Papilledema medical therapy

Overview

The best treatment of papilledema is to address its underlying cause. However the root cause of papilledema is increase intracranial pressure.Drugs are use to decrease intracranial pressure. These drugs acts mainly by either decreasing cerebrospinal fluid production or by increasing its outflow.

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.

• 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 . The most commonly used agent is mannitol.Osmotic agent should be carefully used in patients with renal insufficiency.

• Furosemide- It may be given with mannitol to potentiate its effect . However, it can also exacerbate dehydration and hypokalemia

• Glycerol and urea- were used historically to control ICP via osmoregulation.

• Hypertonic saline bolus — Bolus doses of hypertonic saline may acutely lower intracranial pressure; however, the long-term effect of this early intervention remains unclear..

• 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 to 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. . 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.