Hipertensión intracraneal benigna. Experiencia en 18 años

Retinal hemorrhages due to intracranial hypertension, is it possible to differentiate them from those associated with abuse?

BACKGROUND

Retinal hemorrhages (RHs) are suggestive of abusive head trauma (AHT). Even so, controversy persists about other possible causes, a fact that hinders the diagnosis of abuse.

OBJECTIVE

To determine the prevalence and patterns of RHs associated with increased intracranial pressure (ICP) in young children.

PARTICIPANTS AND METHODS

Prospective, single center study of children aged 29 days-3 years undergoing a lumbar puncture with opening pressure (OP) measured during routine clinical care in the emergency department, over a 4-year period. Children with known causes of RHs were excluded. All the children underwent a detailed ophthalmological examination within 72 h of admission. For children with RHs, an in-depth investigation was carried out to rule out AHT.

RESULTS

Thirty-four patients were included: 20(58.8 %) were boys, median age 11.7 months (range 1-33 months). Overall, 29(85.3 %) had clinical findings of increased ICP. The duration of symptoms was ≤4 days in all patients except one, in whom it was 1.5 months. The median OP was 27cmH2O (range 20-60cmH2O). One of the children was found to have RHs, with evaluation resulting in a diagnosis of AHT. No RHs were found in any of the others studied. Using the Wilson method, we can be confident to an upper limit of 95 % that the probability of RHs occurring secondary to increased ICP alone is at most 0.1.

CONCLUSIONS

RHs were not detected in patients with isolated nontraumatic increased ICP, measured via OP and diagnosed in the ED. Therefore, if RHs are detected, investigation into the possibility of AHT is warranted.

Pseudo-Foster Kennedy syndrome due to idiopathic intracranial hypertension

Foster-Kennedy syndrome has been diagnosed as a direct compression of the optic nerve due to an expansive process that leads to atrophy. In the contralateral eye there is papillary oedema due to intracranial hypertension secondary to the tumour mass effect. The case is presented of a 12-year-old boy with overweight (BMI 26) with right eye papillary oedema and left optic nerve atrophy, that was casually found in an ophthalmological examination. He had no other symptomatology or personal medical history. The neurological examination was normal, and the urgent cranial computed tomography showed no masses. Lumbar puncture was performed with increased cerebrospinal fluid outflow resistance (28 cm H₂O). The rest of studies were normal. Until the appearance of neuroimaging, it was believed that Foster-Kennedy syndrome was pathognomonic of intracranial mass in the frontal area. Pseudo-Foster Kennedy syndrome due to idiopathic intracranial hypertension is very rare, and in the few cases that have been reported in the literature, up to 25% of them are asymptomatic.

[Idiopathic intracranial hypertension: Experience over 25 years and a management protocol]

INTRODUCTION

We present our experience on idiopathic intracranial hypertension (IIH), before and after the introduction of a specific diagnosis and management protocol.

METHOD

A descriptive retrospective study was conducted on patients with IIH over a 25year period (1990-2015), comparing the last 7years (after introduction of the protocol) with the previous 18years.

RESULTS

Among the 18,865 patients evaluated, there were 54 cases of IIH (29 infants and 25 children). A comparison was made between the two time periods: 32 cases in 1990-2008 -published in An Pediatr (Barc). 2009;71:400-6-, and 23 cases in 2008-2015. In post-protocol period, there were 13 patients aged between 3-10months (62% males) with transient bulging fontanelle, and 10 aged between 2-14years (50% males), with papilloedema. A total of 54% of infants had recently finished corticosteroid treatment for bronchitis. In the older children, there was one case associated with venous thrombosis caused by otomastoiditis, one case on corticosteroid treatment for angioma, and another case treated with growth hormone. Transfontanelle ultrasound was performed on all infants, and CT, MRI and angio-MRI was performed on every child. Lumbar puncture was performed on 2 infants in whom meningitis was suspected, and in all children. All patients progressed favourably, with treatment being started in 3 of them. One patient relapsed.

DISCUSSION

Characteristics and outcomes of patients overlap every year. IIH usually has a favourable outcome, although it may be longer in children than in infants. It can cause serious visual disturbances, so close ophthalmological control is necessary. The protocol is useful to ease diagnostic decisions, monitoring, and treatment.