Gabrielle R Bonhomme

Venous sinus stenting shortens the duration of medical therapy for increased intracranial pressure secondary to venous sinus stenosis

Introduction Medical treatment, cerebrospinal fluid (CSF) shunting, and optic nerve sheath fenestration are standard treatments for increased intracranial pressure (ICP) in patients with idiopathic intracranial hypertension (IIH). Venous sinus stenting provides a novel alternative surgical treatment in cases of venous sinus stenosis with elevated ICP. Methods 12 consecutive subjects with papilledema, increased ICP, and radiological signs of dural sinus stenosis underwent cerebral venography and manometry. All subjects had papilledema and demonstrated radiological evidence of dural venous sinus stenosis. Results Six subjects chose venous stenting (Group A) and six declined and were managed conservatively with oral acetazolamide (Group B). The relative pressure gradient across the venous narrowing was 29±16.3 mm Hg in Group A and 17.6±9.3 mm Hg in Group B (p=0.09). The mean lumbar puncture opening pressure was 40.4±7.6 cm H2O in Group A and 35.6±10.6 cm H2O in Group B (p=0.4). Spectral domain optical coherence tomography (SD-OCT) showed mean average retinal nerve fiber layer (RNFL) thickness of 210±44.8 µm in Group A and 235±124.7 µm in Group B. However, the mean average RNFL thickness at 6 months was 85±9 µm in Group A and 95±24 µm in Group B (p=0.6). The total duration of acetazolamide treatment was 188±209 days in Group A compared with 571±544 days in Group B (p=0.07). Conclusions In subjects with venous sinuses stenosis, endovascular stenting offers an effective treatment option for intracranial hypertension which may shorten the duration of medical therapy.

Lymphoma of the orbit masquerading as Tolosa-Hunt syndrome

BackgroundTolosa-Hunt syndrome is a rare clinical syndrome characterized by painful ophthalmoplegia and ipsilateral cranial neuropathies. It is caused by an inflammatory process of unknown etiology.Case presentationWe present a case of a 77-year-old white man with history of Waldenstrom’s macroglobulinemia transforming to large B-cell lymphoma who presented to a community physician complaining of 4 months of isolated right retro-orbital pain and later with diplopia, ptosis, 6th nerve and pupil-sparing partial 3rd nerve palsies as well as progressive neurological findings. His clinical course was complicated by debilitating neurological symptoms and multiple hospitalizations leading to a delay in diagnosis caused by incomplete initial workup.ConclusionThis case is a reminder that lymphoproliferative disorders often mimic other neurologic disorders and that Tolosa-Hunt is a rare diagnosis that must be considered a diagnosis of exclusion.