Idiopathic intracranial hypertension

Modified Dandy criteria[36]Smith JL. Whence pseudotumor cerebri? J Clin Neuroophthalmol. 1985 Mar;5(1):55-6. http://www.ncbi.nlm.nih.gov/pubmed/3156890?tool=bestpractice.com [37]Frisen L. Swelling of the optic nerve head: a staging scheme. J Neurol Neurosurg Psychiatry. 1982 Jan;45(1):13-8. https://www.ncbi.nlm.nih.gov/labs/pmc/articles/PMC491259 http://www.ncbi.nlm.nih.gov/pubmed/7062066?tool=bestpractice.com

• Signs and symptoms of elevated intracranial pressure.

• Absence of localizing findings on neurologic exam.

• Absence of deformity, displacement, or obstruction of the ventricular system, and otherwise normal neurodiagnostic studies, except for increased cerebrospinal fluid pressure (>250 mm H2O) in obese patients. Signs of increased intracranial pressure such as empty sella, venous stenoses, and globe flattening may be present with neuroimaging.

• Awake and alert patient.

• No other causes of increased intracranial pressure present.

Frisén scale[37]Frisen L. Swelling of the optic nerve head: a staging scheme. J Neurol Neurosurg Psychiatry. 1982 Jan;45(1):13-8. https://www.ncbi.nlm.nih.gov/labs/pmc/articles/PMC491259 http://www.ncbi.nlm.nih.gov/pubmed/7062066?tool=bestpractice.com [44]Scott CJ, Kardon RH, Lee AG, et al. Diagnosis and grading of papilledema in patients with raised intracranial pressure using optical coherence tomography vs clinical expert assessment using a clinical staging scale. Arch Ophthalmol. 2010 Jun;128(6):705-11. http://www.ncbi.nlm.nih.gov/pubmed/20547947?tool=bestpractice.com

Details of the Modified Frisén Scale to show stages of papilledema. Primary features (major findings) for each stage are denoted by an asterisk.

Stage 0: normal optic disk

• A. Prominence of the retinal nerve fiber layer at the nasal, superior, and inferior poles in inverse proportion to disk diameter

• B. Radial nerve fiber layer striations, without tortuosity.

Stage I: [Figure caption and citation for the preceding image starts]: Frisén stage IFrom the personal collection of Dr M. Wall; used with permission [Citation ends].

• *A. C-shaped halo that is subtle and grayish with a temporal gap; obscures underlying retinal details

• B. Disruption of the normal striated arrangement in the radial nerve fiber layer

• C. Temporal disk margin normal.

Stage II: [Figure caption and citation for the preceding image starts]: Frisén stage IIFrom the personal collection of Dr M. Wall; used with permission [Citation ends].

• *A. Circumferential halo

• B. Elevation - nasal border

• C. No major vessel obscuration.

Stage III: [Figure caption and citation for the preceding image starts]: Frisén stage IIIFrom the personal collection of Dr M. Wall; used with permission [Citation ends].

• *A. Obscuration of one or more segments of major blood vessels leaving disk

• B. Circumferential halo

• C. Elevation - all borders

• D. Halo - irregular outer fringe with fingerlike extensions.

Stage IV: [Figure caption and citation for the preceding image starts]: Frisén stage IVFrom the personal collection of Dr M. Wall; used with permission [Citation ends].

• *A. Total obscuration of a segment of a major blood vessel on the disk

• B. Elevation - whole nerve head, including the cup

• C. Border obscuration - complete

• D. Halo - complete.

Stage V: [Figure caption and citation for the preceding image starts]: Frisén stage VFrom the personal collection of Dr M. Wall; used with permission [Citation ends].

• *A. Obscuration of all vessels both on the disk and leaving the disk.