Fulminant Idiopathic Intracranial Hypertension With Malignant Systemic Hypertension—A Case Report

We describe a young woman who presented with malignant systemic hypertension and fulminant idiopathic intracranial hypertension. This is a rare combination, but both diagnoses should be considered in patients with optic disc swelling in whom cerebral imaging does not suggest an alternative cause. In this case, malignant hypertension was identified and treated before the idiopathic intracranial hypertension was recognised. Visual failure was evident at presentation and prior to blood pressure manipulation. It is likely that a combination of both conditions increased the vulnerability of the optic nerve head to ischaemic damage. It is also possible that reducing blood pressure in such patients, without treating coexisting raised intracranial pressure, may compound an already compromised ciliary arterial perfusion pressure. It is possible that the secondary elevation in serum aldosterone observed in our case may contribute to the intracranial hypertension. Intracranial hypertension has been previously reported in patients with primary hyperaldosteronism and CSF aldosterone correlates with serum levels. The choroid plexus contains binding sites for mineralocorticoids, including aldosterone, and it is conceivable that raised CSF aldosterone may have an effect on CSF production, although this remains speculative.We therefore recommend careful blood pressure measurement in all patients presenting with idiopathic intracranial hypertension and advise that lumbar puncture is performed in patients with malignant hypertension with optic disc oedema, particularly in overweight young females.