Psuedotumor Cerebri / "intracranial hypertention"

[piratecop]

Here's one. In June I visited an eye doctor for a routine check. A rather normal practice for me prior to every flight physical for my commercial pilots lic. During the exam, he told me that my optic nerve was elevated. ???? / Could be anything from a brain tumor on down! I about fell in the floor. Needless to say, I began testing, MRI's, MRV's, blood, spinal taps, walking a straight line, etc, etc. Come to find out, I have what's called Psuedotumor Cerebri, prodominately in obese women, the male ratio 10 to 1. Have considered becoming certified to dive for quite some time. Now, I am grounded from flying and not sure if I can dive at all????
The doc's have ordered me to lose 30 lbs and have placed me on a med. called Diamox to help relieve the additional cranial fluid. The pounds are slowly coming off and the medicine is working. I am improving. Time will tell. The doctors have said to get the weight off or it will come back, also meaning I will hopefully be taken off of the Diamox as well. Now that I know the symptoms, they slowly began to take over unoticed. The symptoms are gone and I feel much better than I have in a long time. Trying to figure out if I will ever be able to dive and when. Any thoughts on the issue at hand?:depressed:

 

[cutlass]

Diamox (acetazolamide) is used to reduce production of cerebrospinal fluid (CSF) which bathes, cushions, and nourishes the brain and spinal cord. The goal is to reduce internal skull pressure; i.e. intracranial pressure or ICP. It's a drug often used in cases of acute mountain sickness (AMS).

I'm not a neuro guy but AFAIK, pseudotumor cerebri is a condition of increased ICP from an uncertain cause (idiopathic). Oh, there are several suspects for cause but no single one has yet clearly stood out. CSF is produced within the brain by a feature called the choroid plexus. CSF circulates within the skull and flows from interior brain spaces (ventricles) into the spinal column. It eventual drains into the venous blood system; either by absorbtion by the membranes surrounding the brain (the common theory) or by seeping along the cranial nerves to be picked up by the lymphatic system and thence to the venous system.

My first diving-related concern is that any drop in oxygen saturation levels or rise of CO2 levels may result in reflex dilation (enlargement) of brain blood vessels which will increase ICP. This might not be tolerated if the condition is already fragile. I'm not sure about a serious DCS hit, but any inflammatory response to CNS insult will likely elevate ICP. Since vision is at risk, I'd be very very cautious. Obviously, if you wish to dive, you should discuss it first with your doctor(s).

 

[TSandM]

You might want to PM shakeybrainsurgeon -- he's a neurosurgeon, and can probably give you much better advice than I or most other posters can.

 

[piratecop]

Thank you so much for the response back...It's been tough not having others to discuss it with since it is a rarity in males. I will try to contact shakeybrainsurgeon. Thanks again.

 

[piratecop]

Cutlass, you've definately helped as well. I don't know how your so well informed but the info. was quite helpful. Thank you so much.

 

[shakeybrainsurgeon]

The chief risk of pseudotumor cerebri (PC) is visual loss from papilledema or optic nerve swelling. HOWEVER, optic nerve swelling can be hard for some doctors to diagnose. Moreover, there are conditions like pseudopapilledema (harmless) that mimic it. The diagnosis of PC requires documentation of the level of intracranial pressure by a spinal tap done by an expert with you relaxed and with your legs in a straight out position using a large bore needle. (The typical spinal tap, in the curled fetal position in a tense patient, may give falsely high readings.)

Moreover, a new PC patient should have an eye exam by a neuro-opthlamologist using fully dilated pupils. The patient must follow with an eye expert because that's where the risk lies in such patients. I would not trust the diagnosis of optic nerve swelling or PC unless made by experts and verified using a spinal tap.

The role of obesity in PC is well known but not understood. Excessive vitamin intake, particularly A or D, can cause the condition too and should be eliminated (a normal multivitamin is not a problem, but industrial supplements can).

I agree that diving with PC may be problematic because carbon dioxide rises can raise intracranial pressure further. Moreover, diamox in and of itself affects carbon dioxide regulation. I never had a patient with PC who wanted to dive, so you would have to ask DAN about the specific recommendations in this regard. Personally, if I had a patient with PC and active optic nerve edema, I would not recommend it. IF, however, the patient were treated with a surgical shunt and their edema was resolved and they were off diamox, I would not be concerned about diving.

In my experience, most PC patients are not controlled with drugs alone but often need monthly spinal taps or shunting in addition to diamox or steroids. Again, the response to medications must be monitored by frequent eye exams and occasional lumbar puncture.

The condition will reverse with weight loss, although it usually has to be drastic (from obesity or morbid obesity back to normal BMI). The good news is that, in my experience, the condtion is self-limiting. It is usally NOT a lifetime illness, although it may last for years.

Of course, other causes of high intracranial pressure must be ruled out by MRI or CT scanning of the brain and a general medical work up.

I hope this helps.

 

[Girella]

Here's one. In June I visited an eye doctor for a routine check. A rather normal practice for me prior to every flight physical for my commercial pilots lic. During the exam, he told me that my optic nerve was elevated. ???? / Could be anything from a brain tumor on down! I about fell in the floor. Needless to say, I began testing, MRI's, MRV's, blood, spinal taps, walking a straight line, etc, etc. Come to find out, I have what's called Psuedotumor Cerebri, prodominately in obese women, the male ratio 10 to 1. Have considered becoming certified to dive for quite some time. Now, I am grounded from flying and not sure if I can dive at all????
The doc's have ordered me to lose 30 lbs and have placed me on a med. called Diamox to help relieve the additional cranial fluid. The pounds are slowly coming off and the medicine is working. I am improving. Time will tell. The doctors have said to get the weight off or it will come back, also meaning I will hopefully be taken off of the Diamox as well. Now that I know the symptoms, they slowly began to take over unoticed. The symptoms are gone and I feel much better than I have in a long time. Trying to figure out if I will ever be able to dive and when. Any thoughts on the issue at hand?:depressed:

FYI, Idiopathic intracranial Hypertension (IIH) / pseudotumor cerebri (PTC) can be treated (cured in my case) with a relatively new surgery that widens a vein in your head by inserting a stent. Try IIH + transverse sinus vein stent as keywords.

 

[DocVikingo]

Hi Girella,

Piratecop started this thread on October 10, 2008 & last signed onto the board on October 24, 2008. Given that that was about 7.5 years ago, you may wish to PM him.

Regards,

DocVikingo