PAPILLEDEMA

PAPILLEDEMA: Excerpt from Differential Diagnosis in Primary Care

No anatomic analysis of this condition is necessary because most cases of papilledema are caused by intracranial pathology. Three notable extracranial conditions are optic neuritis, hypertension, and pseudotumor cerebri. The polycythemia and right heart failure of chronic pulmonary emphysema may combine to produce papilledema, but this is uncommon.

PAPILLEDEMA

Analysis of the intracranial causes of papilledema is performed using the mnemonic VINDICATE.

1. V—Vascular lesions are aneurysms and arteriovenous malformations that cause subarachnoid hemorrhages. Severe hypertension may lead to an intracerebral hemorrhage or hypertensive encephalopathy, thus causing papilledema. Cerebral thrombosis and emboli rarely lead to papilledema.
2. I—Infection is not a common cause of papilledema unless a space-occupying lesion is produced or the condition persists. Thus, a brain abscess is often associated with papilledema whereas acute bacterial meningitis is not. Chronic cryptococcal meningitis, syphilitic meningitis, and tuberculous meningitis, on the other hand, are often associated with some degree of papilledema. Viral encephalitis may occasionally be associated with papilledema. Cavernous sinus thrombosis and septic thrombosis of the other venous sinuses may produce papilledema.
3. N—Neoplasms, primary and metastatic, are the most common cause of papilledema.
4. D—Degenerative diseases are rarely the cause.
5. I—Intoxication brings to mind lead encephalopathy, but other toxins and drugs rarely cause papilledema.
6. C—Congenital malformations that cause papilledema include the aneurysms and arteriovenous malformations already mentioned plus the various types of hydrocephalus, skull deformities (oxycephaly), hemophilia (because of intracranial hemorrhages), and, occasionally, Schilder disease and other congenital encephalopathies.
7. A—Autoimmune recalls lupus cerebritis and periarteritis nodosa (when associated with severe hypertension).
8. T—Trauma does not usually produce papilledema in the early stages of concussions or epidural or subdural hematomas, but in chronic subdural hematomas it is the rule.
9. E—Endocrine disorders bring to mind the papilledema of malignant pheochromocytomas (with hypertension), and the fact that pseudotumor cerebri occurs in obese, amenorrheic, and emotionally disturbed women.

Approach to the Diagnosis

The approach to the diagnosis of papilledema in someone without hypertension or hypertensive retinopathy must include a thorough neurologic examination and a CT scan. If focal signs are present or the CT scan shows positive findings, referral to a neurosurgeon is indicated. He or she can decide if an MRI is indicated. A spinal tap is contraindicated. If there are no focal signs, it may be worthwhile to differentiate papilledema from optic neuritis by having an ophthalmologist perform a visual field examination. This may also be helpful in differentiating pseudotumor cerebri because there may be bilateral visual defects in the inferior nasal quadrants. Papilledema from increased intracranial pressure will show only an enlarged blind spot (unless there is a tumor of the optic tracts, radiations, or occipital cortex), whereas optic neuritis will show scotomata peripheral to the blind spot (disc). The Appendix will be useful for confirming the diagnosis of a specific disease.

Other Useful Tests

1. CBC (polycythemia)
2. Sedimentation rate (cerebral abscess, infection)
3. Urinalysis (renal disease associated with hypertension)
4. ANA analysis (collagen disease)
5. Blood lead level
6. Visual evoked potentials (optic neuritis)
7. Pulmonary function tests (emphysema)
8. Blood volume (polycythemia vera)
9. 24-hour blood pressure monitoring (hypertension)
10. Spinal tap when imaging study is negative (pseudotumor cerebri)

Book Source Details

• Book Title: Differential Diagnosis in Primary Care
• Author(s): R. Douglas Collins
• Year of Publication: 2007
• Copyright Details: Differential Diagnosis in Primary Care, Copyright © 2007 Lippincott Williams & Wilkins.

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Copyright notice for book excerpts: Copyright © 2008 Lippincott Williams & Wilkins. All rights reserved.

More About This Book: Title: Differential Diagnosis in Primary Care Authors: R. Douglas Collins Publisher: Lippincott Williams & Wilkins Copyright: 2007 ISBN: 0-7817-6812-8

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