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MRI Signs of Intracranial Hypertension Are Common, But Rarely Related to Papilledema

Incidentally detected signs of chronic intracranial hypertension on MRI are common, but these signals are rarely associated with papilledema, according to a prospective cross-sectional study published online on April 19 in JAMA Neurology.

Forty-nine percent of patients had one or more MRI signs of chronic intracranial hypertension, while only 2 percent had papilledema indicated onocular fundus imaging conducted concurrently with MRI, reported Benson S. Chen, MBChB, of the Emory University School of Medicine in Atlanta, Georgia, and colleagues.

“In patients with incidentally detected MRI signs of intracranial hypertension, prompt clinical assessment for signs and symptoms of intracranial hypertension, including ocular fundus examination, is preferable to systematically proceeding to lumbar puncture," they wrote.

The researchers evaluated 296 outpatients who underwent MRI at Emory Healthcare and had ocular fundus images taken at the same time. Most (63.5 percent ) were women and the median age for the cohort was 49.5 years.

The investigators used radiographic photographs from consecutive adult patients to assess MRI signs of intracranial hypertension.

About 28 percent of patients had the most common indication of a brain neoplasm, while disorders of intracranial pressure and headaches were rare (1.4 percent vs. 8.8 percent).

About 33 percent of patients had empty sella, 7.8 percent had optic nerve tortuosity, 1.4 percent had cephaloceles, 0.7 percent had scleral flattening, 15.9 percent had enlarged Meckel caves, and 10.8 percent had increased perioptic cerebrospinal fluid. Only 3 percent of patients had bilateral transverse venous sinus stenosis.

Patients with papilledema had a history of idiopathic intracranial hypertension and significantly greater body mass index along with an increased prevalence of transverse venous sinus stenosis, empty sella, and optic nerve tortuosity found on an MRI compared with patients without papilledema.

The occurrence of papilledema rose from 2.8 percent among patients with a minimum of one MRI sign of intracranial hypertension to 40 percent among patients with at least four MRI signs of intracranial hypertension.

Limitations of the study include that it was terminated early due to the COVID-19 pandemic, and 33.1 percent of the study cohort did not finish a contrast-enhanced evaluation because the protocol was designed for clinical indication on an MRI, the authors noted.

Another limitation is that all MRI assessments were done at a single outpatient imaging facility and that the findings may not represent the general population, they added. ​

“Further research is needed to determine which combination of MRI signs and clinical factors has the highest predictive value for papilledema, and such research would be useful to guide decision-making regarding patient selection for urgent assessments," the researchers concluded.


Dr. Chen disclosed receiving a fellowship from the Neurological Foundation of New Zealand.

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Chen BS, Meyer BI, Saindane AM, et al. Prevalence of incidentally detected signs of intracranial hypertension on magnetic resonance imaging and their association with papilledema. JAMA Neurol 2021; Epub 2021 Apr 19.