Idiopathic intracranial hypertension in children

Pseudotumor cerebri in the paediatric population: clinical features, treatment and prognosis

INTRODUCTION

Pseudotumor cerebri (PC) in prepubertal patients displays certain characteristics that differentiate it from its presentation at the postpubertal stage. The aim of this study is to describe the characteristics of paediatric patients diagnosed with PC at our centre and to compare them according to their pubertal status.

PATIENTS AND METHODS

We included patients aged between 1 and 18 years who were diagnosed with PC in a tertiary-level hospital between 2006 and 2019 and who met the updated diagnostic criteria for PC. They were classified according to body weight and pubertal status. Subsequently, we analysed results from lumbar punctures, neuroimaging studies, ophthalmological assessments, and treatments received during follow-up.

RESULTS

We included 28 patients, of whom 22 were of prepubertal age and 6 were of postpubertal age. The mean age (standard deviation) was 9.04 (2.86) years. Among the postpubertal patients, 83.3% were boys, 66.7% of whom presented overweight/obesity. In the group of prepubertal patients, 27% were boys, 31.8% of whom were overweight. The most frequent symptoms were headache (89.9%) and blurred vision (42.9%). All patients presented papilloedema, and 21.4% manifested sixth nerve palsy. Possible triggers were identified in 28.6% of cases. Nineteen percent of patients presented clinical recurrence, all of whom were prepubertal patients. Complete clinical resolution was achieved in 55.6% of patients.

CONCLUSION

Prepubertal patients with PC show lower prevalence of obesity, higher prevalence of secondary aetiologies, and higher recurrence rates than postpubertal patients.

Stereotactic-Guided Transcerebellar Cisternoperitoneal Shunt Placement for Idiopathic Intracranial Hypertension

BACKGROUND

Idiopathic intracranial hypertension (IIH) can cause debilitating symptoms and optic nerve ischemia if untreated. Cerebrospinal fluid diversion is often necessary to reduce intracranial pressure; however, current ventriculoperitoneal and lumboperitoneal shunting techniques have high failure rates in patients with IIH.

OBJECTIVE

To describe our experience treating IIH with a novel stereotactic-guided transcerebellar cisternoperitoneal shunt (SGTC-CPS) technique that places the proximal shunt catheter in the posterior cisterna magnum.

METHODS

Retrospective perioperative and postoperative data from all patients who underwent SGTC-CPS placement for IIH from March 1, 2015, to December 31, 2020, were analyzed. Patients were positioned as for ventriculoperitoneal shunt placement but with the head turned farther laterally to adequately expose the retrosigmoid space. Using neuronavigation, an opening was made near the transverse-sigmoid junction, and the proximal catheter was inserted transcerebellarly into the posterior foramen magnum.

RESULTS

Thirty-two patients underwent SGTC-CPS placement (29 female; mean body mass index, 36.0 ± 7.5; 14 with prior shunt failures). The mean procedure time for shunt placement was 145 minutes. No intraoperative complications occurred, and all patients were discharged uneventfully. At the 6-month follow-up, 81% of patients (21 of 26) had relief of their presenting symptoms. Shunt survival without revision was 86% (25 of 29) at 1 year and 67% (10 of 15) at 3 years, with no infections.

CONCLUSION

The SGTC-CPS offers an alternative solution for cerebrospinal fluid diversion in patients with IIH and demonstrates a lower failure rate and more durable symptom relief compared with ventriculoperitoneal or lumboperitoneal shunt placement. Using proper techniques and equipment promotes safe and facile placement of the proximal catheter.

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.

Idiopathic intracranial hypertension in children with obesity

AIM

Obesity is an under-recognised risk factor for raised intracranial pressure in the paediatric population. The pathophysiology remains unclear. The aim of our study was to investigate the association between idiopathic intracranial hypertension (IIH) and weight in children.

METHODS

Patients diagnosed with IIH at a tertiary children's hospital were retrospectively identified between April 2017 and April 2019. Information regarding the patients' body mass index, presentation, investigation and treatment was collected and analysed.

RESULTS

In total, 18 patients (M:F 7:11) were identified with a mean age of 11 years (±3.3SD; range: 6-15 years). The mean BMI was 30.3 kg/m² and mean BMI SDS was +2.5. Twelve (66.6%) patients presented with both headaches and eye signs. Three patients were asymptomatic, with papilloedema noted on routine optician review. Of the 18 patients, 15 were treated medically, two had long-term neurosurgical interventions and one patient was managed conservatively.

CONCLUSION

The results show that the majority of children with obesity who develop IIH were female. Awareness regarding IIH secondary to obesity needs to be highlighted to ensure detailed clinical evaluation takes place so that raised intracranial pressure can be diagnosed and managed earlier, to avoid more serious complications such as permanent visual loss.

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.

Atypical idiopathic intracranial hypertension presenting as cyclic vomiting syndrome: a case report

Background

Idiopathic intracranial hypertension is a disorder of increased intracranial pressure in the absence of cerebrospinal outflow obstruction, mass lesion, or other underlying cause. It is a rare phenomenon in prepubertal children and is most typically found in women of childbearing age. The classic presentation consists of headaches, nausea, vomiting, and visual changes; however, children present more atypically. We report a case of idiopathic intracranial hypertension in an otherwise healthy, 4-year-old child with atypical symptoms resembling those of cyclic vomiting syndrome.

Case presentation

A 4-year-old Caucasian, otherwise healthy, male child presented to our emergency department with episodic intermittent early-morning vomiting occurring once every 1–3 weeks without interepisodic symptoms, starting 10 months prior. With outpatient metabolic, autoimmune, endocrine, allergy, and gastroenterology work-up all unremarkable, he was initially diagnosed with cyclic vomiting syndrome. Discovery of mild optic nerve sheath distension on magnetic resonance imaging of the brain 10 months after symptom onset led to inpatient admission and a lumbar puncture notable for an opening pressure of 47 mmHg, with normal cell count and protein levels. He had no changes in visual acuity or optic disc edema on dilated fundoscopic examination. The patient was started on acetazolamide, with resolution of episodic emesis at his last follow-up visit 12 weeks after discharge.

Conclusions

Idiopathic intracranial hypertension presents atypically in prepubescent children, with about one-fourth presenting asymptomatically, and only 13–52% presenting with “classic” symptoms. With a prevalence of only 0.6–0.7 per 100,000, much remains unknown regarding the underlying pathophysiology in this demographic. Cyclic vomiting syndrome, however, has a much higher prevalence in this age group, with a prevalence of 0.4–1.9 per 100. It is thought to be an idiopathic, periodic disorder of childhood, often linked to neurological conditions such as abdominal migraines, epilepsy, mitochondrial disorders, and structural lesions such as chiari malformation and posterior fossa tumors. While cyclic vomiting syndrome is thought to have a benign course, untreated idiopathic intracranial hypertension can have long-term detrimental effects, such as visual loss or even blindness. We present a case of idiopathic intracranial hypertension presenting with symptoms resembling cyclic vomiting syndrome in a 4-year-old child, diagnosed 10 months after initial onset of symptoms. We aim to demonstrate the need for a high level of clinical suspicion and the need for further investigation into underlying pathophysiology in this vulnerable population.

Intracranial Hypertension Recurrence Risk After Wean of Intracranial Pressure-Lowering Medication

BACKGROUND

The proportion of children with recurrent signs and symptoms of intracranial hypertension after medication wean has been reported to be between 18% and 50%. Few studies have reported intracranial hypertension recurrence risk in children while adjusting for each individual's observed follow-up time after medication wean. In addition, the role of intracranial hypertension etiology on the risk of disease recurrence has not been widely studied.

METHODS

The medical charts of patients with intracranial hypertension treated with intracranial pressure-lowering medication were analyzed retrospectively for disease recurrence. Baseline characteristics from diagnosis were recorded in addition to information regarding duration of therapy, medication wean, and recurrence. Survival analyses as well as Poisson regression models with time under observation as an offset were performed.

RESULTS

One hundred and thirty-three patients were included in the study. The cumulative risk of intracranial hypertension recurrence increased rapidly within the first six months after medication wean and was 1.5% at one month, 9.5% at three months, and 20% at six months. This risk leveled off near 12 to 18 months.

CONCLUSIONS

While the cumulative risk of intracranial hypertension recurrence increases most dramatically within the first six months after medication wean, it does not appear to taper until 12 to 18 months. Given the possibility of delayed or asymptomatic recurrences, long-term follow-up is ideal, although patients can likely be seen less frequently after the first 12 to 18 months after medication wean.

Pseudotumor cerebri in the paediatric population: clinical features, treatment and prognosis

INTRODUCTION

Pseudotumor cerebri (PC) in prepubertal patients displays certain characteristics that differentiate it from its presentation at the postpubertal stage. The aim of this study is to describe the characteristics of paediatric patients diagnosed with PC at our centre and to compare them according to their pubertal status.

PATIENTS AND METHODS

We included patients aged between 1 and 18 years who were diagnosed with PC in a tertiary-level hospital between 2006 and 2019 and who met the updated diagnostic criteria for PC. They were classified according to body weight and pubertal status. Subsequently, we analysed results from lumbar punctures, neuroimaging studies, ophthalmological assessments, and treatments received during follow-up.

RESULTS

We included 28 patients, of whom 22 were of prepubertal age and 6 were of postpubertal age. The mean age (standard deviation) was 9.04 (2.86) years. Among the postpubertal patients, 83.3% were boys, 66.7% of whom presented overweight/obesity. In the group of prepubertal patients, 27% were boys, 31.8% of whom were overweight. The most frequent symptoms were headache (89.9%) and blurred vision (42.9%). All patients presented papilloedema, and 21.4% manifested sixth nerve palsy. Possible triggers were identified in 28.6% of cases. Nineteen percent of patients presented clinical recurrence, all of whom were prepubertal patients. Complete clinical resolution was achieved in 55.6% of patients.

CONCLUSION

Prepubertal patients with PC show lower prevalence of obesity, higher prevalence of secondary aetiologies, and higher recurrence rates than postpubertal patients.

Optic nerve sheath fenestration in leukemic patients having increased intracranial pressure: a prospective clinical trial

PURPOSE

This study aimed to assess the safety and efficacy of optic nerve sheath fenestration (ONSF) in leukemic children having increased intracranial pressure with severe uncontrolled visual loss on medical treatment and not eligible for venous sinus stenting.

METHODS

In this non-randomized clinical trial, we included patients presenting with severe sight-threatening papilledema due to increased intracranial pressure following leukemia treatment. All included patients were subjected to a complete history taking, assessment of the visual acuity and fundus examination with fundus photography and grading of papilledema using Frisen scale. Patients were evaluated at 2 weeks and 3 months postoperative by recording the best-corrected visual acuity, assessment of the pupillary reaction and fundus examination and fundus photography with grading of papilledema.

RESULTS

Among 20 patients included in this study, there was a statistically significant improvement in visual acuity of both eyes in all patients. The mean postoperative visual acuity was 0.28 ± 0.10 two weeks after surgery in the right eye and it was 0.42 ± 0.16 in the left eye. The mean visual acuity in the right eye three months after surgery was 0.78 ± 0.19 and it was 0.87 ± 0.17 in the left eye. Three months postoperatively, papilledema resolved completely in both eyes. There were no recorded ocular complications.

CONCLUSION

In this study, ONSF was sight-saving procedure in all leukemic patients with a significant improvement in the visual acuity, stabilization of the visual function and resolving of the papilledema over follow-up period. There were no recorded intraoperative or postoperative complications. Further well-designed studies are needed to assert upon these results.

The Possibility of Intracranial Hypertension in Patients with Autism Spectrum Disorder Using Computed Tomography

Although intracranial pressure is considered to be normal in children with autism spectrum disorder (ASD), we aimed to assess whether such children may have increased intracranial pressure using noninvasive computed tomography (CT). Head CT scans of children with ASD (109 cases, male 91 and female 18, average age 4.3 years) and of children with typical development (60 cases, male 35 and female 25, average age 4.5 years) were acquired. The images were processed to map the shape of the inner skull surface. We predicted that a complex skull shape, based on a marked digital impression, would be indicative of chronically increased intracranial pressure. The data of the scans were extracted and processed to automatically establish inner and outer cranial circumferences. The circularity (reflecting inner skull shape and area) and C-ratio (ratio of inner/outer circumference) were determined and statistically analyzed. The circularity and C-ratio were significantly lower in children with ASD than in children with typical development. A lower circularity was associated with a more complex shape of the inner skull surface, which indicated the presence of intracranial hypertension. Our study suggests that children with ASD may be at a risk for chronic intracranial hypertension. Our technique incorporating the circularity and C-ratio is a useful noninvasive method for screening such patients and could impact future investigations of ASD.

The Clinical Utility of Inpatient Brain Magnetic Resonance Imaging in Children

The clinical applicability and yield of brain magnetic resonance imaging (MRI) in the setting of an inpatient pediatric department has not been investigated. The authors performed a retrospective chart review of nontraumatic/nonneurosurgical children who underwent brain MRI during their hospitalization in a general pediatric department over a 5-year period. Of the 331 children who underwent brain MRI, 148 (45%) had abnormal findings. High-risk headaches and focal seizures were significantly correlated with findings on brain MRI. Diagnostic and therapeutic yields were most significant in acute demyelinating events, acute cerebrovascular disorders, high-risk headaches when supported by neurologic and ophthalmologic findings, focal seizures with evidence of multifocal epileptic activity on an electroencephalogram and ophthalmic complaints when accompanied by cranial nerve palsy and optic nerve impairment. Since the contributions of a brain MRI in hospitalized children is pivotal in specific clinical situations, a judicious decision-making process should be done before its scheduling, in order to optimize clinical care.

Pediatric Pseudotumor Cerebri: Epidemiological Features

Objective:

The purpose was to study the epidemiological and clinical features of Pediatric Pseudotumor Cerebri; we especially evaluated age, sex, sexual maturity, weight, symptoms, duration of the episode, visual acuity, correlation with systemic diseases or drugs.

Methods:

We investigated a population of 40 children (80 eyes), aged between 2 and 18 years, that referred to our Centre (Città della Salute e della Scienza di Torino - presidio Ospedale Regina Margherita) from 2000 to 2018.

All the patients were monitored with visual field exam, fundus exam and Frisen classification, pupillary reflexes, best corrected visual acuity, orthoptic exam.

Then, the demographic characteristics, BMI (body max index) and weight changes, the correlation with systemic diseases or drugs, the Relative Afferent Pupillary Defect (RAPD), the VI cranial nerve deficit, the time required for the diagnosis, the modality of onset, the correlation between diagnosis delay and best corrected visual acuity, the resolution time and the probability of recurrence were studied.

Results:

We observed 2 age peaks in our population, one consisting of adolescents (aged between 11 and 14 years) and one consisting of younger children aged between 4 and 7 years, with a statistically significant correlation between age and BMI.

The deficit of the VI cranial nerve and the diplopia were resolved within the first month, despite the longer time of resolution of the papilledema.

Headache was the main onset symptom, but after reclassifying onset symptoms per weight classes, in overweight children, we found an increased variability of symptoms (dizziness, postural instability, photophobia, nausea, vomit, strabism and diplopia, visual fogging, drowsiness, irritability). Moreover, we found only one totally asymptomatic case, during a routine visit, in a 6 years old overweight child with Down syndrome.

Conclusion:

The Pediatric Pseudotumor Cerebri is, even nowadays, a little known pathology.

To provide a correct diagnostic assessment, it will be imperative to recollect the epidemiological features of this disease.

Infantile Idiopathic Intracranial Hypertension: A Case Study and Review of the Literature

Idiopathic intracranial hypertension, or pseudotumor cerebri, is an increase in cerebrospinal fluid pressure of unknown etiology. It is mostly seen in adults, less frequently in adolescents, rarely in younger children. Only 5 infants meeting idiopathic intracranial hypertension criteria have been mentioned in the literature. We report a case of a previously healthy 9-month-old boy who presented with irritability, decreased appetite, and a bulging fontanelle. Computed tomography (CT) head imaging and cerebrospinal fluid studies revealed normal results. The patient's symptoms transiently resolved after the initial lumbar puncture, but 11 days later, his fontanelle bulged again. A second lumbar puncture revealed an elevated opening pressure of 35 cmH₂O and led to a diagnosis of idiopathic intracranial hypertension in accordance with the modified Dandy Criteria. Treatment with acetazolamide at a dose of 25 mg/kg/d was initiated and the patient remained symptom-free for 6 weeks, followed by another relapse. His acetazolamide dose was increased to 37 mg/kg/d, with no further relapses to date. A diagnosis of idiopathic intracranial hypertension is challenging in infants, because the patients cannot yet verbalize typical idiopathic intracranial hypertension-related symptoms such as positional headaches, diplopia, or pulsatile tinnitus. Furthermore, it is more difficult to assess papilledema in that age group. If undetected and untreated, idiopathic intracranial hypertension may result in permanent visual deficits. Little is known about idiopathic intracranial hypertension in infants, and age-specific treatment guidelines are lacking. We discuss this rare case of infantile idiopathic intracranial hypertension and provide a review of the literature, including an overview of disease characteristics and outcomes of idiopathic intracranial hypertension in this very young age group.

Clinical features of pediatric idiopathic intracranial hypertension

Introduction: Adult idiopathic intracranial hypertension (IIH) is often linked to obesity, however, causes of IIH in children are not well understood. This project identifies potential risk factors and features of pediatric IIH.

Methods: This study consisted of a retrospective chart review of patients ages 5–17 years who were seen at a tertiary care children’s hospital and diagnosed with IIH. Diagnostic criteria included the presence of papilledema, normal neurological exam, normal neuroimaging, normal cerebrospinal fluid composition, and an opening pressure of a lumbar puncture >28 mmHg.

Results: Of the 26 cases of IIH, 19 met all diagnostic criteria for this study, while seven patients were probable IIH, as they lacked papilledema. Intracranial pressure ranged from 28 to 66 mmHg, with a mean of 40.23 mmHg (±10.74). Overall, 50.0% (95% CI: 29.9–70.1%) of IIH patients were obese, with patients 12 years of age and younger exhibiting an overall obesity rate of 30.7% and patients 13 years of age and older having an obesity rate of 69.2%. The overall allergy rate in this IIH patient population was 46.2% (95% CI: 26.6–66.6%).

Conclusion: Obesity appears to have no association with IIH in younger cases, but it is a more common feature in older children. An autoimmune component may play a role in pediatric IIH, given the high rate of atopy observed in this pediatric IIH patient cohort. Because a diagnosis of IIH can have an absence of optic nerve edema, taking a detailed history and performing a thorough examination are keys to diagnosing IIH in the pediatric population.

Pediatric Pseudotumor Cerebri Syndrome

Idiopathic intracranial hypertension, otherwise known as primary pseudotumor cerebri syndrome (PTCS), most frequently occurs in obese women of childbearing age. However, children may be affected as well. This review will address recent findings regarding demographics, diagnosis, and treatment of pediatric PTCS. Prepubertal children with primary PTCS have an equal sex distribution and less frequent obesity compared with adult patients. However, female gender and obesity are risk factors for primary PTCS in postpubertal children. Compared with adults, children with PTCS more frequently present with ocular motility deficits and more often have associated medical conditions that increase the risk of developing PTCS. Visual field testing may be unreliable, and the optimal modality to monitor visual function is unknown. MRI shows signs of elevated intracranial pressure (ICP) in children with PTCS similar to that of adults. It has now been established that elevated ICP in children ≤18 years old is greater than 25 cm H20 in nonobese, nonsedated children, and greater than 28 cm H2O in the remainder. Optical coherence tomography (OCT) may be used to distinguish pseudopapilledema from papilledema, monitor response to treatment in preverbal children, and identify patients with PTCS at risk for permanent visual loss. However, the precise role of OCT in the management of pediatric PTCS remains to be determined.

Therapeutic approaches to pediatric pseudotumor cerebri: New insights from literature data

The pseudotumor cerebri syndrome (PTCS), also known as idiopathic intracranial hypertension (IIH), is characterized by signs and symptoms of increased intracranial pressure such as headache and cranial nerve palsies, in the absence of any space-occupying mass. This condition commonly affects overweight women of childbearing age, even if it is also frequent in men and children. Children with PTCS may present with atypical signs and symptoms, with a different prognosis compared to adults. However, the treatment is the same for both children and adults, even if there are no strict treatment guidelines in regards. All treatment strategies in children are based on retrospective studies and none has been evaluated in prospective or randomized controlled trial studies. This review focuses on literature data on PTCS treatment in children.

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

INTRODUCTION

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

METHOD

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

RESULTS

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

DISCUSSION

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

Prevalence of idiopathic intracranial hypertension and associated factors in obese children and adolescents

BACKGROUND

Idiopathic intracranial hypertension (IIH) is one of the most important and rare complications of obesity. Prevalence of IIH in childhood obesity is not known. The purpose of this study was to determine the prevalence of IIH in obese children and adolescents and to investigate the relevant factors.

METHODS

In this study, 1058 obese children and adolescents between 2 and 18 years of age were included. Funduscopic examination was conducted for all subjects. In cases with papilledema, increase in intracranial pressure was clarified by measuring CSF pressure with a lumbar puncture. Other causes of IIH were ruled out with clinical, laboratory tests and imaging techniques.

RESULTS

Idiopathic intracranial hypertension was diagnosed in 14 subjects (1.32%). Rates of headache and systemic hypertension in subjects with IIH was determined to be 78.6% and 28.6%, respectively. Morning cortisol, fasting insulin and HOMA-IR values were found to be significantly higher in this cases (p<0.05).

CONCLUSIONS

In childhood obesity, IIH should be kept in mind as a serious complication. Funduscopic examination is an easy method that suggests IIH. In particular, obese children with systemic hypertension and refractory headache should be considered for IIH.

Seasonal Variation and Atypical Presentation of Idiopathic Intracranial Hypertension in Pre-Pubertal Children

Idiopathic intracranial hypertension is an enigmatic disorder of elevated cerebrospinal fluid pressure. In adulthood, patients are typically obese women of childbearing age; however, in young children the clinical picture is strikingly different, indicating age-related differences in the aetiology of idiopathic intracranial hypertension. To investigate this phenomenon, we analysed the clinical details of 15 pre-pubertal children with the diagnosis of idiopathic intracranial hypertension. Evaluating the date of initial presentation, we discovered a distinct seasonal variation. Ten patients presented between November and March, thus coinciding with the typical season of paediatric viral and bacterial infections in Germany. Therefore, we suggest an association between intracranial hypertension and possibly concurrent infections in these children. Moreover, eight children presented only with ophthalmologic findings without any other obvious symptoms, raising questions regarding the incidence of undetected cases, particularly in this age group.

Intracranial complications of otitis media: 15 years of experience in 33 patients

OBJECTIVES:

Complications in the central nervous system (CNS) from acute otitis media (AOM) and chronic otitis media (COM) are becoming fewer, although they still represent a challenge for early recognition, adequate treatment, and satisfactory results. This retrospective study analyzed clinical data and therapeutic options in 33 patients with intracranial involvement resulting from otitis media. Important clinical features of intracranial complications and the sequence of the most efficient therapeutic maneuvers are discussed.

METHODS:

Charts of six patients with AOM and 27 patients with COM associated with CNS complications were analyzed for clinical presentation, imaging, and therapeutic approach.

RESULTS:

Ages ranged from 6 months to 79 years, with no gender predilection. Persistent fever, headache, and purulent otorrhea were the main symptoms. Proteus mirabilis, Enterococcus, and Pseudomonas aeruginosa were the most common microorganisms in COM, and Pneumococus and Haemophilus were the most common microorganisms in AOM. Nineteen patients (58%) presented with more than 1 CNS complication, resulting in a total of 56 complications, including 26 cases of otogenic brain abscess, 21 cases of meningitis, 5 cases of lateral sinus thromboses, two cases of subdural empyemas, 1 case of epidural empyema, and 1 case of meningocele. Surgical interventions included craniotomy and drainage of the abscess (n = 17), open mastoidectomy with abscess drained through the mastoid (n = 10), open mastoidectomy alone (n = 8), and closed mastoidectomy (n = 2). Twelve patients who underwent craniotomy had subsequent mastoidectomy for recurrent abscess. At the 6-month, 66% of patients presented without sequelae, 24% presented with sequelae, and 9% died.

CONCLUSION:

Early identification and prompt clinical and surgical intervention with mandatory drainage of the middle ear (primary disease), was essential for better outcome.

Intracranial hypotension and hypertension in children and adolescents

The specific aim of this review is to report the features of intracranial pressure changes [spontaneous intracranial hypotension (SIH) and idiopathic intracranial hypertension (IIH)] in children and adolescents, with emphasis on the presentation, diagnosis, and treatment modalities. Headache associated with intracranial pressure changes are relatively rare and less known in children and adolescents. SIH is a specific syndrome involving reduced intracranial pressure with orthostatic headache, frequently encountered connective tissue disorders, and a good prognosis with medical management, initial epidural blood patching, and sometimes further interventions may be required. IIH is an uncommon condition in children and different from the disease in adults, not only with respect to clinical features (likely to present with strabismus and stiff neck rather than headache or pulsatile tinnitus) but also different in outcome. Consequently, specific ICP changes of pediatric ages required specific attention both of exact diagnosis and entire management.

Overweight and obesity in pediatric secondary pseudotumor cerebri syndrome

PURPOSE

To examine the clinical, demographic, and anthropometric patient characteristics of secondary pseudotumor cerebri syndrome in children and adolescents based on the recently revised diagnostic criteria.

DESIGN

Retrospective observational case series.

METHODS

Patients seen at a tertiary children's hospital for pseudotumor cerebri syndrome were classified as having either primary idiopathic (n = 59) or secondary pseudotumor cerebri syndrome (n = 16), as rigorously defined by recently revised diagnostic criteria. Outcomes included body mass index Z-scores (BMI-Z), height and weight Z-scores, demographics, and clinical features at presentation, such as headache, sixth nerve palsy, and cerebrospinal fluid (CSF) opening pressure.

RESULTS

In this cohort, the associated conditions and exposures seen in definite secondary pseudotumor cerebri syndrome included tetracycline-class antibiotics (n = 11), chronic kidney disease (n = 3), withdrawal from chronic glucocorticoids (n = 1), and lithium (n = 1). Other associations observed in the possible secondary pseudotumor cerebri syndrome group included Down syndrome, vitamin A derivatives, and growth hormone. In comparison with primary pseudotumor cerebri syndrome, definite secondary pseudotumor cerebri syndrome patients were on average older (15.0 vs 11.6 years; P = .003, Mann-Whitney test). According to US Centers for Disease Control (CDC) classifications, 79% of children with secondary pseudotumor cerebri syndrome were either overweight or obese (36% overweight [n = 5] and 43% obese [n = 6]), as compared to 32% nationally.

CONCLUSIONS

Even when a potential inciting exposure is identified for pediatric pseudotumor cerebri syndrome, the possible contribution of overweight and obesity should be considered.

Idiopathic intracranial hypertension associated with polycystic ovarian syndrome

Idiopathic intracranial hypertension is defined as increased intracranial pressure of unknown origin. Idiopathic intracranial hypertension associated with polycystic ovarian syndrome (PCOS) is a rare condition in adolescence. We report the case of a 14-year-old girl with sudden onset of decreased visual acuity, headache and menstrual irregularity. Clinical neurological examination and magnetic resonance imaging of the brain and orbit were normal. Lumbar puncture demonstrated an increased opening pressure of 31 cm H2O. Gynecologic investigation indicated PCOS. Her symptoms improved with medical and surgical treatment for the underlying PCOS.

A review of pediatric idiopathic intracranial hypertension

It is now well recognized that idiopathic intracranial hypertension (IIH) can occur in children. Relative to the adult population, the demographic features and clinical presentation of IIH as well as the diagnosis and treatment guidelines for children are quite different. Although these differences are well established, specific diagnostic and treatment guidelines for pediatric patients have largely been based on the adult literature. Exciting new evidence is now available to assist the clinician in managing pediatric patients with IIH.

[Sixth, seventh and tenth cranial nerve palsies associated with pseudotumor cerebri in a 13-year-old boy]

We describe the case of a 13-year-old boy who presented to the emergency department with an acute onset paresis of the left abducens, facial and vagus nerves. Bilateral papilledema was seen on fundoscopy. Blood tests and brain magnetic resonance imaging and angiography showed no abnormalities. A lumbar puncture revealed an elevated intracranial pressure (575mmH2O) and clear cerebrospinal fluid. The diagnosis of pseudotumor cerebri (PTC) associated with multiple cranial nerve palsies was made. Treatment with acetazolamide was initiated, resulting in progressive improvement with no sequelae and no clinical recurrence over an 8-month follow-up period. PTC in children can present with a wide spectrum of neurological signs, especially cranial nerve palsies which are most likely related to a pressure-dependent stretching mechanism. In 2007, distinctive diagnostic criteria for pediatric PTC were established, including the presence of any cranial nerve palsy in the absence of an identifiable etiology.

Pediatric pseudotumor cerebri

Although PTC most frequently occurs in obese females of childbearing age, the syndrome occurs in children as well.(3),(5) Prepubertal children with PTC have a lower incidence of obesity compared with adults and there is no sex predilection. The onset of puberty is best defined by the onset of secondary sexual characteristics such has menarche, pubic hair, and breast development. Children with PTC have a higher incidence of associated conditions and cranial nerve deficits compared with adults. Similar to adult patients, children are at risk for the development of permanent visual loss. In rare instances, children initially diagnosed with PTC will be found to harbor an intracranial neoplasm such as gliomatosis cerebri. An intracranial pressure of 28 cm H2O has recently been established as the upper limit of normal in children.31 Treatment is indicated for the symptomatic management of headaches and to preserve vision. Most children respond to medications such as acetazolamide, furosemide, or topiramate. Surgical treatment such as ONSF and shunting procedures are indicated for children with severe headaches, visual loss, or both despite maximal tolerated medical treatment.

Idiopathic intracranial hypertension in pediatric patients

Purpose

To evaluate retrospectively the features, treatment, and outcome of idiopathic intracranial hypertension (IIH) in children.

Methods

Nine patients, 15 years and younger, diagnosed with IIH. Inclusion criteria were papilledema, normal brain computer tomography or magnetic resonance imaging, cerebrospinal fluid pressure greater than 250 mm H₂O, normal cerebrospinal fluid content, and a nonfocal neurologic examination except for sixth nerve palsy.

Results

Of the nine patients, eight were girls. Five girls were overweight and one boy was obese. The most common presenting symptom was headache (5 patients). Diplopia or strabismus did not occur in our group. Visual field abnormalities were present in all eyes, and severe visual loss resulting in light perception vision occurred in both eyes of one patient. Eight patients were treated medically with acetazolamide alone, and one girl needed a combination of acetazolamide and corticosteroids. This girl also required optic nerve sheath decompression surgery. Resolution of papilledema and recovery of visual function occurred in all patients.

Conclusions

Idiopathic intracranial hypertension in prepubertal children is rather uncommon. Prompt diagnosis and management are important to prevent permanent visual loss.

Idiopathic intracranial hypertension in children: clinical presentations and management

Background:

Idiopathic intracranial is common in adults, particularly obese young women, but also occurs in children and adolescents.

Aim:

Clinical presentation of idiopathic intracranial hypertension in the pediatric population and how the presenting signs and symptoms may be different from those seen among adult patients.

Results:

This study is a prospective study conducted in the Alexandria Medical School, Egypt, between the periods starting from January 2003 till December 2007. Ten patients were included in this study, 9 patients were treated with repeated spinal taps while only one patient necessitated insertion of a theco-peritoneal shunt.

Conclusion:

Idiopathic intracranial hypertension may occur in children as among adults. If diagnosed early, visual acuity can be saved with proper management.

More than meets the eye? Redefining idiopathic intracranial hypertension

Idiopathic intracranial hypertension (IIH) is a disease of unknown etiology associated with increased intracranial pressure, predominantly affecting obese females of childbearing age. The history of IIH is quite unique, featuring only limited advancements in evidenced-based treatments, but boasting literally countless changes in nomenclature, proposed etiology, and conceptual approach. Despite its elusive pathogenesis, an evolution of our approach to IIH can be traced sequentially through identifiable periods. Contemporary research suggests that we are approaching a new phase in IIH, redefining it as a global neurologic syndrome with more far-reaching effects than previously realized.

Idiopathic intracranial hypertension and facial palsy: case report and review of the literature

We present the case of an 11-year-old obese girl who presented with idiopathic intracranial hypertension affecting first the lateral abducens nerve. She received acetazolamide, but 5 days later she developed lateral, peripheral facial palsy. Imaging evaluation was normal, which primarily excluded cerebral venous thrombosis and sustained the initial diagnosis. Despite some complicating factors (obesity, elevated intracranial pressure), prednisolone was administered for a short-term period to counteract the facial palsy. Ophthalmological residuals resolved within almost 1.5 months, while facial palsy receded after 4 months. Peripheral facial palsy is an extremely rare, but not unknown condition in idiopathic intracranial hypertension. As a symptom, it should be investigated thoroughly, primarily to exclude cerebral venous sinus thrombosis, before it can be attributed to idiopathic intracranial hypertension. As far as treatment is concerned, corticosteroids can be added to the initial treatment with acetazolamide, without worsening already elevated intracranial hypertension or ophthalmologic findings.

Incidence of papilledema and obesity in children diagnosed with idiopathic ''benign'' intracranial hypertension: case series and review

Idiopathic intracranial hypertension is an important cause of headaches in the pediatric population and can lead to permanent blindness if not diagnosed in a timely manner. The aim of this study was to characterize the incidence of papilledema and obesity in children with idiopathic intracranial hypertension. We retrospectively analyzed 27 patients followed at The University of Texas Houston Pediatric Neurology Clinic. Papilledema was absent in 13 (48%) patients. The majority of our patients were nonobese (70%). Our results are contrary to the current medical practice of associating papilledema and obesity with idiopathic intracranial hypertension in childhood and highlight the importance of revised diagnostic criteria in this population needed to detect and manage this condition.

Clinical spectrum of the pseudotumor cerebri complex in children

PURPOSE

Our aim was to improve diagnosis and management of pseudotumor cerebri (PTC; also known as idiopathic intracranial hypertension) in children.

METHODS

We performed a comprehensive analysis of epidemiology, diagnostic work-up, therapy, and clinical follow-up in 53 consecutive patients.

RESULTS

We identified several important aspects to be considered in the management of these children. First, patients may present without obvious symptoms at diagnosis. Second, bilateral papilledema might not or not yet be present in symptomatic patients. Third, measurement of cerebrospinal fluid (CSF) opening pressure may not always be reliable due to drugs used for sedation, which may alter intracranial pressure. Fourth, normal CSF pressure values in childhood are not well established and diagnosis might even be justified if pressure is <20 cm H(2)O. Fifth, associated conditions are frequent (at least in our cohort); however, in most cases, a causative link cannot be proven. Finally, disease relapse is a serious problem (20% in our group), which stresses the importance of standardized follow-up programs.

CONCLUSIONS

PTC constitutes an important and possibly underrecognized disorder in children and adolescents. Considering the high percentage of possibly associated conditions in our study, a detailed diagnostic work-up is crucial to identify treatable underlying conditions.

Intracranial Hypertension in a Boy with Mycoplasma pneumoniae Infection: The First Report

We describe a 7-y-old boy who developed idiopathic intracranial hypertension (IIH) during the convalescent phase of Mycoplasma pneumoniae (M. pneumoniae) infection. Anti-M. pneumoniae antibody and cold hemagglutinin titer were extremely high during his course, and corticosteroid administration was noticeably effective. It supports an immunopathological mechanism for his intracranial hypertension.

Intracranial hypertension in pediatric patients with acute lymphoblastic leukemia

Acute lymphoblastic leukemia (ALL) remains one of the most common malignancies of childhood. Between April 1999 and August 2004, 9 of 207 patients treated at a Tertiary Oncology Service for ALL presented with Intracranial Hypertension (IH). Seven of the patients met the diagnostic criteria for Idiopathic Intracranial Hypertension (IIH). Four of the patients were treated with cerebrospinal fluid (CSF) drainage alone and four required Acetazolamide. Two of the four patients who were treated with Acetazolamide required subsequently a lumbar-peritoneal (LP) shunt. One patient succumbed to his disease before receiving any specific treatment.

Asymptomatic idiopathic intracranial hypertension in children

OBJECTIVE

To define characteristics of pediatric asymptomatic idiopathic intracranial hypertension (IIH).

PATIENTS AND METHODS

We retrospectively reviewed our Neuro-Ophthalmology database (2000-2006) for all cases of symptomatic and asymptomatic pediatric IIH.

RESULTS

Out of 45 IIH cases, 14 (31.1%) were asymptomatic (incidental examination). When compared with children with symptomatic IIH, asymptomatic cases were younger [5.6 (1.8-15) vs 11.0 (5-17) years, P = 0.007], had lower percentage of obesity (14.3% vs 48.4%, P = 0.046), and had male predominance (71.4% vs 38.7%, P = 0.06). Asymptomatic cases required shorter duration of acetazolamide treatment [3 (0-8), vs 6 (0-20) months, P = 0.021], and resulted in complete resolution of swollen discs.

CONCLUSIONS

We speculate that asymptomatic IIH may be more common in young children and could represent a milder form or a presymptomatic phase before evolving into classic symptomatic IIH. Further studies to assess the clinical significance of asymptomatic IIH are warranted.

Pediatric idiopathic intracranial hypertension

Our understanding of pediatric idiopathic intracranial hypertension has been refined since Dr. Simmons Lessell's review in 1992. The use of rigorous methodologies and standard definitions in recent studies has demonstrated distinct demographic trends. Specifically, the incidence of idiopathic intracranial hypertension seems to be increasing among adolescent children, and among older children its clinical picture is similar to that of adult idiopathic intracranial hypertension (female and obese). Within younger age groups there are more boys and nonobese children who may develop idiopathic intracranial hypertension. The pathogenesis of the disease has yet to be elucidated. Idiopathic intracranial hypertension among young children has been associated with several new etiologies, including recombinant growth hormone and all-trans-retinoic acid. More modern neuroimaging techniques such as MRI and MRI-venograms are being used to exclude intracranial processes. Although most cases of pediatric idiopathic intracranial hypertension improve with medical treatment, those who have had visual progression despite medical treatment have undergone optic nerve sheath fenestration and lumboperitoneal shunting. Because idiopathic intracranial hypertension in young children appears to be a different disorder than in adolescents and adults, separate diagnostic criteria for younger children are warranted. We propose new criteria for pediatric idiopathic intracranial hypertension in which children should have signs or symptoms consistent with elevated intracranial pressure, be prepubertal, have normal sensorium, can have reversible cranial nerve palsies, and have an opening cerebrospinal fluid pressure greater than 180 mm H(2)O if less than age 8 and papilledema is present, but greater than 250 mm H(2)0 if age 8 or above or less than 8 without papilledema.

Childhood-onset idiopathic intracranial hypertension: relation of sex and obesity

The purpose of the present study was to perform a meta-analysis of all children with idiopathic intracranial hypertension reported since 1997 combined with our experience in order to investigate sex distribution and frequency of obesity among young children up 11 years of age vs adolescents at age 12-17 years. Overall, 244 children diagnosed with idiopathic intracranial hypertension were found suitable for the proposed meta-analysis: 132 (54%) were younger than 11 years of age; 72 (55%) were male and 60 (44%) were female. In contrast, of 112 older children (age 12-17 years), 79 (70%) were female. The association between age and obesity could be analyzed in 147 patients: only 19 (26%) out of 74 younger children up to age 11 years were reportedly obese, whereas 47 (64%) out of 73 older children were found obese. Differences in age at presentation, sex, and obesity were statistically significant (P < 0.01). Thus, a wide-scale meta-analysis of childhood-onset idiopathic intracranial hypertension revealed that the female/male ratio in children younger than age 11 years seems to be fairly equal, with a relatively low rate of obesity, contrasting to a majority of females in the group of adolescents at high risk to become obese.

Transient bulging fontanelle after vaccination: case report and review of the vaccine adverse event reporting system

OBJECTIVE

To describe the features of transient bulging fontanelle (TBF) after vaccination.

STUDY DESIGN

We searched the Vaccine Adverse Event Reporting System database for reports describing bulging fontanelle. We defined a definite TBF case as a patient with a bulging fontanelle, normal neuroimaging and cerebrospinal fluid analysis, and absence of a depressed level of consciousness, focal neurologic findings, or identified cause. Follow-up had to reveal normal development. Probable cases lacked either lumbar puncture or neuroimaging or both but met all other criteria.

RESULTS

We identified 18 patients with definite or probable TBF. The median age at presentation was 4.5 months, interval from vaccination to symptom onset was 18 hours, and time to resolution was 3 days. Fifteen children were febrile.

CONCLUSIONS

We cannot conclude that vaccines cause TBF. Further controlled studies are necessary. Even if further research verifies TBF as a rare side effect, immunization benefits would still vastly outweigh this hypothetical risk. However, confirmation of a vaccine association could modify the management of infants who develop TBF after immunizations.

Visual failure without headache in idiopathic intracranial hypertension

AIM

To determine the differences in outcome in a group of children with idiopathic intracranial hypertension (IIH) who do not present with headaches.

METHODS

Differences in epidemiological and aetiological factors, clinical presentation, and visual outcome were investigated in children with a diagnosis of IIH presenting with and without headaches to the Paediatric Neurology and Paediatric Ophthalmology Services at Guy's & St Thomas' Hospitals NHS Trust between 1997 and 2002.

RESULTS

Compared to the 29 children with headaches, the 12 children in the non-headache group were younger (7.3 v 9.5 years), presented with more neurological signs (33% v 10%), and were more likely to present with severe visual failure (33% v 4%), with a tenfold increased risk of an enlarged blind spot or field defects (50% v 5%). Permanent visual failure affected a third of all children in the non-headache group, but was rare in children presenting with headaches (33% v 3%), with one patient registered blind and two severely visually impaired.

CONCLUSION

The management of IIH is difficult in the absence of headache. Visual surveillance is vital. These children were treated with an aggressive management programme to reduce cerebrospinal fluid pressure by repeated lumbar puncture, medication, and early surgical intervention if required. Non-invasive monitoring techniques might contribute to a better understanding of the natural history of IIH, improved management, and visual outcome.

[Idiopathic intracranial hypertension: clinical features and outcome]

Idiopathic intracranial hypertension in children is rare. We analyzed clinical presentation and outcome in eight patients (six girls and two boys) diagnosed with idiopathic intracranial hypertension. The mean age was 11.1 years. The most common clinical features were headache, papilledema and visual disturbance (visual loss and diplopia). Response to treatment was satisfactory in all patients except one who presented almost complete bilateral amaurosis requiring extracranial shunting and who later developed optic atrophy. Outcome is usually is benign, but given the possibility of severe loss of visual function, close ophthalmic follow-up is recommended until complete resolution.

Asymptomatic idiopathic intracranial hypertension in young children

Presenting symptoms of idiopathic intracranial hypertension are known to vary with age. Older children may complain of headache, neck pain, diplopia, intracranial noises, or transient visual obscurations. Younger children may present with apathy or irritability. This report describes three young children with no obvious relevant symptoms in whom papilledema was newly found on routine follow-up eye examination for unrelated problems. At presentation, all had early papilledema with negative cranial neuroimaging studies. All remained apparently asymptomatic, but the papilledema progressed. Sedated lumbar puncture showed elevated cerebrospinal fluid pressure in all three. Two were felt to have truly idiopathic intracranial hypertension, whereas the third had jugular venous obstruction. The papilledema responded to treatment with either acetazolamide or furosemide in all three. An apparent lack of symptoms does not rule out chronic increased intracranial pressure in young children.