papilledema and Poor Visual Function in Idiopathic Intracranial Hypertension.

To determine whether the size of the bony optic canal is associated with the severity of papilledema and poor visual function in idiopathic intracranial hypertension (IIH). We performed a retrospective review of definite patients with IIH with requisite brain magnetic resonance imaging allowing for optic canal measurement. Clinical characteristics and automated (Humphrey) visual field results were reviewed; papilledema was graded according to the modified Frisén scale. Cross-sectional area of the optic canals was measured independently by 2 readers and averaged for each canal. Logistic regression modeling was applied. Sixty-nine patients with IIH were included (mean age: 33; 91% women; 65% black). Controlling for age, sex, body mass index, race, and cerebrospinal fluid (CSF) opening pressure, each mm increase in canal size was associated with a 0.50 dB reduction in Humphrey visual field mean deviation (P = 0.006); this was likely mediated by the increased odds of Grade 4-5 papilledema or optic atrophy in patients with larger canals (odds ratio: 1.30 [95% CI: 1.10-1.55; P = 0.003] for Grade 4-5 papilledema or atrophy vs grade <4 papilledema per mm increase in canal size). Poor visual function and severe papilledema or optic atrophy were associated with a larger optic canal. Potential mechanisms include alteration of local CSF flow or bony remodeling at the optic canals.

Kyste anévrysmal osseux : une atteinte exceptionnelle au niveau orbitaire

Aneurysmal bone cyst is a rare benign bone neoplasm of unknown cause. The most commonly affected anatomical sites are the vertebral column and long bones. We report two uncommon cases of primary orbital aneurysmal bone cyst presenting as an acute orbital compartment syndrome due to subperiosteal hemorrhage. Case1is a 45-year-old woman. Imaging studies revealed a small cystic frontal bone tumour associated with a subperiosteal hematoma. The patient achieved full visual recovery after drainage of the hematoma, with no recurrence after treatment. Case2is a 74-year-old woman whose visual acuity was light perception due to severe papilledema. Imaging studies of the orbit revealed a large cystic frontal bone tumor associated with a subperiosteal hematoma causing globe and optic nerve compression. Preoperative arteriography showed a moderate vascular blush. Drainage of the hematoma was performed. A local recurrence with hematoma formation occurred two years after the surgery.

33. A rare case of Guillain–Barre’ syndrome and pseudotumor cerebri, with normal cerebrospinal fluid protein

A 19 years old female patient was referred for assessment of head and cervical pain, upper limbs dysesthesias, diplopia, visual impairment (mainly in left eye) and postural instability. Initial examination revealed left ptosis, left abducent nerve palsy, diffuse hyporeflexia and limb ataxia. At admission lumbar puncture was performed with a normal cerebrospinal fluid analysis and a temporal dispersion of F waves and Skin Reflex was observed by electromyography. In suspicion of a Guillain–Barre syndrome a IV immunoglobulin treatment was administered. In first days after admission a progression of sings and symptoms was observed; a left peripheral facial palsy was also noted. In particular, the visual acuity decreased in both eyes (5/10 at right, 1–2/10 at left), severe bilateral papilledema and increased optic nerves diameters (7.4 mm at left) were revealed. Brain and spine MRI was unremarkable. Thus, through a second lumbar puncture a cerebrospinal fluid pressure of 25 mmHg was measured. In light of this 10 cc of cerebrospinal fluid were subtracted and high dosage escalating diuretic treatment (mannitol, steroid, acetazolamide and topiramate) was administrated. A further slow improvement of motor and visual signs and symptoms was observed. At discharge the patient referred a complete remission of headache and dysesthesias.