Should I contact neurology or cardiology for intracranial hypertension?

Management of Intracranial Hypertension: Neurology is the Primary Contact

For intracranial hypertension, you should contact neurology as the primary specialty, not cardiology. 1 Intracranial hypertension is fundamentally a neurological disorder that requires neurological expertise for proper diagnosis, management, and treatment.

Rationale for Neurological Management

• Intracranial hypertension is defined by clinical criteria including signs and symptoms of increased intracranial pressure (headache, papilledema, vision loss), elevated ICP with normal CSF composition, and no other evident cause on neuroimaging 1

• The 2018 consensus guidelines from the Journal of Neurology, Neurosurgery and Psychiatry clearly establish that management of idiopathic intracranial hypertension requires neurological expertise 1

• The main principles of management are:

  1. Treating the underlying disease
  2. Protecting vision
  3. Minimizing headache morbidity

Diagnostic Approach by Neurology

Neurologists follow a specific diagnostic algorithm for intracranial hypertension:

1. Neurological examination - Looking for cranial nerve involvement (typically only sixth nerve palsy may be present in IIH) 1

2. Neuroimaging - Urgent MRI brain within 24 hours; if unavailable, CT brain with subsequent MRI 1

3. Venography - CT or MR venography is mandatory to exclude cerebral sinus thrombosis within 24 hours 1

4. Lumbar puncture - To check opening pressure and ensure CSF contents are normal 1

Treatment Pathway Under Neurological Care

Neurologists coordinate a comprehensive treatment approach:

• Weight management - For patients with BMI >30 kg/m², weight loss is the only disease-modifying therapy 1, 2

• Medical therapy - Acetazolamide (starting at 250-500 mg twice daily) is typically the first-line medication 2

• Surgical interventions when necessary:

  • CSF diversion procedures (VP shunt preferred due to lower revision rates)
  • Optic nerve sheath fenestration for vision preservation
  • Venous sinus stenting in select cases 2

When Cardiology Consultation May Be Needed

While neurology remains the primary contact, cardiology consultation may be appropriate in specific circumstances:

• When cerebral venous thrombosis is detected and anticoagulation management is needed 1

• In cases where there are concerns about cardiac causes contributing to increased intracranial pressure

• For patients with comorbid cardiac conditions requiring management alongside IIH treatment

Multidisciplinary Approach

Effective management often involves collaboration between:

• Neurologists - Primary management of IIH
• Ophthalmologists - Assessment and monitoring of vision and papilledema
• Neurosurgeons - For surgical interventions when needed
• Weight management specialists - For the essential weight loss component of treatment 2

Follow-up and Monitoring

Regular follow-up with neurology is essential:

• Early review after intervention (24-48 hours)
• Intermediate follow-up (10-14 days or 3-6 weeks)
• Late follow-up (3-6 months) 2

Regular ophthalmologic assessment is also crucial, including visual acuity, pupil examination, formal visual field assessment, and dilated fundal examination 2.

In summary, intracranial hypertension is fundamentally a neurological condition requiring neurological expertise for proper diagnosis and management. While a multidisciplinary approach may be beneficial, neurology should be your primary contact.