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Masri A, Al Jaberi M, Shihadat R, Rayyan A, AlMasri M, Abuna'meh L, Ali M, Al Ryalat N, Hadidy A, Al-Shakkah AA. Pseudotumor cerebri syndrome in children: Clinical characteristic and re-classification. Brain Dev 2022; 44:446-453. [PMID: 35393129 DOI: 10.1016/j.braindev.2022.03.006] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/14/2022] [Revised: 03/14/2022] [Accepted: 03/22/2022] [Indexed: 11/28/2022]
Abstract
AIM To describe the clinical characteristics of children with pseudotumor cerebri syndrome (PTCS) who were diagnosed according to the modified Dandy criteria and to reclassify them according to the newly proposed diagnostic criteria by Freidman. METHODOLOGY This retrospective study included the period from January 2016-to July 2021. RESULTS 50 patients were included; 34 males and 16 females with a male to female ratio of 2.1:1. The average age at onset of symptoms was 8 years. Obesity was noticed in 6 (12%) patients; 34 (68%) had symptoms upon presentation. The most common presenting symptom was headache (28 patients; 56%), papilledema was present in 33 (66%) patients. Most patients (37; 74%) had an initial cerebrospinal fluid (CSF) pressure ≥280 mmH2O. At last follow-up, papilledema resolved in 11/32 (34.3%) patients, and headache resolved in 17/23 (74%) patients. 22/50 (44%) patients fulfilled the definite criteria proposed by Freidman, 11/50 (22%) fulfilled the probable, 10/50 (20%) were categorized as possible, and 7 (14%) patients were categorized as unmet. CONCLUSION PTCS is a chronic condition. Managing patients who do not have papilledema or who do not meet the newly proposed higher CSF pressure is challenging. Although, applying the newly proposed criteria captured most of our patients, however, around one quarter were managed based on clinical experience. This study indicates a strong need for future guidelines tailored specifically for children, taking into consideration that the cut-off point of CSF pressure might not be similar for all populations.
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Affiliation(s)
- Amira Masri
- Department of Paediatrics,division of child neurology , Faculty of Medicine, The University of Jordan.
| | | | | | | | | | - Lina Abuna'meh
- Department of Paediatrics,division of child neurology , Faculty of Medicine, The University of Jordan
| | - Majd Ali
- Department of Paediatrics,division of child neurology , Faculty of Medicine, The University of Jordan
| | - Nosaiba Al Ryalat
- Department of Radiology, Faculty of Medicine, The University of Jordan
| | - Azmy Hadidy
- Department of Radiology, Faculty of Medicine, The University of Jordan
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Boles S, Martinez-Rios C, Tibussek D, Pohl D. Infantile Idiopathic Intracranial Hypertension: A Case Study and Review of the Literature. J Child Neurol 2019; 34:806-814. [PMID: 31309848 DOI: 10.1177/0883073819860393] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
Idiopathic intracranial hypertension, or pseudotumor cerebri, is an increase in cerebrospinal fluid pressure of unknown etiology. It is mostly seen in adults, less frequently in adolescents, rarely in younger children. Only 5 infants meeting idiopathic intracranial hypertension criteria have been mentioned in the literature. We report a case of a previously healthy 9-month-old boy who presented with irritability, decreased appetite, and a bulging fontanelle. Computed tomography (CT) head imaging and cerebrospinal fluid studies revealed normal results. The patient's symptoms transiently resolved after the initial lumbar puncture, but 11 days later, his fontanelle bulged again. A second lumbar puncture revealed an elevated opening pressure of 35 cmH2O and led to a diagnosis of idiopathic intracranial hypertension in accordance with the modified Dandy Criteria. Treatment with acetazolamide at a dose of 25 mg/kg/d was initiated and the patient remained symptom-free for 6 weeks, followed by another relapse. His acetazolamide dose was increased to 37 mg/kg/d, with no further relapses to date. A diagnosis of idiopathic intracranial hypertension is challenging in infants, because the patients cannot yet verbalize typical idiopathic intracranial hypertension-related symptoms such as positional headaches, diplopia, or pulsatile tinnitus. Furthermore, it is more difficult to assess papilledema in that age group. If undetected and untreated, idiopathic intracranial hypertension may result in permanent visual deficits. Little is known about idiopathic intracranial hypertension in infants, and age-specific treatment guidelines are lacking. We discuss this rare case of infantile idiopathic intracranial hypertension and provide a review of the literature, including an overview of disease characteristics and outcomes of idiopathic intracranial hypertension in this very young age group.
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Affiliation(s)
- Sama Boles
- University of Ottawa, Ottawa, Ontario, Canada
| | - Claudia Martinez-Rios
- Department of Medical Imaging, Children's Hospital of Eastern Ontario, University of Ottawa, Ottawa, Ontario, Canada
| | - Daniel Tibussek
- Department of General Pediatrics, Neonatology and Pediatric Cardiology, University Children's Hospital, Heinrich-Heine-University, Düsseldorf, Germany
| | - Daniela Pohl
- Division of Neurology, Children's Hospital of Eastern Ontario, University of Ottawa, Ottawa, Ontario, Canada
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Maffeis L, Dilena R, Guez S, Menni F, Bana C, Osnaghi S, Carrabba G, Marchisio P. Pseudotumour cerebri associated with mycoplasma pneumoniae infection and treatment with levofloxacin: a case report. BMC Pediatr 2019; 19:4. [PMID: 30611233 PMCID: PMC6320575 DOI: 10.1186/s12887-018-1371-9] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2018] [Accepted: 12/13/2018] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND Idiopathic intracranial hypertension (IIH), also known as pseudotumour cerebri syndrome (PTCS), is characterized by the presence of signs and symptoms of raised intracranial pressure without evidence of any intracranial structural cause and with normal cerebrospinal fluid microscopy and biochemistry. Obesity, various systemic diseases and endocrine conditions, and a number of medications are known to be risk factors for PTCS. The medications commonly associated with PTCS are amiodarone, antibiotics, corticosteroids, cyclosporine, growth hormone, oral contraceptives, vitamin A analogues, lithium, phenytoin, NSAIDs, leuprolide acetate, and some neuroleptic drugs. In relation to antibiotics, quinolones may cause intracranial hypertension, and most reported cases of quinolone-induced intracranial hypertension were associated with nalidixic acid, ciprofloxacin, ofloxacin, or pefloxacin. Literature reports of levofloxacin-induced PTCS are rare. Some authors recently hypothesized that Mycoplasma pneumoniae may trigger PTCS. CASE PRESENTATION We report on a 14-year-old overweight White Italian boy who suffered headache, diplopia, and severe bilateral papilloedema after a Mycoplasma pneumoniae infection, exacerbated on levofloxacin intake. A spontaneous improvement in headache and a reduction in diplopia was seen during hospitalisation. Oral acetazolamide therapy led to the regression of papilloedema in about five months. No permanent eye damage has been observed in our patient to date. CONCLUSIONS PTCS pathophysiology may be multifactorial and its specific features and severity may be a consequence of both constitutional and acquired factors interacting synergistically. It may be useful for paediatricians to know that some antibiotics may have the potential to precipitate PTCS in patients who already have an increased CSF pressure due to a transitory imbalanced CSF circulation caused by infections such as Mycoplasma pneumoniae, with headache being the first and most sensitive, but also the least specific, symptom.
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Affiliation(s)
- Laura Maffeis
- Pediatric Highly Intensive Care Unit, Fondazione IRCSS Ca’ Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Robertino Dilena
- Service of Pediatric Neurophysiology , Unit of Clinical Neurophysiology, Fondazione IRCCS Ca’ Granda, Ospedale Maggiore Policlinico, Milan, Italy
| | - Sophie Guez
- Pediatric Highly Intensive Care Unit, Fondazione IRCSS Ca’ Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Francesca Menni
- Pediatric Highly Intensive Care Unit, Fondazione IRCSS Ca’ Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Cristina Bana
- Service of Pediatric Neurophysiology , Unit of Clinical Neurophysiology, Fondazione IRCCS Ca’ Granda, Ospedale Maggiore Policlinico, Milan, Italy
| | - Silvia Osnaghi
- Department of Ophthalmology, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Giorgio Carrabba
- Division of Neurosurgery, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Paola Marchisio
- Pediatric Highly Intensive Care Unit, Fondazione IRCSS Ca’ Granda Ospedale Maggiore Policlinico, and a Department of Pathophysiology and Transplantation, Università degli Studi di Milano, Milan, Italy
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Hamedani AG, Witonsky KFR, Cosico M, Rennie R, Xiao R, Sheldon CA, Paley GL, McCormack SE, Liu GW, Friedman DI, Liu GT, Szperka CL. Headache Characteristics in Children With Pseudotumor Cerebri Syndrome, Elevated Opening Pressure Without Papilledema, and Normal Opening Pressure: A Retrospective Cohort Study. Headache 2018; 58:1339-1346. [PMID: 30137653 DOI: 10.1111/head.13362] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2016] [Revised: 08/22/2016] [Accepted: 05/18/2018] [Indexed: 11/27/2022]
Abstract
BACKGROUND Certain headache characteristics and associated symptoms are commonly attributed to increased intracranial pressure, but they have not been systematically studied among children in the context of revised diagnostic criteria for pseudotumor cerebri syndrome (PTCS). METHODS We performed a retrospective cohort study of patients treated for suspected or confirmed PTCS. Charts were reviewed for PTCS and headache diagnostic criteria and associated characteristics. Chi-squared or Fisher's exact tests were used to compare the frequency of headache characteristics between groups. RESULTS One hundred and twenty-seven individuals were identified: 61 had definite PTCS, 10 had probable PTCS, 31 had elevated opening pressure (OP) without papilledema, and 25 had normal OP without papilledema. Eleven children had no headache (6 with definite PTCS, 5 with probable PTCS). Headache pattern was episodic in 49% (95% CI: 34-64%) of those with definite PTCS, 18% (95% CI 6-37%) of those with elevated OP without papilledema, and 16% (5-36%) of those with normal OP without papilledema. Headache location was more likely to involve the head along with neck or shoulders in those with definite PTCS compared with elevated OP without papilledema (OR = 7.2, 95% CI: 1.9-27.6) and normal OP (OR = 4.5, 95% CI: 1.3-15.6) groups. DISCUSSION While missing data and small cohort size are limitations, this study suggests that headache in PTCS is more likely to involve the head along with neck/shoulders, and that headache in PTCS may be episodic or constant. Headache is occasionally absent in PTCS.
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Affiliation(s)
- Ali G Hamedani
- Department of Neurology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Kailyn F R Witonsky
- Division of Neurology, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Mahgenn Cosico
- Division of Neurology, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Robert Rennie
- Division of Neurology, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Riu Xiao
- Department of Biostatistics and Epidemiology, University of Pennsylvania, Philadelphia, PA, USA
| | - Claire A Sheldon
- Neuro-Ophthalmology Service, Division of Ophthalmology, Children's Hospital of Philadelphia, Philadelphia, PA, USA.,Department of Ophthalmology & Visual Sciences, University of British Columbia, Vancouver, CA, Canada
| | - Grace L Paley
- Neuro-Ophthalmology Service, Division of Ophthalmology, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Shana E McCormack
- Division of Endocrinology & Diabetes, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Geraldine W Liu
- Division of Neurology, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Deborah I Friedman
- Department of Neurology & Neurotherapeutics, University of Texas Southwestern Medical Center, Dallas, TX, USA.,Department of Ophthalmology, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Grant T Liu
- Department of Neurology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA.,Neuro-Ophthalmology Service, Division of Ophthalmology, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Christina L Szperka
- Department of Neurology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA.,Division of Neurology, Children's Hospital of Philadelphia, Philadelphia, PA, USA
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Evidence of Diplopia in Children's Headache Drawings Helps to Differentiate Pseudotumor Cerebri From Migraine. Pediatr Neurol 2018; 79:40-44. [PMID: 29413638 DOI: 10.1016/j.pediatrneurol.2017.10.020] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/14/2017] [Revised: 10/17/2017] [Accepted: 10/29/2017] [Indexed: 02/04/2023]
Abstract
OBJECTIVE This study aimed to determine whether children's headache drawings can distinguish between pseudotumor cerebri and migraine. BACKGROUND Headache features associated with pseudotumor cerebri (pseudotumor; idiopathic intracranial hypertension) are nonspecific and are difficult to distinguish clinically from migraines. Children's headache drawings have a high predictive value for migraine versus nonmigraine headaches. We hypothesized that drawings could help to differentiate pediatric headaches due to pseudotumor cerebri from those associated with migraines. METHODS Children aged six to 18 years old attending university hospital pediatric neurology clinics were asked to draw a picture of how their headache feels. From our database of children's headache drawings, pictures by children with clinically diagnosed pseudotumor were compared with migraine drawings. RESULTS Headache drawings of 21 children (16 females) with pseudotumor were compared with those of 518 children with migraine. Pseudotumor drawings depicted a variety of symptoms including pounding pain (n = 11), pressure-like pain (n = 3), photophobia (3), dizziness (1), and recumbency (1). Severe pain indicators included hammers, bombs, anvil, and vise grip. Positive visual phenomena included scintillations, scotomata, or blurring (n = 8). Negative visual phenomena included field defects (n = 2). Pseudotumor drawings were similar to migraine drawings except that 6 of 21 pseudotumor drawings (28.6%) depicted diplopia (crossed eyes, double images), whereas only three of 518 migraine drawings (0.6%) depicted diplopia (P < 0.000001). CONCLUSIONS Diplopia was depicted in a significantly higher percentage of pseudotumor drawings than migraine drawings. In all other respects, headache drawings by children with pseudotumor cerebri were similar to those drawn by children with migraine.
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Cleves-Bayon C. Idiopathic Intracranial Hypertension in Children and Adolescents: An Update. Headache 2017; 58:485-493. [DOI: 10.1111/head.13236] [Citation(s) in RCA: 31] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2017] [Accepted: 10/31/2017] [Indexed: 12/14/2022]
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Babiker MOE. How high is a 'high' CSF opening pressure in paediatric pseudotumor cerebri? Eur J Paediatr Neurol 2017; 21:248-249. [PMID: 28187821 DOI: 10.1016/j.ejpn.2017.01.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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