What is the recommended imaging approach for a 19-year-old with papilloedema?

From the Guidelines

For a 19-year-old with papilloedema, the recommended imaging approach is to start with an urgent MRI of the brain with contrast, followed by MR venography, as this comprehensive approach is essential to evaluate for intracranial mass lesions, venous sinus thrombosis, and other structural abnormalities that could cause increased intracranial pressure. This approach is supported by the most recent and highest quality study, which emphasizes the importance of MRI in detecting intracranial space-occupying lesions or hydrocephalus, and the role of MR venography in excluding cerebral sinus thrombosis 1.

The use of MRI is preferred over CT due to its ability to provide higher soft tissue contrast resolution of intracranial structures, which is crucial in diagnosing conditions such as idiopathic intracranial hypertension (IIH) 1. The administration of IV contrast can help in characterizing any intracranial space-occupying lesions that may be detected.

Key findings that can be assessed with MRI include posterior globe flattening, intraocular protrusion of the optic nerve, and horizontal tortuosity of the optic nerve, which are important in the diagnosis of IIH 1. Additionally, MRI can aid in the diagnosis of IIH by demonstrating a finding of partially empty sella.

If MRI is not immediately available, a CT scan with contrast should be performed as an initial step, but this should be followed by MRI when possible, as it provides superior soft tissue detail and can detect subtle abnormalities that CT might miss. The imaging should be performed promptly, ideally within 24 hours of presentation, as papilloedema indicates potentially serious underlying conditions that require timely diagnosis.

After imaging, a lumbar puncture may be necessary to measure opening pressure and analyze cerebrospinal fluid, but this should only be done after ruling out mass lesions or obstructive hydrocephalus that could lead to herniation, as recommended by consensus guidelines on the management of IIH 1.

Some key points to consider in the imaging approach include:

• The importance of urgent imaging to evaluate for potentially life-threatening conditions
• The preference for MRI over CT due to its superior soft tissue contrast resolution
• The role of MR venography in excluding cerebral sinus thrombosis
• The need for prompt imaging, ideally within 24 hours of presentation
• The importance of considering lumbar puncture after imaging to measure opening pressure and analyze cerebrospinal fluid.

Overall, the recommended imaging approach for a 19-year-old with papilloedema is to start with an urgent MRI of the brain with contrast, followed by MR venography, to ensure timely diagnosis and treatment of any underlying conditions that may be causing increased intracranial pressure.

From the Research

Imaging Approach for Papilloedema

The recommended imaging approach for a 19-year-old with papilloedema involves several steps:

• Magnetic Resonance Imaging (MRI): MRI of the brain and orbits with venography sequences is the preferred neuroimaging modality to look for indirect imaging signs of increased intracranial pressure (ICP) and to rule out nonidiopathic causes 2.
• MRI Sequences: A combination of MRI sequences including T2-weighted, T1-weighted, and contrast-enhanced T1-weighted sequences can help visualize the macroscopic changes in papilloedema 3.
• Magnetic Resonance Venography (MRV): MRV is recommended to identify cerebral venous sinus thrombosis, which can be a cause of papilloedema 4.
• Additional Imaging: In patients not in a typical demographic group for idiopathic intracranial hypertension (IIH), further investigations such as MRI of the neck and spine, magnetic resonance angiography of the brain, and computed tomography of the chest may be necessary to assess for underlying causes of increased ICP 2.

Key Imaging Findings

Some key imaging findings in papilloedema include:

• Flattening of the posterior sclera
• Protrusion of the optic disc
• Widening of the optic nerve sheath
• Tortuosity of the optic nerve 5
• Enhancement of the swollen optic nerve head on contrast-enhanced T1-weighted sequences 3

Importance of Imaging

Imaging plays a critical role in the detection of pathologies that can cause papilloedema, and early recognition of papilloedema and elevated ICP is essential for ensuring restoration of vision 6, 5.