American Journal of Emergency Medicine (2009) 27, 376.e1376.

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Case Report
Ultrasound diagnosis of papilledema and increased intracranial pressure in pseudotumor cerebri Abstract Bedside ultrasound has been used to identify intracranial hypertension through the measurement of optic nerve sheath diameter. This case report describes the sonographic detection of papilledema and a wide optic nerve sheath in a patient with pseudotumor cerebri who presented to the Emergency Department with headache and photophobia, and in whom fundoscopy was poorly tolerated. Bedside ultrasound may represent an alternate means of assessing for papilledema when a traditional fundoscopic exam is non-diagnostic. A 43-year-old woman presented to the emergency department (ED) with a gradual onset headache for 3 months. She described the headache as dull, nonradiating, constant, and similar to her past headaches. She had associated photophobia, nausea, occasional vomiting, and blurred vision. She denied fever, recent trauma or neck stiffness. The patient's medical history was significant for pseudotumor cerebri, also known as idiopathic intracranial hypertension. Further neurologic history revealed that the patient had undergone lumbar puncture 3 years ago for similar symptoms. The patient's vital signs on presentation were as follows: blood pressure 142/76, pulse rate 93, respiratory rate 18, oral temperature 98.8F, and pulse oximetry of 99% on room air. A finger-stick glucose measurement was 104 mg/dL. The physical examination revealed a well-nourished African American woman with obvious photophobia, in moderate distress due to pain. Ophthalmic examination showed intact extraocular movements, equally round and reactive pupils with consensual accommodation and response. Visual acuity was noted to be 20/60 in both eyes. The patient was unable to tolerate fundoscopy due to her extreme photophobia. The treating emergency physician performed a bedside ocular ultrasound examination using a 10-5 MHz linear array transducer (SonoSite MicroMaxx, Bothell, Wash). Ultrasound examination of both eyes revealed a smoothly contoured hyperechoic prominence, arising from the optic disc and protruding into the posterior chamber (Fig 1). The optic nerve sheath diameter was 7.1 mm in the right eye (Fig. 2) and 6.9 mm in the left eye. Noncontrast computed tomography of
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the brain was unremarkable. Opening pressure during lumbar puncture was more than 550 mm H2O. Closing pressure was 200 mm H2O. The patient experienced significant relief and

Fig. 1 A rounded hyperechoic mass (asterisk) arising from the optic disc and protruding into the posterior chamber, consistent with papilledema.

Fig. 2 Optic nerve sheath diameter of 7.1 mm, consistent with increased intracranial pressure. Note that the measurement is performed 3.0 mm posterior to the globe.

376.e2 was discharged home after ophthalmologic and neurologic follow-up had been ensured. Chart review reveals that the patient was seen in clinic later the same week with significant improvement of her symptoms. Previous research has demonstrated that sonographic optic nerve sheath measurements appear to correlate with intracranial pressure in patients with head trauma [1] and hydrocephalus [2]. A prospective study of intensive care unit patients with head trauma suggests that an optic nerve sheath diameter of more than 5.7 mm (measured 3 mm posterior to the globe) is indicative of elevated intracranial pressure [3]. A prospective study of intensive care and ED patients with invasive intracranial pressure monitoring found that an optic nerve sheath diameter of more than 5 mm correlated with intracranial pressure greater than 20 cm H2) [4]. Our patient's increased optic nerve sheath diameter correlated with a markedly increased opening pressure during lumbar puncture and suggests that optic nerve sheath measurements may play a role in the ED management of patients with suspected pseudotumor cerebri. In addition, the ability to diagnose papilledema using bedside sonography is particularly interesting, as many nonophthalmologist clinicians do not feel confident in their ability to perform an accurate nondilated fundoscopic examination [5]. Ultrasound may provide a useful alternative means of determining the presence or absence of papilledema in a patient in whom fundoscopy cannot be adequately performed.

Case Report Michael B. Stone MD Department of Emergency Medicine SUNY Downstate Brooklyn, NY 11203, USA E-mail address: sunysono@gmail.com doi:10.1016/j.ajem.2008.08.007

References
[1] Tayal VS, Neulander M, Norton HJ, et al. Emergency department sonographic measurement of optic nerve sheath diameter to detect findings of increased intracranial pressure in adult head injury patients. Ann Emerg Med 2007;49(4):508-14 [electronic publication 2006 Sep 25]. [2] Newman WD, Hollman AS, Dutton GN, et al. Measurement of optic nerve sheath diameter by ultrasound: a means of detecting acute raised intracranial pressure in hydrocephalus. Br J Ophthalmol 2002;86 (10):1109-13. [3] Geeraerts T, Launey Y, Martin L, et al. Ultrasonography of the optic nerve sheath may be useful for detecting raised intracranial pressure after severe brain injury. Intensive Care Med 2007;33(10):1704-11 [electronic publication 2007 Aug 1]. [4] Kimberly HH, Shah S, Marill K, Noble V. Correlation of optic nerve sheath diameter with direct measurement of intracranial pressure. Acad Emerg Med 2008;15(2):201-4. [5] Wu EH, Fagan MJ, Reinert SE, Diaz JA. Self-confidence in and perceived utility of the physical examination: a comparison of medical students, residents, and faculty internists. J Gen Intern Med 2007;22 (12):1725-30 [electronic publication 2007 Oct 6].