TREATABLE INTRACRANIAL HYPERTENSION IN PATIENTS WITH LUPUS NEPHRITIS

Idiopathic intracranial hypertension is a disorder of intracerebral pr essure regulation and patients run the risk of permanent visual loss. Intracranial hypertension (IH) has been reported rarely in systemic lu pus erythematosus (SLE). We reviewed the medical records of 127 patien ts with lupus nephritis (LN) who were followed up from 1987 to 1996 in our unit. There were six patients with IH which gave a disease preval ence of 4.7% in those with LN. All were females giving a disease preva lence of 5.2% for that sex, a high rate of occurrence of IH in patient s with LN. Their age ranged from 22 to 34y (27.8 +/- 3.6y). Headache, vomiting and diplopia were the common presenting symptoms and had star ted 7.3 +/- 4.4 weeks prior to the diagnosis of IH. The cerebrospinal (CSF) opening pressure (413.3 +/- 77.0 mmH(2)O) was raised in all case s. Biochemical and cytological analyses of CSF were normal. The only a bnormal radiological finding was partially empty sella in one patient on magnetic resonance imaging (MRI) (performed in three patients) or c omputed tomography (CT) (performed in all patients). All patients had serological evidences of active lupus disease at the time of diagnosis of IH. The renal histology was WHO type IV in four cases and III and V in one each indicating severe renal involvement. Laboratory evidence s of procoagulant activity were found in the form of positive anticard iolipin antibody (aCL) in two patients, lupus anticoagulant (LA) in tw o and an otherwise unexplained isolated prolongation of activated part ial thromboplastin time (APTT) in the other two. Clinically, one or mo re episodes of symptomatic venous or arterial thrombosis had occurred in all subjects. In addition to symptomatic measures, all subjects wer e treated with prednisolone, azathioprine, cyclophosphamide and plasma pheresis according to the protocol of our unit. One patient who did no t receive plasmapheresis and cyclophosphamide had a relapse while all others recovered completely. None received anticoagulant therapy. Youn g females with serologically active lupus, severe forms of renal lesio ns, past history of venous or arterial thrombosis and laboratory evide nces of procoagulant activity, appear to be at increased risk for IH. Thrombotic occlusion of the cerebral arteriolar or venous vascular bed eventually affecting the arachnoid villi and impeding CSF absorption is favoured compared to cerebral venous or sinus thrombosis as the pat hogenic mechanism. Combined immunosuppression and plasmapheresis appea red to be beneficial in short and long term follow-up. We propose that patients with SLE and IH have definable risk and pathogenetic factors and are no more to be considered 'idiopathic'. The condition calls fo r aggressive intervention which leads to an excellent outcome.