A rare patient with idiopathic intracranial hypertension without papilledema presenting with tinnitus

Excerpt

A 51-year-old male had presented with pulsatile tinnitus and vertigo which had emerged 1.5 months ago and progressed. The patient had initially applied to an otorhinolaryngology clinic where otorhinolaryngological examinations including audiometric tests were found to be within normal limits. Therefore, the patient was consulted to the neurology clinic for further investigations. The patient defined tinnitus as a sensation of hearing an intermittent sound like humming in both ears. Over the last month, the sensation had progressed such that she started to have difficulty concentrating on daily routines. The patient stated that her complaints deteriorated during lying position. Besides, the patient suffered from vertigo attacks which she defined as spinning-like sensation and feeling of unsteadiness lasting for a few seconds that was exacerbated by head movement. Her medical history was unremarkable. On neurological examination, the cranial nerve examinations including eye movements were normal. The head impulse test did not reveal an abnormality. The best-corrected visual acuity was bilateral 20/20. Funduscopic examination was bilateral normal. Other assessments including motor, sensory, and cerebellar exams were within normal ranges. Laboratory investigations including hemogram, blood biochemistry, ferritin, TSH, folic acid, B12, and vitamin D were within normal limits. Cranial MRI did not show a space-occupying lesion or a vascular lesion; however, imaging features suggesting the diagnosis of idiopathic intracranial hypertension (IIH) including vertical tortuosity of the optic nerves, peri-optic nerve sheath distention, and partially empty cella were detected (Fig. 1). MR venography findings were within normal limits. Remarkably, the patient did not state concurrent headache or any visual disturbances. Further interrogation revealed that she had gained 10 kg body weight over the last 3-month period (BMI at admission was 32). No other causative agent including drug usage or a medical comorbidity (lupus, sleep apnea syndrome, etc.) was identified. With a provisional diagnosis of IIH without papilledema, a lumbar puncture (LP) was performed in a lateral decubitus position which revealed an opening pressure of 220 mm H₂0. Ten cc cerebrospinal fluid (CSF) was drained, and the CSF closing pressure was measured as 60 mm H₂0. Soon after the LP, the patient stated dramatic resolution of her symptoms. The following day, the patient was discharged with acetazolamide 2×250 mg therapy and nutrition recommendations for obesity. On polyclinic follow-up 3 weeks later, the patient was symptom-free, and she had lost 3 kg within this interval.

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