PAPILLEDEMA

No anatomic analysis of this condition is necessary because most cases of papilledema are caused by intracranial pathology. Three notable extracranial conditions are optic neuritis, hypertension, and pseudotumor cerebri. The polycythemia and right heart failure of chronic pulmonary emphysema may combine to produce papilledema, but this is uncommon. Analysis of the intracranial causes of papilledema is performed using the mnemonic VINDICATE. V—Vascular lesions are aneurysms and arteriovenous malformations that cause subarachnoid hemorrhages. Severe hypertension may lead to an intracerebral hemorrhage or hypertensive encephalopathy, thus causing papilledema. Cerebral thrombosis and emboli rarely lead to papilledema. I—Infection is not a common cause of papilledema unless a space-occupying lesion is produced or the condition persists. Thus, a brain abscess is often associated with papilledema, whereas acute bacterial meningitis is not. Chronic cryptococcal meningitis, syphilitic meningitis, and tuberculous meningitis, in contrast, are often associated with some degree of papilledema. Viral encephalitis may occasionally be associated with papilledema. Cavernous sinus thrombosis and septic thrombosis of the other venous sinuses may produce papilledema. N—Neoplasms, primary and metastatic, are the most common cause of papilledema. D—Degenerative diseases are rarely the cause. I—Intoxication brings to mind lead encephalopathy, but other toxins and drugs rarely cause papilledema. C—Congenital malformations that cause papilledema include the aneurysms and arteriovenous malformations already mentioned plus the various types of hydrocephalus, skull deformities (oxycephaly), hemophilia (because of intracranial hemorrhages), and, occasionally, Schilder disease and other congenital encephalopathies. A—Autoimmune disorders recall lupus cerebritis and periarteritis nodosa (when associated with severe hypertension). T—Trauma does not usually produce papilledema in the early stages of concussions or epidural or subdural hematomas, but in chronic subdural hematomas it is the rule. E—Endocrine disorders bring to mind the papilledema of malignant pheochromocytomas (with hypertension) and the fact that pseudotumor cerebri occurs in obese, amenorrheic, and emotionally disturbed women.

Approach to the Diagnosis

The approach to the diagnosis of papilledema in someone without hypertension or hypertensive retinopathy must include a thorough neurologic examination and a computed tomography (CT) scan. If focal signs are present or the CT scan shows positive findings, referral to a neurosurgeon is indicated. He or she can decide if a magnetic resonance imaging (MRI) is indicated. A spinal tap is contraindicated. If there are no focal signs, it may be worthwhile to differentiate papilledema from optic neuritis by having an ophthalmologist perform a visual field examination. This may also be helpful in differentiating pseudotumor cerebri because there may be bilateral visual defects in the inferior nasal quadrants. Papilledema from increased intracranial pressure will show only an enlarged blind spot (unless there is a tumor of the optic tracts, radiations, or occipital cortex), whereas optic neuritis will show scotomata peripheral to the blind spot (disc). Appendix A will be useful for confirming the diagnosis of a specific disease.

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PARESTHESIAS, DYSESTHESIAS, AND NUMBNESS

	V	I	N	D
	Vascular	Inflammatory	Neoplasm	Degenerative
Peripheral Nerve	Causalgia Raynaud disease Buerger disease Arteriosclerosis Ischemic neuritis			Pellagra Beriberi Nutritional neuropathy
Nerve Plexus	Leriche syndrome		Pancoast tumor
Nerve Root		Tabes dorsalis Tuberculosis	Metastatic and primary tumors of the cord and spine (multiple myeloma)	Herniated disc Cervical and lumbar spondylosis
Spinal Cord	Anterior spinal artery occlusion Aortic aneurysm	Poliomyelitis Epidural abscess Tuberculosis Syphilis	Metastatic and primary tumors of the cord and spine	Spondylosis Disc disease Pernicious anemia
Brain	Cerebral embolus, thrombus, hemorrhage Carotid or basilar artery insufficiency Migraine	Neurosyphilis Encephalitis Brain abscess	Brain tumor	Senile dementia Presenile dementia

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PARESTHESIAS, DYSESTHESIAS, AND NUMBNESS

I	C	A	T	E
Intoxication	Congenital	Autoimmune	Trauma	Endocrine
		Allergic
Alcoholic neuropathy Isoniazid toxicity Lead and arsenic neuropathy	Porphyria	Infectious neuronitis Periarteritis nodosa	Trauma Hematoma Laceration Neuroma Frostbite	Tetany of hypoparathyroidism Aldosteronism
	Scalenus anticus Cervical rib	Infectious neuronitis	Contusion Laceration Fracture	Diabetic neuropathy
	Spondylolisthesis		Fracture Herniated disc
Transverse myelitis from radiation	Spina bifida Myelocele Syringomyelia	Guillain–Barré syndrome Multiple sclerosis	Fracture Herniated disc Hematoma
Alcoholism Bromism Encephalopathy Opiates, barbiturates, etc.	Atrioventricular anomalies Aneurysm Epilepsy Cerebral palsy	Lupus cerebritis Multiple sclerosis	Depressed fracture Subdural hematoma	Pituitary tumor Acromegaly

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Other Useful Tests

1. CBC (polycythemia)
2. Sedimentation rate (cerebral abscess, infection)
3. Urinalysis (renal disease associated with hypertension)
4. ANA analysis (collagen disease)
5. Blood lead level
6. Visual evoked potentials (optic neuritis)
7. Pulmonary function tests (emphysema)
8. Blood volume (polycythemia vera)
9. 24-hour blood pressure monitoring (hypertension)
10. Spinal tap when imaging study is negative (pseudotumor cerebri)

Pictures

Book Source Details

• Book Title: Differential Diagnosis in Primary Care
• Author(s): R. Douglas Collins MD, FACP
• Year of Publication: 2007
• Copyright Details: Differential Diagnosis in Primary Care, Copyright © 2007 Lippincott Williams & Wilkins.

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Copyright Details: Differential Diagnosis in Primary Care, Copyright © 2008 Williams & Wilkins.

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More About This Book: Title: Differential Diagnosis in Primary Care Authors: R. Douglas Collins MD, FACP Publisher: Lippincott Williams & Wilkins Copyright: 2007 ISBN: 0-7817-6812-8

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