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Endgames Case Review

Progressive blurred vision in a 44 year old woman

BMJ 2018; 360 doi: https://doi.org/10.1136/bmj.k579 (Published 15 March 2018) Cite this as: BMJ 2018;360:k579
  1. Aled R Daniels, neuropathology registrar,1,
  2. Becky Hunt, radiology registrar,2,
  3. Mario Teo, consultant neurosurgeon2,
  4. Kathreena M Kurian, consultant neuropathologist2
  1. 1Department of neuropathology, Southmead Hospital, Bristol, UK
  2. 2Institute of Clinical Neurosciences, Bristol, UK
  1. Correspondence to A Daniels aleddaniels{at}gmail.com

A 44 year old woman presented to her optometrist with a 10 week history of progressive blurred vision. She had no headaches or nausea. Funduscopy showed bilateral papilloedema. Subsequent magnetic resonance imaging (MRI) of the brain (fig 1, 2, 3) revealed a large frontal durally based lesion involving the superior sagittal sinus, causing mass effect and vasogenic oedema.

Fig 1

Sagittal T1 volume post gadolinium 1 mm reconstruction showing a large, avidly enhancing, left frontal convexity extra axial mass with a broad dural base and bony hyperostosis. There is mass effect with sulcal effacement and compression of left frontal lobe and distortion of the anterior body and genu of the corpus callosum

Fig 2

Axial T1 volume post gadolinium 1 mm reconstruction

Fig 3

Coronal T1 volume post gadolinium 1 mm reconstruction

Questions

  • 1. What are the causes of bilateral papilloedema?

  • 2. What is the most likely diagnosis?

  • 3. How would you manage this patient?

Answers

1. What are the causes of bilateral papilloedema?

Short answer

Papilloedema is the term given to optic disc swelling caused by raised intracranial pressure. Causes include intracranial lesions, cerebral oedema, increased production of cerebrospinal fluid, decreased absorption of cerebrospinal fluid, obstruction of venous outflow, or idiopathic intracranial hypertension.

Discussion

Papilloedema occurs because of raised intracranial pressure being transmitted through the optic nerve sheath to the optic disc. The raised pressure disrupts axoplasmic flow within the nerve, resulting in accumulation of fluid and protein within an oedematous-appearing optic disc.1

Early changes on funduscopy include the loss of spontaneous venous pulsations, progressing to elevation of the optic disc, obliteration of the cup, and …

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