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Pseudotumor cerebri


Key points

  • Definition: Pseudotumor cerebri (PTC) is a clinical entity characterized by intracranial hypertension in patients without other demonstrable intracranial disease, including but not limited to primary or secondary neoplasm.

  • Synonyms: idiopathic intracranial hypertension, benign intracranial hypertension.

  • Classic clue: Obese female of childbearing age with diplopia, headache (HA), nausea, vomiting, and pulsatile tinnitus. Physical examination proves papilledema, visual field cuts, and cranial nerve (CN) VI palsy. Imaging shows “slit-like” ventricles, buckling of optic nerve (ON), increased cerebrospinal fluid (CSF) in ON sheath, reverse cupping of ON heads, flattening of posterior globes, and empty sella.

Imaging

Computed tomography features

  • Computed tomography (CT) was previously primarily performed to rule out other causes of intracranial hypertension including brain tumor.

  • May see small or slit-like ventricles (see Figure 47-1 , B - D ), and empty sella sign. , ,

    FIGURE 47-1 ■, A, A 30-year-old obese female presents with nausea and vomiting, HA, pulsatile tinnitus, and papilledema. Axial T2 weighted image shows increased CSF within subarachnoid space surrounding ON. Slit-like ventricles shown on T1 (B) , T2 (C) , and CT (D) images at first glance appear normal. On second look, they are probably “too good to be true” in this situation.

  • Some suggest slit-like ventricles are “poor” neuroimaging sign of PTC because of low occurrence rate. Reported sensitivity is 3.3%, and specificity is 100%. ,

  • Untreated swelling of optic disc may progress to profound vision loss.

  • PTC is a diagnosis of exclusion.

  • CT scan results are typically reported as “normal.”

  • Clinicians have been cautioned against relying on CT alone for evaluating increased intracranial pressure, particularly in pediatric patients. ,

  • Remember what Said said: “A negative CT scan is not adequate to support a diagnosis of pseudotumor.” ,

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