Incidence and Demographics of Pediatric Intracranial Hypertension

Ultrasound-guided initial diagnosis and follow-up of pediatric idiopathic intracranial hypertension

BACKGROUND

Idiopathic intracranial hypertension in children often presents with non-specific symptoms found in conditions such as hydrocephalus. For definite diagnosis, invasive intracranial pressure measurement is usually required. Ultrasound (US) of the optic nerve sheath diameter provides a non-invasive method to assess intracranial pressure. Transtemporal US allows imaging of the third ventricle and thus assessment for hydrocephalus.

OBJECTIVE

To investigate whether the combination of US optic nerve sheath and third ventricle diameter can be used as a screening tool in pediatric idiopathic intracranial hypertension to indicate elevated intracranial pressure and exclude hydrocephalus as an underlying pathology. Further, to analyze whether both parameters can be used to monitor treatment outcome.

MATERIALS AND METHODS

We prospectively included 36 children with idiopathic intracranial hypertension and 32 controls. Using a 12-Mhz linear transducer and a 1-4-Mhz phased-array transducer, respectively, optic nerve sheath and third ventricle diameters were determined initially and during the course of treatment.

RESULTS

In patients, the mean optic nerve sheath diameter was significantly larger (6.45±0.65 mm, controls: 4.96±0.32 mm) and the mean third ventricle diameter (1.69±0.65 mm, controls: 2.99±1.31 mm) was significantly smaller compared to the control group, P<0.001. Optimal cut-off values were 5.55 mm for the optic nerve sheath and 1.83 mm for the third ventricle diameter.

CONCLUSIONS

The combined use of US optic nerve sheath and third ventricle diameter is an ideal non-invasive screening tool in pediatric idiopathic intracranial hypertension to indicate elevated intracranial pressure while ruling out hydrocephalus. Treatment can effectively be monitored by repeated US, which also reliably indicates relapse.

Persistent Elevation of Opening Pressure Despite Treatment and Symptom Resolution in Pediatric Intracranial Hypertension

BACKGROUND

Currently no guidelines for repeating a lumbar puncture to guide management in primary intracranial hypertension (PIH) exist.

METHODS

An institutional database of patients 18 years and younger followed in the institution's pediatric intracranial hypertension clinic was examined for opening pressure changes in PIH at diagnosis, before medication wean, and following medication wean, as well as to examine whether measurements at the time of diagnosis differed between those with and without disease recurrence.

RESULTS

Forty-two patients were included in this study; 36% were male and the mean age at diagnosis was 11.01 years. Treatment duration averaged 9.68 months in those without recurrence and 8.5 months in those with recurrence. Average body mass index percentile of patients with disease recurrence was 83.7 and 72.1 in those without recurrence (P = 0.16). Average opening pressure values of all patients at diagnosis, prewean, and postwean was 36.53 cm H2O, 30.7 cm H2O, and 31.1 cm H2O, respectively. There was no statistically significant difference in opening pressures across these time points (P = 0.14). The change in opening pressure from diagnosis to postwean was statistically significant with a reduction of 5.18 cm H2O (P = 0.04). There was no statistical difference between change in opening pressure at diagnosis versus postwean between those with and without recurrence (P = 0.17).

CONCLUSIONS

This clinical observational study suggests that mean opening pressure measurements in patients with PIH remain elevated both before and after medication wean despite papilledema resolution and patient-reported PIH symptoms. Clinically, this suggests that other features such as signs of optic disc edema and symptoms should be used to inform a clinical determination of disease recurrence and treatment course.

Diagnosis and treatment of disorders of intracranial pressure: consensus statement of the Spanish Society of Neurology's Headache Study Group

Primary intracranial pressure disorders include idiopathic intracranial hypertension and spontaneous intracranial hypotension. Remarkable advances have been made in the diagnosis and treatment of these 2entities in recent years. Therefore, the Spanish Society of Neurology's Headache Study Group (GECSEN) deemed it necessary to prepare this consensus statement, including diagnostic and therapeutic algorithms to facilitate and improve the management of these disorders in clinical practice. This document was created by a committee of experts belonging to GECSEN, and is based on a systematic review of the literature, incorporating the experience of the participants, and establishes practical recommendations with levels of evidence and grades of recommendation.

A Novel Nomogram Based on Quantitative MRI and Clinical Features for the Prediction of Neonatal Intracranial Hypertension

Intracranial hypertension (ICH) is a serious threat to the health of neonates. However, early and accurate diagnosis of neonatal intracranial hypertension remains a major challenge in clinical practice. In this study, a predictive model based on quantitative magnetic resonance imaging (MRI) data and clinical parameters was developed to identify neonates with a high risk of ICH. Newborns who were suspected of having intracranial lesions were included in our study. We utilized quantitative MRI to obtain the volumetric data of gray matter, white matter, and cerebrospinal fluid. After the MRI examination, a lumbar puncture was performed. The nomogram was constructed by incorporating the volumetric data and clinical features by multivariable logistic regression. The performance of the nomogram was evaluated by discrimination, calibration curve, and decision curve. Clinical parameters and volumetric quantitative MRI data, including postmenstrual age (p = 0.06), weight (p = 0.02), mode of delivery (p = 0.01), and gray matter volume (p = 0.003), were included in and significantly associated with neonatal intracranial hypertension risk. The nomogram showed satisfactory discrimination, with an area under the curve of 0.761. Our results demonstrated that decision curve analysis had promising clinical utility of the nomogram. The nomogram, incorporating clinical and quantitative MRI features, provided an individualized prediction of neonatal intracranial hypertension risk and facilitated decision making guidance for the early diagnosis and treatment for neonatal ICH. External validation from studies using a larger sample size before implementation in the clinical decision-making process is needed.

Advances for pediatricians in 2022: allergy, anesthesiology, cardiology, dermatology, endocrinology, gastroenterology, genetics, global health, infectious diseases, metabolism, neonatology, neurology, oncology, pulmonology

The last year saw intensive efforts to advance knowledge in pediatric medicine. This review highlights important publications that have been issued in the Italian Journal of Pediatrics in 2022. We have chosen papers in the fields of allergy, anesthesiology, cardiology, dermatology, endocrinology, gastroenterology, genetics, global health, infectious diseases, metabolism, neonatology, neurology, oncology, pulmonology. Novel valuable developments in epidemiology, pathophysiology, prevention, diagnosis and treatment that can rapidly change the approach to diseases in childhood have been included and discussed.

Evaluation of Retinal Vascular and Structural Alterations in Pediatric Idiopathic Intracranial Hypertension Patients without Papilledema

PURPOSE

The aim of this study was to evaluate retinal structural and microvascular alterations using optical coherence tomography-angiography (OCTA) in pediatric idiopathic intracranial hypertension (IIH) patients with regressed papilledema.

METHODS

This study included 40 eyes of 21 IIH patients and 69 eyes of 36 healthy controls. Radial peripapillary capillary (RPC) vessel density and peripapillary retinal nerve fiber layer (RNFL) thickness were evaluated by XR Avanti AngioVue OCTA (Optovue, Fremont, CA, USA). The data were obtained from measurement zones that are automatically divided into two equal hemispheres (superior and inferior) and eight quadrants (superior-temporal, superior-nasal, inferior-temporal, inferior-nasal, nasal-superior, nasal-inferior, temporal-superior, temporal-inferior). Initial cerebrospinal fluid (CSF) pressure, grade of papilledema, and duration of follow-up were recorded.

RESULTS

There were significant differences in RPC vessel densities and RNFL thicknesses between the study groups (p ˃ 0.05). Significantly higher RPC vessel density measurements were observed in the patient group for the whole image, peripapillary, inferior-hemi, and whole nasal quadrants (p < 0.05). Except for the temporal-superior, temporal-inferior, inferior-temporal, and superior-temporal quadrants, the RNFL in all regions was significantly thicker in the IIH group than in the control group (p ˂ 0.001).

CONCLUSIONS

RNFL thickness and RPC vessel density were significantly different between the IIH patient and control groups, suggesting that retinal microvascular and subclinical structural changes that were potentially secondary to CSF pressure can persist after the resolution of papilledema. However, our results should be confirmed by further longitudinal studies investigating the progress of these alterations to determine their effects on peripapillary tissues.

Sleep Disturbances in Adolescents With Idiopathic Intracranial Hypertension

BACKGROUND

We aimed to assess the presence of sleep disturbances in adolescents with idiopathic intracranial hypertension (IIH) and to determine whether demographic, anthropometric, and clinical factors are associated with disrupted sleep.

METHODS

Sleep disturbances and patterns were evaluated in a cohort of adolescents (aged 12 to 18 years) with ongoing IIH and compared with a healthy age- and sex-matched control group. All participants responded to three self-rating questionnaires: the School Sleep Habits Survey (SSHS), the Pediatric Sleep Questionnaire (PSQ), and the Depression, Anxiety, and Stress Scale. The study group's demographic, clinical, laboratory, and radiological data were documented, and their association with sleep patterns was examined.

RESULTS

Thirty-three adolescents with ongoing IIH and 71 healthy controls were included. There was a significantly higher prevalence of sleep disturbances in the IIH group compared with the controls (SSHS, P < 0.001 and PSQ, P < 0.001), as well as of their independent subscales: sleep-related breathing disorders (P = 0.006), daytime sleepiness (P = 0.04), sleep/wake disruptions (P < 0.001), and sleep-related depressive tendencies (P < 0.001). According to subgroup analyses, these differences were also present between the normal-weight adolescents but not between the overweight IIH and control adolescents. No differences were found in the demographic, anthropometric, and IIH disease-related clinical measures between individuals with IIH with disrupted and normal sleep patterns.

CONCLUSIONS

Sleep disturbances are common among adolescents with ongoing IIH, irrespective of their weight and disease-related characteristics. Screening adolescents with IIH for sleep disturbances is recommended as part of their multidisciplinary management.

Long-term monitoring of children with Pseudo Tumor Cerebri Syndrome by transbulbar sonography

Determination of optic nerve sheath diameter (ONSD) with transbulbar sonography has become an easily accessible and time-effective tool in the assessment of increased intracranial pressure. The aim of our study was to evaluate the usefulness of transbulbar sonography in the initial diagnosis and in follow-up examinations of children and adolescents with the diagnosis of pseudotumor cerebri syndrome (PTCS). We retrospectively reviewed imaging results of 24 patients aged 0.75-17 years with PTCS. Serial transbulbar sonography examinations were performed between 2011 and 2021. Sonographic evaluation included the ONSD, papilledema and subarachnoid space. 240 sonographic measurements taken at 108 time points in 17 patients met the inclusion criteria. All patients underwent serial lumbar punctures and routine fundoscopy in close relation to transbulbar sonography. We found that ONSD values remained high in all patients. The longest follow-up period was dated 2498 days (6.84 years) after initial diagnosis. Papilledema resolved in close correlation to fundoscopy normalization. In 16/17 patients the subarachnoid space remained cystic in appearance. These findings were independent of clinical symptoms and lumbar puncture opening pressure. We conclude that transbulbar sonography is a useful diagnostic tool in the initial diagnostic workup of children with PTCS. On follow-up however ONSD values and the cystic transformation of the subarachnoid space remained pathologic in the majority of cases while papilledema resolved parallel to fundoscopy findings. Serial measurements of ONSD are therefore of limited value in the follow-up of patients with PTCS and cannot be considered a reliable tool in subsequent therapeutic decisions.

Different Characteristics of Pre-Pubertal and Post-Pubertal Idiopathic Intracranial Hypertension: A Narrative Review

Idiopathic intracranial hypertension (IIH) affects both children and adults. There are currently no clinical trials in IIH for those who are adolescents or children. The aims of this narrative review were to characterise the differences between pre- and post-pubertal IIH and to highlight the need to be more inclusive in clinical trial planning and recruitment. A detailed search of the scientific literature was performed using the PubMed database, from inception until 30 May 2022 using keywords. This included English language papers only. The abstracts and full texts were reviewed by two independent assessors. The literature revealed that the pre-pubertal group had a more variable presentation. The presenting features in the post-pubertal paediatric group were more akin to adults with headache as the dominant feature. They were also more likely to be female and have an increased body mass index. A clear limitation of the literature was that a number of paediatric studies had variable inclusion criteria, including secondary causes of raised intracranial pressure. Pre-pubertal children do not display the same predilection towards the female sex and obesity as post-pubertal children, who have a similar phenotype to the adult cohort. Inclusion of adolescents in clinical trials should be considered given the similar phenotype to adults. There is a lack of consistency in the definition of puberty, making the IIH literature difficult to compare. Inclusion of secondary causes of raised intracranial pressure has the potential to confound the accuracy of analysis and interpretation of the results.

Improving pediatric idiopathic intracranial hypertension care: a retrospective cohort study

To describe the clinical course and prognosis of pediatric idiopathic intracranial hypertension (IIH) and examine the preferred management setting. IIH is characterized by increased intracranial pressure and is often associated with headaches and visual complaints. IIH is a preventable cause of vision loss in children. Hence, a rapid diagnosis followed by prompt treatment and follow-up is essential. However, standardization of the management of IIH in the pediatric population is not well established. Computerized medical charts of all 82 pediatric (< 18 years) patients diagnosed with IIH between 2007 and 2018 in the metropolitan area of Jerusalem were reviewed. Comparison was made between children followed in a multidisciplinary clinic in tertiary centers and those followed elsewhere. Detailed demographic and clinical data, as well as data regarding the follow-up setting and clinical course of the disease, were collected and analyzed. Recurrent IIH-related hospital returns were selected as a measurable marker for the uncontrolled disease. Recurrent IIH-related hospital return rate was significantly lower and occurred later among children followed by multidisciplinary teams compared to individual experts. Follow-up in multidisciplinary clinics improve the quality of life, and financial burden and may prevent permanent visual impairment in children with IIH.

Case Report of Idiopathic Intracranial Hypertension in Pregnancy

Idiopathic intracranial hypertension (IIH) is a disease of increased intracranial pressure with an unknown cause that is seen most often in women during their childbearing years. Women can be under care for IIH when they become pregnant, or it may occur during pregnancy. In the past, women with IIH who became pregnant were often counseled to terminate their pregnancies, to give birth early, and even to be sterilized to prevent future pregnancies. Today, multiple therapeutic options are available. In this case report, I describe the case of a woman with IIH who was treated with a cerebral spinal fluid shunt and gave birth to two sets of twins. This case report adds new information to the limited nursing literature currently available on this disease.

Pseudotumor cerebri syndrome in children: Clinical characteristic and re-classification

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.

New-Onset Headache and Abnormal Eye Movements in a Four-Year-Old Child: Indicators of Increased Intracranial Pressure

A four-year-old previously healthy child presented with new-onset, diffuse, severe headache, and left sixth nerve palsy. The child was evaluated at several acute care facilities, at which the symptom of "crossing eyes" was not addressed specifically. At our emergency department, on day 6 of symptoms, a left cranial nerve 6 palsy was diagnosed; on brain MRI scan, there was evidence of increased intracranial pressure (distended optic nerve sheaths, flattened posterior sclerae), which was confirmed by lumbar puncture, which showed an opening pressure of >36 cm H₂O. Idiopathic intracranial hypertension (IIH) was diagnosed, and all symptoms abated with two months of treatment with acetazolamide. IIH should be considered in a child with headache and abnormal eye movements.

Recovery of Vision after Optic Nerve Sheath Fenestration in Children and Adolescents with Elevated Intracranial Pressure

PURPOSE

To evaluate the effect of optic nerve sheath fenestration (ONSF) on the recovery of visual function in pediatric patients with optic disc swelling owing to increased intracranial pressure.

DESIGN

Retrospective case series.

METHODS

Medical chart review of all pediatric patients who underwent ONSF between 2009 and 2020 at the Children's Hospital of Philadelphia. Visual function was assessed at pre and postoperative visits. The main outcome measures were visual acuity, color vision, extraocular motility, visual field mean deviation, retinal nerve fiber layer thickness measured by optical coherence tomography.

RESULTS

Fourteen pediatric patients (10 females; mean ± SD age of 14 ± 2.6 years; range, 8.5-17.5 years) were included. Five patients underwent bilateral surgeries. Ten patients were diagnosed with idiopathic intracranial hypertension. Of the 10 idiopathic intracranial hypertension patients, 3 had a previous history of weight gain and 2 of systemic steroid treatment; these can be referred to as pseudotumor cerebri. The mean ± SD follow-up length was 16.4 ± 12.3 months. VA improved from 20/138 to 20/68 in the operated eye (P = .0003) and from 20/78 to 20/32 in the nonoperated eye (P = .02). Color vision improved in the operated eye (P = .04), extraocular motility improved in the operated and nonoperated eye (P = .002 and P = .04 respectively). Visual field mean deviation improved in the operated (-23.4 dB to -11.5 dB, P < .0001) and nonoperated eye (-19.8 dB to -6.8 dB, P = .02). Retinal nerve fiber layer thickness improved in the operated eye (349.1 to 66.2 µm; P < .0001). The postoperative improvement was observed as early as the postoperative day 1.

CONCLUSIONS

ONSF produces a rapid and persistent vision improvement in both the operated eye and the nonoperated eye. In children and young adults with papilledema and elevated intracranial pressure causing vision loss that is severe at presentation or refractory to standard medical management, ONSF should be considered.

Increase in Pediatric Pseudotumor Cerebri Syndrome Emergency Department Visits, Inpatient Admissions, and Surgeries During the COVID-19 Pandemic

BACKGROUND

Pediatric pseudotumor cerebri syndrome (PTCS) is a vision-threatening condition that is associated with female sex and obesity in pubertal and postpubertal children. It is unknown whether the increase in childhood obesity during the COVID-19 pandemic has affected the rates and characteristics of pediatric PTCS.

METHODS

We conducted a retrospective study of children evaluated for PTCS (inpatient or emergency department) at our children's hospital before (March 19, 2015 to March 19, 2020) and during (March 20, 2020 to February 20, 2021) the pandemic. We compared the monthly number of inpatient and emergency department encounters for pediatric PTCS before and during the pandemic. In addition, anthropometric and ophthalmologic characteristics of children evaluated for pediatric PTCS before and during the pandemic were compared.

RESULTS

A total of 36 encounters in the 5 years before the pandemic and 26 encounters in the 11 months during the pandemic were identified. The median monthly number of encounters for pediatric PTCS was significantly higher during the pandemic compared with the 5 years before the pandemic (2 vs 0, P = 0.0021). Compared with prepandemic patients, children evaluated during the pandemic were older (median age 16 vs 14 years, P = 0.02), with higher rates of obesity (85% vs 66%, P = 0.05) and lower likelihood of reporting Caucasian race (4% vs 31%, P = 0.02). Pandemic patients had worse presenting visual acuity (median logMAR 0.14 vs 0.05, P = 0.05) and were more likely to have fulminant presentation (23% vs 6%, P = 0.04) and require surgical intervention (23% vs 6%, P = 0.04).

CONCLUSIONS

At our children's hospital, the rate of inpatient admissions and emergency department visits for pediatric PTCS increased during the pandemic. The severity of disease and frequency of surgical treatment also increased. Racial and ethnic minorities seem to be disproportionately affected. These changes may be related to increasing rates of childhood obesity during the pandemic.

Recognition of intracranial hypertension using handheld optical coherence tomography in children (RIO Study): a diagnostic accuracy study protocol

INTRODUCTION

Paediatric intracranial hypertension (IH) is a rare but serious condition that can pose deleterious effects on the brain and vision. Estimating intracranial pressure (ICP) in children is difficult. Gold standard direct ICP measurement is invasive and carries risk. It is impractical to routinely perform direct ICP measurements over time for all children at risk of IH. This study proposes to assess the diagnostic accuracy of handheld optical coherence tomography (OCT), a non-invasive ocular imaging method, to detect IH in children.

METHODS AND ANALYSIS

This is a prospective study evaluating the diagnostic accuracy of handheld OCT for IH in at risk children. Inclusion criteria include clinical and/or genetic diagnosis of craniosynostosis, idiopathic intracranial hypertension, space occupying lesion or other conditions association with IH and age 0-18 years old. Exclusion criteria include patients older than 18 years of age and/or absence of condition placing the child at risk of IH. The primary outcome measures are handheld OCT and 48-hour ICP assessments, which will be used for diagnostic accuracy testing (sensitivity, specificity, positive predictive value, negative predictive value and accuracy). Main secondary outcome measures include visual acuity, fundoscopic examination, contrast sensitivity, visual field testing and visual evoked potentials, wherever possible.

ETHICS AND DISSEMINATION

Ethical approval was granted for this study by the East Midlands Nottingham 2 Research Ethics committee (UOL0348/IRAS 105137). Our findings will be disseminated through presentation at relevant meetings, peer-reviewed publication and via the popular media.

TRIAL REGISTRATION NUMBER

ISRCTN52858719.

Infantile idiopathic intracranial hypertension: case report and review of the literature

Background

Idiopathic intracranial hypertension is an infrequent condition of childhood, and is extremely rare in infants, with only 26 cases described. The etiology is still unknown. Typical clinical manifestations change with age, and symptoms are atypical in infants, thus the diagnosis could be late. This is based on increased opening pressure at lumbar puncture, papilloedema and normal cerebral MRI. The measurement of cerebrospinal fluid opening pressure in infants is an issue because many factors may affect it, and data about normal values are scanty. The mainstay of treatment is acetazolamide, which allows to relieve symptoms and to avoid permanent visual loss if promptly administered.

Case presentation

We report the case of an 8-month-old infant admitted because of vomit, loss of appetite and irritability; later, also bulging anterior fontanel was observed. Cerebral MRI and cerebrospinal fluid analysis resulted negative and after two lumbar punctures he experienced initial symptom relief. Once the diagnosis of idiopathic intracranial hypertension was made, he received oral acetazolamide, and corticosteroids, with progressive symptom resolution.

Conclusions

Infantile idiopathic intracranial hypertension is extremely rare, and not well described yet. Bulging anterior fontanel in otherwise healthy infants with normal neuroimaging should be always considered suggestive, but can be a late sign, while irritability and anorexia, especially if associated with vomiting, may represent an early sign. In such cases, lumbar puncture should be always done, hopefully with cerebrospinal fluid opening pressure measurement, which is among coded diagnostic criteria, but whose threshold is controversial in infants. Early diagnosis, timely treatment and strict follow-up help to prevent vision loss or death of affected infants.

Idiopathic Intracranial Hypertension in a Malaysian Preschooler

A four-year-old girl presented with a three-day history of squint and irritability. Examination showed reduced visual acuity in both eyes, the presence of a false localizing sign, and bilateral optic disc swelling. On investigation, her blood laboratory workup was within the normal range. Imaging of the brain showed no evidence of a space-occupying lesion or cerebral venous sinus thrombosis. The lumbar puncture opening pressure was 27cmH₂0 and the cerebrospinal fluid workup was normal. The diagnosis of idiopathic intracranial hypertension (IIH) was made based on the diagnostic criteria for pseudotumor cerebri syndrome. She was successfully treated with acetazolamide with resolved symptoms and signs. This highlights the possibility of IIH presenting with inconspicuous symptoms in preschool children, which needs a high index suspicion by clinicians. Hence, solving the challenges in the workup, especially in children, is very crucial.

Experiences of Pain and Quality of Life in Pediatric Intracranial Hypertension

OBJECTIVE

To examine psychosocial correlates, specifically pain intensity, pain interference, and quality of life (QOL), in patients with pediatric intracranial hypertension. We hypothesized that parents and children who report higher levels of pain intensity and interference would be associated with lower QOL.

METHODS

Eighty-three patients and their families seen in the pediatric intracranial hypertension clinic of a large pediatric hospital completed self-report and parent proxy measures on QOL, mood, and other psychosocial correlates. Bivariate correlations were conducted between parent proxy and self-reports and regression analyses between pain and psychosocial correlate variables were examined.

RESULTS

Parent proxy and child reports were highly correlated. Body mass index (BMI) was a significant predictor of parent proxy report of pain intensity with higher BMI associated with higher parent proxy ratings of pain intensity. Parents reported significantly higher levels of pain interference for their children compared to child report. Parent ratings of child depression symptoms, BMI, and age were significant predictors of pain interference. Higher BMI and depression symptoms and younger age were associated with more pain interference. Overall QOL was similar to other headache populations but lower than other chronic illness and healthy populations.

CONCLUSIONS

Pediatric intracranial hypertension is associated with decreased QOL. Body mass index was a significant predictor of pain intensity and interference and should be monitored closely in clinic. Clinical care should include psychosocial screening to identify patients who would benefit from interventions to reduce the impact of this condition.

Approach to the Diagnosis of Pediatric Headache

Headache in children and adolescents is a common symptom that can be worrisome to patients, their parents and clinicians due to the myriad of underlying etiologies, both benign and life-threatening. The evaluation of headache must be directed primarily to exclude secondary causes. A detailed headache history, recognition of headache patterns and red flags and thorough physical and neurological examinations are essential in the diagnosis; and identifies patients requiring further workup. Considerations for neuroimaging and ancillary testing are also discussed.

Disordered Eating Behaviors in Young Individuals With Idiopathic Intracranial Hypertension

BACKGROUND

The objective of this study was to assess the prevalence of disordered eating behaviors (DEBs) in young individuals with idiopathic intracranial hypertension (IIH) and to identify predictors of DEBs in this population.

METHODS

Individuals with IIH aged eight to 25 years and their matched controls responded to a self-rating survey comprised of the Eating Attitude Test-26 for assessing the presence of DEBs and the Depression, Anxiety and Stress Scale.

RESULTS

Fifty-three subjects with IIH and 106 healthy controls were included. DEBs were significantly more prevalent in individuals with IIH (P < 0.001). Individuals with IIH and DEBs were more likely to have longer periods of treatment [odds ratio: 1.07, 95% CI: 1.02-1.41), P = 0.008] and to have lost a significant amount of weight during the course of treatment [odds ratio: 9.06 (95% CI: 1.30-62.9), P = 0.026]. Depression, anxiety, and stress were more prevalent in the IIH group than in the controls (P = 0.004) and were associated with DEBs in these individuals (P = 0.01).

CONCLUSIONS

There is an increased prevalence of DEBs among young individuals with IIH, which persists even after disease resolution, and is associated with higher reported rates of depression, anxiety, and stress. Medical caregivers should have heightened awareness to DEBs in individuals with IIH with the aim of early identification and intervention.

Prevalence of Adrenal Insufficiency and Glucocorticoid Use in Pediatric Pseudotumor Cerebri Syndrome

BACKGROUND

The pathophysiology underlying pseudotumor cerebri syndrome (PTCS) is complex and not well understood. There are clear differences between PTCS in adults and pediatrics. Few and isolated case reports have suggested that adrenal function may be involved, yet no large cohort study has examined this relationship.

METHODS

We conducted a retrospective single-center study of children who presented with a diagnosis of PTCS and had cortisol testing measured between January 2010 and September 2019. We included all subjects meeting the revised PTCS diagnostic criteria after the chart review. Based on morning, random or 1-μg cosyntropin stimulated cortisol levels, adrenal functioning was classified as: (1) insufficient (peak cortisol <16 μg/dL and AM cortisol <5 μg/dL), (2) at risk (peak cortisol 16-20 μg/dL, AM cortisol 5-13 μg/dL, or random <13 μg/dL), or (3) sufficient (peak cortisol >20 μg/dL and AM or random cortisol >13 μg/dL).

RESULTS

A total of 398 individuals were reviewed, and 64 were included for analysis. Of these, 40.6% were men, of mixed race and ethnicity with a mean age of 10.5 (SD 4.7) years. Of these, 23% and 52% had insufficient or at-risk cortisol levels. The majority of those in the insufficient (70%) or at-risk (80%) groups were exposed to topical, nasal, or inhaled glucocorticoids but not systemic. Only 60% and 12% of those with PTCS with insufficient or at-risk cortisol testing, respectively, underwent definitive testing with a stimulation test.

CONCLUSIONS

Glucocorticoid use and hypocortisolism are prevalent in PTCS and need consideration as a potential underlying cause. Most children had insufficient or at-risk cortisol levels, and many did not undergo further testing/workup. Children who present with PTCS, particularly young, males should be evaluated for adrenal insufficiency and its risk factors, including nonsystemic steroids. Prospective studies are necessary to further evaluate the effect of cortisol in relation to pediatric PTCS.

Neuroimaging Features of Intracranial Hypertension in Pediatric Patients With New-Onset Idiopathic Seizures, a Comparison With Patients with Confirmed Diagnosis of Idiopathic Intracranial Hypertension: A Preliminary Study

A cutoff value of 6.0 mm for optic nerve sheath dilation may be used as a screening imaging marker to suspect elevated opening pressure with specificity of 88% in pediatric patients with new-onset idiopathic seizures.

Detection of intracranial hypertension in children using optical coherence tomography: a systematic review

OBJECTIVES

To evaluate the diagnostic capability of optical coherence tomography (OCT) in children aged under 18 years old with intracranial hypertension (IH).

DESIGN

Systematic review.

METHODS

We conducted a systematic review using the following platforms to search the keywords 'optical coherence tomography' and 'intracranial hypertension' from inception to 2 April 2020: Cochrane Central Register of Controlled Trials, EMBASE, MEDLINE, PubMed and Web of Science, without language restrictions. Our search returned 2729 records, screened by two independent screeners. Studies were graded according to the Oxford Centre for Evidence-Based Medicine and National Institutes of Health Quality Assessment Tool for observational studies.

RESULTS

Twenty-one studies were included. Conditions included craniosynostosis (n=354 patients), idiopathic IH (IIH; n=102), space-occupying lesion (SOL; n=42) and other pathology (n=29). OCT measures included optic nerve parameters, rim parameters (notably retinal nerve fibre layer thickness) and retinal parameters. Levels of evidence included 2b (n=13 studies), 3b (n=4) and 4 (n=4). Quality of 10 studies was fair and 11 poor. There was inconsistency in OCT parameters and reference measures studied, although OCT did demonstrate good diagnostic capability for IH in craniosynostosis, IIH and SOL.

CONCLUSIONS

This systematic review identified various studies involving OCT to assist diagnosis and management of IH in children with craniosynostosis, IIH, SOL and other pathology, in conjunction with established clinical measures of intracranial pressure. However, no level 1 evidence was identified. Validating prospective studies are, therefore, required to determine optimal OCT parameters in this role and to develop formal clinical guidelines.

PROSPERO REGISTRATION NUMBER

CRD42019154254.

Non-traumatic pediatric intracranial hypertension: key points for different etiologies, diagnosis, and treatment

Intracranial hypertension can be an acute life-threatening event or slowly deteriorating condition, leading to a gradual loss of neurological function. The diagnosis should be taken in a timely fashioned process, which mandates expedite measures to save brain function and sometimes life. An optimal management strategy is selected according to the causative etiology with a core treatment paradigm that can be utilized in various etiologies. Distinct etiologies are intracranial bleeds caused by traumatic brain injury, spontaneous intracranial hemorrhage (e.g., neonatal intraventricular hemorrhage), or the rare pediatric hemorrhagic stroke. The other primary pediatric etiologies for elevated intracranial pressure are intracranial mass (e.g., brain tumor) and hydrocephalus related. Other unique etiologies in the pediatric population are related to congenital diseases, infectious diseases, metabolic or endocrine crisis, and idiopathic intracranial pressure. One of the main goals of treatment is to alleviate the growing pressure and prevent the secondary injury to brain parenchyma due to inadequate blood perfusion and eventually inadequate parenchymal oxygenation and metabolic state. Previous literature discussed essential characteristics of the treatment paradigm derived mainly from pediatric brain traumatic injuries' treatment methodology. Yet, many of these etiologies are not related to trauma; thus, the general treatment methodology must be tailored carefully for each patient. This review focuses on the different possible non-traumatic etiologies that can lead to intracranial hypertension with the relevant modification of each etiology's treatment paradigm based on the current literature.

Assessment of Pediatric Pseudotumor Cerebri Clinical Characteristics and Outcomes

Pseudotumor cerebri also known as idiopathic intracranial hypertension is a relatively uncommon disorder of unknown pathophysiology. Although pseudotumor cerebri occurs in both children and adults, the pseudotumor cerebri literature is heavily dominated by adult studies. The aim of this study is to retrospectively describe the clinical presentation, imaging, treatment, and outcomes of a large pediatric pseudotumor cerebri population over a 23-year period. We also discuss secondary pseudotumor cerebri (44%) as well as the increasingly recognized patient subgroups without headache (13.3%) and without papilledema (7.3%). Female sex, obesity, and initial symptoms were consistent with the literature; however radiographic findings were surprisingly low in this cohort. Headache outcomes at 1 week, 1 month, and 3 months following initial lumbar puncture/treatment and visual function outcomes are reported.

Idiopathic Intracranial Hypertension in the United States: Demographic and Socioeconomic Disparities

Background: Obesity's risk increases for low-income, female, young, and Black patients. By extrapolation, idiopathic intracranial hypertension (IIH)—a disease associated with body mass index—would potentially display socioeconomic and demographic disparities.

Methods: IIH incidence (per 100,000) was investigated with respect to sex, age, income, residence, and race/ethnicity, by querying the largest United States (US) healthcare administrative dataset (1997–2016), the National (Nationwide) Inpatient Sample.

Results: Annual national incidence (with 25th and 75th quartiles) for IIH was 1.15 (0.91, 1.44). Females had an incidence of 1.97 (1.48, 2.48), larger (p = 0.0000038) than males at 0.36 (0.26, 0.38). Regarding age, largest incidence was among those 18–44 years old at 2.47 (1.84, 2.73). Low-income patients had an incidence of 1.56 (1.47, 1.82), larger (p = 0.00024) than the 1.21 (1.01, 1.36) of the middle/high. No differences (χ² = 4.67, p = 0.097) were appreciated between urban (1.44; 1.40, 1.61), suburban (1.30; 1.09, 1.40), or rural (1.46; 1.40, 1.48) communities. For race/ethnicity (χ² = 57, p = 2.57 × 10⁻¹²), incidence was largest for Blacks (2.05; 1.76, 2.74), followed by Whites (1.04; 0.79, 1.41), Hispanics (0.67; 0.57, 0.94), and Asian/Pacific Islanders (0.16; 0.11, 0.19). Year-to-year, incidence rose for all strata subsets except Asian/Pacific Islanders (τ = −0.84, p = 0.00000068).

Conclusion: IIH demonstrates several sociodemographic disparities. Specifically, incidences are larger for those low-income, Black, 18–44 years old, or female, while annually increasing for all subsets, except Asian/Pacific Islanders. Hence, IIH differentially afflicts the US population, yielding in healthcare inequalities.

Detection of intracranial hypertension in children using optical coherence tomography: a systematic review protocol

INTRODUCTION

Intracranial hypertension (ICH) in children can have deleterious effects on the brain and vision. It is notoriously difficult to estimate intracranial pressure (ICP) in children and existing methods deliver suboptimal diagnostic accuracy to be used as screening tools. Optical coherence tomography (OCT) may represent a valuable, non-invasive surrogate measure of ICP, as has been demonstrated in a number of associated conditions affecting adults. More recently, OCT has been employed within the paediatric age group. However, the role of OCT in detecting ICH in children has not been rigorously assessed in a systematic review for all relevant conditions. Here, we propose a systematic review protocol to examine the role of OCT in the detection of ICH in children.

METHODS AND ANALYSIS

Electronic searches in the Cochrane Central Register of Controlled Trials, Medline, Embase, Web of Science and PubMed will identify studies featuring OCT in detecting ICH in children. Two independent screeners will identify studies for inclusion using a screening questionnaire. The systematic search and screening will take place between 2 April 2020 and 1 June 2020, while we aim to complete data analysis by 1 September 2020. Quality assessment will be performed using the National Institutes of Health Quality Assessment Tool for Observational Cohort and Cross-Sectional Studies. The primary outcome measure is the sensitivity and specificity of OCT in detecting ICH in children. Secondary outcomes measures include conditions associated with ICH per study, direct ICP monitoring, sensitivity and specificity of other measures for ICP and OCT parameters used.

ETHICS AND DISSEMINATION

Ethical approval is not required for the proposed systematic review as no primary data will be collected. The findings will be disseminated through presentations at scientific meetings and peer-reviewed journal publication.

PROSPERO REGISTRATION NUMBER

CRD42019154254.

Pseudotumor Cerebri Syndrome: From Childhood to Adulthood Risk Factors and Clinical Presentation

INTRODUCTION

Although considered uncommon, pseudotumor cerebri syndrome (PTC) is a significant cause of headache among children and adults. However, the presenting symptoms may be different among diverse age groups. In the present study, we compared the risk factors and clinical presentation of PTC across life-from childhood to adulthood.

METHODS

A retrospective survey of PTC patients aged 7 years or older between 2011 and 2013 was carried out. Pooled analyses were performed comparing characteristics from our data with those of published data subdivided into 3 age groups: pre-young children, adolescents, and adults.

RESULTS

Our cohort consisted of 72 patients: 32 children (10 pre-young children, 22 adolescents) and 40 adults. Within the pre-young children age group: 20% were females versus 82% in the adolescent age group and 85% of the adult age group. Obesity was found in 10% of the young children group, 64% of the adolescents, and 80% of the adults. Headache was reported in 70% young children, 82% adolescents, and 83% adults. Pooled analysis of 1499 patients showed that young children with PTC tend to complain less about headache compared with older ones. Vomiting and visual impairment were most common among adolescents, and dizziness and tinnitus were most common in adults.

CONCLUSION

PTC has different risk factors and clinical presentation throughout life. In young children, there is no gender preference and most patients are not obese. Risk factors in adolescents resemble those of adults.

Long-Term Follow-up of Pseudotumor Cerebri Syndrome in Prepubertal Children, Adolescents, and Adults

PURPOSE

Pseudotumor cerebri syndrome can have a recurrent course. We compared the long-term disease course, recurrences, and final visual outcomes in prepubertal children, adolescents, and adults.

METHODS

In this retrospective observational study, patients were divided into prepubertal children (group A) adolescents (group B), and adults (group C).

RESULTS

Sixty-five patients (56 females, nine males) were included, 26.2% in group A, 24.6% in group B, and 49.2% in group C. Age at diagnosis was 8.6 ± 2.0 years, 14.3 ± 1.5 years, and 31.9 ± 9.7 years for the prepubertal children, adolescents, and adults, respectively. Medical treatment duration was similar (2.4 to 3.3 years, P > 0.05). Recurrences were observed in 23.5% of prepubertal children, 50% of adolescents, and 28.1% of adults. Recurrences occurred within 1.3 ± 0.6 years from treatment cessation in the prepubertal group compared with 3.8 ± 5.1 years in adolescents and 2.7 ± 2.0 years in adults (P = 0.267). Optic neuropathy was evident in 41% of group A, 31% of group B, and 87.5% of group C (P < 0.001). Obesity and cerebrospinal fluid opening pressures were unassociated with either relapsing rates or final visual outcomes in all groups.

CONCLUSIONS

Pseudotumor cerebri syndrome exhibits a relapsing course in a third of cases. Recurrences tend to occur within one year after treatment cessation in prepubertal children, and within three years in older patients, revealing the importance of longer follow-up, especially in adults. Optic neuropathy was more common in adults along with a tendency for visual decline. Longer treatment times were associated with fewer recurrences.

Asymptomatic Versus Symptomatic Idiopathic Intracranial Hypertension in Children

BACKGROUND

Idiopathic intracranial hypertension is a rare neurologic condition characterized by elevated intracranial pressure with normal cerebrospinal fluid analysis and neuroimaging. A subset of pediatric idiopathic intracranial hypertension patients are coincidentally found to have papilledema and elevated intracranial pressure without symptoms (eg, headache, visual blurring, tinnitus). This study aims to investigate the features of asymptomatic pediatric idiopathic intracranial hypertension.

METHODS

Retrospective case-control study of patients aged 0 to 18 years who received idiopathic intracranial hypertension diagnosis from 2005 to 2016. Subjects were included if they met established diagnostic criteria for idiopathic intracranial hypertension diagnosis. Subjects were classified as symptomatic if they presented with 1 symptom related to elevated intracranial pressure, and asymptomatic if no symptoms were present. Statistical analysis was performed to compare the 2 groups.

RESULTS

12 (22.6%) of 53 pediatric idiopathic intracranial hypertension subjects were asymptomatic. Compared to symptomatic idiopathic intracranial hypertension, asymptomatic idiopathic intracranial hypertension had younger age of onset, lower initial opening pressure on lumbar puncture, lower optic nerve edema grades bilaterally, lower likelihood of globe flattening on magnetic resonance imaging (MRI), and smaller required dose of acetazolamide for resolution of papilledema (all P < .05).

CONCLUSION

Asymptomatic idiopathic intracranial hypertension is common among pediatric patients with papilledema and is an important disease entity that requires special clinical management. It may exist as a milder version of idiopathic intracranial hypertension that occurs in younger children, or as a precursor state that later evolves into symptomatic disease.

Pseudotumor Cerebri Syndrome in Children

PURPOSE OF REVIEW

Pseudotumor cerebri syndrome (PTCS) may affect both children and adults; however, the risk factors and clinical presentation vary greatly between these populations. This review aims to highlight the entity of PTCS in children and the unique considerations in this population; review the epidemiology and demographics; discuss the clinical presentation, revised diagnostic criteria, and approach to evaluation; review management strategies; and discuss the prognosis and long-term outcomes in children with PTCS.

RECENT FINDINGS

Clinical presentation can be variable in children and may be less obvious than in their adult counterparts. Papilledema can also be challenging to diagnose in this population. The upper limits for opening pressure on lumbar puncture differ in children, with a cut-off of 25 cm H20 (or 28 cm H2O in a sedated or obese child). Morbidity related to visual loss, pain and reduced quality of life lends urgency towards accurately identifying, evaluating and managing children with PTCS. There are no randomised controlled studies to allow for evidence-based recommendations for the management of PTCS in children. Further studies are needed to clarify and consolidate management approaches in this population.

Demographics, clinical features, and response to conventional treatments in pediatric Pseudotumor Cerebri syndrome: a single-center experience

OBJECTIVE

The goal of this study was to better understand pediatric Pseudotumor Cerebri syndrome, and its relationship to age, obesity, and other medical conditions; and to evaluate response to conventional treatments.

METHODS

A retrospective chart review was performed on consecutive patients who were diagnosed with PTCS between January 1, 2007, and July 31, 2014. A total of 78 patients were included in this study: 54 female (69.3%) and 24 male (30.7%). Variables including age, sex, body mass index, concomitant medical conditions, secondary causes, associated symptoms, physical exam findings, imaging results, recurrence of symptoms, and treatment modalities were analyzed. Patients were grouped into "pre-kindergarten," "elementary," and "adolescent" based on their age; and weight categories of underweight, normal weight, overweight, moderately, and severely obese.

RESULTS

Mean age of symptom onset was 11.92 ± 4.09 years. Elementary and adolescent age patients were more likely to be overweight, moderately obese, and severely obese, while this finding was not found for patients in pre-kindergarten group. Headache (83.3%) and visual disturbances (48.7%) were the most common presenting complaints. Asthma (16.6%) was the most common associated concomitant medical condition. Medical management resulted in resolution in 84% of population, 15% required surgical interventions, and the recurrence rate was found to be 20.5%. There was a statistically significant trend in success with medical management in younger patients (p = 0.04), while medically refractory PTCS was seen in adolescent females. Recurrence of PTCS had a linear trend with increased occurrence in adolescent age group with higher BMI. Asthma was observed to be frequently associated with PTCS in our cohort. Obesity is strongly associated with PTCS, not only in the adolescent group but also in the younger elementary age group. Treatment remains similar to management in the adults with a good response (84%) to medical management and a low relapse rate.

Predictors of Primary Intracranial Hypertension in Children Using a Newly Suggested Opening Pressure Cutoff of 280 mm H2O

OBJECTIVES

We assessed the clinical characteristics of primary intracranial hypertension (PIH) in children using a newly recommended threshold for cerebrospinal fluid opening pressure (280 mm H₂O).

METHOD

Cross-sectional study of patients age ≤21 years who had a lumbar puncture done for evaluation of PIH. Patients were excluded if lumbar puncture was done for a suspected infection, seizure, mental status changes, multiple sclerosis, or Guillain-Barre syndrome. Cases were identified using a text-search module followed by manual review. We performed χ2 analysis for categorical data and Mann-Whitney U test for continuous data, followed by a binary logistic regression.

RESULTS

We identified 374 patients of whom 67% were female, median age was 13 years interquartile range (11 to 16 years), and admission rate was 24%. Using an opening pressure cutoff of 250 mm H₂O, 127 patients (34%) were identified as having PIH, whereas using the new cutoff 105 patients (28%) met PIH criteria. Predictors for PIH included optic disc edema or sixth nerve palsy using both old, odds ratio (OR) 7.6 (4.3, 13.5), and new cutoffs, OR 9.7 (95% confidence interval 5.1, 18.5). Headache duration ≤61 days is predictive of PIH using the new cutoff OR 4.1 (95% confidence interval 1.3, 12.8). A model is presented which stratifies patients into groups with low (7%), medium (18%), and high (greater than 42%) risk of PIH.

CONCLUSIONS

A higher cerebrospinal fluid opening pressure threshold in the criteria of PIH is associated with PIH patients with a different symptom profile. Children with optic disc edema, bulging fontanel or sixth nerve palsy, are at increased risk for PIH.

Intracranial hypertension: a current review

PURPOSE OF REVIEW

To provide a current review of recent publications with regards to intracranial hypertension.

RECENT FINDINGS

Attempts were made to provide pediatric data; however, the recent completion of the Idiopathic Intracranial Hypertension Treatment Trial (IIHTT) has provided a wealth of data with regards to adult intracranial hypertension.The pediatric incidence of intracranial hypertension ranges between 0.63 and 0.71 per 100 000 children. A majority of pediatric cases responded to acetazolamide, with resolution of headache averaging 3.8 weeks. Most patients require less than 1 year of treatment with male sex, older age at diagnosis, primary intracranial hypertension, and lack of headache being predictors of good response. Fluorescein angiography has the highest accuracy in distinguishing true papilledema from pseudopapilledema. The IIHTT found Frisen grade of papilledema was within 1 grade in 92.8% of patients. Monitoring of potassium levels is not required and aplastic anemia was not seen in patients taking acetazolamide.

SUMMARY

Although the newer pediatric studies report incidence rates in pediatric intracranial hypertension are lower than seen in adults, intracranial hypertension is still a concern in pediatrics. There has been a wealth of information with regards to symptomatology, treatment, and outcomes from the IIHTT that will hopefully assist with management in the pediatric population.

Cranial morcellation decompression for refractory idiopathic intracranial hypertension in children

BACKGROUND

Primary idiopathic intracranial hypertension (PIIH) in children is rare and has a poorly understood pathophysiology. It is characterized by raised intracranial pressure (ICP) in the absence of an identified brain lesion. Diagnosis is usually confirmed by the measurement of a high cerebrospinal fluid (CSF) opening pressure and exclusion of secondary causes of intracranial hypertension. Refractory PIIH may lead to severe visual impairment. The purpose of this study was to evaluate a cranial morcellation decompression (CMD) technique as a new surgical alternative to stabilize intracranial pressure in PIIH.

MATERIALS AND METHODS

A literature review was carried out, disclosing only 7 pediatric cases of PIIH treated with surgical skull expansion. In addition, we describe here one case of our own experience treated by CMD.

CONCLUSIONS

CMD surgery is a safe and effective option to control refractory PIIH in selected patients.

Pediatric Intracranial Hypertension: a Current Literature Review

PURPOSE OF REVIEW

The purpose of this review is to provide an update on pediatric intracranial hypertension.

RECENT FINDINGS

The annual pediatric incidence is estimated at 0.63 per 100,000 in the USA and 0.71 per 100,000 in Britain. The Idiopathic Intracranial Hypertension Treatment Trial found improvement in visual fields, optical coherence tomography, Frisen grade, and quality of life with acetazolamide compared to placebo in adult patients, and these findings have been translated to the pediatric population. Pediatric intracranial hypertension is a disorder that if left untreated can lead to poor quality of life and morbidity. There are no current treatment studies in pediatrics, but adult data suggests acetazolamide remains an acceptable first-line medication.

Secondary Intracranial Hypertension in Pediatric Patients With Leukemia

BACKGROUND

We investigated the clinical characteristics of a pediatric population with hemato-oncological disease and intracranial hypertension, analyze the therapeutic response and outcome, and compare its characteristics with respect to a control group with idiopathic intracranial hypertension.

METHODS

We retrospectively analyzed patients with hemato-oncological disease and secondary intracranial hypertension in our center during the past five years. We compared these individuals with a historical cohort with idiopathic intracranial hypertension from our institution (control group).

RESULTS

We identified eight patients, all with leukemia, and 21 controls. Mean age at diagnosis was 10.6 years, and 62% of individuals were female. Most of them were under treatment with drugs (62% corticosteroids, 75% active chemotherapy). Mean opening pressure of cerebrospinal fluid was 35 cm H₂O. All had headache, but only 28% complained of visual symptoms. Only 12.5% exhibited papilledema at the time of diagnosis (versus 71% in controls). All of them were treated with acetazolamide, with average therapy duration of nine months, and all had a favorable outcome (versus 57% of controls who needed second-line treatment). None of them showed long-term visual complications (versus 20% of controls).

CONCLUSIONS

Patients with hemato-oncological disease and secondary intracranial hypertension may not develop typical symptomatology. Thus, diagnosis and recognition of this entity among this cohort may be difficult. Associated factors are diverse and do not show an obvious causal relationship. A high index of suspicion must be maintained for diagnosis, because a favorable outcome is expected with prompt treatment. Acetazolamide is effective as a first-line therapy and caused few side effects.