|
 
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| CASE REPORT |
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| Year : 2023 | Volume
: 3
| Issue : 2 | Page : 478-480 |
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Antipsychotic pitfalls: Risperidone-induced idiopathic intracranial hypertension
Arumugam Balraj
Aravind Eye Hospital, Pondicherry, India
| Date of Submission | 16-Oct-2022 |
| Date of Acceptance | 15-Dec-2022 |
| Date of Web Publication | 28-Apr-2023 |
Correspondence Address:
Arumugam Balraj
Aravind Eye Hospital, Thavalakuppam, Pondicherry - 605 007
India
 Source of Support: None, Conflict of Interest: None
DOI: 10.4103/IJO.IJO_2714_22
Idiopathic intracranial hypertension (IIH) is a rare but potentially severe condition causing visual loss. Use of many drugs has been associated with the occurrence of IIH. We report the case of a 47-year-old female treated with risperidone for schizophrenia who presented with features of IIH. Withdrawing the offending drug, in addition to acetazolamide, drastically improved her symptoms within a month. We report this rare case to emphasize that a commonly used atypical antipsychotic medication (risperidone) can rarely cause IIH.
Keywords: Benign intracranial hypertension, idiopathic intracranial hypertension, risperidone, schizophrenia
How to cite this article:
Balraj A. Antipsychotic pitfalls: Risperidone-induced idiopathic intracranial hypertension. Indian J Ophthalmol Case Rep 2023;3:478-80 |
Idiopathic intracranial hypertension (IIH) is a well-known entity where the intracranial cerebrospinal fluid (CSF) pressure is elevated in the absence of obvious infections, venous thrombosis, or intracranial mass lesions.[1] IIH has been synonymously described as pseudotumor cerebri or benign intracranial hypertension. Many drugs have been associated with the occurrence of IIH. We report a 47-year-old female being treated with risperidone for schizophrenia, who presented with symptoms of IIH. To our knowledge, only a few such risperidone-induced cases have been reported in the literature.[2],[3] We report this case for its rare presentation.
| Case Report | |  |
A 47-year-old obese lady presented with a severe headache for 10 days. She had blurred vision in both eyes, which progressed over 2 days. She was a known case of schizophrenia on treatment under psychiatry for the past 5 years. She was treated for schizophrenia with the following drugs: trihexyphenidyl hydrochloride 2 mg, procyclidine 5 mg, oxcarbazepine 600 mg, clozapine 25 mg, loxapine 25 mg, quetiapine 100 mg, amisulpride 400 mg, ziprasidone 40 mg, and haloperidol 20 mg. The patient was advised to undergo electroconvulsive therapy (ECT) for schizophrenia, but she did not undergo it. Four milligrams of risperidone was then added in the last year to control her psychiatric symptoms. She did not have any other comorbidity. Her body mass index (BMI) was >40. She had an increase in weight of about 35 kg in 1 year. On ophthalmological examination, visual acuity in both eyes was 6/6p, color vision was normal in both eyes, central field was normal, intraocular pressure (IOP) was 13 mmHg in the right eye and 12 mmHg in the left eye, blood pressure (BP) was 130/80 mmHg, extraocular movements were full, pupil examination was unremarkable, anterior segment examination was within normal limit, and fundus examination revealed bilateral disc edema with splinter hemorrhages and obscuration of both temporal and nasal disc margins of Frisen grading of papilledema of stage II [Figure 1]. Routine blood investigations were within normal limits. On neuroimaging, magnetic resonance imaging (MRI) brain with orbit and magnetic resonance venography (MRV) revealed significant fluid surrounding the bilateral optic nerve sheath. CSF signal attenuation was noted inside the sella turcica, with the pituitary gland appearing to be compressed inferiorly, suggesting empty sella and hypoplastic left transverse sinus, which were all sugges tive of IIH [Figure 2]. Subsequent lumbar puncture revealed a CSF opening pressure of >30 cm H2O with normal CSF composition. IIH was diagnosed based on the modified Dandy's diagnostic criteria.[4] The antipsychotic drug risperidone was stopped after psychiatric consultation, and she was treated medically with oral acetazolamide 250 mg thrice daily for IIH as the initial management. On review, a month later, she was doing well with no headache or further loss of vision. | Figure 1: Fundus photographs showing grade II optic disc edema with peripapillary nerve fiber hemorrhages in both eyes (a and b). IIH = idiopathic intracranial hypertension
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 | Figure 2: Magnetic resonance imaging brain with orbit showing significant fluid surrounding the bilateral optic nerve sheath in the axial section (a); the pituitary gland appears to be compressed inferiorly, suggestive of empty sella in the sagittal section (b); and magnetic resonance venogram showing hypoplastic left transverse sinus (c)
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| Discussion | | |
IIH usually occurs in females of the reproductive age group (15–45 years). Many drugs such as tetracyclines, retinoids, growth hormones, oral contraceptive pills, Vitamin A, lithium, and danazol have been implicated in causing IIH. To date, risperidone causing IIH has only been reported in a few cases worldwide.[2],[3] Both genetic and nongenetic factors have been implicated in antipsychotic-related weight gain, but the precise biological mechanism is still unclear. Lane et al.[5] studied 15 genetic polymorphisms, such as 5-HT2A 102-T/C, 5-HT2C − 759-C/T, 5-HT6 267-C/T, BDNF 66-Val/Met, and CYP2D6 188-C/T, in schizophrenia patients taking risperidone and found that these genetic polymorphisms significantly induce weight gain. Some studies suggest that metabolic changes in insulin-sensitive tissues, such as antipsychotic-induced insulin resistance and increasing leptin in the body, can trigger sudden weight gain.[6],[7] A study conducted by Allison et al.[8] on 26 adults treated with risperidone revealed a mean weight gain of 2.1 kg in a 10-week period and concluded that risperidone is associated with rapid weight gain. Safer[9] and Hellings et al.[10] also found significant weight gain on taking risperidone; they also concluded that weight gain was more in younger age individuals than adults. The proposed mechanisms in various case reports demonstrate rapid weight gain, as seen in our case. Our patient had an acute increase in body weight of about 35 kg for 1 year. The association based on a few case reports is insufficient to support a causal relationship between risperidone and IIH. More descriptions of similar cases as well as longer follow-up are needed.
Simple bedside fundus examination in the setting of persistent headache is a simple method of rapidly detecting papilledema, and thus preventing subsequent visual morbidity.
Carbonic anhydrase inhibitors decrease CSF production by inhibiting the carbonic anhydrase enzyme in the choroid plexus. IIH is initially treated with carbonic anhydrase inhibitors such as acetazolamide and methazolamide and diuretics such as spironolactone, triamterene, chlorthalidone furosemide, and others to reduce the intracranial pressure. Among these, oral acetazolamide is the most commonly used drug (1–4 g/day in divided doses).[9],[10] Our case responded very well to oral acetazolamide 250 mg thrice daily for 1 month. Shunt procedures/bariatric surgery must be considered as a last resort. Ultimately, to improve long-term weight management, individual counseling linked to lifestyle modification with low-salt, low-calorie diet and regular exercise should be attempted to reduce weight.
Withdrawing the offending drug in addition to acetazolamide drastically improved her symptoms within a month, similar to other cases reported so far.
In this case, it is reasonable to consider that the patient's weight gain was an effect of risperidone drug.
| Conclusion | | |
Detailed drug history is thus very essential in every case of IIH because stopping the offending drug is a modifiable risk factor for treating IIH. Prolonged use of risperidone requires proper surveillance, and routine ophthalmologic examinations should be performed.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given her consent for her images and other clinical information to be reported in the journal. The patient understands that her name and initials will not be published and due efforts will be made to conceal her identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
| References | | |
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| 4. | Friedman DI, Jacobson DM. Diagnostic criteria for idiopathic intracranial hypertension. Neurology 2002;59:1492-5. |
| 5. | Lane HY, Liu YC, Huang CL, Chang YC, Wu PL, Lu CT, et al. Risperidone-related weight gain: Genetic and nongenetic predictors. J Clin Psychopharmacol 2006;26:128-34. |
| 6. | Lampl Y, Eshel Y, Kessler A, Fux A, Gilad R, Boaz M, et al. Serum leptin level in women with idiopathic intracranial hypertension. J Neurol Neurosurg Psychiatry 2002;72:642-3. |
| 7. | Burghardt KJ, Seyoum B, Mallisho A, Burghardt PR, Kowluru RA, Yi Z. Atypical antipsychotics, insulin resistance and weight; A meta-analysis of healthy volunteer studies. Prog Neuropsychopharmacol Biol Psychiatry. 2018;83:55-63. |
| 8. | Allison DB, Mentore JL, Heo M, Chandler LP, Cappelleri JC, Infante MC, et al. Antipsychotic-induced weight gain: A comprehensive research synthesis. Am J Psychiatry 1999;156:1686-96. |
| 9. | Safer DJ. A comparison of risperidone-induced weight gain across the age span. J Clin Psychopharmacol 2004;24:429-36. |
| 10. | Hellings JA, Zarcone JR, Crandall K, Wallace D, Schroeder SR. Weight gain in a controlled study of risperidone in children, adolescents and adults with mental retardation and autism. J Child Adolesc Psychopharmacol 2001;11:229-38. |
[Figure 1], [Figure 2]
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