Signs of Intracranial Hypertension on MRI Not Commonly Associated With Papilledema

The study also says chronic intracranial hypertension likely does not require systematic lumbar puncture, unless papilledema is present.

Among patients undergoing brain magnetic resonance imagining (MRI), signs of intracranial hypertension are common; however, the prevalence of papilledema is rare, according to study results published in JAMA Neurology.

A team of investigators conducted a prospective cross-sectional study to determine the frequency of signs of intracranial hypertension in adult outpatients undergoing MRI and whether such symptoms were associated with papilledema. 

Following MRI, patients underwent bilateral nonmydriatic fundus photography and were assessed for headache, visual symptoms, and ocular history. Primary outcomes were the prevalence of MRI-detected signs of intracranial hypertension and the prevalence of papilledema confirmed via ocular fundus photography. 

Patients underwent unenhanced sagittal type 1-weighted and axial type 2-weighted imaging, and patients who underwent MRI with contrast were administered 0.2 mL/kg body weight intravenous gadolinium-based contrast agent prior to contrast-enhanced type 1-weighted imaging. 

Of the 388 patients screened, 296 patients (median age, 49.5 years; 63.5% women) were eligible to participate in the study. Brain neoplasm was the the most common indication for MRI (27.7%) followed by investigation of nonheadache neurologic symptoms (19.6%) and diagnosis or monitoring of multiple sclerosis, neuromyelitis optica spectrum disorder, and myelin oligodendrocyte glycoprotein-associated disease (18.9%). 

MRI signs of intracranial hypertension included empty sella, protrusion of the optic nerve head, flattening of the posterior sclera, increased perioptic cerebrospinal fluid (CSF), tortuosity of the optic nerve, enlarged Meckel caves, cephaloceles, cerebella tonsillar descent, and bilateral transverse venous sinus stenosis. 

At least 1 sign was present in 49.0% of patients: 33.1% of patients had empty sella, 15.9% of patients had enlarged Meckel caves, 10.8% of patients had increased perioptic CSF, 7.8% of patients had optic nerve tortuosity, 1.4% of patients had cephaloceles, and 0.7% of patients had scleral flattening. Of the 198 patients who received contrast, bilateral transverse venous sinus stenosis was present in 3.0% of patients. 

Upon fundus photography, only 5 patients had papilledema; 2 patients had a history of idiopathic intracranial hypertension and worsening headaches, 2 patients had glioblastoma, and 1 patient had a history of temporal lobe-onset seizures secondary to meningoencephalocele. 

Compared with patients with at least 1 sign of MRI-detected intracranial hypertension, the prevalence of papilledema increased from 2.8% to 40.0% for patients with 4 or more signs. 

“In patients with incidentally detected MRI signs of IH, prompt clinical assessment for signs and symptoms of IH, including ocular fundus examination, is preferable to systematically proceeding to lumbar puncture,” the study shows. “Further research is needed to determine which combination of MRI signs and clinical factors has the highest predictive value for papilledema, and such research would be useful to guide decision-making regarding patient selection for urgent assessments,” concluded the investigators. 

Disclosure: One study author declared affiliations with the biotech, pharmaceutical, and/or device companies. Please see the original reference for a full list of authors’ disclosures.  


Chen BS, Meyer BI, Saindane AM, et al. Prevalence of incidentally detected signs of intracranial hypertension on magnetic resonance imaging and their association with papilledema. JAMA Neurol. Published online April 19, 2021. doi:10.1001/jamaneurol.2021.0710