ORIGINAL CONTRIBUTION Papilledema as the Presenting Manifestation of Spinal Schwannoma Fiona Costello, MD, Randy H. Kardon, MD, PhD, Michael Wall, MD, Patricia Kirby, MD, Timothy Ryken, MD, and Andrew G. Lee, MD A 63-year-old woman with headache, blurred vision, bilat- eral optic disc edema, and normal cranial magnetic reso- nance imaging scan underwent lumbar puncture that re- vealed an elevated opening pressure (290 mm water), a pro- tein level of 114 mg/dl, and mild pleocytosis. Spinal magnetic resonance imaging later demonstrated a sacral tu- mor, which proved to be a schwannoma with sarcoid-like features. After surgical removal of the tumor, the patient’s manifestations resolved. This case emphasizes that low spi- nal cord tumors can cause elevated intracranial pressure without causing markedly elevated cerebrospinal fluid pro- tein or cells, or any myelopathic manifestations, perhaps by obstructing sacral cerebrospinal drainage. Comprehensive spine imaging should be a part of the evaluation of a patient with papilledema who has normal brain imaging but abnor- mal spinal fluid constituents. (J Neuro-Ophthalmol 2002;22: 199–203) S pinal tumors are an uncommon cause of increased intra- cranial pressure (1–8). Papilledema may be the sole clinical manifestation (1,2,6). We present a case of a sacral schwannoma that caused papilledema without symptoms of spinal dysfunction, and discuss the reported tumor types and locations, as well as possible mechanisms for increased intracranial pressure. CASE REPORT A 63-year-old woman came for treatment because of a 3-month history of intermittent blurred vision and occa- sional headaches. She did not describe experiencing pulse- synchronous tinnitus or double vision. Her medical history included diabetes, hypothyroidism, controlled hyperten- sion, hyperlipidemia, and remote seizures. Her regular medications were Lipitor, Glucophage, Synthroid, and mul- tivitamins; She did not describe using lithium, tetracycline, vitamin A, or corticosteroids. Her weight had been stable in the previous year. The patient’s height was 5' 1, and her weight was 200 pounds. The results of a general neurologic examina- tion were completely normal. The ophthalmology evalua- tion revealed a best-corrected visual acuity of 20/25 OD and 20/20 OS. Slit lamp biomicroscopy showed nuclear cata- ract. The pupils, intraocular pressures, and ocular motility were normal. Ophthalmoscopy showed bilateral optic disc edema with surrounding peripapillary hemorrhages (Fig. 1). Goldmann perimetry showed enlargement of the blind spots in both eyes (Fig. 2). Magnetic resonance imaging (MRI) scans of the head were normal except for dilation of both optic nerve sheaths and flattening of the posterior globes in both orbits; these findings were consistent with raised intracranial pressure. The sella turcica was normal. A lumbar puncture revealed an opening pressure of 290 mm water. Analysis of the ce- rebrospinal fluid demonstrated an elevated protein of 114 mg/dl (normal <46 mg/dl) and 20 leukocytes mm 3 (normal <5 leukocytes), 98% of which were monocytes. The CSF formula was otherwise normal, as were urinalysis and base- line serologic studies. Magnetic resonance imaging was per- formed along the entire spinal axis in search of a source of Departments of Ophthalmology (FC, AGL, RHK, MW), Neurology (AGL, MW), Pathology (PK), and Neurosurgery (AGL, TR), University of Iowa Hospitals and Clinics, Iowa City, Iowa. Supported in part by an unrestricted grant from Research to Prevent Blindness, Inc., New York, NY. Address correspondence to Andrew G. Lee, MD, Department of Oph- thalmology, 200 Hawkins Drive PFP, University of Iowa Hospitals and Clinics, Iowa City, IA 52242, USA; E-mail: andrew-lee@uiowa.edu FIG. 1. Fundus, showing optic disc edema and peripapil- lary hemorrhages. J Neuro-Ophthalmol, Vol. 22, No. 3, 2002 DOI: 10.1097/01.WNO.0000028862.11084.C3 199