Covid 19 Associated Idiopathic Intracranial Hypertension and Acute Vision loss

Abstract

Headache is a frequent complaint in COVID-19 while intracranial hypertension leading to acute vision loss is unusual. A 49-years-old female presented with persistent headache and vision loss and was found Covid 19 positive. Investigations suggested Covid 19 associated intracranial hypertension. She improved with medical management but again presented with acute vision loss. The visual loss was managed by endoscopic optic nerve fenestration surgery. She had significant recovery in vision during follow up period. Persistent headache in Covid 19 should have a high index of suspicion for idiopathic intracranial hypertension to avoid irreversible vision loss.

Background

Covid − 19 is the current health problem all over the world. Commonly, it manifests with respiratory symptoms but neuro-ophthalmic presentations have also been found. [1] Headache is one of the important clinical feature of Covid 19 however; persistent headache is also the main feature of idiopathic intracranial hypertension. Advance stage of Idiopathic intracranial hypertension causes vision loss and requires surgical intervention. Covid 19 induced intracranial hypertension and vision loss is rare. [2] We present the second case report of Covid 19 induced Idiopathic intracranial hypertension leading to vision loss and review the literature on this rare but important clinical entity.

Case Presentation

A 49-year-old lady presented in emergency medicine with persistent headache and progressive vision loss in both eyes for last 5 days. This vison loss started one day after the headache and was progressive. There was no other significant contributory history of fever, vomiting, convulsion or trauma. She turned out to be Rapid Antigen test positive and admitted in isolation ward. She had single dose of Covid 19 vaccine (Covishield) about four months back.

Patient had body mass index of 23 with normal physical examination. ENT examination didn’t find any abnormality. Ophthalmic examination found 6/36 visual acuity in both eyes with normal pupillary reactions. Retinoscopy found Frisen grade 3 papilloedema in both optic discs.

Neurology examination was also found normal. CSF tap was done for biochemical and microbiological examination. This CSF puncture for analysis improved her vision and pressure was found more than 25 cm H₂O. A possibility of intracranial hypertension was kept and managed accordingly.

Magnetic resonance imaging of brain (Fig. 1) found empty sella turcica without any other significant vascular or meningeal abnormality. Bilateral optic nerves showed tortuosity, increased thickness and ballooning. Cerebrospinal fluid pressure was more than 25cmH₂O while biochemical analysis was normal. D-dimers levels were less than 1.0ug/ml FEU while serum ferritin levels were 171.0ng/ml. The clinical history and examination, and radiology didn’t find any other cause of intracranial hypertension. Keeping this in view, diagnosis of Covid-19 induced intracranial hypertension was made. She underwent supportive management of mild Covid-19 and mannitol infusion and oral acetazolamide 250 mg twice daily. Patient showed improvement in headache and vision, and became Covid-19 RTPCR negative on fourth day of admission. She was discharged on oral medication. However; on tenth day of discharge, patient presented again with deterioration of vision. Ophthalmic examination found perception of hand movement close to face in both eyes. Fundus examination and MRI brain also had similar findings as earlier. A multidisciplinary decision for trans-nasal endoscope B/L optic nerve decompression was taken and performed under general anaesthesia. Bilateral optic canals were opened as per the standard surgical protocol. However, optic sheath fenestration led to further vision loss in the immediate post operative period. The urgent MRI scan showed edematous optic nerves bilaterally with no other abnormality (Fig. 2 and 3). Parental methyl prednisolone was started and showed progressive improvement in vision. Follow up after four weeks found favourable outcome with visual acuity of 6/12 on left side and 6/36 on right side. Patient has been kept on regular follow up. The visual acuity was 6/6 in left eye and 6/36 in right eye at the time of final follow up.

Fig. 1.

MRI showing tortuous optic nerves bilaterally

Fig. 2.

MRI in immediate post-operative period showing thickened optic sheaths right more than left

Fig. 3.

MRI in immediate postoperative period showing empty sella and normal dural sinuses

Discussion

The pathogenesis of idiopathic intracranial hypertension remains elusive although various vascular, hormonal and metabolic factors have been implicated. [3–5] It is predominantly found in young, obese, females in child bearing age.[5] Clinically presentation includes (in order of decreasing incidence) headache that increases on coughing or Valsalva manoeuvre, transient visual disturbances on bending or standing, pulsatile tinnitus, back pain, dizziness, neck pain, visual loss, cognitive disturbances, radicular pain and horizontal diplopia.[5] Fundus examination shows papilledema that warrants neuroimaging (CT/MRI with angiography) to excludes tumour or other causes of increased intracranial pressure. Neuroimaging may show empty sella, flattening of posterior aspect of orbital globe, distension of perioptic subarchnoid space, tortuous optic nerve, attenuation of cerberovenous sinuses and stenosis of transverse sinus. Normal cerebrospinal analysis with pressure more that 25 cm H₂O makes the diagnosis of idiopathic intracranial hypertension. Abducen nerve palsy is also found in IIH without papilledema. Treatment include reduction of BMI and life modification. Acetazolamide is drug of choice. Lumbar drain is required in refractory cases while acute and progressive vision loss required optic sheath fenestration although optic decompression is also sufficient as observed in our case.[6, 7] Unilateral optic nerve fenestration also lead to visual improvement in contralateral eye.

Covid 19 has challenged every speciality of the medical science. Covid 19 cause viral neurotropism, immunologic upregulation, vasodilation and vascular permeability, endothelial dysfunction, coagulopathy. These pathological mechanisms lead to neuro-opththalmic complications like causes optic neuritis, papillophlebitis, papilledema, visual disturbance associated with posterior reversible encephalopathy syndrome, and vision loss caused by stroke. [1] Covid 19 associated intracranial hypertension is unusual while just one case report on associated acute vision loss.[2, 8, 9] This is the second case report of Covid 19 induced idiopathic intracranial hypertension leading to acute vision loss. This case report emphasises on keeping a high index of suspicion of idiopathic intracranial hypertension in Covid 19 positive patients as vision loss is inevitable. Intervention without any delay leads to complete recovery of vision as observed in present case although immediate postoperative surgical complication put up some glitches in the case.

Conclusion

Persistent headache in Covid 19 shouldn’t be ignored as it may be symptom of Idiopathic intracranial hypertension which is an unusual complication of Covid 19. Early diagnosis and prompt management in such cases gives best visual outcome.

Funding Sources

None.

Declarations

Conflict of Interest

The authors have no conflicts of interest to declare.