Pseudotumor Cerebri, also called idiopathic intracranial hypertension, is a medical condition characterized by increased pressure within the skull (intracranial pressure). If left untreated, the condition can progress and potentially cause permanent vision loss. Medical malpractice occurs when a healthcare provider fails to timely diagnose this condition or provide the appropriate treatment to reduce pressure in the skull. There is litigation involving the Mirena IUD and Pseudotumor Cerebri.What causes Pseudotumor Cerebri?
The human brain is protected by a layer of cerebrospinal fluid. This fluid is constantly circulating through a network of venous channels called the dural venous sinuses. Since there is very little space in these channels, it is critical that the production of cerebrospinal fluid equals the rate of absorption or removal. When it does not, the balance is disrupted, and the intracranial pressure increases. Over time, this increase in intracranial pressure puts pressure on the optic nerve located on the underside of the brain causing the patient to lose their vision. At first, the patient may just experience blurry vision or loss of peripheral vision. However, if left untreated, the condition can quickly progress to the point where the patient loses vision completely.Who is at risk for developing Pseudotumor Cerebri?
Research has shown that certain factors put an individual at higher danger of developing idiopathic intracranial hypertension. Those factors include:
- Obesity (especially recent weight gain in women)
- Under the age of 44 (usually late 20’s early 30’s)
- Menstrual irregularity
- Adrenal insufficiency
- Cushing disease
- Certain medications (such as cimetidine, corticosteroids, danazol, isotretinoin (Accutane), levothyroxine, lithium, minocycline, nalidixic acid, nitrofurantoin, tamoxifen, tetracycline, trimethoprimsulfamethoxazole, vitamin A, and human growth hormone)
- Medical conditions (such as chronic renal failure and systemic lupus erythematosus)
Pseudotumor Cerebri is diagnosed based upon the patient’s symptoms, physical examination (including a fundoscopic examination), and diagnostic testing.
a. Signs and Symptoms
Typically patients with Pseudotumor Cerebri exhibit symptoms of increased intracranial pressure. This includes headaches, tinnitus, double vision, and uncommonly, radiculopathy in the upper extremities.
Also, nearly all patients with Pseudotumor Cerebri present with papilledema, optic disc swelling caused by increased intracranial pressure. The symptoms of papilledema include dimming or blackout vision in one or both eyes, progressive vision loss of peripheral vision in one or both eyes, loss of central vision, loss of color vision, and blurring of vision. Not all of these symptoms have to be present for papilledema to exist.
b. Physical Examination
A typical physical examination includes the uses of a fundoscope to check for papilledema. If papilledema is present, the optic disc will look enlarged with blurred margins. Venous engorgement may be seen. There may also be a loss of venous pulsations and flame hemorrhages in the area adjacent to the optic disc. Sometimes red lines are visualized extending from the area of the optic disc.
A computerized visual fields test may be performed to identify blind spots in each eye. In patients with Pseudotumor Cerebri, there may be enlargement of the normal blind spot.
When the optic nerve is severely damaged, the patient may have trouble reading an eye chart.
Occasionally, an ocular motility test will reveal a limited and abnormal movement of one or both of the eyes resulting from increased intracranial pressure.
c. Diagnostic Studies
The most common diagnostic test used to visualize the optic nerve is magnetic resonance imaging (MRI). This test uses a giant magnet to excite water molecules in the soft tissues of the brain. MRI is particularly sensitive for ruling out other possible causes of vision loss such as tumors, hydrocephalus, and inflammatory disease. Common findings in patients with Pseudotumor Cerebri include flattened posterior globes, compressed and inflamed optic nerves, changes in the size of the ventricles, and/or an empty sella. If any of these findings are present, this may be evidence of Pseudotumor Cerebri.
Occasionally, an MR venography may be used to visualize narrowing of the dural venous sinuses, which is a typical feature of Pseudotumor Cerebri.
Another test commonly used to diagnose Pseudotumor Cerebri is a lumbar puncture (“spinal tap”). This test is performed by inserting a small needle into the spine to measure the pressure of the cerebrospinal fluid. In patients with Pseudotumor Cerebri, the opening pressure is elevated but the cells of the cerebrospinal fluid are normal, and there is no evidence of bacterial or viral infection.Treatment options for Pseudotumor Cerebri
The primary goal in treating Pseudotumor Cerebri is reducing the pressure in the skull and preventing further vision loss. If caught in its early stages, Pseudotumor Cerebri can be successfully treated with medications such as acetazolamide (Diamox), topiramate (Topomax), zonisamide (Zonegran), and furosemide (Lasix). If the condition is severe, a shunt or drain may need to be surgically placed in the skull or spine to improve the flow of the cerebrospinal fluid and reduce the pressure in the skull. In some cases, a procedure call Optic Nerve Sheath Fenestration may be performed to help prevent visual loss by relieving pressure on the optic nerve.When is the failure to diagnose or treat medical malpractice?
Pseudotumor Cerebri is a far-reaching medical condition that, if caught early, can be successfully treated before the patient experiences permanent vision loss. Medical malpractice can occur if the physician fails to recognize the signs and symptoms, fails to conduct a proper physical examination, fails to perform a lumbar puncture, fails to order the correct diagnostic studies, fails to timely diagnose the condition, and fails to adequately treat the condition.
Many times patients with Pseudotumor Cerebri do not understand why they are losing their vision, and the first doctor they encounter is a primary care doctor, an urgent care doctor, or an emergency room doctor. It is important to note that each of these physicians has been trained to conduct a fundoscopic examination, which, if Pseudotumor Cerebri is present, should reveal evidence of papilledema. It would be a breach of the standard of care if the physician identified the condition, but failed to refer the patient to a specialist such as an ophthalmologist, neuro-ophthalmologist, or a neurologist that can treat the condition.Sample Settlements and Verdicts
Below are some sample verdicts from around the country in Pseudotumor Cerebri cases. These verdicts are interesting and illustrative for attorneys trying to figure out how juries value these cases when they believe the doctor made a mistake.
Please note that the value of a case depends on many factors making it impossible to assume the result in one case is predictive of the result in another. In reality, every case is unique and different, and each case presents unique challenges.
Some of these cases are 18 years old. Why? Because there are not a lot of these cases going to trial.
- 2011, Massachusetts Settlement: $1,400,000. A woman suffered loss of vision due to Pseudotumor Cerebri. She alleged that the medical clinic personnel failed to perform appropriate testing and failed to timely refer her for treatment. The case settled before trial for $1,400,000.
- 2002, Ohio Verdict: $8,600,000. In January of 1997, the Plaintiff began experiencing severe headaches and loss of peripheral vision. She went to see her physician who diagnosed her with Pseudotumor Cerebri but failed to refer her timely for surgery. As a result, the Plaintiff ultimately lost her peripheral vision. At trial, the jury returned a verdict for $8,600,000.
- 1991, District of Columbia Verdict: $4,000,000. The Plaintiff presented to her internist complaining of headaches and loss of vision. Her internist correctly diagnosed her with Pseudotumor Cerebri and referred to a neurologist. The neurologist told the patient her condition was stable and did not provide any treatment. Five months later, the Plaintiff completely lost her vision. At trial, the jury returned a verdict for $4,000,000.
- 1999, New Jersey Verdict: $1,475,000. A 20-year-old woman presented to the emergency room with complaints of headaches for 2-3 weeks and progressively blurred vision for 2-3 days. The emergency room physician conducted a fundoscopic examination and noted papilledema but did not make a differential diagnosis of Pseudotumor Cerebri. After being referred to a neurologist, the neurologist failed to confirm the diagnosis and did not recommend treatment or surgery. As a result, the young woman suffered permanent vision loss. The case was tried before a jury in Essex County, New Jersey, who returned a verdict of $1,475,000.
- 1998, Pennsylvania Settlement: $450,000. A 53-year-old housewife is blinded by Pseudotumor Cerebri. The victim brings a lawsuit alleging that her ophthalmologist should have diagnosed the condition. The case settled in no small measure because the victim died shortly before trial, effectively destroying the claim for all of the future pain and suffering and medical bills and costs associated with her condition.
- 1998, Pennsylvania Verdict: $5,000,000. A 35-year-old man went to his neurologist complaining of headaches and vision problem. The neurologist correctly diagnosed him with Pseudotumor Cerebri. However, the man alleged the neurologist failed to properly refer him to a neuro-ophthalmologist who could treat his condition with surgery to alleviate the intracranial pressure. The lack of treatment caused the man to suffer permanent vision loss. The jury returned a verdict of $5,000,000.
If you or someone you love has suffered as the result of failure to diagnose or treat Pseudotumor Cerebri or any other medical condition, call 800-553-8082 or get a free medical malpractice consultation online.More Information