Papilledema + headache
Diagnosis of exclusion
PopulationObese young women
Opening pressure>25 cm H₂O (adults)
Must excludeCVST via MRV
First-lineWeight loss + acetazolamide
Obese young woman, pulsatile tinnitus, papilledema — but exclude sinus thrombosis first.
Modified Dandy criteria + MRI signs
- Papilledema
- Normal exam (CN VI palsy allowed)
- Normal brain MRI (supportive signs only)
- Normal CSF composition
- Opening pressure >25 cm H₂O in adults
- Empty sella
- Posterior globe flattening + optic nerve sheath distension
- Transverse sinus stenosis (on MRV)
◆ Signature clue
Headache + papilledema + pulsatile tinnitus in an obese young woman with normal parenchyma → do NOT call it IIH until MRV excludes CVST (transverse/sigmoid sinus thrombosis).
Diagnosis
Modified Dandy criteria: LP opening pressure >25 cm H₂O with normal CSF. MRI/MRV shows empty sella, globe flattening, nerve sheath distension, transverse sinus stenosis — and excludes CVST.
Management
Weight loss 5–10% + acetazolamide (IIHTT) ± topiramate. Escalate to ONSF / CSF shunt / venous stenting if vision is threatened.