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August 21, 2013
Letter to the Editor

Revised diagnostic criteria for the pseudotumor cerebri syndrome in adults and children

September 24, 2013 issue
81 (13) 1159-1165

Abstract

The pseudotumor cerebri syndrome (PTCS) may be primary (idiopathic intracranial hypertension) or arise from an identifiable secondary cause. Characterization of typical neuroimaging abnormalities, clarification of normal opening pressure in children, and features distinguishing the syndrome of intracranial hypertension without papilledema from intracranial hypertension with papilledema have furthered our understanding of this disorder. We propose updated diagnostic criteria for PTCS to incorporate advances and insights into the disorder realized over the past 10 years.

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Letters to the Editor
24 January 2014
REPLY to Drs. Wall and Corbett
Denorah I Friedman, Professor, Neurology & Neurotherapeutics and Ophthalmology
Grant Liu, Philadelphia, PA, Kathleen Digre, Salt Lake City, UT

We thank Drs. Wall and Corbett for their comments. We suggest calling the syndrome, inclusive of all etiologies, the "pseudotumor cerebri syndrome" (PTCS)--a condition of increased intracranial pressure and papilledema due to all causes as long as the brain parenchyma is normal. This reflects the most common term used globally. [1] Neuro-ophthalmologists and other physicians still refer to the condition as "pseudotumor" and patients are also familiar with this name. We retained the term "idiopathic intracranial hypertension" (IIH) to refer to the specific condition that most frequently occurs in overweight women of childbearing age where no specific etiology is apparent. IIH was the term used in the previous criteria proposed by Friedman and Jacobson in 2002 [2] which has been cited almost 500 times since then. Thus, there is no conflict regarding terminology used for the IIH Treatment Trial and we are hopeful that the trial will provide us greater understanding of the pathophysiologic basis of IIH. Our recent criteria were expanded to be able to diagnose patients with the idiopathic form and those with a secondary cause. Most importantly, there are now official guidelines for children, a population that was not included in any of the previous criteria because of lack of high quality normative data for CSF pressure in this population.

To clarify the term "the Dandy Criteria," we remind readers that Dr. Dandy reported a series of cases of patients seen in the 1930s, when the only diagnostic techniques available were pneumoencephalography ("trephine and air injection") and lumbar puncture. [3] It is possible that some of his cases did not actually have IIH, as some had atypical manifestations, such as cerebrospinal fluid pleocytosis, preceding head trauma, drowsiness, and transient hemiplegia. He summarized his findings but did not propose diagnostic criteria. It should also be noted that Dr. Lawton Smith suggested the Modified Dandy Criteria, but the title of his manuscript was "Whence Pseudotumor Cerebri" and did not refer to IIH. [4] He specified an opening pressure of 200 mm CSF, which subsequent studies have shown to be too low. All previous criteria have accepted symptoms and signs. Headache and tinnitus are common and non-specific symptoms. True transient obscurations are more indicative of intracranial hypertension than another condition but may also be confused with transient visual loss occurring with migraine by clinicians who are not familiar with the description of this symptom.

The validity of diagnosing the syndrome of intracranial hypertension without papilledema has been contentious as long as we have been in the field of neuro-ophthalmology. The previous criteria do not directly address the diagnosis of IIH without papilledema, which has become pervasive in the world of headache medicine with unintended consequences. Unfortunately, allowing a diagnosis based on headache and elevated CSF pressure alone leads to a false positive and erroneous diagnoses and potentially unnecessary surgical interventions and incorrect medical treatments. Finally, the older criteria do not address the all too common scenario of an obese female patient with optic disc swelling, normal imaging, but an opening pressure of 190 mm of CSF. Most experienced clinicians would consider the measured opening pressure in this case to be falsely low, given the characteristic clinical presentation, and treat the patient as if she had elevated intracranial pressure. The newly proposed criteria allow for a "probable" diagnosis of pseudotumor cerebri syndrome in such instances.

1. The Pseudotumor Cerebri Syndrome. Johnson I, Owler B, Pickard J, eds. Cambridge University Press, New York, 2007

2. Friedman DI, Jacobson DM. Diagnostic criteria for idiopathic intracranial hypertension. Neurology 2002;59:1492-5.

3. Dandy WE. Intracranial pressure without brain tumor. Ann Surg 1937;106:492-513.

4. Smith JL. Whence pseudotumor cerebri? J Clin Neuro-ophthalmol 1985;5:55-56.

For disclosures, contact the editorial office at [email protected].

13 September 2013
Reply to Dr. De Simone et al
Deborah I Friedman, Professor of Neurology & Neurotherapeutics and Ophthalmology
Deborah I. Friedman, Dallas, TX; Grant T. Liu, Philadelphia, PA; Kathleen B. Digre, Salt Lake City, UT

We agree with De Simone et al. that LP opening pressure alone is not suitable for making a diagnosis of IIH with or without papilledema and this was one of the main reasons that the new guidelines are more stringent. The new guidelines require papilledema or a sixth nerve palsy for a definite diagnosis of pseudotumor cerebri syndrome (PTCS), and more than one neuro-image result for patients without papilledema. The old cut-off value of 200 mm of CSF was arbitrary and based on a misinterpretation of a previous study that showed values of 250 mm CSF or greater were diagnostic, those less than 200 mm CSF were normal, and values between 200-249 mm CSF were non-diagnostic. [1] Our cut-off values for opening pressure are based on this previous study in adults with an unquestionable diagnosis of PTCS, and consistent with the previous guidelines specifying an opening pressure of 250 mm CSF in adults.[2] The values for children are based on a reference range to determine normal opening pressure. Those values were confirmed in a second study showing that most children with papilledema had opening pressures above 280 mm CSF.[3,4] Diplopia is more common in patients with papilledema than without papilledema but is sometimes the initial presentation of PTCS before papilledema develops. As De Simone et al. correctly point out, the presence of transverse venous sinus stenosis as an isolated neuro-radiological finding does not appear to distinguish true IIH/PTCS from chronic primary headache; thus two other accompanying imaging findings must be present to meet the imaging criteria.

1. Corbett JJ, Mehta MP. Cerebrospinal fluid pressure in normal obese subjects and patients with pseudotumor cerebri. Neurology 1983;33:1386- 1388.

2. Friedman DI, Jacobson DM. Diagnostic criteria for idiopathic intracranial hypertension. Neurology 2002;59:1492-1495.

3. Avery RA, Shah SS, Licht DJ, et al. Reference range of cerebrospinal fluid opening pressure in children undergoing diagnostic lumbar puncture. N Engl J Med 2010;363:891-893.

4. Avery RA, Licht DJ, Shah SS, et al. CSF opening pressure in children with optic nerve head edema. Neurology 2011;76:1658-1661.

For disclosures, please contact the editorial office at [email protected].

10 January 2014
The Modified Dandy Criteria for Idiopathic Intracranial Hypertension, No Need to Fix What is not Broken
Michael Wall, Professor
Michael Wall, M.D. Iowa City, IA; James J. Corbett, M.D., Jackson, MS
Friedman et al. suggest new criteria for the diagnosis of pseudotumor cerebri syndrome and idiopathic intracranial hypertension. [1] We disagree with the need for this since the nomenclature we have used over the years and for the Idiopathic Intracranial Hypertension Treatment Trial (IIHTT), we believe, is simpler, is accurate, describes the condition, and is easily modified as new information surfaces.

Diseases or syndromes should be named for what they are "idiopathic intracranial hypertension" rather than what they are not "pseudotumor cerebri," "primary pseudotumor cerebri" or "pseudotumor cerebri syndrome (PTCS)." This was impressed on us during a visit to the National Eye Institute many years ago when we were told "we are not going to fund a pseudo anything." We do not believe there is need for the term PTCS. Secondary causes of intracranial hypertension should also be called what they are: e.g. vitamin A-induced intracranial hypertension, tetracycline-induced intracranial hypertension, steroid withdrawal-related intracranial hypertension, rather than subsuming them with the PTCS acronym . When criteria for IIH are not met and no secondary cause is found - "intracranial hypertension of unknown cause" should be used. The naming convention we propose is unambiguous; PTCS could mean any of the above diagnoses.

Regarding criteria, Walter Dandy [2] suggested requirements to separate IIH from other causes of raised intracranial pressure, in particular brain tumor, that were codified in an editorial by J. L. Smith in 1985. He called them the modified Dandy criteria (even though Dandy did not directly specify criteria for the diagnosis of IIH).[3] These modified Dandy criteria have been used successfully for many years.

We agree with our colleagues that as we learn more about IIH and secondary forms of intracranial hypertension, criteria for the diagnosis of the various causes of intracranial hypertension should be amended to more clearly separate IIH from secondary causes. We have updated the modified Dandy criteria for the IIHTT (Table). Once the results of this clinical trial are published, any treatment recommendations will apply most directly to patients that meet these criteria and not another set of criteria. We suggest that idiopathic intracranial hypertension is the most appropriate name for this disease and that the modified Dandy criteria continue to be used and updated when appropriate as they remain excellent diagnostic criteria.

Table. IIHTT modified Dandy Criteria

1. Signs and symptoms of increased intracranial pressure

2. Absence of localizing findings on neurologic examination

3. Absence of deformity, displacement, or obstruction of the ventricular system and otherwise normal neurodiagnostic studies, except for evidence of increased cerebrospinal fluid pressure (greater than 200 mm water).* Abnormal neuroimaging except for empty sella turcica, optic nerve sheath with filled out CSF spaces, and smooth-walled non flow-related venous sinus stenosis or collapse should lead to another diagnosis

4. Awake and alert

5. No other cause of increased intracranial pressure present *For CSF opening pressure of 200 to 250 mm water required at least one of the following:

-Pulse synchronous tinnitus

-VI palsy

-Frisen Grade II papilledema

-Echography for drusen negative and no other disc anomalies mimicking disc edema present

-MRV (Magnetic Resonance Venography) with lateral sinus collapse/stenosis preferably using ATECO technique

-Partially empty sella on coronal or sagittal views and optic nerve sheaths with filled out CSF spaces next to the globe on T2 weighted axial scans


.

1. Friedman DI, Liu G, Digre KB. Revised diagnostic criteria for the pseudotumor cerebri syndrome. Neurology 2013;81:1159-1165.

2. Dandy WE. Intracranial pressure without brain tumor. Ann Surg 1937;106:492-513.

3. Smith JL. Whence pseudotumor cerebri? J Clin Neuro-ophthalmol 1985;5:55-56.

For disclosures, contact the editorial office at [email protected].

2 January 2014
Re: IDIOPATHIC INTRACRANIAL HYPERTENSION: PAPILLEDEMA OR NOT? THIS IS THE QUESTION!
Deborah Friedman, Professor
Kathleen Digre MD, Salt Lake City, UT; Grant Liu MD, Philadelphia, PA

We thank Liguori et al. for their comments and appreciate that there will always be occasional exceptions to any rule. However, in our experience, patients who are diagnosed with PTCS on the basis of CSF pressure alone-without other objective findings-rarely have the disorder. We have seen devastating consequences in patients who are diagnosed incorrectly and subjected to unnecessary medications and surgical procedures that carry significant risk. The LP opening pressure is a snapshot in time, and may be influenced by the presence of cephalgia and other technical factors. The therapeutic response to CSF removal and acetazolamide are not specific to PTCS.

For disclosures, contact the editorial office at [email protected].

2 January 2014
Papilledema and CSF opening pressure below 28 cm H2O. Is it pseudotumor cerebri though?
Daniel Tibussek, Child Neurologist
Felix Distelmaier, Duesseldorf, Germany

Friedman et al. recently revised the diagnostic criteria for pseudotumor cerebri syndrome (PTCS). [1] The authors mentioned "probable PTCS" as a subgroup of PTCS. We support the clinical relevance of this subgroup, particularly in children. We previously challenged the term "upper limit" of the CSF opening pressure (OP) when propagating the diagnosis "probable idiopathic intracranial hypertension" for children with an OP even below 20 cm H2O but with clinical signs and symptoms suggestive of PTCS. [2] Here, we report a group of 11 pediatric PTCS patients with a CSF opening pressure between 21 and 27 cm H2O. This is a subgroup of patients identified in a recent nationwide survey; it represents 18% of the total number of PTCS patients discovered. [3] Friedman et al.'s revised diagnostic criteria prompted us to look for clinical information which would support the diagnosis PTCS. All 11 patients had papilledema, documented in a tertiary ophthalmology clinic in six. Five children had additional abducens nerve palsy. Three patients had a relapse as indicated by recurrence of papilledema or abducens nerve palsy. Additional symptoms were pulsatile tinnitus (n=1), vertigo (n=1), headache (n=8), visual loss (n=4). All but two patients received medical treatment with acetazolamide. Two children required escalation of medical treatment because of persisting abducens nerve palsy. In two cases, a second LP documented an opening pressure of 34 and 35 cm H2O.

We believe that the majority of these patients with a "normal" opening pressure are likely to suffer from PTCS or "probable PTCS" and medical treatment was justified. OP measurement in children is not always easy. Parental reports of circumstances under which the LP was done often leave considerable doubt on the reliability of pressure results. We would conclude that: 1) a single LP is neither diagnostic nor exclusive in suspected cases of PTC; 2) OP measured during an LP is a snapshot of a highly dynamic process; and 3) results of opening pressure measurement must be correlated with the clinical history, clinical signs, and symptoms of the patient and results of follow-up studies.

1. Friedman DI, Liu GT, Digre KB. Revised diagnostic criteria for the pseudotumor cerebri syndrome in adults and children. Neurology 2013;81:1159-1165.

2. Distelmaier F, Mayatepek E, Tibussek D . Probable idiopathic intracranial hypertension in pre-pubertal children. Arch Dis Child 2008;93:356-357.

3. Tibussek D, Distelmaier F, von Kries R, Mayatepek E. Pseudotumor cerebri in childhood and adolescence -- results of a Germany-wide ESPED-survey. Klin Padiatr 2013;225:81-85.

For disclosures, please contact the editorial office at [email protected].

7 November 2013
IDIOPATHIC INTRACRANIAL HYPERTENSION: PAPILLEDEMA OR NOT? THIS IS THE QUESTION!
Claudio Liguori, Medical Doctor
Claudio Liguori, Rome, Italy; Andrea Romigi, Rome, Italy; Maria Albanese, Rome, Italy; Maria G Marciani, Rome, Italy; Fabio Placidi, Rome, Italy

Friedman et al. [1] updated the diagnostic criteria for idiopathic intracranial hypertension (IIH). We would like to add the following case to reports of patients presenting chronic daily headache with elevated lumbar puncture (LP) opening pressure without papilledema. [2-3]. We saw an obese female patient with global headache associated with nausea and back pain that began one month earlier. Brain MRI/venography was normal, papilledema was not detected, and optic/ocular examinations were normal. LP revealed an opening pressure of 177 mm with normal CSF contents. Amitriptyline was initiated for chronic daily headache and patient was advised to lose weight and improvement was noted. Six months later, she complained of severe, global, non- steroidal anti-inflammatory drug resistant headache taking place over the previous four weeks. She showed a 12-pound weight gain. The repeated brain MRI/venography was normal and we did not detect papilledema or optic/ocular abnormalities. LP documented an opening pressure of 313 mm with normal CSF contents. Treatment with acetazolamide was initiated and the symptoms resolved. The revised criteria [1] did not support an IIH diagnosis yet it is possible that our patient could have been affected by IIH with a progressive evolution. Development of papilledema is possible. We suggest that patients presenting clinical conditions similar to our case could be diagnosed as probable IIH requiring vigilant follow-up.

1. Friedman DI, Liu GT, Digre KB. Revised diagnostic criteria for the pseudotumor cerebri syndrome in adults and children. Neurology 2013;81:1159-1165.

2. Marcelis J, Silberstein SD. Idiopathic intracranial hypertension without papilledema. Arch Neurol 1991;48:392-399.

3. Wang SJ, Silberstein SD, Patterson S, et al. Idiopathic intracranial hypertension without papilledema: a case-control study in a headache center. Neurology 1998;51:245-249.

For disclosures, contact the editorial office at [email protected].

5 November 2013
REPLY TO Dr. Dasheiff
Deborah I. Friedman, Professor
Deborah Friedman, Dallas, TX; Grant Liu, Philadelphia, PA; Kathleen Digre, Salt Lake City, UT

The goal of our article was to clarify the diagnostic criteria for Pseudotumor Cerebri Syndrome (PTCS) and provide a list of commonly associated secondary conditions. [1] The associated conditions listed are exactly that--associations--and there was no implication that they are causal. A discussion of etiology and pathogenesis is beyond the scope of our article, yet the "duck soup" list of associations provides no real clues as to the mechanism of developing intracranial hypertension. However, PTCS and Idiopathic Intracranial Hypertension (IIH) are rare disorders. It could be argued, and we often do, that IIH is a disorder affecting obese women of childbearing age. There are many women around the world who fit that description but very few develop IIH. There may be a genetic component that makes some women susceptible and we eagerly await the results of the IIH trial for more answers.

Thank you for your feedback,

Daffy, Donald and Daisy

For disclosures, contact the editorial office at [email protected].

16 October 2013
Ducks in a row
Richard Dasheiff, Neurologist

I applaud Friedman et al. [1] on their attempt to clarify and improve the conceptualization of pseudotumorcerebri (PC). In so doing, they inadvertently stumble over the supporting and ancillary data as so often happens. Table 1, even with references, is a reflection of inadequate understanding and inappropriate use of associations made between a given disease/syndrome and potential etiologies. For example, many patients have renal failure, anemia, sleep apnea and Down syndrome, but PC is rare, and the cause/effect relationship is unknown in the patients who have both. To further impugn the Table, sleep apnea is not a disorder of hypercapnia (nor hypoxia), but fractionated sleep causing excessive daytime sleepiness. [2] If authors wish to convince readers to adopt a new classification system and diagnostic criteria, then all their ducks must be in a row. The paper would have been better without Table 1, which reflects an area in need of improvement.

1. Friedman DI, Liu GT, Digre KB. Revised diagnostic criteria for the pseudotumorcerebri syndrome in adults and children. Neurology 2013; 81: 1159-1165.

2. Dasheiff RM, Finn R. Clinical Foundation for Efficient Treatment of Obstructive Sleep Apnea. J Oral MaxillofacSurg 2009;67: 2171-2182.

For disclosures, please contact the editorial office at [email protected].

11 September 2013
Cerebrospinal fluid opening pressure in IIH diagnosis
Roberto De Simone, Headache Centre Director
Roberto De Simone, Naples, Italy; Angelo Ranieri, Naples, Italy; Silvana Montella, Naples, Italy

While we appreciate the IIH criteria update by Friedman et al. [1], we believe that opening pressure (OP) alone does not negate the diagnosis of IIH/IIHWOP. Requiring that OP be above 250mmH20 will miss many cases. Intracranial pressure (ICP) monitoring [2-5] demonstrated that ICP shows large diurnal fluctuations in IIH/IIHWOP patients, ranging from normal to definitely pathological values. Many patients with papilledema fulfilling Friedman criteria A-D might be diagnosed as "definite" or "probable" depending on timing of their instable ICP estimation. Similarly, in chronic headache patients without papilledema presenting with abducens palsy (uncommon also in cases with papilledema) or with a combination of 3 out of 4 suggestive radiologic findings, the diagnosis of IIHWOP will vary from "definite" to "not suggested" largely depending on lumbar puncture timing. Considering ICP fluctuations and impracticability of routine ICP monitoring, we believe that OP, paradoxically, should never constitute the only reason to refute IIH/IIHWOP diagnosis. In a large chronic primary headache series, [5] a continuous or intermittent ICP greater than 200 mmH2O was associated with sinus stenosis. We recommend keeping the 200 mmH20 cut-off value at least until the role of venous stenosis in IIH mechanisms is clarified.

1. Friedman DI, Grant TL, Kathleen BD. Revised diagnostic criteria for the pseudotumor cerebri syndrome in adults and children. Neurology August 21, 2013, doi: 10.1212/WNL.0b013e3182a55f17

2. Johnston I, Paterson A. Benign intracranial hypertension:I. Diagnosis and prognosis. Brain 1974; 97: 289-300.

3. Spence JD, Amacher AL, Willis NR. Benign intracranial hypertension without papilledema. Role of 24-hour cerebrospinal fluid pressure monitoring in diagnosis and management. Neurosurgery 1980;7:326-336.

4. Torbey MT, Geocadin RG, Razumovsky AY, Rigamonti D, Williams MA. Utility of CSF pressure monitoring to identify idiopathic intracranial hypertension without papilledema in patients with chronic daily headache. Cephalalgia 2004; 24:495-502.

5. Bono F, Salvino D, Tallarico T, et al. Abnormal pressure waves in headache sufferers with bilateral transverse sinus stenosis. Cephalalgia 2010; 30:1419–1425

For disclosures, contact the editorial office at [email protected].

Information & Authors

Information

Published In

Neurology®
Volume 81Number 13September 24, 2013
Pages: 1159-1165
PubMed: 23966248

Publication History

Received: January 3, 2013
Accepted: May 24, 2013
Published online: August 21, 2013
Published in print: September 24, 2013

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Disclosure

D. Friedman has served as a site investigator for Quark Pharmaceuticals and MAP Pharmaceuticals and has received honoraria as a speaker for Allergan and for advisory work to MAP Pharmaceuticals and Merck. She received research support from Merck and the National Eye Institute and is on the Editorial Board of Neurology Reviews. G. Liu has consulted for Ipsen and received book royalties from Elsevier. K. Digre receives grant support from the National Eye Institute. Go to Neurology.org for full disclosures.

Study Funding

Supported by an unrestricted grant from Research to Prevent Blindness, Inc., New York, NY, to the Department of Ophthalmology & Visual Sciences, University of Utah.

Authors

Affiliations & Disclosures

Deborah I. Friedman, MD, MPH
From the University of Texas Southwestern Medical Center (D.I.F.), Dallas; Hospital of the University of Pennsylvania, Children's Hospital of Philadelphia, and the Perelman School of Medicine at the University of Pennsylvania (G.T.L.), Philadelphia; and the University of Utah (K.B.D.), Salt Lake City.
Disclosure
Scientific Advisory Boards:
1.
(1) Quark Pharmaceuticals, (2) Zogenix, (3) MAP Pharmaceuticals, (4) Merck.
Gifts:
1.
NONE
Funding for Travel or Speaker Honoraria:
1.
NONE
Editorial Boards:
1.
Neurology Reviews (editorial board), Headache (Associate Editor 2013)
Patents:
1.
NONE
Publishing Royalties:
1.
NONE
Employment, Commercial Entity:
1.
NONE
Consultancies:
1.
NONE
Speakers' Bureaus:
1.
NONE
Other Activities:
1.
NONE
Clinical Procedures or Imaging Studies:
1.
NONE
Research Support, Commercial Entities:
1.
(1) Merck, (2) Quark Pharmaceuticals, (3) Electrocore Pharmaceuticals (all to institutions)
Research Support, Government Entities:
1.
NEI U10 EY017387.
Research Support, Academic Entities:
1.
NONE
Research Support, Foundations and Societies:
1.
NONE
Stock/stock Options/board of Directors Compensation:
1.
NONE
License Fee Payments, Technology or Inventions:
1.
NONE
Royalty Payments, Technology or Inventions:
1.
NONE
Stock/stock Options, Research Sponsor:
1.
NONE
Stock/stock Options, Medical Equipment & Materials:
1.
NONE
Legal Proceedings:
1.
Expert witness for cases of pseudotumor cerebri, retained by both plaintiff and defense attorneys.
Grant T. Liu, MD
From the University of Texas Southwestern Medical Center (D.I.F.), Dallas; Hospital of the University of Pennsylvania, Children's Hospital of Philadelphia, and the Perelman School of Medicine at the University of Pennsylvania (G.T.L.), Philadelphia; and the University of Utah (K.B.D.), Salt Lake City.
Disclosure
Scientific Advisory Boards:
1.
(1) Ipsen scientific advisory board
Gifts:
1.
NONE
Funding for Travel or Speaker Honoraria:
1.
NONE
Editorial Boards:
1.
(1) Dr. Liu serves on the Editorial Board of the Journal of Neuro- Ophthalmology, but receives no compensation for this.
Patents:
1.
NONE
Publishing Royalties:
1.
(1) Dr. Liu has received royalty payments for his part in writing the book, "Neuro-Ophthalmology: Diagnosis and Management," 2nd edition, Elsevier (2010).
Employment, Commercial Entity:
1.
NONE
Consultancies:
1.
(1) Ipsen
Speakers' Bureaus:
1.
NONE
Other Activities:
1.
NONE
Clinical Procedures or Imaging Studies:
1.
NONE
Research Support, Commercial Entities:
1.
NONE
Research Support, Government Entities:
1.
NONE
Research Support, Academic Entities:
1.
NONE
Research Support, Foundations and Societies:
1.
(1) the Children's Hospital of Philadelphia Women's Committee
Stock/stock Options/board of Directors Compensation:
1.
NONE
License Fee Payments, Technology or Inventions:
1.
NONE
Royalty Payments, Technology or Inventions:
1.
NONE
Stock/stock Options, Research Sponsor:
1.
NONE
Stock/stock Options, Medical Equipment & Materials:
1.
NONE
Legal Proceedings:
1.
NONE
Kathleen B. Digre, MD
From the University of Texas Southwestern Medical Center (D.I.F.), Dallas; Hospital of the University of Pennsylvania, Children's Hospital of Philadelphia, and the Perelman School of Medicine at the University of Pennsylvania (G.T.L.), Philadelphia; and the University of Utah (K.B.D.), Salt Lake City.
Disclosure
Scientific Advisory Boards:
1.
NONE
Gifts:
1.
NONE
Funding for Travel or Speaker Honoraria:
1.
NONE
Editorial Boards:
1.
Journal of Neuro-ophthlamology, Editorial board member; Headache Currents, editorial Board member
Patents:
1.
NONE
Publishing Royalties:
1.
NONE
Employment, Commercial Entity:
1.
NONE
Consultancies:
1.
NONE
Speakers' Bureaus:
1.
NONE
Other Activities:
1.
NONE
Clinical Procedures or Imaging Studies:
1.
NONE
Research Support, Commercial Entities:
1.
Pfizer, Anterior Ischemic Optic Neuropathy : possible trigger factors related to the development of AION--Site PI
Research Support, Government Entities:
1.
NEI: Idiopathic Intracranial Hypertension Treatment Trial--Site PI
Research Support, Academic Entities:
1.
NONE
Research Support, Foundations and Societies:
1.
NONE
Stock/stock Options/board of Directors Compensation:
1.
NONE
License Fee Payments, Technology or Inventions:
1.
NONE
Royalty Payments, Technology or Inventions:
1.
NONE
Stock/stock Options, Research Sponsor:
1.
NONE
Stock/stock Options, Medical Equipment & Materials:
1.
NONE
Legal Proceedings:
1.
NONE

Notes

Correspondence to Dr. Friedman: [email protected]
Go to Neurology.org for full disclosures. Funding information and disclosures deemed relevant by the authors, if any, are provided at the end of the article.

Author Contributions

Drs. Friedman, Liu, and Digre contributed to the concept of the paper and the drafting and revision of the manuscript for important intellectual content.

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