Sensitivity of papilledema as a sign of shunt failure in children

Long-term sequelae of normocephalic pansynostosis: a rare but insidious entity

OBJECTIVE

Patients with normocephalic pansynostosis, who have a grossly normal head shape, are often overlooked early in life and present late with elevated intracranial pressure (ICP) requiring timely cranial vault expansion. This study evaluates the long-term clinical outcomes of patients with normocephalic pansynostosis.

METHODS

We retrospectively reviewed patients with a clinical and radiographic diagnosis of primary pansynostosis who underwent vault reconstruction between 2000 and 2023. Clinical and treatment course after craniofacial interventions was followed in patients with normocephaly to assess outcomes.

RESULTS

Thirty-five patients with primary pansynostosis were identified, of which eight (23.5%) had normocephaly and underwent initial vault expansion at a mean age of 5.0 ± 2.4 years. All eight patients (50.0% male) presented with symptoms of elevated ICP including headaches (50.0%), nausea and vomiting (50.0%), and developmental delay (62.5%) and/or signs of elevated ICP including papilledema (75.0%) and radiologic thumbprinting on head computed tomography scan (87.5%). Three of the four normocephalic patients who had over 7 years of postoperative follow-up developed subjective headaches, vision changes, or learning and behavioral issues in the long-term despite successful vault reconstruction.

CONCLUSIONS

Our longitudinal experience with this rare but insidious entity demonstrates the importance of timely intervention and frequent postoperative monitoring, which are critical to limiting long-term neurological sequelae. Multidisciplinary care by craniofacial surgery, neurosurgery, ophthalmology, and neuropsychology with follow-up into adolescence are recommended to assess for possible recurrence of elevated ICP secondary to cranio-cerebral disproportion.

Intracranial Pressure Patterns in Children with Sagittal Craniosynostosis

BACKGROUND

Elevated intracranial pressure (ICP) in sagittal craniosynostosis has a wide spectrum of reported incidence, and patterns are not well understood across infancy and childhood. Characterizing the natural history of ICP in this population may clarify risks for neurocognitive delay and inform treatment decisions.

METHODS

Infants and children with sagittal craniosynostosis and unaffected control subjects were prospectively evaluated with spectral-domain optical coherence tomography from 2014 to 2021. Elevated ICP was determined based on previously validated algorithms using retinal optical coherence tomography parameters.

RESULTS

Seventy-two patients with isolated sagittal craniosynostosis and 25 control subjects were evaluated. Overall, 31.9% ( n = 23) of patients with sagittal craniosynostosis had evidence of ICP greater than or equal to 15 mmHg, and 27.8% ( n = 20) of patients had ICP greater than or equal to 20 mmHg. Children with sagittal craniosynostosis younger than 6 months were more likely to have normal ICP (88.6% <15 mmHg; 91.4% <20 mmHg) than those aged between 6 and 12 months (54.5%, P = 0.013; 54.5%, P = 0.005) than those older than 12 months (46.2%, P < 0.001; 53.8%, P = 0.001). ICP was directly correlated with severity of scaphocephaly ( P = 0.009). No unaffected control subjects at any age exhibited retinal thickening suggestive of elevated ICP.

CONCLUSION

Elevated ICP is rare in isolated sagittal craniosynostosis younger than 6 months, but it becomes significantly more common after 6 months of age, and may correlate with severity of scaphocephaly.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Risk, II.

Transorbital point-of-care ultrasound versus fundoscopic papilledema to support treatment indication for potentially elevated intracranial pressure in children

PURPOSE

To compare transorbital point-of-care ultrasound techniques -optic nerve sheath diameter (US-ONSD) and optic disc elevation (US-ODE)- with fundoscopic papilledema to detect potentially raised intracranial pressure (ICP) with treatment indication in children.

METHODS

In a prospective study, 72 symptomatic children were included, 50 with later proven disease associated with raised ICP (e.g. pseudotumour cerebri, brain tumour, hydrocephalus) and 22 with pathology excluded. Bilateral US-ONSD and US-ODE were quantified by US using a 12-MHz-linear-array transducer. This was compared to fundoscopic optic disc findings (existence of papilledema) and, in 28 cases, invasively measured ICP values.

RESULTS

The sensitivity and specificity of a cut-off value of US-ONSD (5.73 mm) to detect treatment indication for diseases associated with increased ICP was 92% and 86.4%, respectively, compared to US-ODE (0.43 mm) with sensitivity: 72%, specificity: 77.3%. Fundoscopic papilledema had a sensitivity of 46% and a specificity of 100% in this context. Repeatability and observer-reliability of US-ODE examination was eminent (Cronbach's α = 0.978-0.989). Papilledema was detected fundoscopically only when US-ODE was > 0.67 mm; a US-ODE > 0.43 mm had a positive predictive value of 90% for potentially increased ICP.

CONCLUSION

In our cohort, transorbital point-of-care US-ONSD and US-ODE detected potentially elevated ICP requiring treatment in children more reliably than fundoscopy. US-ONSD and US-ODE indicated the decrease in ICP after treatment earlier and more reliably than fundoscopy. The established cut-off values for US-ONSD and US-ODE and a newly developed US-based grading of ODE can be used as an ideal first-line screening tool to detect or exclude conditions with potentially elevated ICP in children.

Non-Invasive Quantitative Approximation of Intracranial Pressure in Pediatric Idiopathic Intracranial Hypertension Based on Point-of-Care Ultrasound of the Optic Nerve Sheath Diameter

BACKGROUND

To investigate whether ultrasound-based optic nerve sheath diameter (US-ONSD) is a reliable measure to follow up children with idiopathic intracranial hypertension (IIH). In addition, to analyze the inter- and intra-individual relationships between US-ONSD and intracranial pressure (ICP), and to investigate whether an individualized mathematical regression equation obtained from two paired US-ONSD/ICP values can be used to approximate ICP from US-ONSD values.

METHODS

159 US examinations and 53 invasive ICP measures via lumbar puncture (LP) were performed in 28 children with IIH. US-ONSD was measured using a 12 Mhz linear transducer and compared to ICP values. In 15 children, a minimum of 2 paired US-ONSD/ICP determinations were performed, and repeated-measures correlation (rmcorr) and intra-individual correlations were analyzed.

RESULTS

The cohort correlation between US-ONSD and ICP was moderate (r = 0.504, p < 0.01). Rmcorr (r = 0.91, p < 0.01) and intra-individual correlations (r = 0.956-1) of US-ONSD and ICP were excellent. A mathematical regression equation can be calculated from two paired US-ONSD/ICP values and applied to the individual patient to approximate ICP from US-ONSD.

CONCLUSIONS

Related to excellent intra-individual correlations between US-ONSD and ICP, an individualized regression formula, created from two pairs of US-ONSD/ICP values, may be used to directly approximate ICP based on US-ONSD values. Hence, US-ONSD may become a non-invasive and reliable measure to control treatment efficacy in pediatric IIH.

Influence of sex and disease etiology on the development of papilledema and optic nerve sheath extension in the setting of intracranial pressure elevation in children

Introduction

Dilatation of the optic nerve sheath diameter and swelling of the optic disc are known phenomena associated with intracranial pressure elevation.

Research question

Do sex and disease etiology have an impact on the development of optic disc elevation and optic nerve sheath extension in children in the setting of ICP elevation? Fundoscopic papilledema and point-of-care-ultrasound techniques-optic nerve sheath diameter (US-ONSD) and optic disc elevation (US-ODE) - were compared in this regard.

Material and methods

72 children were included in this prospective study; 50 with proven pathology (e.g. pseudotumor cerebri, tumor), 22 with pathology excluded. Bilateral US-ONSD and US-ODE were quantified by US using a 12-MHz-linear-array-transducer. This was compared with fundoscopic optic disc findings and in 28 patients with invasive ICP values, stratified for sex and etiology.

Results

In patients with proven disease, significant more girls (69%) had fundoscopic papilledema compared with boys (37%, p < 0.05). Girls had also larger US-ODE values (0.86 ± 0.36 mm vs. 0.65 ± 0.40 mm in boys). 80% of tumor patients had initial papilledema (100% girls, 79% boys), compared with 50% in pseudotumor cerebri (PTC) (83% girls, 30% boys). US-ONSD had no sex- and no etiology-specificity.

Discussion and conclusion

Presence of papilledema appears to be influenced by sex and etiology, whereas US-ONSD is not. Girls seem more likely to develop papilledema under similar conditions. Male sex and PTC appear as risk factors for being undetected by fundoscopic findings. US-ONSD and US-ODE seem useful tools to identify pathologies with potentially increased ICP requiring treatment in children regardless of sex and etiology.

Sensitivity of Papilledema as a Sign of Increased Intracranial Pressure

Our study evaluates the sensitivity of papilledema as a sign of high intracranial pressure in children. Patients younger than 18 years old, diagnosed with increased ICP, and who had received dilated fundus examination between 2019 and 2021 were retrospectively reviewed. Factors including the patient's age, sex, aetiology, duration of signs or symptoms, intracranial pressure (ICP), and presence of papilledema were evaluated. We included 39 patients in this study, whose mean age was 6.7 years. The 31 patients without papilledema had a mean age of 5.7 years, and 8 patients (20%) with papilledema had a mean age of 10.4 (p < 0.037). The mean duration of signs or symptoms was nine weeks in patients without papilledema and seven weeks in those with papilledema (p = 0.410). The leading causes of increased ICP with papilledema were supratentorial tumor (12.5%), infratentorial tumor (33.3%), and hydrocephalus (20%) (p = 0.479). Papilledema was statistically significantly more common in older patients. We found no statistical significance between sex, diagnosis, and symptoms. The relatively low incidence of papilledema (20%) in our study shows that papilledema's absence does not ensure the absence of increased ICP, especially in younger patients.

Early and long-term skull growth after surgical correction for sagittal synostosis in relation to the occurrence of papilledema

OBJECTIVE

Stagnation of skull growth is correlated with papilledema in craniosynostosis. In this retrospective cohort study, we describe the postoperative skull growth after surgical correction for sagittal synostosis and its relation to the development of papilledema.

METHODS

Patients with isolated sagittal synostosis at our center between 2005 and 2012 were included. Occipitofrontal circumference (OFC) was analyzed, at 3 time points (preoperative, 2 years postoperative, and last OFC measurement) and 3 phases (initial postoperative growth, long-term growth, and overall growth), and related to papilledema on fundoscopy.

RESULTS

In total, 163 patients were included. The first time interval showed a decline in skull growth, with subsequent stabilization at long term. Papilledema occurred postoperatively in 10 patients. In these patients, the OFC at 2 years and at last follow-up (T3) were significantly smaller than in patients without papilledema. A larger OFC resulted in a decreased odds of developing papilledema at both postoperative time points (at T2 (OR = 0.40, p = 0.01) and at T3 (OR 0.29, p < 0.001)). Sensitivity and specificity analysis indicated that an OFC below 0.25 SD at T2 (sensitivity 90%, specificity 65%) and below 0.49 at T3 (sensitivity 100%, specificity 60%) are related to the occurrence of papilledema.

CONCLUSION

A small OFC is correlated with the occurrence of papilledema. A decline in OFC within 2 years postoperatively is common in sagittal synostosis and is acceptable up to a value of 0.25SD. Patients with an OFC at last follow-up of less than 0.5SD are at risk for developing papilledema.

Ophthalmological Evaluation in Children Presenting With a Primary Brain Tumor

BACKGROUND

Children with a brain tumor are prone to develop visual impairment, which to date is often underestimated and unrecognized. Our aim was to assess the prevalence of ophthalmological evaluation and abnormal ophthalmological findings, and investigate whether demographic and tumor-related characteristics are associated with abnormal ophthalmological findings in children presenting with a primary brain tumor.

METHODS

Medical records of all 90 children diagnosed with a primary brain tumor between June 2018 and May 2019 and treated at the Princess Máxima Center for Pediatric Oncology, a tertiary referral center in the Netherlands, were retrospectively reviewed. Univariate regression analysis was used to investigate associations between demographic, tumor-related and clinical characteristics, and abnormal ophthalmological findings.

RESULTS

Sixty children (34 male [56.7%]; median [range] age, 9.3 [0-16.9] years) underwent ophthalmological evaluation within 6 weeks before or after diagnosis, 11 children (5 male [45.5%]; median [range] age, 5.7 [0.1-17.2] years) were seen more than 6 weeks before or after diagnosis, and 19 children (7 male [36.8%]; median [range] age, 7.2 [1.9-16.6] years) did not receive ophthalmological evaluation within at least 6 months from diagnosis. A total of 19 children (21.1%) presented with visual symptoms as first sign leading to the diagnosis of a brain tumor. Children who presented with visual symptoms (odds ratio [OR], 22.52; 95% confidence interval [CI], 4.90-103.60) and/or hydrocephalus (OR, 3.60; 95% CI, 1.38-9.36) at diagnosis were more often seen for ophthalmological evaluation. The most common abnormal ophthalmological findings were eye movement disorders (66.0%), papilledema (44.1%), and visual field defects (58.1%). Eye movement disorders occurred more frequently in patients with an infratentorial tumor (OR, 4.71; 95% CI, 1.03-21.65). The risk of papilledema was associated with older age (OR, 1.19; 95% CI, 1.05-1.34), hydrocephalus (OR, 9.63; 95% CI, 2.68-34.61), and infratentorial (OR, 9.11; 95% CI, 1.77-46.78) and supratentorial (OR, 13.13; 95% CI, 1.92-89.52) tumors.

CONCLUSIONS

In this study, most children with a primary brain tumor underwent ophthalmological evaluation around diagnosis, 21% of the children were not evaluated. The high prevalence of abnormal ophthalmological findings stresses the importance of early standardized ophthalmological evaluation to detect visual impairment and provide timely treatment to potentially prevent permanent visual loss.

Escape from Prism

A 14-year-old boy with a history of shunted congenital hydrocephalus began having headaches with nausea and vomiting after transcontinental flights. He gradually developed horizontal diplopia indicative of mild bilateral sixth nerve palsy, without papilledema or ventriculomegaly. Intracranial pressure monitoring showed no signs of elevation. After he subsequently developed papilledema, surgical exploration showed shunt malfunction, and shunt replacement produced rapid resolution of symptoms. This case demonstrates the importance of relying on clinical history and neuro-ophthalmologic examination in patients with hydrocephalus and suspected shunt failure, even when objective confirmatory evidence of intracranial pressure elevation is lacking.

Resolution of Papilledema Following Ventriculoperitoneal Shunt or Endoscopic Third Ventriculostomy for Obstructive Hydrocephalus: A Pilot Study

Background and Objectives: Ventriculoperitoneal Shunt (VPS) and Endoscopic Third Ventriculostomy (ETV) are both gold standard procedures to reduce intracranial pressure (ICP) in patients with obstructive hydrocephalus, which often results in papilledema. This comparative study was carried out at the Department of Neurosurgery of Dhaka Medical College and Hospital to compare the efficacy of VPS and ETV in the resolution of papilledema in 18 patients with obstructive hydrocephalus. Materials and Methods: The success of CSF diversion was evaluated by a decrease in retinal nerve fiber layer (RNFL) thickness by optical coherence tomography (OCT) and modified Frisen grading of papilledema at the same time. The statistical analyses were carried out by using paired sample t test and the Spearman’s correlation coefficient test. The level of significance (p value) was set at <0.05. Results: After 7 days, both VPS and ETV were able to reduce RNFL thickness of both eyes with a p value = 0.016 (right eye) and 0.003 (left eye) in group A (VPS) and with a p value <0.001 (both eyes) in group B (ETV). Change of Frisen grading after CSF diversion was not satisfying for both the procedures with p value > 0.05. Further, the inter-group comparison between VPS and ETV showed no difference in decreasing RNFL thickness and modified Frisen grading (p value = 0.56). Conclusion: VPS and ETV procedures both appear very efficient in treating obstructive hydrocephalus, which in turn reduces papilledema in these patients. This paper is preliminary and requires further work.

Elevated Intracranial Pressure in Patients with Craniosynostosis by Optical Coherence Tomography

BACKGROUND

Craniosynostosis may lead to elevated intracranial pressure, which may be implicated with impaired neurocognitive development. However, accurately measuring intracranial pressure is challenging, and patterns in craniosynostosis patients are poorly characterized. Spectral-domain optical coherence tomography may enable noninvasive assessment of intracranial pressure in pediatric patients with craniosynostosis.

METHODS

Pediatric patients with craniosynostosis undergoing surgical intervention between 2014 and 2019 prospectively underwent optical coherence tomographic evaluation. Intracranial pressure was directly measured intraoperatively in a subset of cases. Optical coherence tomographic parameters were compared to directly measured intracranial pressure and used for pattern assessment.

RESULTS

Optical coherence tomography was performed in 158 subjects, among which 42 underwent direct intracranial pressure measurement during an initial cranial procedure. Maximal retinal nerve fiber layer thickness, maximal retinal thickness, and maximal anterior projection optical coherence tomographic parameters were positively correlated with intracranial pressure (p ≤ 0.001), with all parameters showing significantly higher values in patients with intracranial pressure thresholds of 15 mmHg (p < 0.001) and 20 mmHg (p ≤ 0.007). Patients with maximal retinal nerve fiber layer thickness and maximal anterior projection exceeding set thresholds in optical coherence tomography of either eye demonstrated 77.3 percent sensitivity and 95.0 percent specificity for detecting intracranial pressure above 15 mmHg, and 90.0 percent sensitivity and 81.3 percent specificity for detecting intracranial pressure above 20 mmHg. Patients with associated syndromes or multiple suture involvement and patients aged 9 months or older were significantly more likely to have elevated intracranial pressure above 15 mmHg (p ≤ 0.030) and above 20 mmHg (p ≤ 0.035).

CONCLUSIONS

Spectral-domain optical coherence tomography can noninvasively detect elevated intracranial pressure in patients with craniosynostosis with reliable sensitivity and specificity. This technology may help guide decisions about the appropriate type and timing of surgical treatment.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Diagnostic, I.

Ophthalmological findings in children with non-syndromic craniosynostosis: preoperatively and postoperatively up to 12 months after surgery

Aims

Craniosynostosis is a congenital condition characterised by premature fusion of one or more cranial sutures. The aim of this study was to analyse ophthalmic function before and after cranial surgery, in children with various types of non-syndromic craniosynostosis.

Methods

Children referred to Uppsala University Hospital for surgery of non-syndromic craniosynostosis were examined preoperatively. Visual acuity was measured with Preferential Looking tests or observation of fixation and following. Strabismus and eye motility were noted. Refraction was measured in cycloplegia and funduscopy was performed. Follow-up examinations were performed 6–12 months postoperatively at the children’s local hospitals.

Results

One hundred twenty-two children with mean age 6.2 months were examined preoperatively. Refractive values were similar between the different subtypes of craniosynostosis, except for astigmatism anisometropia which was more common in unicoronal craniosynostosis. Strabismus was found in seven children, of which four had unicoronal craniosynostosis.

Postoperatively, 113 children were examined, at mean age 15.9 months. The refractive values decreased, except for astigmatism and anisometropia in unicoronal craniosynostosis. Strabismus remained in unicoronal craniosynostosis. Two new cases with strabismus developed in unicoronal craniosynostosis and one in metopic, all operated with fronto-orbital techniques. No child had disc oedema or pale discs preoperatively or postoperatively.

Conclusion

Ophthalmic dysfunctions were not frequent in children with sagittal craniosynostosis and preoperative ophthalmological evaluation may not be imperative. Children with unicoronal craniosynostosis had the highest prevalence of strabismus and anisometropia. Fronto-orbital techniques used to address skull deformity may be related to a higher prevalence of strabismus postoperatively.

OS reboot

Cerebrospinal fluid (CSF) diversion or shunting procedures are the most commonly performed surgery for the treatment of hydrocephalus and are often employed in the management of elevated intracranial pressure due to a variety of diseases. Despite their popularity however, approximately 50% of shunts fail within the first two years, and several revisions are required within the first decade after placement. Ophthalmologists may encounter patients with a CSF shunt to evaluate for concerns of vision loss or diplopia and to determine if papilledema is present. We discuss the neuro-ophthalmic manifestations and evaluation of possible CSF shunt malfunction.

Intracranial pressure patterns in children with craniosynostosis utilizing optical coherence tomography

BACKGROUND

Better understanding the incidence and patterns of elevated intracranial pressure (ICP) in patients with craniosynostosis may facilitate more timely intervention to alter neurocognitive outcomes. Spectral-domain optical coherence tomography (OCT) of the retina can non-invasively diagnose elevated ICP, and has demonstrated high sensitivity and specificity among patients with craniosynostosis. This study sought to characterize patterns of elevated ICP among patients with craniosynostosis.

METHODS

Quantitative retinal parameters were prospectively assessed in both eyes of patients with craniosynostosis using spectral-domain OCT. Based on retinal OCT thresholds associated with elevated ICP (> 15 mmHg), subjects were assigned an OCT diagnosis of elevated or non-elevated ICP which was analyzed relative to clinical characteristics and craniosynostosis patterns.

RESULTS

Eighty subjects (aged 0.2-18 years) with craniosynostosis were enrolled; among these, 67 (84%) were nonsyndromic. OCT evaluation was performed at initial vault expansion in 56 (70%) patients. Among this subset, 27 (48%) patients had peri-papillary changes suggestive of elevated ICP, reflecting a 44% incidence in nonsyndromic and 83% in syndromic patients. The median age at initial vault expansion was higher among those with elevated ICP (11.1 months) than those without (7.8 months; p = 0.04.) Multi-suture synostosis was associated with changes consistent with elevated ICP in 9 (75%) patients compared with 18 (41%) with single suture synostosis (p = 0.05).

CONCLUSIONS

OCT of the retina produces a potentially sensitive indicator of ICP in craniosynostosis patients. Elevated ICP may be associated with number of involved sutures and older patient presentation, and refining appropriate "cutoffs" will be important as the technology becomes more widespread.

Retinal Findings in Young Children With Increased Intracranial Pressure From Nontraumatic Causes

OBJECTIVES

Increased intracranial pressure (ICP) has been suggested in legal settings as an alternative cause of retinal hemorrhages (RHs) in young children who may have sustained abusive head trauma. We assessed the prevalence and characteristics of RHs in children with increased ICP.

METHODS

We conducted a prospective, multicenter study of children <4 years old with newly diagnosed increased ICP as determined by using direct measurement and/or clinical criteria. Infants who were premature, neonates, and suspected survivors of abusive head trauma were excluded on the basis of nonocular findings. Fundus examinations were performed; extent, number, and type of RH in each of 4 distinct retinal zones were recorded.

RESULTS

Fifty-six children (27 boys) were studied (mean age 15.4 months; range 1-43 months). All of the children had elevated ICP that required intervention. One child had papilledema. No child (0%; 95% confidence interval: 0%-6.4%) or eye (0%; 95% confidence interval: 0%-3.3%) was found to have an RH. Causes of increased ICP included hydrocephalus, intraventricular hemorrhage, congenital malformations, malfunctioning shunts, and the presence of intracranial space-occupying lesions.

CONCLUSIONS

Although acute increased ICP can present in children with a pattern of peripapillary superficial RHs in the presence of papilledema, our study supports the conclusion that RHs rarely occur in the absence of optic disc swelling and do not present beyond the peripapillary area in the entities we have studied.

Intraoperative intracranial pressure monitoring in the pediatric craniosynostosis population

OBJECTIVEEvaluation of increased intracranial pressure (ICP) in the pediatric craniosynostosis population based solely on ophthalmological, clinical, and radiographic data is subjective, insensitive, and inconsistent. The aim of this study was to examine the intraoperative ICP before and after craniectomy in this patient population.METHODSThe authors measured the ICP before and after craniectomy using a subdural ICP monitor in 45 children. They regulated end-tidal carbon dioxide and the monitoring site under general anesthesia to record consistent ICP readings.RESULTSThe average age of the patient population was 29 months (range 3.8-180.5 months). Thirty-seven patients (82.2%) were undergoing initial craniosynostosis procedures. All craniosynostosis procedures were categorized as one of the following: frontoorbital advancement (n = 24), frontoorbital advancement with distraction osteogenesis (n = 1), posterior vault distraction osteogenesis (n = 10), and posterior vault reconstruction (n = 10). Nineteen of 45 patients (42.2%) had syndromic or multisuture craniosynostosis. The mean postcraniectomy ICP (8.8 mm Hg, range 2-18 mm Hg) was significantly lower than the precraniectomy ICP (16.5 mm Hg, range 6-35 mm Hg) (p < 0.001). Twenty-four patients (53%) had elevated ICP prior to craniectomy, defined as ≥ 15 mm Hg. Only 4 (8.9%) children had papilledema on preoperative funduscopic examination (sensitivity 17%, specificity 100%, negative predictive value 51%, and positive predictive value 100%). There were no significant differences in elevated precraniectomy ICP based on type of craniosynostosis (syndromic/multisuture or nonsyndromic) or age at the time of surgery. Patients undergoing initial surgery in the first 12 months of life were significantly less likely to have elevated precraniectomy ICP compared with patients older than 12 months (26.3% vs 73.1%, p = 0.005).CONCLUSIONSIn this study, the authors report the largest cohort of syndromic and nonsyndromic craniosynostosis patients (n = 45) who underwent precraniectomy and postcraniectomy ICP evaluation. A craniectomy or completed craniotomy cuts for distractors effectively reduced ICP in 43/45 patients. The authors' findings support the notion that papilledema on funduscopy is a highly specific, however poorly sensitive, indicator of increased ICP, and thus is not a reliable screening method. These findings indicate that even nonsyndromic patients with craniosynostosis are at risk for increased ICP. Furthermore, patients who present prior to 12 months of age appear less likely to have elevated ICP on presentation. Further studies with other noninvasive imaging of the retina may be useful as an adjunct tool for determining elevated ICP.

Retinal Hemorrhages: Abusive Head Trauma or Not?

Abusive head trauma is an important cause of morbidity and mortality in infants and young children. Retinal hemorrhages (RHs) are frequently seen, particularly during dilated eye examination of these children. This review focuses on the evaluation of children with RH, with emphasis on the differential diagnosis, pathophysiology, and distinguishing features of RHs due to abusive head trauma. Many causes exist for RHs in infants and children. Most medical and accidental traumatic causes result in a pattern of RH that is nonspecific and not typical of the pattern and distribution of RHs seen in children with abusive head trauma. In children with intracranial hemorrhage and concerns for abuse, the finding of severe, multilayered RHs extending to the periphery of the retina is very specific for abuse as the cause of the findings, especially if retinoschisis is present. There are few other accidental traumatic mechanisms associated with retinoschisis, and the history of such a traumatic event is readily apparent. The indications for ophthalmologic consult, optimal timing of the eye examination, and significance of the findings are specifically discussed.

Identification of Optic Nerve Swelling Using Point-of-Care Ocular Ultrasound in Children

OBJECTIVE

The aim of this study was to determine the feasibility and accuracy of point-of-care (POC) ocular ultrasound (US) when performed by a pediatric emergency medicine (PEM) physician to detect optic nerve abnormalities concerning for swelling, as compared with the fundus examination performed by an ophthalmologist.

METHODS

This was a single-center, prospective cohort pilot study of children aged 12 months to 18 years who required optic disc evaluation by an ophthalmologist. Eligible subjects were enrolled from the emergency department, inpatient wards, and neuro-ophthalmology outpatient clinic of an urban, tertiary care children's hospital. Point-of-care ocular US, specifically assessing optic nerve sheath diameter and optic disc elevation, was performed. Findings on US were compared with findings identified by an ophthalmologist on dilated fundus examination.

RESULTS

Seventy-six subjects were enrolled; 20 (26%) of 76 had findings concerning for optic nerve swelling diagnosed by an ophthalmologist on fundus examination. Using a sonographic definition for optic nerve swelling of optic nerve sheath diameter greater than 4.5 mm or the presence of optic disc elevation, the sensitivity and specificity were 90% and 55%, respectively. The success rate of POC ocular US was 100%, and the mean time to completion was 8 minutes. For emergency department subjects in whom direct fundus examination was attempted, the PEM physician could visualize the optic disc and assess for swelling in only 40% (14/35) of examinations.

CONCLUSIONS

The results of our study suggest that POC ocular US performed by PEM physicians was feasible and determined to be sensitive but nonspecific in the detection of optic nerve swelling. Additional larger studies may determine generalizability to other nonophthalmologist physicians performing POC ocular US.

How to use…the direct ophthalmoscope

Ophthalmoscopy and red reflex examination are core medical skills required to identify sight-threatening and life-threatening disease. We discuss the predictive utility and limitations of findings with an ophthalmoscope and tips as to how to optimise these. We outline important considerations in three clinical scenarios: an abnormal red reflex, an abnormal optic disc and retinal haemorrhages in the context of child protection concerns.

Papilledema in children with hydrocephalus: incidence and associated factors

OBJECTIVE The aim of this study was to report the incidence of and the factors associated with papilledema in children with hydrocephalus. METHODS Patients younger than 15 years of age who had been diagnosed with hydrocephalus and treated by extra-ventricular drainage or ventriculoperitoneal shunt surgery between 2005 and 2015 were retrospectively reviewed. Factors including patient age and sex, etiology of hydrocephalus, duration of signs or symptoms, intracranial pressure (ICP), and presence of papilledema were evaluated. RESULTS Forty-six patients, whose mean age was 6.3 ± 4.7 years, were included in the study. The 19 patients without papilledema had a mean age of 2.7 ± 2.7 years, and the 27 patients with papilledema had a mean age of 8.8 ± 4.2 years (p < 0.001). The mean ICP was 19.9 ± 10.0 cm H₂O among those without papilledema and 33.3 ± 9.1 cm H₂O among those with papilledema (p < 0.001). The mean duration of signs or symptoms was 3.0 ± 4.6 months in the patients without papilledema and 3.4 ± 3.9 months in those with papilledema (p = 0.704). The patients with papilledema were older and presented with higher ICP than those without. The causes of hydrocephalus were tumor (59%), congenital anomaly (19%), hemorrhage (13%), and infection (9%). CONCLUSIONS Papilledema was more common in patients who were older, who had higher ICP, and whose hydrocephalus had been induced by brain tumor. However, since papilledema was absent in 41% of the children with hydrocephalus, papilledema's absence does not ensure the absence of hydrocephalus, especially in younger patients.

Evaluation of Optical Coherence Tomography to Detect Elevated Intracranial Pressure in Children

Importance

Detecting elevated intracranial pressure in children with subacute conditions, such as craniosynostosis or tumor, may enable timely intervention and prevent neurocognitive impairment, but conventional techniques are invasive and often equivocal. Elevated intracranial pressure leads to structural changes in the peripapillary retina. Spectral-domain (SD) optical coherence tomography (OCT) can noninvasively quantify retinal layers to a micron-level resolution.

Objective

To evaluate whether retinal measurements from OCT can serve as an effective surrogate for invasive intracranial pressure measurement.

Design, Setting, and Participants

This cross-sectional study included patients undergoing procedures at the Children's Hospital of Philadelphia from September 2014 to June 2015. Three groups of patients (n = 79) were prospectively enrolled from the Craniofacial Surgery clinic including patients with craniosynostosis (n = 40). The positive control cohort consisted of patients with hydrocephalus and suspected intracranial hypertension (n = 5), and the negative control cohort consisted of otherwise healthy patients undergoing a minor procedure (n = 34).

Main Outcomes and Measures

Spectral-domain OCT was performed preoperatively in all cohorts. Children with cranial pathology, but not negative control patients, underwent direct intraoperative intracranial pressure measurement. The primary outcome was the association between peripapillary retinal OCT parameters and directly measured elevated intracranial pressure.

Results

The mean (SD) age was 34.6 (45.2) months in the craniosynostosis cohort (33% female), 48.9 (83.8) months in the hydrocephalus and suspected intracranial hypertension cohort (60% female), and 59.7 (64.4) months in the healthy cohort (47% female). Intracranial pressure correlated with maximal retinal nerve fiber layer thickness (r = 0.60, P ≤ .001), maximal retinal thickness (r = 0.53, P ≤ .001), and maximal anterior retinal projection (r = 0.53, P = .003). Using cut points derived from the negative control patients, OCT parameters yielded 89% sensitivity (95% CI, 69%-97%) and 62% specificity (95% CI, 41%-79%) for detecting elevated intracranial pressure. The SD-OCT measures had high intereye agreement (intraclass correlation, 0.83-0.93) and high intragrader and intergrader agreement (intraclass correlation ≥0.94). Conventional clinical signs had low sensitivity (11%-42%) for detecting intracranial hypertension.

Conclusions and Relevance

Noninvasive quantitative measures of the peripapillary retinal structure by SD-OCT were correlated with invasively measured intracranial pressure. Optical coherence tomographic parameters showed promise as surrogate, noninvasive measures of intracranial pressure, outperforming other conventional clinical measures. Spectral-domain OCT of the peripapillary region has the potential to advance current treatment paradigms for elevated intracranial pressure in children.

Noninvasive methods of detecting increased intracranial pressure

The detection of elevated intracranial pressure (ICP) is of paramount importance in the diagnosis and management of a number of neurologic pathologies. The current gold standard is the use of intraventricular or intraparenchymal catheters; however, this is invasive, expensive, and requires anesthesia. On the other hand, diagnosing intracranial hypertension based on clinical symptoms such as headaches, vomiting, and visual changes lacks sensitivity. As such, there exists a need for a noninvasive yet accurate and reliable method for detecting elevated ICP. In this review, we aim to cover both structural modalities such as computed tomography (CT), magnetic resonance imaging (MRI), ocular ultrasound, fundoscopy, and optical coherence tomography (OCT) as well as functional modalities such as transcranial Doppler ultrasound (TCD), visual evoked potentials (VEPs), and near-infrared spectroscopy (NIRS).

Identification of optic disc elevation and the crescent sign using point-of-care ocular ultrasound in children

Point-of-care ocular ultrasound has been used to detect papilledema. In previous studies, investigators have evaluated only optic nerve sheath diameter as a screen for increased intracranial pressure. In this series of 4 children, we demonstrate 2 additional optic nerve abnormalities using point-of-care ocular ultrasound: optic disc elevation and the crescent sign. Assessing the optic nerve for each of these 3 findings may assist the examiner in detecting papilledema.

Bilateral Papilledema as the First Sign of Ventriculoperitoneal Shunt Dysfunction§

A 12 year-old girl patient with a history of ventriculoperitoneal shunt placement at the age of 6 months presented with progressive bilateral decrease in visual acuity. Ophthalmologic examination was consistent with bilateral papilledema. No other systemic manifestations of increased intracranial pressure were evident and laboratory work-up excluded other inflammatory or infectious processes. We present here an interesting case of a patient with ophthalmologic manifestations as the initial finding of ventriculoperitoneal shunt dysfunction.

Effects of lowering cerebrospinal fluid pressure on the shape of the peripapillary retina in intracranial hypertension

PURPOSE

To analyze the deformations of the peripapillary retinal pigment epithelium-basement membrane (ppRPE/BM) layer in response to procedures that lower intracranial pressure (ICP). Second, to demonstrate how shape changes may complement the mean retinal nerve fiber layer (RNFL) thickness as a measure of intracranial hypertension (ICH) and papilledema.

METHODS

We used geometric morphometrics on spectral-domain optical coherence tomography images to analyze shape change of the ppRPE/BM layer after several interventions that lower cerebrospinal fluid (CSF) pressure. We also evaluated the effects of pressure-lowering interventions on both the anterior-posterior displacement of ppRPE/BM and the mean RNFL thickness. Forty-one patients with ICH and papilledema were studied before and after lumbar puncture (20), CSF shunt (9), and medical treatment of idiopathic ICH (23). We also compared the shape of 30 normal subjects to 23 patients whose papilledema resolved after medical treatment.

RESULTS

The ppRPE/BM-layer in ICH and papilledema is characterized by an asymmetric anterior deformation that moves posteriorly and becomes more V-shaped after each pressure-lowering intervention. The differences were statistically significant for all three groups. These shape changes also occur in patients with ongoing ICH who have secondary optic atrophy (without papilledema). Posterior displacement at the margin of the ppRPE/BM layer correlated strongly with overall shape changes.

CONCLUSIONS

The subsurface contour of the ppRPE/BM layer is a dynamic property that changes with CSF pressure-lowering interventions. It can supplement the RNFL thickness as an indirect gauge of ICP and is particularly helpful in patients with secondary optic atrophy. Direct measurements of displacement at the basement membrane opening may serve as a more convenient office-based surrogate for shape analysis.

Resolution of papilledema after endoscopic third ventriculostomy versus cerebrospinal fluid shunting in hydrocephalus: a comparative study

Object

In this study the authors compare the efficacy of endoscopic third ventriculostomy (ETV) versus CSF shunting for resolution of papilledema in hydrocephalus.

Methods

This comparative case series study recruited 12 patients (24 eyes) with hydrocephalus who underwent either an ETV (Group 1, 6 patients [12 eyes]) or CSF shunt treatment (Group 2, 6 patients [12 eyes]). A complete ophthalmological examination including retinal nerve fiber layer (RNFL) evaluation by optical coherence tomography was provided for all patients before surgery and in the 1st week, 1st month, and 3rd month postoperatively. The 2 groups were compared for quantitative changes in RNFL thickness and, thereby, resolution of papilledema. Statistical evaluation was performed using the Mann-Whitney U-test with the aid of SPSS version 16.0.

Results

The mean preoperative RNFL thickness was 259.7 ± 35.8 μm in Group 1 and 244.5 ± 53.4 μm in Group 2 (p = 0.798). The mean decrease in RNFL thickness was 101.3 ± 38.8 μm, 141.2 ± 34.6 μm, and 162.0 ± 35.9 μm in Group 1 versus 97.0 ± 44.6 μm, 143 ± 45.6 μm, and 130.0 ± 59.8 μm in Group 2 for the postoperative 1st week, 1st month, and 3rd month, respectively. There was no significant difference between the two groups with respect to decrease in RNFL thickness during the 1st week, 1st month, and 3rd month (p = 0.563, p = 0.753, and p = 0.528, respectively).

Conclusions

This is the first study to quantitatively evaluate papilledema in assessing the success of ETV and CSF shunting. The authors' results indicated that ETV is as effective as CSF shunting with respect to decreasing intracranial pressure and resolution of papilledema.

Patterns of retinal hemorrhage associated with increased intracranial pressure in children

OBJECTIVE

Raised intracranial pressure (ICP) has been proposed as an isolated cause of retinal hemorrhages (RHs) in children with suspected traumatic head injury. We examined the incidence and patterns of RHs associated with increased ICP in children without trauma, measured by lumbar puncture (LP).

METHODS

Children undergoing LP as part of their routine clinical care were studied prospectively at the Children's Hospital of Philadelphia and retrospectively at Nationwide Children's Hospital. Inclusion criteria were absence of trauma, LP opening pressure (OP) ≥ 20 cm of water (cm H2O), and a dilated fundus examination by an ophthalmologist or neuro-ophthalmologist.

RESULTS

One hundred children were studied (mean age: 12 years; range: 3-17 years). Mean OP was 35 cm H2O (range: 20-56 cm H2O); 68 (68%) children had OP >28 cm H2O. The most frequent etiology was idiopathic intracranial hypertension (70%). Seventy-four children had papilledema. Sixteen children had RH: 8 had superficial intraretinal peripapillary RH adjacent to a swollen optic disc, and 8 had only splinter hemorrhages directly on a swollen disc. All had significantly elevated OP (mean: 42 cm H2O).

CONCLUSIONS

Only a small proportion of children with nontraumatic elevated ICP have RHs. When present, RHs are associated with markedly elevated OP, intraretinal, and invariably located adjacent to a swollen optic disc. This peripapillary pattern is distinct from the multilayered, widespread pattern of RH in abusive head trauma. When RHs are numerous, multilayered, or not near a swollen optic disc (eg, elsewhere in the posterior pole or in the retinal periphery), increased ICP alone is unlikely to be the cause.

Retinal hemorrhage in abusive head trauma

Retinal hemorrhage is a cardinal manifestation of abusive head trauma. Over the 30 years since the recognition of this association, multiple streams of research, including clinical, postmortem, animal, mechanical, and finite element studies, have created a robust understanding of the clinical features, diagnostic importance, differential diagnosis, and pathophysiology of this finding. The importance of describing the hemorrhages adequately is paramount in ensuring accurate and complete differential diagnosis. Challenges remain in developing models that adequately replicate the forces required to cause retinal hemorrhage in children. Although questions, such as the effect of increased intracranial pressure, hypoxia, and impact, are still raised (particularly in court), clinicians can confidently rely on a large and solid evidence base when assessing the implications of retinal hemorrhage in children with concern of possible child abuse.