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Pseudotumor cerebri: how can music make a difference?

January 10th, 2010 · No Comments · music and the brain

Recently a friend of mine was given this diagnosis:  Pseudotumor cerebri.  She had been having terrible headaches and was experiencing increasingly blurry vision.  Today she had an MRI and a spinal tap.  Unfortunately, the spinal tap did not get any fluid so she has to have one done again on Monday.  The first thing I asked myself was whether or not music might be able to help.  Now hopefully on Monday she will at least take her iPod with her and have queued up some music that will distract her from the procedure.

There are many medical procedures that can be greatly eased simply by listening to music through headphones or on an iPod.  Think about this when you’re told that you need a certain procedure and if possible, plan the music that you want to listen to very specifically in advance.  I can program headphones for you, but you can also do it for yourself if you have time.
Papilledema is defined as disc swelling produced by increased ICP; it may be asymmetric, UL, or BL. True optic disc swelling or edema can be a very ominous sign.  Acutely, the vision, color vision, and pupillary responses are normal, but the blind spot is increased on visual field testing. Chronic forms lead to loss of vision and loss of visual fields. Fortunately, most perceived optic disc swelling is a manifestation of a congenital optic disc variation.

Differential Diagnosis

Pseudotumor cerebri

–Other symptoms: Headache, nausea, and vomiting all worse in morning, transient visual obscurations, diplopia

–Diagnosis includes increased ICP, normal imaging, normal CSF

–More common in obese females

Optic neuritis

–May be associated with postviral syndromes or meningoencephalitis

–Loss of vision, pain on eye movement

–Vision usually improves within a few weeks, but not full recovery

Optic neuropathy

–Compressive: Associated with NF1 and optic nerve glioma, presents with progressive visual loss, strabismus, nystagmus, proptosis

–Infiltrative: From cancers (leukemias, lymphomas), infection, or inflammation (sarcoidosis, TB, toxocariasis, toxoplasmosis, CMV); optic disc swelling, vision loss, and hemorrhages

–Toxic/nutritional optic neuropathy: Symmetric neuropathy from nutritional deficiency (thiamine, B12), drugs (tobacco/alcohol, chloramphenicol, rifampin), toxins (lead, methanol); visual field and vision loss; may recover with treatment

–Leber optic neuropathy: Mitochondrial DNA transmission, presents late teens to middle 20s; visual field and vision loss, may spontaneously improve

Increased ICP: Idiopathic intracranial hypertension, intracranial hemorrhage, space-occupying lesion

Growth hormone supplementation

Retinal hemorrhage and loss of vision

Retinal vein occlusion

Malignant hypertension: Associated with retinal hemorrhage, exudates, and cotton wool spots

Optic neuropathy, nonarteritic or arteritic

Demyelinating disease

Infectious conditions: Toxoplasmosis, Lyme disease, Bartonella; hard exudates may be visible funduscopically

Workup and Diagnosis

History

–History of HA, nausea or vomiting, recent viral illness

–Family history of visual loss, neurologic disorder

–PMH or signs and symptoms consistent with known systemic diseases; e.g., hypertension, diabetes, thyroid disease, growth hormone therapy

–Nutritional deficiencies; exposure to toxins such as tobacco or alcohol; recent drug use; exposure to ticks and animals

Physical exam

–Visual acuity, confrontational visual fields, pupillary response, extraocular muscle movements, proptosis

–Dilated fundus evaluation

–Neurologic exam for signs and symptoms of demyelinating disease, localizing deficit

Labs

–Titers for CMV, Lyme, toxocariasis, toxoplasmosis

Radiology

–CT or MRI of the brain and orbits for suspicion of intracranial mass, mass effect or hemorrhage

Studies

–Lumbar puncture may be indicated to establish presence or absence of, or to relieve, increased intracranial pressure

Ophthalmologic consultation to rule out congenital variation to avoid unnecessary and expensive differential testing

Treatment

Condition-dependent: Treatment of underlying systemic disease is often the only treatment

Pseudotumor cerebri and other causes of intracranial hypertension: Weight loss, Diamox or Lasix, planned recumbency, LP shunt or optic nerve sheath fenestration if loss of visual function

Space-occupying lesion or hemorrhage: Neurosurgical intervention

Meningoencephalitis: IV antibiotics

Infectious optic neuropathy: Treat underlying cause and consider systemic steroids (controversial)

Optic neuritis: IV (not oral) steroids

Optic nerve glioma treatment controversial: Observation if slowly progressive, resection if only one nerve involved, radiation if chiasm involved, shunts if increased ICP

Toxic or nutritional: Stop offending toxin or supply nutritional supplementation

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