|Year : 2012 | Volume
| Issue : 1 | Page : 45-47
Pseudotumor cerebri in a post-mastectomy Nigerian
Dawotola A David1, Odigie I Vincent2, Yusufu M. D. Lazarus2, Jimoh O Abdullahi3, Ibinaye O Philip4, Ketiku K Kingsley5
1 Department of Radiotherapy and Oncology Centre, Ahmadu Bello University Teaching Hospital, Zaria, Nigeria
2 Breast and Endocrine Unit, Ahmadu Bello University Teaching Hospital, Zaria, Nigeria
3 Neuro-surgery Unit, Department of Surgery, Ahmadu Bello University Teaching Hospital, Zaria, Nigeria
4 Department of Radiology, Ahmadu Bello University Teaching Hospital, Zaria, Nigeria
5 Department of Radiotherapy, CMUL, Lagos, Nigeria
|Date of Web Publication||22-Sep-2012|
Dawotola A David
Department of Radiotherapy and Oncology Centre, Ahmadu Bello University Teaching Hospital, Zaria
Source of Support: None, Conflict of Interest: None
Background: Pseudotumor cerebri, commonly known as idiopathic intracranial hypertension, is a rare syndrome that manifests mainly as a consequence of raised intracranial pressure. Headache is the major presenting symptom. The diagnosis of this condition is established by exclusion, with the aid of computerized tomographic scan, magnetic resonance imaging, and examination of cerebrospinal fluid tap. We present a patient with advanced invasive ductal carcinoma that was successfully managed for pseudotumor cerebri.
Case Report: The patient was a 46-year-old female with stage III invasive ductal carcinoma of the right breast that was treated with modified radical mastectomy, radiotherapy, and combination chemotherapy. She had also taken tamoxifen for 8 months when she developed headache and persistent non-projectile vomiting. She had two episodes of generalized seizures with associated dizziness which resolved on phenobarbitone. She had no neurological deficits. Computerized tomographic scan of the brain revealed features of raised intracranial pressure, and there was no focal intracerebral or cerebellar lesion. A diagnosis of idiopathic pseudotumor cerebri was entertained using the modified Dandy Criteria. She responded well to acetazolamide and dexamethasone.
Conclusion: Pseudotumor cerebri should be considered in cancer patients presenting with raised intracranial pressure of sudden onset in the absence of clinical and radiological evidence of brain metastases. We advocate prompt therapy in patients with pseudotumor cerebri to prevent or minimize morbidity.
Keywords: Breast cancer, pseudotumor cerebri, tamoxifen, treatment
|How to cite this article:|
David DA, Vincent OI, Lazarus YM, Abdullahi JO, Philip IO, Kingsley KK. Pseudotumor cerebri in a post-mastectomy Nigerian. Arch Int Surg 2012;2:45-7
|How to cite this URL:|
David DA, Vincent OI, Lazarus YM, Abdullahi JO, Philip IO, Kingsley KK. Pseudotumor cerebri in a post-mastectomy Nigerian. Arch Int Surg [serial online] 2012 [cited 2020 Feb 21];2:45-7. Available from: http://www.archintsurg.org/text.asp?2012/2/1/45/101276
| Introduction|| |
Pseudotumor cerebri, commonly known as idiopathic intracranial hypertension (IIH), is a rare syndrome that manifests mainly as a consequence of raised intracranial pressure. Its etiology is unknown. It has been associated with various medical conditions such as obesity, ,, and administration of certain medications such as cimetidine, corticosteroids, levothyroxine, lithium, minocycline, nalidixic acid, nitrofurantoin, tamoxifen, tetracycline, and sulfonamides. ,
The annual incidence of this benign condition has been reported to vary from 0.9 to 2.2 cases per 100,000 population, occurring predominantly in females. , No age is exempt.  Headache is the major presenting symptom. Other symptoms include dizziness, nausea, and vomiting, and visual and neurological deficits. , The diagnosis of this condition is established by exclusion of other diseases that have similar symptoms with the aid of computerized tomographic (CT) scan, magnetic resonance imaging (MRI), and cerebrospinal fluid (CSF) assessment. ,,,
IIH has been described in the Western literature.  To our knowledge, this is the first report of pseudotumor cerebri from the premier Radiotherapy and Oncology Centre in Northern Nigeria.
| Case Report|| |
A 46-year-old female patient who was referred for postoperative radiotherapy after modified radical mastectomy for stage 3 invasive ductal carcinoma of the right breast. She had completed six courses of cyclical polychemotherapy consisting of cyclophosphamide, adriamycin, and 5-fluorouracil (CAF) in therapeutic doses, and she was on 20 mg tamoxifen daily.
Four weeks after the last course of chemotherapy, she was commenced on external radiotherapy to the right anterior chest wall, supraclavicular and axillary regions, using Cobalt-60 Teletherapy machine.
After receiving 20 Gy out of the total prescribed dose of 50 Gy in 5 weeks, she developed headache and persistent non-projectile vomiting. There were no focal neurological deficits. Her blood pressure was 120/70 mmHg, Body Mass Index (BMI) was 20.3 kg/m 2 , visual acuity was preserved, and there was no papilledema. Routine laboratory tests, which included complete blood counts, serum electrolytes and urea, liver function tests, and random blood sugar, were all normal.
Radiotherapy was suspended. She had two episodes of generalized seizures with associated dizziness which resolved on phenobarbitone. Urgent CT scan of the brain revealed edema of the brain with compression of the body of the lateral ventricles. There was no focal intracerebral or cerebellar lesion [Figure 1]. In view of the patient's alertness, symptoms of ICP (headache, vomiting), absence of focal brain lesion or neurological deficit, a diagnosis of idiopathic pseudotumor cerebri was made using the modified Dandy Criteria [Table 1].
|Table 1: Modified Dandy Criteria for the diagnosis of idiopathic intracranial hypertension,|
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|Figure 1: Brain CT scan showing compression of body of lateral ventricles and effacement of the sulci with diffuse edema. No focal intracerebral or cerebellar mass is seen|
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She was commenced on parenteral dexamethasone and acetazolamide. Her recovery was uneventful and her symptoms completely subsided in 10 days. She went on to complete her radiotherapy and has remained well and asymptomatic at 7 months of follow-up.
| Discussion|| |
Pseudotumor cerebri, otherwise known as IIH, is a disorder of unknown etiology. There is paucity of literature on its occurence in the guinea savannah. Literature search revealed a case of IIH in a young girl in the south of Nigeria.  Historically, IIH was first described by Quinkne in the late 19 th century.  It has been associated with various medical conditions and medications, such as pregnancy, obesity, and l-thyroxine. ,, Our patient did not present with any of these clinical features.
Symptoms of IIH often mimic brain metastasis, with headache being the most common presentation in over 90% of patients.  Other symptoms may include dizziness, tinnitus, nausea, vomiting, and seizure, as seen in our patient. Papilledema is often diagnostic of this condition in the setting of IIH. However, the index patient had no papilledema probably because of the short duration of time between diagnosis and initiation of therapy. It is of clinical note that IIH without papilledema had also been reported in the literature. 
The criteria for the diagnosis of IIH are based on the modified Dandy Criteria , [Table 1]. A diagnosis of IIH in ourpatient was made because the modified Dandy Criteria for the diagnosis of IIH were fullfilled. ,, In this patient, no causative or associated factor could be demonstrated except administration of tamoxifen, an anti-estrogen. Tamoxifen has been associated with IIH and may be a contributory cause in this patient. ,
Brain CT and MRI are valuable tools in the diagnosis of IIH because brain metastases in patients with extracranial neoplasms are easily excluded by their use.  Medical treatment (nonoperative) with acetazolamide and parenteral steroid was successful in the patient, as in other reports, recovery was complete with no residual morbidity. ,
It is the authors' opinion that pseudotumor cerebri should be a differential diagnosis in cancer patients presenting with raised intracranial pressure of sudden onset in the absence of brain metastases. We also advocate prompt therapy in patients with IIH to prevent or minimize morbidity.
| References|| |
|1.||Viera DS, Marsruha MR, Goncalves AL, Zukerman E, Senne Soares CA, Naffah-Mazzacoratti Mda G, et al. Idiopathic intracranial hypertension with and without papilloedema in consecutive series of patients with chronic migraine. Cephalagia 2008;28:609-13. |
|2.||Binder DK, Harton JC, Lawton MT, McDermott MW. Idiopathic intracranial hypertension. Neurosurgery 2004;54:538-51. |
|3.||Johnson I, Paterson A. Benign intracranial hypertension, diagnosis and prognosis. Brian 1979;97:289-300. |
|4.||Radhakrishnan K, Ahlskog JE, Garrity JA, Kurland LT. Idiopathic intracranial hypertension. Mayo Clin Proc 1994;69:169-80. |
|5.||Ramadan NM. Headache caused by raised intracranial pressure and intracranial hypertension. Curr Opin Neurol 1996;9:214-8. |
|6.||Radharrishnan K, Thacker AK, Bohlaga NH, Maloo JC, Gerryo SE. Epidemiology of idiopathic intracranial hypertension: A prospective and case-control study. J Neurol Sci 1993;116:18- 28. |
|7.||Duncan FJ, Corbett JJ, Wall M. The incidence of pseudotumour cerebri. Population studies in Iowa and Louisiana. Arch Neurol 1988;45:875-7. |
|8.||Bassan H, Beckner L, Stolovitch C, Kesler A. Asymptomatic idiopathic intracranial hypertension in children. Acta Neurol Scand 2008;118:251-5. |
|9.||Snyder H, Robinson K, Shah D, Brennan R, Handrigan M. Signs and symptoms of patient with brain tumors presenting to the emergency department. J Emerg Med 1993;11:253-8. |
|10.||Cinciripini GS, Donahue S, Borchert MS. Idiopathic intracranial hypertension in perpubertal pediatric patients: characteristics, treatment, and outcome. Am J Ophthalmol 1999;127:178-82. |
|11.||Weisberg LA, and Nice CN. Computed tomographic evaluation of increased intracranial pressure. Radiology 1977;122:133-6. |
|12.||Suzuki H, Takanashi J, Kobayashi K, Nagasawa K, Tashima K, Kohno Y. MRI imaging of idiopathic intracranial hypertension. Am J Neuroradiol 2001;22:196-9. |
|13.||Brodsky MC, Vaphiades M. Magnetic resonance imaging in pseudotumor cerebri. Ophthalmlogy 1998;105:1686-93. |
|14.||Schellinger PD, Meink HM, Thron A. Diagnostic accuracy of MRI compared to (contrast-enhanced Computed Tomography (CCT) in patients with brain metastases. J Neuroncol 1999;44:275-81. |
|15.||Smith JL. Whence pseudotumour cerebri? J Clin Neuro-ophthalmol 1985;5:55-6. |
|16.||Wald SL. Disorders of cerebrospinal fluid circulation and brain edema. In Neurology in Clinical Practice. 1990;2:1431- 58. |
|17.||Craig JJ, Maalholland DA, Gibson JM. Idiopathic intracranial hypertension (Pseudotumour cerebri) or benign intracranial hypertension. Ulster Med J 2001;70:31-5. |
|18.||Onwuchekwa AC, Nwankwo CN, Chapp-Jumbo EN. A 14-year-old Nigerian female with Idiopathic intracranial hypertension (Pseudotumor cerebri) or benign intracranial hypertension. Afr Health Sci 2002;2:124-6.. |
|19.||Huna-Baron R, Kupersmith MJ. idiopathic Intracranial Hypertension in pregnancy. J Neurology 2002;249:1078-81. |
|20.||Sugerman HJ, Felton WL, Sismanis A, Kellum JM, DeMaria EJ, Sugerman EL. Gastric surgery for pseudotumor cerebri Associated with severe obesity. Ann Surg 1999;229:634-40. |
|21.||Campos SP, Olitsky S. Idiopathic intracranial hypertension after L-thyroxine therapy for Acquired primary hypothyroidism. Clin Pediatr (Phila) 1995;34:334-7. |
|22.||Friedman DI. Pseudotumour cerebri presenting as headache. Expert Rev. Neurother 2008;8:397-407. |
|23.||Vierra DS, Masruha MR, Goncalves AL, Zukerman E, Senne Soares CA, Naffah-Mazzacaratti Mda MF. Idiopathic Intracranial Hypertension with or without Papilloedema in a consecutive series of patient with chronic migraine. Cephalalgia 2008;28:609-13. |
|24.||Friedman DI, Jacobson DM. Diagnostic criteria for idiopathic intracranial hypertension. Neurology 2002;59:1492-5. |
|25.||Tomsak RL, Nifferegger AS, Remler BF. Treatment of pseudotumour cerebri with Diamox (acetazolamide). J Clin Neuro-opthalmol 1988;8:93-8. |
|26.||Chansoria M, Agrawal A, Ganghoriya P, Raghu RB. Pseudotumour Cerebri with Transient Oculomotor Palsy. Indian J Pediatr 2005;72:1047-8. |