Idiopathic intracranial hypertension (IIH), also known as pseudotumor cerebri or benign intracranial hypertension (BIH), is a disorder characterized by chronically elevated intracranial pressure and signs and symptoms resulting from the raised intracranial pressure in the absence of any detectable underlying causative lesion or pathology.
Presentation
The presenting features are [8]:
- Headache: The most common symptom, almost universally present. It is generalized, throbbing, worse on waking, and aggravated by factors which temporarily increase cerebrospinal fluid pressure such as straining, coughing, or changing posture. 50 % of patients complain of nausea.
- Obesity: Up to 90 per cent of patients are overweight.
- Papilledema: Universally present. Fundus examination of every patient with headache is vital.
- Visual symptoms: Visual obscurations, persistent blurring, or scotomas are reported by 30 to 70 % of patients. Washed out vision, halos and flickering lights lasting for a few seconds may be present. Excess straining and posture change can provoke obscurations, but they can also occur spontaneously. Occasionally, sudden and permanent loss of vision results from infarction of the optic nerve. About 30 per cent of patients complain of horizontal diplopia due to sixth nerve palsy, which may be bilateral. The cause is a false localizing sign of raised intracranial pressure.
Entire Body System
- Fatigue
[…] chronic fatigue syndrome would represent the most common and least severe and IIH the least common and most extreme. [ncbi.nlm.nih.gov]
We ask about general symptoms (anxious mood, depressed mood, fatigue, pain, and stress) regardless of condition. Last updated: January 31, 2019 [patientslikeme.com]
[…] constellation of symptoms associated with Chiari I malformation and pseudotumor cerebri, including exertional headaches, visual changes, tinnitus, lower cranial nerve dysfunction, brainstem dysfunction, sensory changes, ataxia, abnormal reflexes, and fatigue [csfinfo.org]
[…] diseases classified elsewhere G91.8 Other hydrocephalus G91.9 Hydrocephalus, unspecified G92 Toxic encephalopathy G93 Other disorders of brain G93.1 Anoxic brain damage, not elsewhere classified G93.2 Benign intracranial hypertension G93.3 Postviral fatigue [icd10data.com]
- Arm Pain
Other symptoms of IIH may include pulsatile tinnitus and shoulder or arm pain. Palsies may be seen involving cranial nerves VI, VII and VIII.(2) The worldwide epidemic of obesity is certain to increase the prevalence of this disorder. [acatoday.org]
Other common symptoms include transient altered vision, particularly on movement or bending over, intracranial noise (pulse synchronous tinnitus), stiff neck, back and arm pain, pain behind the eye, exercise intolerance, and memory difficulties. [rarediseases.org]
Other symptoms of IIH include pulse-synchronous tinnitus, and shoulder or arm pain [ 2, 3 ]. Ophthalmologic signs of IIH include decreased visual acuity, visual field loss, and papilledema. [karger.com]
- Acute Onset of Symptoms
“Fulminant IIH” was defined as the acute onset of symptoms and signs of intracranial hypertension (less than 4 weeks between onset of initial symptoms and severe visual loss), rapid worsening of visual loss over a few days, and normal brain MRI and MR [n.neurology.org]
Some studies have identified factors independently associated with a worse visual outcome: Gender (male) Race (Black) Morbid obesity Anemia Obstructive sleep apnea Acute onset of symptoms and signs of raised ICP (fulminant IIH) Recurrence may occur in [eyewiki.aao.org]
Fulminant course Rarely, patients with IIH may have an acute onset of symptoms and signs of raised ICP (so-called “fulminant” or “malignant” IIH), with rapid worsening of visual loss over a few days, but meet the criteria for IIH with normal brain MRI [em-consulte.com]
Respiratoric
- Respiratory Insufficiency
Systemic diseases: Anemia, chronic respiratory insufficiency, hypertension, multiple sclerosis, Lyme disease, psittacosis, chronic renal disease, thrombocytopenic purpura, sarcoidosis, systemic lupus erythematosus and Reye syndrome. [symptoma.com]
Anemia [43] Chronic respiratory insufficiency Familial Mediterranean fever Hypertension Polyangiitis overlap syndrome Psittacosis Chronic renal disease Reye syndrome Sarcoidosis Thrombocytopenic purpura Behcet syndrome [44, 45] Hypervitaminosis A [46, [emedicine.medscape.com]
- Hyposmia
Do patients with idiopathic intracranial hypertension suffer from hyposmia? Med Hypotheses. 2008;71(5):816–817. 24. Khoo KF, Kunte H. Olfactory dysfunction in patients with idiopathic intracranial hypertension. Neurology. 2014;82(2):189. 25. [dovepress.com]
Gastrointestinal
- Nausea
Nausea, often treated with 5-hydroxytryptamine (5-HT3) receptor antagonists, approved for perioperative and chemotherapy-induced nausea, are used off-label to treat nausea and vomiting outside of those settings. [ncbi.nlm.nih.gov]
Symptoms are typical for other types of hydrocephalus - headache, nausea and vomiting, usually combined with tinnitus. However, unlike most cases of hydrocephalus, no blockage of CSF can be seen. [house.wikia.com]
- Vomiting
Acute or subacute headache, nausea and vomiting, and visual loss were present in all patients. The first lumbar puncture performed for the diagnosis showed a mean CSF opening pressure of 54.1 cm H 2 O (range 29 to 60 cm H 2 O). [n.neurology.org]
Symptoms are typical for other types of hydrocephalus - headache, nausea and vomiting, usually combined with tinnitus. However, unlike most cases of hydrocephalus, no blockage of CSF can be seen. [house.wikia.com]
Summary A 27-year-old woman with a history of recurrent nausea and vomiting in the setting of idiopathic intracranial hypertension (IIH) was admitted for control of unremitting nausea and vomiting. [ncbi.nlm.nih.gov]
Cardiovascular
- Hypertension
Abstract Purpose Transverse sinus stenosis is commonly seen in patients with idiopathic intracranial hypertension. It is not clear whether it is the cause or the result of idiopathic intracranial hypertension. [ncbi.nlm.nih.gov]
Idiopathic intracranial hypertension ( IIH ), previously known as pseudotumor cerebri and benign intracranial hypertension, is a condition characterized by increased intracranial pressure (pressure around the brain) without a detectable cause. [2] The [en.m.wikipedia.org]
There are two categories of IH: primary intracranial hypertension and secondary intracranial hypertension. Primary intracranial hypertension, now known as idiopathic intracranial hypertension (IIH), occurs without known cause. [rarediseases.org]
What is Benign Intracranial Hypertension (BIH, Pseudotumour Cerebri, PTC, Idiopathic Intracranial Hypertension, IIH) Statistics on Benign Intracranial Hypertension (BIH, Pseudotumour Cerebri, PTC, Idiopathic Intracranial Hypertension, IIH) Risk Factors [myvmc.com]
Musculoskeletal
- Neck Pain
April Newsletter, Lewitt Headache & Neck Pain Clinic, PLLC, Greensboro, NC [earcentergreensboro.com]
Positive acetazolamide-related effects on QOL appeared to be primarily mediated by improvements in visual field, neck pain, pulsatile tinnitus, and dizziness/vertigo that outweighed the side effects of acetazolamide. [ncbi.nlm.nih.gov]
[…] shoulder and/or neck pain tinnitus vomiting Diagnosis of IIH: The only truly definitive diagnostic tests for IIH are a lumbar puncture (LP) (spinal tap) or or by epidural or intraventricular pressure monitoring (CSF pressure monitoring). [healthcentral.com]
pain Blurred vision Buzzing sound in the ears (tinnitus) Dizziness Double vision (diplopia) Nausea, vomiting Vision problems such as flashing or even loss of vision Low back pain, radiating along both legs Headaches may get worse during physical activity [nlm.nih.gov]
[…] behind the eyes or when moving the eyes Pulse synchronous tinnitus (described as a swooshing sound in sync with the patient’s heartbeat) Tinnitus Hearing loss Shoulder, back, and/or neck pain Ophthalmoplegia (paralysis of extraocular muscles) There are [medtronic.com]
- Back Pain
Transient visual obscurations, back pain, and tinnitus (pulse synchronized and non-pulsatile) were also commonly reported. [2minutemedicine.com]
Pulsatile tinnitus Cranial nerve palsies (especially CN VI ) Back pain References: [3] [4] Diagnostics The following tests should always be performed Ophthalmologic examination Opthalmoscopy: bilateral papilledema Visual field test may show peripheral [amboss.com]
Her low-back pain, diagnosed as facet syndrome, resolved with a course of spinal manipulation. [acatoday.org]
Everyone with BIH has different sets of symptoms, but common ones include headache, visual disturbances, dizziness, back pain, nausea and vomiting, memory problems and a dislike of bright light. [netdoctor.co.uk]
- Shoulder Pain
Postpartum headache is described as headache and neck or shoulder pain during the first 6 weeks after delivery. [ncbi.nlm.nih.gov]
Other common symptoms include pulsatile tinnitus (ringing in the ears) and neck and shoulder pain. Intracranial hypertension can be either acute or chronic. [nei.nih.gov]
The pain may also be experienced in the neck and shoulders. [5] Many have pulsatile tinnitus, a whooshing sensation in one or both ears (64–87%); this sound is synchronous with the pulse. [5] [6] Various other symptoms, such as numbness of the extremities [en.m.wikipedia.org]
The pain may also be experienced in the neck and shoulders. Many have pulsatile tinnitus, a whooshing sensation in one or both ears (64–87%); this sound is synchronous with the pulse. [en.wikipedia.org]
Evan Johnson Tackles Puzzling Neck and Shoulder Pain at the North American Spine Society Dr. Evan Johnson Talks Back Pain and More at NASS 2018 Dr. Evan Johnson Talks Hip And Back Pain at NASS Annual Meeting Dr. [columbianeurosurgery.org]
Ears
- Tinnitus
Among audiovestibular symptoms, tinnitus and dizziness are commonly reported, while vertigo and hearing impairment are infrequent reports. [ncbi.nlm.nih.gov]
The most common symptoms are diffuse headaches, although various visual symptoms and pulsatile tinnitus are also common. [amboss.com]
- Pulsatile Tinnitus
The most common symptoms are diffuse headaches, although various visual symptoms and pulsatile tinnitus are also common. [amboss.com]
This study aimed to report the author's 15-year experience with the systematic evaluation and treatment of patients with pulsatile tinnitus. Between August 1981 and August 1996, 145 patients with pulsatile tinnitus were evaluated. [ncbi.nlm.nih.gov]
- Hearing Impairment
Among audiovestibular symptoms, tinnitus and dizziness are commonly reported, while vertigo and hearing impairment are infrequent reports. [ncbi.nlm.nih.gov]
Eyes
- Diplopia
A 34-year-old morbidly obese woman with a history of idiopathic intracranial hypertension (IIH) presented with a 1-month history of bilateral vision loss, diplopia, and left eye pain after being lost to follow-up for 6 years. [ncbi.nlm.nih.gov]
- Blurred Vision
The symptoms of the disease may be ordered according to prevalence as follows: headache due to increased intracranial pressure, blurred vision and diplopia. [ncbi.nlm.nih.gov]
- Visual Impairment
In patients who have severe visual impairment or progressive visual deterioration despite medical management, surgical or interventional treatment may be considered. [dovepress.com]
It can lead to visual impairment but prompt diagnosis and treatment in most of the cases will prevent potentially permanent visual loss. [ncbi.nlm.nih.gov]
- Enlarged Blind Spot
The most common visual field defect was a partial arcuate defect with an enlarged blind spot, and the average (SD) CSF opening pressure was 343.5 (86.9) mm H 2 O. [2minutemedicine.com]
Results of ophthalmologic examination revealed bilateral papilledema, an enlarged blind spot in both eyes, and a normal visual acuity. [jamanetwork.com]
Intracranial hypertension fulfilling the following criteria: alert patient with neurological examination that either is normal or demonstrates any of the following abnormalities: a) papilloedema b) enlarged blind spot c) visual field defect (progressive [healthcentral.com]
- Photophobia
We present a 38-year old primigravid renal transplant patient at 7 weeks of gestation who presented with 2 weeks of intense, throbbing, holocranial headache, nausea, vomiting, photophobia, diplopia and progressive visual loss. [ncbi.nlm.nih.gov]
The patient is a 37 y/o female who presents with complaints of two months of intermittent severe frontal headaches associated with some decreased vision, nausea/vomiting and photophobia. [ultrasoundoftheweek.com]
Eye pain, photophobia, blurry vision, and nausea/vomiting are all common symptoms in IIH, but these symptoms are also present in other causes of headache. [mdedge.com]
[…] which may be worse in the morning (the most common symptom) Dizziness Nausea Transient visual obscurations characteristic of papilledema Papilledema causing impaired vision, especially peripheral visual field defects and enlargement of the blind spot Photophobia [medtronic.com]
At the time of hospitalization, her weight was 63 kg and her height, 158 cm, and she had severe generalized headache, nausea, muscle weakness, hyperreflexia, and photophobia. [jamanetwork.com]
Neurologic
- Headache
It relieves papilledema in all cases and improves headaches in most cases. KEYWORDS: Headache; idiopathic intracranial hypertension; papilledema; venous sinus stenosis; venous sinus stenting [ncbi.nlm.nih.gov]
Drug-related headache. Headache. 1989 Jul;29(7):441-4. PubMed PMID: 2759851. Alvarez-Cermeño JC, Fernández JM, O'Neill A, Moral L, Saiz-Ruiz J. Lithium-induced headache. Headache. 1989 Apr;29(4):246-7. PubMed PMID: 2497083. [headachejournal.org]
The patient had no personal or family history of migraines, tension headaches, aneurysms, clotting disorders, bleeding disorders, or renal disease, and stated that she had never experienced this type of headache before. [mdedge.com]
Migraine With Aura - the Basics Migraine Without Aura - the Basics New Daily Persistent Headache - The Basics Orgasmic and Preorgasmic Headache - The Basics Paroxysmal Hemicrania - The Basics Post-Traumatic Headache - The Basics Primary Exertional Headache [healthcentral.com]
Headache. 2006; 46 (8):1255-1260. doi:10.1111/j.1526-4610.2006.00527.x. [CrossRef] [PubMed] [jaoa.org]
- Papilledema
When papilledema is absent, the diagnosis becomes less clear. Some physicians have argued that the absence of papilledema rules out IIH, whereas others maintain that elevated OP is sufficient for diagnosis. [ncbi.nlm.nih.gov]
This article reviews the treatment of papilledema-related visual loss in pseudotumor cerebri syndrome, one of the most common causes of papilledema encountered by neurologists. [journals.lww.com]
- Meningism
Throughout history, many terms have been used, including serous meningitis, pseudotumor cerebri, otitic hydrocephalus, angioneurotic hydrocephalus, toxic hydrocephalus, meningeal hypertension, hypertensive meningeal hydrops, pseudoabscess, intracranial [ncbi.nlm.nih.gov]
- Dizziness
Among audiovestibular symptoms, tinnitus and dizziness are commonly reported, while vertigo and hearing impairment are infrequent reports. [ncbi.nlm.nih.gov]
Read about people's experiences with dizziness and balance problems Gillian's dizziness started following a bout of flu. [brainandspine.org.uk]
Symptom ... s may include a headache behind your eyes, ringing in your ears, nausea, vomiting, dizziness, blurred vision or double vision.The cause of pseudo tumor cerebri is unknown, but it is thought to be linked to an excess amount of cerebrospinal [sharecare.com]
- Stroke
The Basics Tension-Type Headaches - The Basics Transformed Migraine - The Basics Resources: National Institute of Neurological Disorders and Stroke. [healthcentral.com]
It focuses on patient management—from stroke prevention through acute stroke management, through chronic care—and offers how-to guidance on implementing diagnostic and treatment protocols. [books.google.com]
[…] from a stressed vessel rupturing, or an ischemic stroke from lack of blood flow to the affected area of the brain. [mdedge.com]
Altschul Leads Breakfast Program on Stroke Dr. Altschul Leads SVIN Discussion on New Stroke Treatments Dr. Altschul on Twitter Chat for World Stroke Day 2014 Dr. Altschul Takes to Twitter for World Stroke Day Chat Dr. [columbianeurosurgery.org]
National Institute of Neurological Disorders and Stroke. "Pseudotumor Cerebri Information Page." Bethesda. Last updated November 1, 2010. - 2. Intracranial Hypertension Research Foundation. - 3. Bond, DW; Charlton, CPJ; Gregso, RM. [migraine.com]
Workup
- Visual assessment: Visual acuity, color vision, motility assessment and fundus examination
- Visual field: The most common defects are enlargement of the blind spots, generalized constriction of the fields, and scotomas caused by optic nerve damage. There may be a predilection for visual field loss in the inferior nasal quadrants.
- Fundus fluorescein angiography: Is necessary if fundus examination is not equivocal for diagnosis of papilledema.
- Radiology: For detecting underlying pathology and especially ruling out mass lesions and hydrocephalus before doing lumbar puncture. Computed tomography (CT) scanning shows small and slit-like cerebral ventricles which may increase in volume as intracranial hypertension resolves. A similar appearance is seen on magnetic resonance imaging (MRI). Sagittal sinus thrombosis may be visualized on CT scanning as the characteristic 'empty delta' sign due to clot within the sinus. MRI is superior to CT and provides graphic images of sinus thrombosis. Occasionally MR or CT angiography may be needed to exclude sinus thrombosis or conventional venography if thrombolytic therapy is contemplated.
- Lumbar puncture: To acquire CSF sample, to measure CSF pressure and establish presence of raised pressure. At lumbar puncture the opening pressure is greater than 200 mm cerebrospinal fluid. In simple obesity the cerebrospinal fluid pressure may be as high as 250 mm; therefore the diagnostic significance of cerebrospinal fluid pressure must therefore be correlated with the clinical picture. In the few patients whose cerebrospinal fluid pressure is equivocal, continuous monitoring may demonstrate intermittent peaks of raised pressure.
- Cerebrospinal fluid analysis: The composition of the cerebrospinal fluid is entirely normal, and the presence of white cells or a raised protein concentration cast serious doubt on the diagnosis. CSF is analyzed for white blood cell and differential counts, red blood cell count, glucose, total protein, quantitative protein electrophoresis, microbial microscopy and culture for aerobic bacteria and acid-fast bacilli, cytology, cryptococcal antigens, and syphilis markers.
- Blood analysis: Complete blood count, serum iron and iron-binding capacity, erythrocyte sedimentation rate, procoagulant profile (in patients with a previous history of thrombosis or MRI evidence of dural venous sinus occlusion on MRI), antinuclear antigen (ANA) profile (e.g. anti-dsDNA and anti-ssDNA), Lyme screening test if the history is suggestive.
Visual Field Test
- Central Scotoma
A bedside ocular examination showed 20/100 in both eyes while using glasses; no visual field cuts or obvious central scotoma was present. The patient was alert and oriented to time and place. [mdedge.com]
Central scotomas, inferior nasal defects, and peripheral constriction are the next most common field defects. 28 It is still unclear which factors predispose to permanent visual loss. [dx.doi.org]
Treatment
Weight loss is strongly recommended with exercise regime and diet management.
Pharmacologic therapy [9]:
- Acetazolamide and furosemide
- Amitriptyline or propranolol for the prophylaxis of headache
- Corticosteroids are added in case of inflammatory etiology
Surgical approach [10]:
- If visual function continues to deteriorate, optic nerve sheath fenestration (decompression), lumboperitoneal or ventriculoperitoneal shunts to divert cerebrospinal fluid and intracranial venous sinus stenting may be attempted.
Prognosis
Idiopathic intracranial hypertension does not increase the mortality risk. The papilledema may lead to irreversible optic neuropathy with accompanying constriction of the visual field and loss of color vision. Prolonged papilledema can adversely affect the central visual acuity as well. Timely diagnosis and treatment can preserve vision [7].
Etiology
In the majority of patients with idiopathic intracranial hypertension, no cause can be identified. The most commonly affected patients are obese young women. A higher body mass indexes (BMIs) and recent weight gain is associated with the increased risk, but the causative mechanisms are not clear. Pregnancy and menstrual irregularity are also risk factors [2].
In absence of obesity, other risk factors associated with idiopathic intracranial hypertension are:
- Drugs: Exposure or withdrawal of certain exogenous substances, like corticosteroids, vitamin A (> 100,000 U/day)/retinoic acid, antibiotics, carbidopa, levodopa, amiodarone, indomethacin, levonorgestrel implants, oral contraceptives, cyclosporine, danazol, growth hormone, lithium, and phenytoin.
- Systemic diseases: Anemia, chronic respiratory insufficiency, hypertension, multiple sclerosis, Lyme disease, psittacosis, chronic renal disease, thrombocytopenic purpura, sarcoidosis, systemic lupus erythematosus and Reye syndrome.
- Disruption of cerebral venous flow: An impaired absorption of cerebrospinal fluid (CSF) may result from any compression of cerebral veins (extravascular tumors, secondary thrombosis due to coagulopathy) or a venous flow anomaly.
- Preceding minor head injury has shown some association.
- It has been suggested that an empty sella may be associated with about 4 % of cases. There is raised intracranial pressure in combination with incompetence of the diaphragm sellae. Clinical hypopituitarism does not occur, but occasionally the empty sella may harbor a prolactinoma [3].
Epidemiology
The incidence of idiopathic intracranial hypertension in the United States has been estimated to range from 0.9 to 1.0 per 100,000 in the general population. The female preponderance over males ranges from 3:1 to 8:1. The incidence in women is 1.6-3.5 per 100,000 overall, with an incidence of 7.9-20 per 100,000 in overweight women of childbearing age (17 to 44 years). Very rarely, it is familial and may occur in more than one generation. Although men have a lower incidence, they are twice as likely as women to lose visual function as a result of papilledema [4].
Pathophysiology
The mechanism by which intracranial pressure rises is poorly understood and the contribution of various factors controversial. Since the intracranial contents are housed in a rigid container, an increase in cerebrospinal fluid pressure in theory may result from an increase in blood volume, swelling of the brain parenchyma, or an increase in the cerebrospinal fluid volume due to overproduction or malabsorption. However, there is little evidence to suggest that increased blood volume or cerebrospinal fluid production have any causative role [5].
Although idiopathic intracranial hypertension occurs more in overweight women, the role of obesity is not clear. In some cases, a familial link between obesity and idiopathic intracranial hypertension has been documented. Obesity may increase intraabdominal pressure leading to raised cardiac filling pressures. This may result in impeded venous return from the brain [6]. The increased intracranial pressure interrupts the axoplasmic flow of the optic nerves giving rise to papilledema which may lead to irreversible optic neuropathy.
Prevention
Obesity is strongly correlated to idiopathic intracranial hypertension and therefore, weight management can contribute to prevention of this condition in many people. A high index of suspicion in overweight women and pregnant women complaining of visual disturbance is important for timely diagnosis and management.
Summary
Idiopathic intracranial hypertension (IIH), also known as pseudotumor cerebri or benign intracranial hypertension (BIH), is a syndrome of raised intracranial pressure occurring in the absence of an intracranial mass lesion or enlargement of the cerebral ventricles due to hydrocephalus. The condition occurs predominantly in obese women of childbearing age. The chronically elevated intracranial pressure leads to symptoms of headache and visual loss, with papilledema, which may lead to progressive optic atrophy and blindness [1]. It was previously called benign intracranial hypertension but the term is not preferred anymore because of the significant morbidity associated with the condition.
Patient Information
Definition: Idiopathic intracranial hypertension, also known as pseudotumor cerebri, is a condition in which the pressure of the fluid inside the skull is increased leading to damage to the optic nerves.
Cause: The cause is unknown, however, it occurs more in overweight women, pregnancy, and is associated with deficiency and excess of vitamin A, and some other drugs, inflammatory conditions and infectious diseases.
Symptoms: Headache, nausea, washed out vision with loss of vividness of colors and transient obscuration of vision is common. Headache may be mild to severe, and may increase with bending or coughing.
Diagnosis: Vision is tested and the presence of increased cerebrospinal fluid pressure is established by examining the optic nerve at the back of the eye with an instrument called ophthalmoscope and by examining the fluid pressure with a needle inserted in the lower part of the spine in the back.
Treatment and follow-up: Weight reduction is an important aspect of treatment of this condition. Medications are given to reduce the intracranial pressure. If the raised pressure does not respond to medication and the optic nerve is in danger of permanent damage, surgery may be done to reduce the pressure in the skull and within the optic nerve.
References
- Wall M. Idiopathic intracranial hypertension (pseudotumor cerebri). Curr Neurol Neurosci Rep. Mar 2008;8(2):87-93.
- Friedman DI, Jacobson DM. Idiopathic intracranial hypertension. J Neuroophthalmol. Jun 2004; 24(2):138-45.
- Degnan AJ, Levy LM. Pseudotumor cerebri: brief review of clinical syndrome and imaging findings. AJNR Am J Neuroradiol. 2011; 32(11):1986-93.
- Radhakrishnan K, Ahlskog JE, Cross SA, Kurland LT, O'Fallon WM. Idiopathic intracranial hypertension (pseudotumor cerebri). Descriptive epidemiology in Rochester, Minn, 1976 to 1990. Arch Neurol. Jan 1993; 50(1):78-80.
- Ireland B, Corbett JJ, Wallace RB. The search for causes of idiopathic intracranial hypertension. A preliminary case-control study. Arch Neurol. 1990; 47:315.
- Increased intra-abdominal pressure and cardiac filling pressures in obesity-associated pseudotumor cerebri. Neurology. 1997; 49(2):507.
- Rowe FJ, Sarkies NJ. Visual outcome in a prospective study of idiopathic intracranial hypertension. Arch Ophthalmol 1999; 117:1571.
- Giuseffi V, Wall M, Siegel PZ, Rojas PB. Symptoms and disease associations in idiopathic intracranial hypertension (pseudotumor cerebri): a case-control study. Neurology 1991; 41:239.
- Johnson LN, Krohel GB, Madsen RW, March GA Jr. The role of weight loss and acetazolamide in the treatment of idiopathic intracranial hypertension (pseudotumor cerebri). Ophthalmology. 1998; 105:2313.
- Feldon SE. Visual outcomes comparing surgical techniques for management of severe idiopathic intracranial hypertension. Neurosurg Focus 2007; 23:E6.