A Surge of Fulminant Idiopathic Intracranial Hypertension One Year After The Start of the COVID 19 Pandemic A case series

Authors: Bashaer Al-Dhahwani, Arnav Gupta, Danah Albreiki. The Ottawa Eye Institute.
Author Disclosure Block: B. Al-Dhahwani: None. A. Gupta: None. D. Albreiki: None.

Purpose: To report a surge of fulminant idiopathic intracranial cases after one year of lockdown due to Covid-19. To describe the characteristics , the outline of management and the final visual outcome in six cases of fulminant idiopathic intracranial hypertension. 

Study Design: Retrospective chart review 

Methods: The medical records of six patients were reviewed. All patients presented with fulminant idiopathic intracranial hypertension at the University of Ottawa, Ottawa Eye Institute from May 2021 to Nov, 2021.“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 to weeks, normal brain MRI and MR venography (or CT venogram) apart from high ICP features, and a lumbar puncture showing opening pressure more than 25 CmH2O and a normal cerebrospinal fluid composition. 

Results: Six cases with fulminant IIH were included (5 women and one man, mean age 29.5 years [range 18 to 39 years]). All were overweight. One patient was six weeks pregnant, one patient had iron-deficiency anemia and one had known obstructive sleep apnea syndrome. 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 44.4 cm H2O (range 25.5 to 75 cm H2O). The patinet with the lowest opening pressure was on acetazolamide at the time of the lumbar puncture. In addition to the initial lumbar puncture, medical treatment included acetazolamide (2 to 4 g/day) in all patients in addition to IV methylprednisolone in four patients . Surgical treatment (optic nerve sheath fenestration) was performed in all cases. The interval between the evaluation by neuroophthalmology and the surgical intervention ranged between 1 day to 3 days. 66.6% patients (4 out of 6) reported significant improvement of their visual function, and the two remaining patients (33.3%) remained stable. 

Conclusions: There is a recent surge of fulminant Idiopathic intracranial cases after one year of lockdown due to Covid-19 restrictions. The negative impact of the covid lockdown on the health and wellbeing including the recent increase in weight in a large proportion of the population is thought to play a role in this recent surge of fulminant IIH. Urgent surgery coupled with acetazolamide is recommended in these patients, and temporizing measures such as large volume lumbar punctures, lumbar drains, and IV steroids can be considered.