Papilledema medical therapy
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Kalsang Dolma, M.B.B.S.[2]
Overview
The mainstay of treatment of papilledema is to treat the underlying cause which is often increased intracranial pressure. Drugs are used to decrease intracranial pressure which either decrease cerebrospinal fluid (CSF) production or increase the outflow of CSF.
Medical Therapy
- Acetazolamide — Carbonic anhydrase inhibitors are believed to reduce the rate of cerebrospinal fluid production. Acetazolamide is the usual first line treatment for idiopathic intracranial hypertension. Acetazolamide is successful in stabilizing vision in 47 to 67 percent of patients.[1][2]
- Mannitol — Osmotic diuretics are drugs used to reduce brain volume by drawing free water out of the tissue and into the circulation, where it is excreted by the kidneys, thus dehydrating brain parenchyma.[3] [4] [5] The most commonly used agent is mannitol. Osmotic agents should be carefully used in patients with renal insufficiency.
- Furosemide- It may be given with mannitol to potentiate its effect.[6] [7] However, it can also exacerbate dehydration and hypokalemia.
- Hypertonic saline bolus — Bolus doses of hypertonic saline may acutely lower intracranial pressure; however, the long-term effect of this early intervention remains unclear.[8].
- Glucocorticoids — Glucocorticoids may have a role in the setting of intracranial hypertension caused by brain tumors, CNS infections and other inflammatory conditions. In contrast, glucocortoicoids are not considered to be useful in intracranial hemorrhage.
- Hyperventilation — Use of mechanical ventilation to lower PaCO2 from 26 to 30 mmHg has been shown to rapidly reduce intracranial pressure through vasoconstriction and a decrease in the volume of intracranial blood. Hyperventilation also results in respiratory alkalosis, which may buffer post-injury acidosis. The effect of hyperventilation on intracranial pressure is short-lived. [9]. Following therapeutic hyperventilation, the patient's respiratory rate should be tapered back to normal over several hours to avoid a rebound effect Therapeutic hyperventilation should be considered as an urgent intervention when elevated intracranial pressure complicates cerebral edema, intracranial hemorrhage, and tumor. Regardless of the cause of increased intracranial pressure, hyperventilation should be tapered back to normal over several hours to avoid a rebound effect
- Weight reduction - Medically and surgically induced weight reduction (eg,gastric banding or gastric bypass procedures) may be necessary in morbidly obese patients. Case series of idiopathic intracranial pressure patients undergoing gastric surgery report improvement of symptoms and signs of increased intracranial pressure.[10] [11]
References
- ↑ Matthews YY (2008). "Drugs used in childhood idiopathic or benign intracranial hypertension". Arch Dis Child Educ Pract Ed. 93 (1): 19–25. doi:10.1136/adc.2006.107326. PMID 18208981. Unknown parameter
|month=ignored (help) - ↑ Youroukos S, Psychou F, Fryssiras S, Paikos P, Nicolaidou P (2000). "Idiopathic intracranial hypertension in children". J. Child Neurol. 15 (7): 453–7. PMID 10921516. Unknown parameter
|month=ignored (help) - ↑ Paczynski RP (1997). "Osmotherapy. Basic concepts and controversies". Crit Care Clin. 13 (1): 105–29. PMID 9012578. Unknown parameter
|month=ignored (help) - ↑ Nath F, Galbraith S (1986). "The effect of mannitol on cerebral white matter water content". J. Neurosurg. 65 (1): 41–3. doi:10.3171/jns.1986.65.1.0041. PMID 3086519. Unknown parameter
|month=ignored (help) - ↑ Bell BA, Smith MA, Kean DM; et al. (1987). "Brain water measured by magnetic resonance imaging. Correlation with direct estimation and changes after mannitol and dexamethasone". Lancet. 1 (8524): 66–9. PMID 2879175. Unknown parameter
|month=ignored (help) - ↑ Wilkinson HA, Rosenfeld SR (1983). "Furosemide and mannitol in the treatment of acute experimental intracranial hypertension". Neurosurgery. 12 (4): 405–10. PMID 6406929. Unknown parameter
|month=ignored (help) - ↑ Pollay M, Fullenwider C, Roberts PA, Stevens FA (1983). "Effect of mannitol and furosemide on blood-brain osmotic gradient and intracranial pressure". J. Neurosurg. 59 (6): 945–50. doi:10.3171/jns.1983.59.6.0945. PMID 6415245. Unknown parameter
|month=ignored (help) - ↑ Bhardwaj A, Ulatowski JA (2004). "Hypertonic saline solutions in brain injury". Curr Opin Crit Care. 10 (2): 126–31. PMID 15075723. Unknown parameter
|month=ignored (help) - ↑ Laffey JG, Kavanagh BP (2002). "Hypocapnia". N. Engl. J. Med. 347 (1): 43–53. doi:10.1056/NEJMra012457. PMID 12097540. Unknown parameter
|month=ignored (help) - ↑ Sugerman HJ, Felton WL, Sismanis A, Kellum JM, DeMaria EJ, Sugerman EL (1999). "Gastric surgery for pseudotumor cerebri associated with severe obesity". Ann. Surg. 229 (5): 634–40, discussion 640–2. PMC 1420807. PMID 10235521. Unknown parameter
|month=ignored (help) - ↑ Nadkarni T, Rekate HL, Wallace D (2004). "Resolution of pseudotumor cerebri after bariatric surgery for related obesity. Case report". J. Neurosurg. 101 (5): 878–80. doi:10.3171/jns.2004.101.5.0878. PMID 15540933. Unknown parameter
|month=ignored (help)