GENERAL NEUROLOGY
Papilledema
David Goldemund M.D.
Updated on 12/07/2024, published on 27/05/2024
Updated on 12/07/2024, published on 27/05/2024
Introduction
Epidemiology
Definition
The term “inflammatory cerebral amyloid angiopathy” can be used as an umbrella term encompassing two subtypes: cerebral amyloid angiopathy-related inflammation and amyloid β-related angiitis 2,6. However, many authors interchange the terms “cerebral amyloid angiopathy-related inflammation” and “inflammatory cerebral amyloid angiopathy,” either encompassing of amyloid β-related angiitis 8 or in distinction to it 3. Still others refer to only cerebral amyloid angiopathy-related inflammation alone 1,4,5,10 or amyloid β-related angiitis alone 7 without mention of the other.
Atrial fibrillation (AF or Afib)
→ see separate chapter
Etiopathogenesis
Ophthalmologic Findings
Ophthalmologic Findings
Ophthalmologic Findings
Clinical Presentation
Diagnostic evaluation
Differential diagnosis
Management
Therapy
Prognosis
Foster-Kennedy Syndrome (FKS)
- characterized by anosmia and visual loss (central scotoma), which may be unilateral or bilateral depending on the stage of the disease
- it is defined by compressive optic nerve damage (atrophy) in one eye and contralateral papilledema, resulting from increased intracranial pressure secondary to an intracranial space-occupying lesion
- there are typically three types of FKS
- type 1 – the most common form with optic atrophy in the ipsilateral eye and papilledema in the contralateral eye
- type 2 – bilateral papilledema and unilateral optic atrophy
- type 3 – bilateral papilledema progressing to bilateral optic atrophy
- the prognosis for papilledema varies depending on the underlying cause and duration of the edema
- timely intervention can lead to resolution; delayed treatment may result in permanent visual impairment
- závratě a synkopy (> 50%)
- ischemické CMP
- ICH (v ruptury důsledku aneuryzmat)
- zřídka poruchy vizu (poruchy ZP, amaurosis, retinální hemoragie)
- sekundární hypertenze (z postižení renálních arterií)
- diagnostické je oslabení pulsu (“bezpulsová nemoc“), rozdíl na HKK > 20mm Hg
- 98% pacientů má chybějící puls na alespoň jedné končetině
- Raynaudův fenomén
- končetinové klaudikace
- aortální regurgitace (20-25%)
- hypertensive arteriolopathy is the most common cause of intracerebral hemorrhage
- the relative risk of ICH in a patient with arterial hypertension compared to an individual without hypertension is approximately 4
- hypertension leads to bleeding by two mechanisms:
- rupture of an artery affected by chronic hypertension
- an acute or subacute severe hypertension leading to rupture of a previously unaffected artery (malignant hypertension)
- typical localization: basal ganglia, thalamus, cerebellum, pons
- a secondary propagation of hematoma into the ventricles (hemocephalus) or SA space is possible
- a secondary propagation of hematoma into the ventricles (hemocephalus) or SA space is possible
- hypertension leads to hypertrophy and degeneration of the media of small arteries (lipohyalinosis, fibrinoid necrosis)
- the findings suggestive of a hypertensive etiology:
- history of hypertension
- typical ICH localization
- absence of any other apparent cause of bleeding
- left ventricular hypertrophy
- leukoaraiosis on CT scan or MRI
- hypertensive retinopathy
- high blood pressure on admission is not a conclusive indicator of hypertensive disease; it can be a consequence of a stress reaction and intracranial hypertension
Imunosupresiva – cytostatika
- cca 50-70% pacientů vyžaduje doplňující léčbu imunosupresivy
- u méně agresivních forem:
- azathioprin (IMURAN) 1-2 mg/kg/den
- mykofenolat (CELLCEPT)
- azathioprin (IMURAN) 1-2 mg/kg/den
- u agresivních forem:
- metotrexát 0.15-3 mg/kg/den
- cyklofosfamid (ENDOXAN) 2mg/kg/den
- metotrexát 0.15-3 mg/kg/den
Nová imunosupresiva [Mekinian, 2015]
-
- monoklonální protilátka proti receptoru pro IL 6 – tocilizumab (ROACTEMRA)
- TNF alfa blokátor – u rezistentních stavů
- monoklonální protilátka proti receptoru pro IL 6 – tocilizumab (ROACTEMRA)
- compensate blood pressure (BP) in all ICH patients, start as soon as possible after bleeding
- combine pharmacological and non-pharmacological approaches
- target BP: < 130/80 mm Hg
- reduce salt uptake
- avoid smoking, alcohol and drug abuse
- treat sleep apnea if present
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