From the Guidelines
The workup of bilateral papilledema should begin with urgent neuroimaging, preferably MRI with contrast, or CT if MRI is unavailable, to rule out life-threatening causes such as mass lesions, hydrocephalus, or venous sinus thrombosis. This approach is supported by the American College of Radiology Appropriateness Criteria for headache in children, which recommends MRI as the imaging modality of choice if there are signs of increased intracranial pressure and concern for possible tumor 1.
Initial Evaluation
The initial evaluation should also include a comprehensive ophthalmologic examination, including:
- Visual field testing
- Optical coherence tomography to establish baseline visual function and monitor progression
- Fundoscopy and visual acuity testing
- Laboratory tests, such as complete blood count, comprehensive metabolic panel, and screening for conditions like hypertension, anemia, and endocrine disorders
Lumbar Puncture
A lumbar puncture should be performed to measure opening pressure and analyze cerebrospinal fluid, unless contraindicated by imaging findings suggesting increased intracranial pressure 1.
Management
If idiopathic intracranial hypertension is suspected, particularly in young overweight women, treatment may include weight loss, acetazolamide (starting at 500mg twice daily, increasing as needed up to 2g daily), or topiramate (25mg daily, titrating up to 50mg twice daily) 1. For severe or progressive visual loss, surgical interventions such as optic nerve sheath fenestration or CSF shunting procedures may be necessary.
Follow-up
Regular follow-up with both neurology and ophthalmology is crucial to monitor visual function and response to treatment, with documentation of visual acuity, pupil examination, formal visual field assessment, and dilated fundal examination to grade the papilledema 1. Papilledema represents optic disc swelling due to increased intracranial pressure, and prompt diagnosis and management are essential to prevent permanent vision loss.
From the Research
Workup of Bilateral Papilledema
Bilateral papilledema is a condition characterized by optic nerve head edema secondary to raised intracranial pressure (ICP) 2. The workup of bilateral papilledema involves several steps:
- Measuring blood pressure and ruling out pseudopapilledema 2
- Performing magnetic resonance imaging (MRI) of the brain and orbits with venography sequences to look for indirect imaging signs of increased ICP and to rule out nonidiopathic causes 2
- Conducting a lumbar puncture with measurement of opening pressure and evaluation of cerebrospinal fluid (CSF) composition 2
- Assessing for underlying causes of increased ICP, including conditions that decrease CSF outflow or increase CSF production 2, 3, 4
Diagnostic Considerations
The diagnosis of bilateral papilledema requires consideration of various etiologies, including:
- Idiopathic intracranial hypertension (IIH) 2, 3, 4, 5
- Cerebral edema, hydrocephalus, space-occupying lesions, infection, and other conditions that increase ICP 6
- Conditions that decrease CSF outflow, such as cerebral venous sinus thrombosis or impairment of cerebral sinus drainage 2, 4
Imaging Studies
Imaging plays a critical role in the detection of pathologies that can cause papilledema. The following imaging studies may be useful:
- MRI with contrast and CE-MRV for the diagnosis of IIH 6
- MRI of the neck and spine, magnetic resonance angiography of the brain, and computed tomography of the chest to identify secondary causes of intracranial hypertension 2
Treatment
Treatment of bilateral papilledema is directed at correcting the underlying cause. Options include: