From the Guidelines
The workup of bilateral papilledema should include a lumbar puncture with an opening pressure measurement to evaluate for increased intracranial pressure, as recommended by the 2018 consensus guidelines on management of idiopathic intracranial hypertension 1. The normal opening pressure in adults is 10-25 cmH2O (or 100-250 mmH2O) when measured in the lateral decubitus position. The procedure should be performed after neuroimaging (typically MRI with contrast or CT if MRI is unavailable) to rule out mass lesions, hydrocephalus, or other structural causes that could contraindicate lumbar puncture. During the procedure, the patient should be positioned in the lateral decubitus position with legs extended, and the opening pressure should be measured with a manometer before any CSF is withdrawn. Additional CSF should be collected for analysis including cell count, protein, glucose, cultures, cytology, and other specialized tests as clinically indicated. If the opening pressure is elevated (>25 cmH2O), this may indicate idiopathic intracranial hypertension (IIH), especially if other CSF parameters are normal. In cases of confirmed IIH, therapeutic drainage of CSF (typically 20-30 mL) during the procedure may provide temporary symptomatic relief. The lumbar puncture should be performed using a standard technique with a 20-22 gauge spinal needle, with careful attention to sterile technique and patient comfort. This procedure is essential in the diagnostic algorithm for papilledema as it helps distinguish between various etiologies and guides appropriate management, as also supported by other studies such as the 2018 guidelines for the use of antifungal agents in patients with invasive fungal diseases in Taiwan 1, although the primary focus of these guidelines is on the management of cryptococcal disease. It's worth noting that other studies, such as the 2000 practice guidelines for the management of cryptococcal disease, also emphasize the importance of controlling elevated intracranial pressure, but the most recent and relevant guidelines for the workup of bilateral papilledema are provided by the 2018 consensus guidelines on management of idiopathic intracranial hypertension 1. Key points to consider in the workup and management of bilateral papilledema include:
- Performing a lumbar puncture with opening pressure measurement after neuroimaging to rule out structural causes
- Collecting CSF for analysis to guide diagnosis and management
- Considering therapeutic drainage of CSF in cases of confirmed IIH
- Using a standard technique with attention to sterile technique and patient comfort
- Following up with patients to monitor for worsening of visual fields or papilledema, as recommended by the 2018 consensus guidelines on management of idiopathic intracranial hypertension 1.
From the Research
Workup of Bilateral Papilledema
- The workup of bilateral papilledema typically involves a combination of clinical evaluation, imaging studies, and lumbar puncture to determine the underlying cause of increased intracranial pressure (ICP) 2, 3, 4, 5.
- Imaging studies such as magnetic resonance imaging (MRI) of the brain and orbits with venography sequences can help identify indirect signs of increased ICP and rule out non-idiopathic causes 3.
- Lumbar puncture with measurement of opening pressure and evaluation of cerebrospinal fluid (CSF) composition is also an essential part of the workup, as it can help confirm the diagnosis of increased ICP and guide further management 2, 3, 5.
Lumbar Puncture Opening Pressure
- The normal opening pressure on lumbar puncture is typically considered to be between 10-25 cm H2O 2.
- An elevated opening pressure, such as 29 cm H2O, is indicative of increased ICP and can be seen in conditions such as idiopathic intracranial hypertension (IIH) or secondary causes of intracranial hypertension 2, 3, 5.
- The opening pressure can be used to monitor the response to treatment and adjust management as needed 2.
Management of Bilateral Papilledema
- The management of bilateral papilledema depends on the underlying cause of increased ICP and may involve medical or surgical interventions 3, 4, 5.
- For patients with IIH, weight loss and oral acetazolamide are often the initial treatments, while surgical options such as ventriculoperitoneal shunting may be considered for patients who do not respond to medical therapy or have significant visual impairment 3, 4, 5.
- In cases where there is a secondary cause of intracranial hypertension, treatment is directed at correcting the underlying cause, such as relieving venous sinus stenosis or treating an underlying infection 2, 6.