{"paper_id":"3698fd8a-a353-462f-870d-2a8f18777d97","body_text":"Case Report Mathews Journal of Neurology\nhttps://doi.org/10.30654/MJN.10023\n1\nVol No: 07, Issue: 01\nReceived Date: December 19, 2022\nPublished Date: February 15, 2023\nCitation: Shalbafan B, et al. (2022). Case Report: Optical \nCoherence Tomography, as a Non-Invasive Approach \nto Evaluate Intracranial Pressure in Normal Pressure \nHydrocephalus Patients, as with their Treatment \nFollow-ups and VP Shunts Reprogramming Procedures. \nMathews J Neurol. 6(1):020.\nCopyright: Shalbafan B, et al. © (2022). This is an \nopen-access article distributed under the terms of the \nCreative Commons Attribution License, which permits \nunrestricted use, distribution, and reproduction in any \nmedium, provided the original author and source are \ncredited.\nBita Shalbafan\nClinical Research Development Center of Labbafinejad \nHospital, Shahid Beheshti University of Medical \nSciences, Tehran, Iran, Tel: +989161119656\nE-mail: Shalbafan.b@gmail.com\nABSTRACT\nA 50 years old female patient stepped into Neurology practice, who \nhad been suffering from intractable headaches and followed up for 10 \nyears. At the meantime, she was secondarily assessed by Endometriosis \nstage-II. Meanwhile, the lab workup did not reflect much of an off the \nchart hormonal study, Anemia was a point of consideration. Although \ntreatment for Anemia was successfully fulfilled, no progression was noted \nwith mending Endometriosis symptoms and headaches. To that end, the \npatient was referred to Neurologist. She underwent a brain MRI study \nand was reported by empty Sella as an incidental finding. As a result, \nfundus photography was performed to check for papilledema, where \nno significant findings were reported. However, thus Empty Sella was \nin combination with severe headaches, Optical Coherence Tomography \n(OCT) was employed to have a closer look into her Optic Disc. OCT \nfindings of the Retinal Nerve Fiber Layer (RNFL) over the Circumpapillary \nTomogram and choroidal folds, concluded a micro-papilledema that \nfinally provided an explanation for those chronic headaches. To that end, \nthe patient went through a Lumber Puncture (LP), where an intracranial \npressure (ICP) of 29 cmH2O was measured, CSF exam showed no \ncells and so normal Biochemical analysis. She was eke prescribed by \nAcetazolamide and constantly studied through the OCT , in order to \n*Corresponding Author\nCase Report: An IIH Induced Endometriosis that Diagnosed \nby OCT , and Revealed Ten Years Dilemma of HPG Axis \nDysfunction due to Pressure Effect of CSF on Pituitary Stalk\nBita Shalbafan1,*, Seyed Kianoosh Naghibzadeh2, Hajar Aminzadeh3,4, Hossein Lanjanian5,6, Bardia D \nBaloutch7, Katayon Berjis8, Hamid Sajjadi9,10\n1Clinical Research Development Center of Labbafinejad Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran\n2Department of Biological Sciences, Tarbiat Modares University, Tehran, Iran\n3Department of Cognitive Science Studies, Shahid Beheshti University, Tehran, Iran\n4Department of Cognitive Modeling, Institute for Cognitive Science Studies, Tehran, Iran\n5Molecular Biology and Genetics Department, Engineering and Natural Science Faculty, Istinye University, Istanbul, Turkey\n6Cellular and Molecular Endocrine Research Center, Research Institute for Endocrine Sciences, Shahid Beheshti University of Medical Sciences, \nTehran, Iran\n7TRUST/FALCON RAY Imaging (X-Ray and Visible Spectrum) Tehran, Iran\n8Department of Reproductive Biology, Academic Center for Education, Culture and Research, Qom branch, Qom, Iran\n9Director, Department of Ophthalmology, Acacia Medical Center, Dubai, UAE\n10Director of Neuro-Ophthalmology, San Jose Eye and Laser Medical Center, California, USA\n\nISSN : 2572-6536\n2\nMathews Journal of Neurology\nhttps://doi.org/10.30654/MJN.10023\ncomprehend the ICP reduction based on RNFL thickness \ndecrease and clinical review. Along with ICP reduction, \nimprovements were observed in Endometriosis symptoms. \nSuch recovery was likewise perceived in headaches to \noccur in lower frequencies, duty cycles and severities. \nResearch has indicated the correlation between IIH and the \noccurrence of Gynecologic disorders, including Endometrial \nissues and Polycystic Ovarian Syndrome (PCOS). Androgen \nexcess has been discussed to be prevalent among women \nwith IIH. An NIH fundamental diagnostic criterion for PCOS, \ndemands a clinical or biochemical element of androgen \nexcess. Otherwise, The ICP elevation by IIH impacts on \nPituitary Stalk, which causes the Hypothalamic-Pituitary-\nGonadal Axis (HPG Axis) to become misaligned with respect \nto its mechanism. The HPG Axis encounters the unified \nfunctionality of those included glands. Once the Pituitary \nStalk withstands an Empty Sella, changes in Gonadotropin \nReleasing Hormone (GnRH), would leave metabolic \nimpacts on Endometriosis development. The additional \nmalfunctioning among the HPG Axis would cause alternations \nin Follicle Stimulating Hormone (FSH) and Luteinizing \nHormone (LH), which both contribute to Endometriosis. \nMoreover, the HPG Axis, as a unified hormonal system to \nbe disturbed, would drawback a lack of balance in Estradiol \nProgesterone (EP). Such impairment would transform the \nUterine tissue and could therefore influence the progression \nof Endometriosis. Gynecologists are hence recommended to \nconsider the probability of IIH or any condition that elevates \nthe ICP; meanwhile experiencing patients’ long-term lack of \nresponse to Endometriosis treatments, in combination with \nheadaches. Thus, the IIH or any ICP elevating condition could \nbe easily diagnosed in their early stages and monitored \nby simple and non-invasive studies of Optic Disc Optical \nCoherence Tomography (Disc OCT). Therefore, an OCT study \ncould be a cost-effective approach to maintain the quality of \ncare for women with Endometriosis, who may alternatively \nbe tolerated by IIH, even in its early stages.\nKeywords: Endometriosis, Idiopathic Intracranial \nHypertension (IIH), Optic Coherence Tomography (OCT), \nHeadache.\nINTRODUCTION AND LITERATURE\nHeinrich Quincke initially defined Pseudotumor Cerebri \n(PTC) in 1983, as a defect in Cerebrospinal Fluid (CSF) \ndynamics that results in Raised Intracranial Pressure \n(RICP) [1]. Thus, the etiology of the disease has been mostly \nunknown, it was further entitled as Idiopathic Intracranial \nHypertension (IIH) [1]. Visual Impairment caused by \nPapilledema is one of its known symptoms [1], for which \nfunduscopic exams have been widely used to diagnose and \nverify it [2]. However, as long as the evaluation of increased \nICP has recently experienced to be a more accurate approach \nvia Optical Coherence Tomography (OCT), IIH diagnosis has \neke become an interesting subject of study [3]. Research has \nindicated the correlation between IIH and the occurrence of \ngynecologic disorders, including Endometrial disorders [4] \nand Polycystic Ovary Syndrome (PCOS) [5]. \nThe reviewed case encounters a female patient suffering \nfrom Endometriosis along with dilemmatic headaches for \nten years. Hence, this case review aims to reflect the potential \nof OCT as a non-invasive solution to approach the cause of \nthose endometrial disorders that come in combination with \nsevere headaches for long durations of time.\nCASE REPORT\nA 50 years old female stepped into Neurology practice with \nher Gynecologist referral to receive treatment for her severe \nheadaches. Her referral otherwise contained a complete \nmedical history, regarding her Obstetric and Gynecologic \nbackgrounds. The cited record encountered her obstetric \nexperiences of her 4 pregnancies (Gravidity 4), where 3 of \nthem were delivered after 40 weeks (Para 3) and remained \nalive (Living 3). However, one of them was an Ectopic \nPregnancy (EP1) that belonged to an experience of 15 years \nprior to the addressing referral. Her concluded Obstetric \nhistory was therefore a G3 P4 L3 EP1, from which all the 3 \nterminations were by normal vaginal delivery without any \ncomplications. The first pregnancy was just a year after her \nMenarche, and the other two each occurred in an annual \nsequence, forwarding to it. Secondary Dysmenorrhea with \na Visual Analog Scale (VAS) of score 3 (out of 10) was her \ncomplication a year after her last delivery, along with \nSevere Dyspareunia with a VAS score of 10 (out of 10). The \nabove reviewed Ectopic Pregnancy of her, induced an intra-\nabdominal hemorrhage that was drained out by Laparotomy; \nwhere the surgeon reported a Score-2 Endometriosis, based \non their observation. Since that incident of 15 years before \nthis referral, she had been experiencing more or less regular \nmenstruations, regardless of her Hypermenorrhea and a few \ndays of Perimenstrual Spotting. Her sexual aspect of living \n\nISSN : 2572-6536\n3\nMathews Journal of Neurology\nhttps://doi.org/10.30654/MJN.10023\nwas not intact anymore after she stopped having intercourse, \nfollowed by her husband’s passing away, 10 years before \nthe reviewing referral. The referral notes also remarked an \nabdominopelvic review of her by ultrasonography, where a \nmoderate Adenomyosis was reported.\nAt the meantime, she was assessed by intractable headaches, \nsome assuming Migraine and others addressed it as tension \nheadaches and followed for 10 years to have her headaches \ncontrolled.\nOn the other hand, regardless of her lab workup not reflect \nmuch of an off the chart hormonal study, the Anemia induced \nby Hypermenorrhea was a point of consideration to provide \na possible reason for headache. Although treatment for \nAnemia was successfully fulfilled, no progression was noted \nwith mending Endometriosis symptoms and her headaches’ \nseverity, frequency or duty cycle. When She underwent \nan MRI and reported coping with Empty Sella (Figure 1). \nThe referenced Mid-Sagittal Brain MR Image was acquired \nthrough the T2 sequence of Magnetic Resonance Imaging, \nwhere the CSF is more brightly projected \n[6]. Therefore, \nEmpty Sella (filled with water) could be noted from the high \nsignal intensity \n[7] of her Sella Turcica. \nFigure 1. Arrow indicates Empty Sella in Mid-Sagittal cut of the patient’s Brain MRI (T2 Sequence).\nWhereas the Empty Sella was a red flag for Raised Intracranial \nPressure (RICP) in combination with severe headaches, \nthere were no significant findings in ophthalmologic \nconsultation and normal Fundoscopy. Optical Coherence \nTomography (OCT) was moreover performed to investigate \nthe Optic-Nerve head more accurately. Raised Intracranial \nPressure (RICP) was concluded to consequently project a \nMicro-Papilledema, identified through the 3D Optic Disc OCT \n(Figure 2). \n\nISSN : 2572-6536\n4\nMathews Journal of Neurology\nhttps://doi.org/10.30654/MJN.10023\nOtherwise, regardless of the Micro-Papilledema being \nprojected through her OCT Circumpapillary Tomogram \n(Figure 3 ) over the normative database; a time-wise \nprogression of papilledema is sequentially concluded, as it \ncomplies with Sajjadi 2017 Pattern 2 of PTC in absence of \nvisible or Micro-Papilledema \n[8].\nFigure 2. Micro-papilledemas are pointed with arraws in patient’s 3-Dimensional OCT a)Right Optic \nNerve Head b)Left Optic Nerve Head (S:Superior,I:Inferior)\nOD (Right Eye)                Figure3. Bilateral projection of patient’s OCT CP-NFL Tomogram and Fundus              OS (Left Eye)\nTo that end, the patient went through Lumber Puncture \n(LP); where Idiopathic Intracranial Hypertension (IIH) \nwas confirmed, by the Cerebrospinal Fluid (CSF) Opening \nPressure to be 29 cmH2O at her LP , as with meeting the \nnormal Cerebrospinal Fluid (CSF) lab workup. This could \nrule out other possibilities, in order to verify IIH. She was eke \nprescribed by Acetazolamide and constantly studied through \nOCT and went under clinical reviews to comprehend the ICP \nreduction based on RNFL thickness decrease Along with \nICP decrease, improvements were observed in Gynecologic \nSymptoms. Such recovery was likewise perceived in \nheadaches to occur in lower frequencies and severities.\nDiscussion\nAndrogen excess was discussed to be prevalent among \nwomen with IIH \n[9]. An NIH fundamental diagnostic criterion \nfor Polycystic Ovary Syndrome (PCOS), demands a clinical or \nbiochemical element of androgen excess \n[10]. Otherwise, The \nICP elevation by IIH impacts on Pituitary Stalk [11] and Empty \nSella Turcica \n[12], which causes the Hypothalamic-Pituitary-\nGonadal (HPG) Axis to confront fault in its mechanism [13]. \nHPG Axis encounters the unified functionality of those \nincluded glands \n[14]. Once the Pituitary Stalk withstands an \nEmpty Sella, changes in Gonadotropin-Releasing-Hormone \n(GnRH) \n[15] would leave metabolic effects on Endometriosis \ndevelopment [16]. This mechanism has been reflected visually \nin Figure 4.\n\nISSN : 2572-6536\n5\nMathews Journal of Neurology\nhttps://doi.org/10.30654/MJN.10023\nThe additional malfunctioning among HPG Axis would cause \nalternations in FSH and LH [17], which both contributes to \nEndometriosis [18]. Moreover, when HPG Axis is disturbed \nas a unified hormonal system, would drawback a lack of \nbalance in Estradiol Progesterone \n[19]. Such impairment \nwould transform the Uterine tissue and could therefore \ninfluence the progression of Endometriosis \n[19], [20].\nAnother study has similarly outlined Hyperprolactinemia to \nbe significantly associated with Endometriosis, in a study of \n256 infertile females \n[21]. Empty Sella was cited as an etiologic \nconcern for Hyperprolactinemia, where MR visualizations \nof the Sellar area could reveal it \n[22]. On the other hand, \nsuch a phenomenon was reported in some cases to lead to \nthe proliferation of Proliferative Endometrial Glandular \nCells and raise the probability of Endometrial Cancer Cell \ndevelopment \n[23]. Another dilemmatic case of an adolescent \nfemale was reported to suffer from Endometrial issues and \nPCOS, which was concluded to be driven by IIH \n[24].\nGynecologists are hence recommended to consider the \nprobability of IIH or any condition that elevates the ICP; \nmeanwhile experiencing a long-term lack of response to \nEndometriosis treatments, in combination with headaches. \nThus, the IIH or any ICP elevating condition could be \neasily diagnosed in early stages by OCT \n[8], [25], as long as \nits volumetric tomography reveals much more clinical \ninformation than ophthalmic clinical reviews, such as the \nmicro-papilledema \n[26] of this case. OCT observation of such a \ncondition by changes in RNFL thickness [8], [27] and Choroidal \nfold has been so far a novel approach in diagnosing IIH \nand ICP elevated disorders \n[27]. Patients could be likewise \nmonitored by OCT as a noninvasive [28], non-ionizing [29] and \ncost-effective approach [30].\nOtherwise, some reports warned about the adoption and \nwithdrawal of pharmacologic treatments for Endometriosis, \nsuch as Leuprorelin Acetate \n[31] and Danazol [32], which could \ninduce IIH. This would therefore develop a transactional \nprogression of both disorders, increasing clinical overheads \nfor patients and so negatively impacting their quality of life.\nLIMIT ATION\nThe patient came into Neurology practice with a referral \nnote from a registered Gynecologist to receive treatment \nfor her headaches. Her former medical data, by which she \nwas evidently diagnosed with Endometriosis during that \npast 15 years, couldn’t be unfortunately retrieved. Thus, the \nlack of proper EMR systems has been a regional liability, and \nshe didn’t have a physical copy of her medical records with \nher. Those medical records included her abdominopelvic \nultrasonic studies and lab workups. However, her referral \nnote that addressed her Endometriosis was acceptable, \nsince she was experiencing relative symptoms at the time. \nThe referral otherwise encountered data that could verify \nGynecologist assertions. This includes the rational alignment \nof her noted medical history and the result of the addressed \nultrasonic study of her Abdominopelvic region, along with \nFigure 4. RICP Relation with Endometrial Issues [4]\n\nISSN : 2572-6536\n6\nMathews Journal of Neurology\nhttps://doi.org/10.30654/MJN.10023\nNeurological findings, as discussed above. Such a conclusion \ncould hence make that referral note genuine.\nCONCLUSION\nThis case report reviewed the clinical narration of a patient, \nwho had been suffering from Endometriosis symptoms and \nagonizing headaches during her past 10 years from stepping \ninto Neurology practice. Her Endometriosis was concluded \nto be induced by IIH, which she was considerably relieved \nafter her Raised ICP treatment. The mechanism of HPG Axis \nmisalignment, driven by her Empty Sella and its effect on \nher GnRH intensity, was described to trigger Endometriosis \nby leaving an impact on LH and FSH levels. This event was \ndiscussed to not only affect the patient’s quality of life with \nEndometriosis symptoms, but also raise the possibility \nof carcinogenic proliferation. Otherwise, a treatment of \nEndometriosis was cited to may have negative impulses, as it \ncould originate IIH, which irritates a transactional progression \nof both issues. As a non-invasive and cost-effective tool, OCT \nwas recommended to be utilized for screening patients with \nthose Endometrial disorders that are resistant to treatment \nand might also experience a Neurological indication, such \nas headaches. 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