Diagnosis and treatment of intracranial hypertension

Endocranial Hypertension (EH) is an abnormal elevation of brain pressure and a medical emergency. There is a lack of data on its frequency and it can be caused by multiple causes. This article focuses on the EH that presents with headache.

The series of EH symptoms is similar, regardless of the underlying pathology. It is probable that the diagnosis of EH is made in secondary care, since patients require urgent referrals from primary care, to obtain images and make additional studies that help the diagnosis, and thus prevent deterioration, including loss of the vision.

Why don’t you recognize yourself?

Insidious onset and nonspecific symptoms: The insidious nature of the onset of HE can lead to delayed diagnosis and misdiagnosis. Some of the key characteristic symptoms are nonspecific and the signs may not be recognized immediately.

A study describing the presentation of intracranial tumors in children and young adults prior to diagnosis found that the symptoms and signs not localized (headache, parental concern, lethargy, fatigue, drowsiness, loss of appetite, irritability, stunting) were more than twice as frequent as focal neurological signs (such as paralysis of the 6th craniranian pair and visual disturbances).

History and incomplete examinations: Only 52% of hospitalized neurological patients recalled having been examined with an ophthalmoscope. There is evidence that in patients who go to the emergency department with headache, the medical examination and the preparation of the history are inadequate; only 0.3% had a complete history record; A typical history of headache would have recorded the type and location of pain, onset, duration, severity, associated symptoms, any precipitating factors, history of headaches and medications. The fundoscopy is part of the complete neurological examination, and the EH can easily go unnoticed if the funduscopy is not done, or if the funduscopy is not interpreted correctly. Direct ophthalmoscopy can be difficult if it is not practiced on a regular basis.

Why is this important?

The consequences of not detecting EH in a timely manner can cause permanent loss of vision, permanent neurological deficit and, finally, death. The lack of recognition of HE has led to malpractice trials.

What are its clinical characteristics?

The form of presentation of the EH is very varied. People can report:

– Headache: The typical characteristics of constant headache of recent onset or almost constant severe are specific and only one third of patients with EH report that the headache is worse upon awakening. Most patients complain of a progressive worsening of headache for weeks, but some may develop a rapid increase in EH in a matter of hours or days.

Visual alterations: transient blurred vision. Visual darkening, double vision, visual loss.

Associated symptoms: Other symptoms are: neck pain, back pain, throbbing tinnitus, lethargy, changes in behavior, weakness, vomiting, motor or speech problems, decreased consciousness and seizures.

How is the investigation continued and what is the treatment?

If there is papilledema and there is no evidence of malignant hypertension, neuroimaging should be requested on the same day (magnetic resonance imaging of the skull and orbits, with intravenous contrast and venography, or cranial CT with venogram).

Venography can exclude thrombosis of the cerebral venous sinus. After excluding a structural endocranial lesion by neuroimaging, it is considered safe to perform a lumbar puncture (lateral decubitus) to record the opening pressure and send the cerebrospinal fluid for analysis, in order to exclude infectious, malignant and inflammatory causes. .

High-risk patients are those with imminent visual loss. These patients need close observation and often urgent surgical treatment due to the risk of permanent visual loss.

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