The Diagnosis Of Increased Intracranial Hypertension And Other Dangerous Headaches – My Minicourse Review

So after watching Resource (2) below on idiopathic intracranial hypertension, I wanted to review the causes of dangerous headaches again.

First, I wanted to make sure that had the list of potentially dangerous headaches (that can mascerade as benign) firmly planted in my mind. And the reminder list I use is Dr. Reuben Strayer of EM Updates of Jan 15, 2015: Headache in the Emergency Department: 13 Dangerous Causes. Dr. Streyer reminds us that:

Emergency clinicians do not rule in migraine or other benign causes of headache. unless the headache is congruent to an established pattern for that patient, the history and physical specifically targets these 13 conditions.

And the above rule should also apply to all clinicians including office practioners and urgent care practioners. And here is Dr. Strayer’s graphic [each diagnosis trigger (history and physical) is well described in Dr. Strayer’s post and should be reviewed.]:

When I originally reviewed Dr. Streyer’s post, I created my own blog post based on his but with some additional information:  13 Dangerous Headaches–A List From Dr Reuben Strayer of EM Updates[Resource (1) below]. Posted on September 24, 2015 by Tom Wade MD. [Note to myself – review that post along with all the other resources listed in this post. My post has additional resources for Dr. Strayer’s list].

So, after doing the above review, I watched POCUS Cases 3 Idiopathic Intracranial Hypertension and Ocular POCUS from Emergency Medicine CasesPOCUS Cases Videost [Resource (2) below]. It is a really good video and only twelve minutes long. I’ve transcribed some excerpts:

The case is of a 26 yo black female who comes to the emergency department after having many days and many visits to healthcare professionals for headache.

She’s quite vague in how she describes the headache. She says that it might be on one side of her head one day and on the other side of her head another day. The severity also changes with some days being quite severe and other days being mild. But she generally says that she constantly has some degree of a low grade headache, just some days are worse than others.

She’s also noticed some vision changes. She says she’s getting blurry vision in both eyes and it’s getting worse.

But she has no neurological changes and she is able to walk [and] to drive her car and to do all of her activities of daily living without any difficulties.

The most striking part of the physical examination was her vision. Her visual acuity is quite poor. In her left eye she [is 20/400]. In her right eye she [is only 20/200].

She went to a doctor earlier in the day and he wrote a note recommending a CT scan [of the head].

The patient consented to a CT scan [of the head in the emergency department].

She was told by the doctor who sent her to the ER that a CT scan of the head would be able to find anything that was wrong with her. The doctor also told her that it would rule out all of the pathology  that was concerning for this patient. She was told that if there were tumors, they’d be able to see it and if there was any cause of her headaches and her vision change a CT scan would be able to see it.

I went back to chat with the patient after the CT scan and I told her that the radiologist looked through the CT scan of the head and told me that the CT scan of the head was normal. I relayed this information to the patient.

And the patient asked, “Well, what now?”

I could sense the patient’s frustration. This is a patient who has been to multiple healthcare professionals and was told that there was no cause that they could identify for her symptoms.

The patient was getting worse and was told that the CT scan would find all of the answers that she would need.

After chatting with her some more, I zoned in on the eyes. I figured that doing a good eye exam might lead to some answers.

The lecturer states that he is not the greatest at fundoscopy.

In fact, now I use my ultrasound skills in lieu of fundoscopy because my fundoscopy skills are so poor.

In truth, direct fundoscopy through an undilated pupil is very difficult to do for any physician in any patient and especially so in the bright environment of the emergency department. The fact that the patient was in pain makes direct fundoscopy even more difficult.

And there are many reasons why dilating eyes in the emergency department is impractical.

The beautiful pictures of papilledema that we see on the internet and in text books are obtained with fundus cameras working in eyes that have been dilated.

So Dr. Robert Simard then, from 4:20 to 7:40, demonstrates how to use ocular Point of Care Ultrasound (POCUS) to diagnose increased intracranial pressure.

This patient’s ocular POCUS was positive for increased intracranial pressure.

In the setting of a patient who has a headache, vision changes, and increased intracranial pressure, the next step that I wanted for the patient was to undergo a lumbar puncture to measure the opening pressure.

The patient’s opening pressure peaked at 34 cm of water.

So in this case I was concerned that this patient actually had idiopathic intracranial hypertension. The bilateral papilledema [detected on ocular ultrasound] helped me make that diagnosis and then noticing that the optic nerve sheath diameter also being dilated helped me make this diagnosis.

When neurology assessed the patient they completed the workup by doing both a CT venogram and an MR venogram to confirm that this patient didn’t have an occlusion that was causing the symptoms. And when these were both negative, and when these were both negative, the diagnosis of idiopathic intracranial hypertension was made.

Neurology referred the patient to neurosurgery who put in a drain into the ventricles to help drain the CSF fluid because they were concerned that the patient was basically going blind.

When I went to visit her on the ward two days later, she noted that her vision was much improved after [the neurosurgeons] inserted the drain.

From 9:35 to the end of the vidcast, Dr. Simard discusses some critical technical points on the performance of ocular POCUS for the determination of increased intracranial pressure.

The  next article I reviewed was Etiology and Diagnosis of Intracranial Hypertension Using MRI to Narrow an Index Patient’s Differential [Resource (3) below]. This is a wonderful article which is very much worth reviewing. [Note to myself: when reviewing this post, be sure and review Resource (3) also.] 

Here are a few excerpts from the slides of Resource (3) link above:

Causes of Increased Intracranial Hypertension: A More Complete Differential Diagnosis

  1. Increased Blood Volume
    1. Occlusion (e.g. venous thrombosis)
    2. Blood outside vessels
  2. Increased Brain Volume
    1. Intracranial mass (e.g. tumor)
    2. Cerebral Edema
  3. Increased CSF Volume
    1. Increased production (e.g. from choroid plexus papilloma
    2. Decreased absorption/obstruction to CSF outflow
  4. Idiopathic Intracranial Hypertension

So if a careful evaluation of all imaging studies are deemed by the neuroradiologist normal, then the diagnosis is Idiopahic Intracranial Hypertension (formerly called Pseudotumor Cerebri) which is a diagnosis of exclusion.

And here are some charts from Resource (4) below, The diagnosis and management of idiopathic intracranial hypertension and the associated headache [PubMed Abstract]:

There are additional Resources below to review.


(1) 13 Dangerous Headaches–A List From Dr Reuben Strayer of EM Updates
Posted on September 24, 2015 by Tom Wade MD

(2) POCUS Cases 3 Idiopathic Intracranial Hypertension and Ocular POCUS from Emergency Medicine CasesPOCUS Cases Videos.

(3) Etiology and Diagnosis of Intracranial Hypertension Using MRI to Narrow an Index Patient’s Differential,  Michael A. Dyer, Harvard Medical School, July 2009. Beth Israel Deaconess Medical Center Department of Radiology, Dr. Gillian Lieberman. This slide presentation article is an outstanding quick easy to understand review.

(4) The diagnosis and management of idiopathic intracranial hypertension and the associated headache [PubMed Abstract] [Full Text HTML] [Full Text PDF]. Ther Adv Neurol Disord. 2016 Jul;9(4):317-26. doi: 10.1177/1756285616635987. Epub 2016 Mar 21.

(5) The Imaging of Idiopathic Intracranial Hypertension And Of Spontaneous Intracranial Hypotension Posted on March 2, 2017 by Tom Wade MD

(6) Differential Diagnosis + Appropriate Imaging Evaluation Of Headache – Help From the ACR Posted on March 2, 2017 by Tom Wade MD

(7) Emergency Department Management of Acute Headache  from Management of Pain And Procedural Sedation, a free open source e-book by Reuben Strayer, Sergey Motov, & Lewis Nelson, eds. What follows is from the introduction of this section of the book:

Headache causes nearly 5 million visits to US EDs annually and is the fifth most common cause of an ED visit. (Friedman 2014) Headache is sometimes attributable to a pathological process that can acutely threaten life or neurological functioning; identifying such a process is the primary responsibility of the acute care provider. Headache may also be related to a non-dangerous secondary cause, which often requires a specific acute treatment, such as sinus headache, which should be treated with decongestants, or strep throat, treated with antibiotics and anti-inflammatory medications. The focus of this chapter will not be on these secondary headaches but rather on primary headaches, that is, the various chronic episodic headache disorders that cause the majority of ED headache visits. (Friedman 2007) The list of primary headache disorders is extensive. (IHS 2013) This chapter will focus on migraine, the treatment of which is applicable to other primary headaches. We will also discuss two primary headaches that have distinct treatments, cluster headache and medication overuse headache.

(6) Pediatric Headache From The Pediatric Emergency Playbook and Pediatric EM Morsels Posted on October 10, 2016 by Tom Wade MD

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