Idiopathic intracranial hypertension presenting with isolated unilateral facial nerve palsy: a case report

Abstract

Background Idiopathic intracranial hypertension, also known as pseudotumor cerebri, is a disorder characterized by increased intracranial pressure of unclear pathogenesis in the absence of other structural and obstructive lesions that is predominantly, although not exclusively, seen in obese women of childbearing age. Patients with idiopathic intracranial hypertension commonly present with a headache, transient visual obscurations, and intracranial noises with some cranial nerves occasionally involved, most commonly CN VI. We report idiopathic intracranial hypertension presenting with isolated complete unilateral facial nerve palsy, as the sole cranial nerve involved, which is a presentation rarely reported in the literature. Case presentation A 40-year-old Hispanic woman with a history of obesity and hypertension presented to our emergency department complaining of bifrontal headache for 3 days associated with nausea, vomiting, transient visual disturbances, and a picture of right-sided cranial nerve VII palsy. Her neurologic examination including other cranial nerves was otherwise normal, but a fundus examination revealed bilateral grade II papilledema. Imaging studies ruled out structural and obstructive lesions as possible causes of her symptoms and lumber puncture results were unremarkable except for an increased opening pressure. She was then started on prednisone and acetazolamide. Two days later, she reported a dramatic improvement in both headache and facial nerve palsy. Conclusions Idiopathic intracranial hypertension should be suspected in obese young women presenting with headache and transient visual complaints and some cranial nerve abnormalities. Idiopathic intracranial hypertension is a diagnosis of exclusion and imaging studies should always be performed to rule out other structural and obstructive lesions. In this case report, we aimed to draw attention to the possibility of idiopathic intracranial hypertension presenting with unilateral cranial nerve VII palsy as the only cranial nerve involved, which needs a high index of suspicion by clinicians. The mechanisms of cranial nerve VII palsy in idiopathic intracranial hypertension are not well understood and prompt further investigation.

Raised Intracranial Pressure (Pseudotumour Cerebri) Associated With Severe Acute Respiratory Syndrome Coronavirus 2

“…Initially, her most severe symptom was thoracic and chest pain, reflecting radicular pain, which has been described in raised ICP (8). The second case developed abducens palsies secondary to the raised ICP, and a left facial nerve palsy was also likely due to the raised ICP, which has been reported previously (9). In the context of the COVID-19 pandemic, there is a theoretical risk of infection transmission to clinicians when performing ophthalmoscopy (10).…”

Atypical idiopathic intracranial hypertension presenting as cyclic vomiting syndrome: a case report

“…The underlying pathophysiology is thought to differ in this population, compared with the classic demographic of women of childbearing age, as it is not typically associated with obesity and can present atypically, with the classic daily diffuse, non-pulsating headache exacerbated with Valsalva only found in about 37%, nausea and vomiting in only 13–52%, and transient visual deficits in only 42% [ 3 , 4 ]. Cranial neuropathies have often been reported, most commonly cranial nerve (CN) VI (abducens nerve) palsies [ 2 ], but also hemifacial spasm, CN IV (trochlear nerve) palsies, generalized ophthalmoparesis [ 11 ], and a single reported case of isolated CN VII (facial nerve) palsy [ 12 ].…”

Pseudotumor Cerebri Syndrome Complicated by Diffuse Ophthalmoparesis and Polyradiculopathy

“…1 While sixth nerve palsies are most frequently recognized, other cranial neuropathies including facial palsy have been described, albeit in isolation. 3 The mechanism by which cranial neuropathies occur in IIH is not completely understood, though is hypothesized to be secondary to pressure exerting traction forces on cranial nerves. 3 There are rare reports of ophthalmoparesis in PTCS patients with high opening pressure, which resolved after shunting.…”

“…3 The mechanism by which cranial neuropathies occur in IIH is not completely understood, though is hypothesized to be secondary to pressure exerting traction forces on cranial nerves. 3 There are rare reports of ophthalmoparesis in PTCS patients with high opening pressure, which resolved after shunting. 4 In this case, the presence of cervical polyradiculopathy limits the definitive diagnosis of PTCS according to standard criteria and suggested a possible concomitant condition.…”