Can pseudotumor cerebri cause radiating pain into arms with stiffness and paresthesia?

Pseudotumor Cerebri Does NOT Typically Cause Radiating Arm Pain with Stiffness and Paresthesia

Pseudotumor cerebri (idiopathic intracranial hypertension) does not characteristically cause radiating pain into the arms with stiffness and paresthesia—these symptoms should prompt evaluation for alternative diagnoses such as cervical spine pathology or peripheral nerve disorders. 1, 2

Classic Presentation of Pseudotumor Cerebri

The typical symptom profile of pseudotumor cerebri is well-defined and does not include upper extremity radicular symptoms:

Primary Symptoms

• Headache occurs in nearly 90% of patients, typically holocephalic or unilateral throbbing, worse in the morning after supine positioning and improving with upright posture throughout the day 3, 2
• Visual disturbances including transient visual obscurations and papilledema are hallmark features 2, 4
• Pulsatile tinnitus (pulse-synchronous) is a characteristic symptom 2, 4
• Diplopia, typically horizontal due to sixth nerve palsy, may occur 2, 4
• Nausea and vomiting related to elevated intracranial pressure 3, 2

What Pseudotumor Cerebri Does NOT Cause

• Mental and neurological function remain unaffected in pseudotumor cerebri 5
• There are no focal or lateralized neurological deficits such as hemiparesis or sensory changes in the extremities 3
• The neurological examination should be normal except for papilledema and possible sixth nerve palsy 1, 2

When Radicular Symptoms DO Occur with Elevated Intracranial Pressure

Radicular neck and back pain with extremity symptoms can occur, but only in the context of leptomeningeal disease, not pseudotumor cerebri:

• Leptomeningeal metastases present with multifocal signs including focal or irradiating (radicular) neck and back pain, radicular signs with weakness, and sensorimotor deficits of extremities 3
• These patients have cancer as the underlying diagnosis, not idiopathic intracranial hypertension 3
• This represents a completely different pathophysiological process involving tumor cell invasion of the meninges 3

Critical Diagnostic Algorithm

If a patient presents with suspected pseudotumor cerebri PLUS arm pain, stiffness, and paresthesia:

Step 1: Verify the Diagnosis

• Perform MRI brain and orbits to confirm typical findings: empty sella (70% of cases), posterior globe flattening (80% of cases), enlarged optic nerve sheaths, and normal brain parenchyma 6, 1
• Include MR venography to exclude venous sinus thrombosis 6, 1
• Perform lumbar puncture confirming elevated opening pressure >250 mm H₂O with normal CSF composition 1, 2

Step 2: Investigate Alternative Causes for Arm Symptoms

• Order cervical spine MRI to evaluate for:
  • Cervical radiculopathy
  • Spinal cord compression
  • Disc herniation
  • Cervical spondylosis
• Consider nerve conduction studies if peripheral neuropathy is suspected
• Evaluate for thoracic outlet syndrome or other peripheral nerve entrapments

Step 3: Rule Out Serious Pathology

• If the patient has a cancer history, consider leptomeningeal metastases with cerebrospinal MRI and CSF cytology 3
• Assess for mass lesions that could cause both elevated ICP and spinal cord/nerve root compression 3

Common Pitfall to Avoid

Do not attribute all neurological symptoms to pseudotumor cerebri simply because elevated intracranial pressure is present. 3, 2 The diagnosis of pseudotumor cerebri requires a normal neurological examination aside from papilledema and sixth nerve palsy 1, 2. Any additional focal neurological findings, including radicular symptoms in the arms, indicate either:

• A separate concurrent condition requiring independent evaluation
• An incorrect diagnosis of pseudotumor cerebri when the true etiology is structural pathology or leptomeningeal disease 3

Treatment Implications

If pseudotumor cerebri is confirmed and arm symptoms are from a separate condition:

• Treat the pseudotumor cerebri with weight loss (first-line in overweight patients) and acetazolamide (first-line medication for mild visual loss) 1
• Simultaneously address the cervical spine or peripheral nerve pathology based on specific findings
• Monitor for visual function decline, which requires urgent surgical intervention (optic nerve sheath fenestration or ventriculoperitoneal shunt) 1, 2