PC2172: Idiopathic Intracranial Hypertension: Is the Etonogestrel Contraceptive Implant a Possible Culprit?

Introduction: Idiopathic Intracranial Hypertension (IIH) is a serious condition that can result in permanent vision loss. Known risk factors include the use of estrogen containing contraceptives and elevated Body Mass Index (BMI). Data is limited regarding a possible link to progesterone.

Case Description: A retrospective case series of 3 cases over a 2 year period in a small community child neurology practice (2 providers). These cases represent 50% of all IIH cases identified in post-pubescent females during this time, in chronological order.

Discussion: Case “A”: 16-year-old female with BMI of 23, systemic lupus erythematosus on azathioprine, hydroxychloroquine (HC), and etonogestrel subdermal contraceptive implant (ECSI) presents with headaches and bilateral papilledema. Magnetic resonance imaging (MRI) and magnetic resonance venography (MRV) show an empty sella and narrowing of bilateral transverse sinuses. Treated with acetazolamide (ACZ) 1 GM twice daily (BID). “Elevated opening pressure” initially attributed to lupus cerebritis vs. medication effect of HC. Symptoms continued after discontinuation of HC. ACZ ultimately titrated to 1.5GM BID with full symptom resolution for >3 months.

Case “B”: 17-year-old female with BMI of 24 presents 6 weeks after ECSI placement with new onset headaches, blurry vision, and tinnitus. Bilateral papilledema on exam. Brain MRI and MRV unremarkable. Lumbar puncture with opening pressure of 23 cm H20. ECSI removal declined by patient. Initial treatment with ACZ 250 mg, however patient did not tolerate medication titration and ACZ was discontinued. ECSI was then removed and replaced by intrauterine contraceptive resulting in full symptom resolution, without symptom recurrence for >12 months.

Case “C”: 19-year-old female with BMI of 33 and history of fully resolved intracranial hypertension at age 17. ECSI placed 1 year later. 9 weeks following placement, she reported 10 day history of daily headaches, dizziness, and blurry vision. Restarted on ACZ with symptom resolution for >15 months.

Conclusion: While many patients using the ECSI report headaches, the relationship between ECSI and development of IIH remains under-investigated. This report adds 3 additional cases, highlighting the need for additional research and consideration. We recommend evaluation for papilledema if experiencing new onset headaches while using the ECSI. Medical treatment with ACZ may preserve contraceptive use with ECSI, however if unsuccessful, consider removal of the device.