Authors: Jovi Chau-Yee Wong, Anna Kabanovski, Edward A. Margolin, Jonathan A. Micieli

Author Disclosure Block: J.C. Wong: None. A. Kabanovski: None. E.A. Margolin: None. J.A. Micieli: None.

Abstract Body:

Purpose: Magnetic Resonance Venography (MRV) or Computer Tomography Venography (CTV) is routinely obtained to rule-out dural venous sinus thrombosis (DVST) in patients with papilledema, but the urgency and necessity of these tests is still debated. Our goal was to determine the utility of MRV/CTV in overweight women with incidentally discovered papilledema and patients presenting due to symptomatic intracranial hypertension (IC-HTN) to neuro-ophthalmology.

Study Design: Retrospective study of consecutive female patients with papilledema seen at tertiary neuro-ophthalmology clinics at the University of Toronto.

Methods: Female patients with papilledema were included in the study if the met the inclusion criteria of: i) age 16-50 years ii) papilledema iii) Optical coherence tomography (OCT) Retinal Nerve Fibre Layer (RNFL) thickness of greater than 100 μm iv) Body mass index (BMI) greater than 25 kg/m² based on self-reported weight and height v) MRV or CTV of the head. Exclusion criteria: personal or family history of venous thrombosis, rheumatological disease, cancer or pregnancy. Patients were divided into Group-1 (incidentally discovered papilledema) and Group-2 (sought medical attention due to symptoms of IC-HTN).

Results: 103 patients (n=45 Group-1, n=58 Group-2) were included with a final diagnosis of idiopathic intracranial hypertension (IIH; n=94), drug-induced IC-HTN (n=4), DVST (n=2), intracranial mass (n=2) and POEMS (n=1). Group-2 patients were significantly more likely to have pulsatile tinnitus (p=0.017), transient visual obscurations (p=0.007) and showed a trend for increasing headache (p=0.058). Group-2 patients had a higher lumbar puncture opening pressure (38.5 vs. 33.0, p=0.013), but there was no difference in age, BMI, OCT-RNFL thickness or mean deviation between groups. MRV/CTV revealed distal transverse sinus stenosis in 42/45 (93%) of Group-1 patients and 57/58 (98%) of Group-2 patients. DVST was initially reported in 2 Group-1 patients and 2 Group-2 patients; however, false positive results were found in both Group-1 patients after further imaging review or repeat imaging and the 2 confirmed DVST patients had significant neurological symptoms.

Conclusions: DVST is rare among overweight women with papilledema without risk factors. No patient with incidentally discovered papilledema was ultimately diagnosed with DVST and MRV/CTV may be interpreted incorrectly leading to false positive results. Therefore, there is room for clinical judgment when deciding to perform MRV/CTV in the workup in overweight women with incidentally discovered papilledema without risk factors.