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

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.

An Unusual Case of Headache in a Child: Idiopathic Intracranial Hypertension with Diagnostic Challenge

Introduction

In children, idiopathic intracranial hypertension (IIH) is relatively uncommon. It is characterized by an increase in intracranial pressure, in the absence of evidence of underlying brain disease, structural abnormalities, hydrocephalus, or abnormal meningeal improvement. However, very rarely it can occur without papilledema, even though it is the most recognizable clinical sign. Due to this, a delay in diagnosis can lead to severe visual impairments.

Case presentation

We describe a patient with a chronic headache but no papilledema. His neurological and systemic examinations were otherwise unremarkable. A lumbar puncture revealed a high opening pressure of 450 mmH₂O and normal cerebrospinal fluid (CSF) parameters. Magnetic resonance imaging of the brain revealed only tortuous optic nerves, no parenchymal lesions, and no evidence of venous sinus thrombosis. He required acetazolamide treatment. Our patient's symptoms improved significantly in 2 months with medical treatment, weight loss, and exercise, with no development of papilledema.

Conclusion

There is a wide range of clinical manifestations of IIH, making it difficult to decide when to begin treatment.

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.

Pediatric Headache in Primary Care and Emergency Departments: Consensus with RAND/UCLA Method

Headache is the most frequent neurological symptom in childhood and the main reason for admission to pediatric emergency departments. The aim of this consensus document is to define a shared clinical pathway between primary care pediatricians (PCP) and hospitals for the management of children presenting with headache. For the purposes of the study, a group of hospital pediatricians and a group of PCP from the Emilia Romagna’s health districts were selected to achieve consensus using the RAND/UCLA appropriateness method. Thirty-nine clinical scenarios were developed: for each scenario, participants were asked to rank the appropriateness of each option from 1 to 9. Agreement was reached if ≥75% of participants ranked within the same range of appropriateness. The answers, results, and discussion helped to define the appropriateness of procedures with a low level of evidence regarding different steps of the diagnostic-therapeutic process: primary care evaluation, emergency department evaluation, hospital admission, acute therapy, prophylaxis, and follow-up. The RAND proved to be a valid method to value appropriateness of procedures and define a diagnostic-therapeutic pathway suitable to the local reality in the management of pediatric headache. From our results, some useful recommendations were developed for optimizing the healthcare professionals’ network among primary care services and hospitals.

Current Perspectives on Idiopathic Intracranial Hypertension without Papilloedema

The pseudotumor cerebri syndrome embraces disorders characterised by raised intracranial pressure, where the commonest symptom is headache (90%). Idiopathic intracranial hypertension without papilloedema (IIHWOP) is increasingly recognised as a source of refractory headache symptoms and resultant neurological disability. Although the majority of patients with IIHWOP are phenotypically similar to those with idiopathic intracranial hypertension (IIH), it remains uncertain as to whether IIHWOP is nosologically distinct from IIH. The incidence, prevalence, and the degree of association with the world-wide obesity epidemic is unknown. Establishing a diagnosis of IIHWOP can be challenging, as often lumbar puncture is not routinely part of the work-up for refractory headaches. There are published diagnostic criteria for IIHWOP; however, some report uncertainty regarding a pathologically acceptable cut off for a raised lumbar puncture opening pressure, which is a key criterion. The literature provides little information to help guide clinicians in managing patients with IIHWOP. Further research is therefore needed to better understand the mechanisms that drive the development of chronic daily headaches and a relationship to intracranial pressure; and indeed, whether such patients would benefit from therapies to lower intracranial pressure. The aim of this narrative review was to perform a detailed search of the scientific literature and provide a summary of historic and current opinion regarding IIHWOP.

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.

Inflammation in Obesity-Related Complications in Children: The Protective Effect of Diet and Its Potential Role as a Therapeutic Agent

Obesity is a growing health problem in both children and adults, impairing physical and mental state and impacting health care system costs in both developed and developing countries. It is well-known that individuals with excessive weight gain frequently develop obesity-related complications, which are mainly known as Non-Communicable Diseases (NCDs), including cardiovascular disease, type 2 diabetes mellitus, metabolic syndrome, non-alcoholic fatty liver disease, hypertension, hyperlipidemia and many other risk factors proven to be associated with chronic inflammation, causing disability and reduced life expectancy. This review aims to present and discuss complications related to inflammation in pediatric obesity, the critical role of nutrition and diet in obesity-comorbidity prevention and treatment, and the impact of lifestyle. Appropriate early dietary intervention for the management of pediatric overweight and obesity is recommended for overall healthy growth and prevention of comorbidities in adulthood.

Pediatric intracranial hypertension. Experience from 2 Tertiary Centers

OBJECTIVE

To review the experience of 2 tertiary centers in Saudi Arabia with intracranial hypertension (IH) in the pediatric population.

METHODS

We retrospectively reviewed and analyzed pediatric patients diagnosed with IH from June 2002 to May 2017 in 2 institutes.

RESULTS

We identified 53 patients (30 females and 23 males) with a mean age of 7 years at the time of presentation. Among them, 41 patients were younger than 12 years, and 12 were older. Obese and overweight patients constituted 27.00% (n = 14) of all cases, 8 (66.7%) of whom were older than 12 years. The most common presenting feature was papilledema followed by headache. Vitamin D deficiency, which constituted the most common associated condition, was identified in 12 (22.6%) patients. Acetazolamide was the treatment option in 98.11% of patients, and only 5.7% underwent surgical interventions. The length of follow-up ranged from 6 months to 8 years.

CONCLUSION

Intracranial hypertension is rare in children and commonly seen in overweight females older than 12 years similar to adults. Patients younger than 12 years tend to develop secondary IH. More studies are needed to characterize the clinical presentation and guide the management plan.

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.

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.

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.

Detecting optic nerve head swelling on ultrasound and optical coherence tomography in children and young people: an observational study

BACKGROUND

Following high-profile cases, referrals for evaluation of 'suspicious optic discs' to eye clinics in the UK have sharply increased, asking ophthalmologists to reliably distinguish between true and pseudopapilloedema. Optic nerve sheath dilatation (ONSD) on ocular ultrasound (US) is considered a reliable sign of true papilloedema, but this test is not widely available. Recently, anterior bowing of Bruch's membrane (BM) and increased retinal nerve fibre layer thickness on optical coherence tomography (OCT) have emerged as indicators of intracranial hypertension, and OCT is widely available. We aimed to evaluate safety and efficacy of the diagnostic workup in our service, with particular emphasis of diagnostic reliability of US and OCT.

METHODS

Retrospective service evaluation/cohort study of children and young people younger than 16 years investigated for 'suspicious discs' over a 7-month period in 2016 at a single eye care provider in London, UK. 61 children and young people underwent clinical assessment, US scan and OCT.

RESULTS

Of 61 cases, 3 had intracranial pathology. At presentation, only one had ONSD on US and anterior bowing of BM on OCT. Increased nerve fibre layer thickness in at least one of three relevant sectors was observed in two cases. All three cases of intracranial pathology, however, had significant points in their presenting or medical history.

CONCLUSION

Ophthalmologists and optometrists must not rely on funduscopy and ocular imaging when assessing a child for possible intracranial disease; history and basic neurological assessment are critical in the diagnostic workup.

Pediatric Intracranial Hypertension

Primary (idiopathic) intracranial hypertension has been considered to be a rare entity, but with no precise estimates of the pediatric incidence in the United States. There have been attempts to revise the criteria over the years and adapt the adult criteria for use in pediatrics. The clinical presentation varies with age, and symptoms tending to be less obvious in younger individuals. In the prepubertal population, incidentally discovered optic disc edema is relatively common. By far the most consistent symptom is headache; other symptoms include nausea, vomiting tinnitus, and diplopia. Treatment mainstays include weight loss when appropriate and acetazolamide. Furosemide may exhibit a synergistic benefit when used in conjunction with acetazolamide. Surgical interventions are required relatively infrequently, but include optic nerve sheath fenestration and cerebrospinal fluid shunting. Pain and permanent vision loss are the two major complications of this disorder and these manifestations justify aggressive treatment. Once intracranial hypertension has resolved, up to two thirds of patients develop a new or chronic headache type that is different from their initial presenting headache.

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.

Noninvasive methods of detecting increased intracranial pressure

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

Manifestations of Pediatric Intracranial Hypertension From the Intracranial Hypertension Registry

OBJECTIVE

The purpose of this study was to examine the presenting symptoms, demographics, and interventions in pediatric patients enrolled in the Intracranial Hypertension Registry.

METHODS

We analyzed confirmed intracranial hypertension patients ≤18 years at the time of initial diagnosis who were enrolled in the registry.

RESULTS

A total of 203 patients met the criteria for inclusion; 142 (70%) were considered primary intracranial hypertension. Females made up 72.5% (103 of 142) and 75.8% (47 of 61) in the primary intracranial hypertension and secondary intracranial hypertension groups, respectively. There were no clinically significant differences in age, body mass index, or opening pressure between the primary intracranial hypertension and secondary intracranial hypertension groups. Symptoms most often reported were headache and blurred vision. Bilateral optic disc edema occurred in 89.3% of primary intracranial hypertension and 78.7% of secondary intracranial hypertension patients. When divided into pre- and postpubertal status, 32.5% of patients were classified prepubertal; 77.3% of these had primary intracranial hypertension. This resulted in a female to male ratio of 1:1.04 for prepubertal and 6:1 for postpubertal primary intracranial hypertension patients. The body mass index was significantly higher in the postpubertal primary intracranial hypertension group (P = 0.0014). There was no significant difference in opening pressure.

CONCLUSIONS

The common symptoms of intracranial hypertension, including headache, optic disc edema, and vision changes, occurred with similar frequencies in our cohort to those reported in the literature. In separate subanalyses, we found significantly higher rates of obesity in postpubertal females with primary intracranial hypertension. The female-to-male ratios in the postpubertal primary intracranial hypertension and secondary intracranial hypertension groups were higher than reported in the literature.

Intracranial Hypertension Without Papilledema in Children

This study aims to determine the frequency of intracranial hypertension without papilledema in children. Charts of patients evaluated in a pediatric intracranial hypertension clinic at our institution were retrospectively reviewed. The patients were divided into 2 groups depending on whether they had presence or absence of optic nerve edema at the time of presentation. Age, body mass index, and opening cerebrospinal fluid pressures were considered continuous variables and compared by Wilcoxon rank sum test because of non-normality. A P-value of 0.05 was considered significant. A total of 228 charts were reviewed; 152 patients met the criteria for intracranial hypertension, and 27 patients (17.8%) met the criteria of headache without optic nerve edema. There was no clinically significant difference in age, body mass index, opening pressure, and modified opening pressure between the 2 groups.

Physical Examination Findings Among Children and Adolescents With Obesity: An Evidence-Based Review

Overweight and obesity affects 1 in 3 US children and adolescents. Clinical recommendations have largely focused on screening guidelines and counseling strategies. However, the physical examination of the child or adolescent with obesity can provide the clinician with additional information to guide management decisions. This expert-based review focuses on physical examination findings specific to children and adolescents with obesity. For each physical examination element, the authors define the finding and its prevalence among pediatric patients with obesity, discuss the importance and relevance of the finding, describe known techniques to assess severity, and review evidence regarding the need for additional evaluation. The recommendations presented represent a comprehensive review of current evidence as well as expert opinion. The goal of this review is to highlight the importance of conducting a targeted physical examination during pediatric weight management visits.

Idiopathic intracranial hypertension in children: Diagnostic and management approach

Idiopathic intracranial hypertension (IIH) is a rare neurological disorder in children. It is characterized by raised intracranial pressure (ICP) in the absence of brain parenchymal lesion, vascular malformations, hydrocephalus, or central nervous system (CNS) infection. The diagnosis is usually confirmed by high opening pressure of cerebrospinal fluid (CSF) with exclusion of secondary causes of intracranial hypertension. If not treated properly, it may lead to severe visual dysfunction. Here we review the etiology, clinical presentation, diagnostic criteria and management of IIH in children through illustration of the clinical and radiological presentation of a 13-year-old overweight girl who presented with severe headache, diplopia and bilateral papilledema. Otherwise, she had unremarkable neurological and systemic examinations. Lumbar puncture showed a high CSF opening pressure (360-540 mmH2O). Her investigations showed normal complete blood count (CBC), normal renal, liver, and thyroid function tests. Cerebrospinal fluid (CSF) and blood chemistry were unremarkable. Magnetic resonant image (MRI) of the brain demonstrated empty sella turcica, tortuous optic nerves, and flattening of the posterior sclera. Magnetic resonant venography (MRV) showed focal narrowing of the distal transverse sinuses and absence of venous sinus thrombosis. She required treatment with acetazolamide and prednisolone. With medical treatment, weight reduction, and exercise, our patient had a remarkable improvement in her symptoms with resolution of papilledema in two months. This review highlights the importance of early recognition and management of IIH to prevent permanent visual loss.

Intracranial Hypertension in Children: Etiologies, Clinical Features, and Outcome

This retrospective study aimed to describe the clinical presentations, possible causes, and outcomes of children with idiopathic intracranial hypertension who presented to the authors' clinic. The mean age at onset of symptoms in the authors' cohort of 19 children was 6 years (range: 7 months to 12 years). Most patients (90%) were under 11 years old and (84.2%) symptomatic. The probable cause was identified in 7/19 (37.0%) patients. The most common cause was vitamin D deficiency (26.3%). Other associated probably coincidental comorbidities included sinusitis (5/19, 26.3%), hypophosphatasia (1/19), Pyle disease (1/19), and measles vaccine (1/19). Apart from 2 patients who required lumboperitoneal shunt, the cerebrospinal fluid pressure returned to normal in all patients within a period of 6 weeks to 1 year (average, 5 months). Of those who followed up with the authors' ophthalmologist, 30.7% developed optic atrophy or pallor; 75% of these patients had previous ocular comorbidities.

Intracranial Hypertension in Children without Papilledema

Researchers at Nationwide Children's Hospital studied the frequency of intracranial hypertension without papilledema in children followed in a multispecialty pediatric intracranial hypertension clinic.

Has rising pediatric obesity increased the incidence of idiopathic intracranial hypertension in children?

OBJECTIVE

Idiopathic intracranial hypertension (IIH) in children is an uncommon but significant cause of morbidity, including permanent visual loss. It is important to understand if, like obesity, IIH in children is on the rise and is related to that increase. The aim of this study is to compare the recent incidence rate of pediatric IIH in a tertiary care hospital with earlier data published from that same hospital.

DESIGN

Retrospective chart review.

PARTICIPANTS

All children aged 2 to 16 years diagnosed with IIH at the IWK Health Centre in Halifax between 1997 and 2007.

METHODS

Charts of eligible patients were reviewed to ensure all diagnostic criteria for IIH were met. Incidence and obesity rates were calculated based on data from Statistics Canada.

RESULTS

Twelve cases (5 males, 7 females) fulfilling the diagnostic criteria for IIH were identified, for an annual incidence of 0.6 cases per 100,000 children with no sex predilection (p = 0.51). Obesity was noted in 75% of patients examined (9/12). Children older than 12 years were more likely to be obese (6/6, 100%) compared with those younger than 12 years (3/6, 50%).

CONCLUSIONS

The calculated incidence is lower than that found in an earlier study for the same geographic region (0.9 cases per 100,000 children) despite increasing obesity rates. This decrease may be a reflection of improved diagnostic techniques or may indicate that factors other than obesity govern IIH predilection in younger children.

The role of venous sinus outflow obstruction in pediatric idiopathic intracranial hypertension

OBJECT

The authors examined the role of venous sinus obstruction in the etiology of idiopathic intracranial hypertension (IIH) by reviewing more than 200 MR venograms performed in suspected cases of IIH.

METHODS

Individual MR venograms performed in cases of suspected IIH at the Children's Hospital at Westmead in Sydney, Australia, were reviewed. The authors excluded cases in which an intervention was performed before the scan or a structural cause for venous obstruction was identified. Cases with confirmed hydrocephalus were also excluded. For each of the 145 remaining scans, the authors completed a detailed review on a slice-by-slice basis of the 2D source images used to compile the rendered 3D MR venogram. The anatomical configuration of the dural venous sinuses and any areas of decreased flow in circulation were then noted. Where possible, they correlated their radiological findings with evidence of raised intracranial pressure based on LP opening pressures. They also reviewed a control group of 50 MR venograms.

RESULTS

Seventy-six (52%) of 145 scans showed evidence of venous obstruction in the dominant-side circulation. Substantial nonphysiological collateral circulation was seen in 68% of cases with dominant-sided obstruction, suggesting a process of recanalization. In contrast, in the absence of dominant-sided obstruction, collateral circulation was uncommon. In 27 cases, CSF opening pressure measurements were available. In 20 cases the opening pressures were in excess of 20 cm H(2)O. Of those, 17 demonstrated evidence of dominant-sided venous outflow obstruction. Among those cases, the median opening pressure was 34 cm H(2)O. Dominant-sided venous outflow obstruction was seen in only 2 of 50 MR venograms in the control group. Furthermore, evidence of collateral circulation was also uncommon in the control group. There was a highly statistically significant difference between rates of dominant-sided venous obstruction in the suspected IIH and control groups (p ≤ 0.001).

CONCLUSIONS

A majority of patients presenting for investigation of suspected IIH demonstrated evidence of dominant-sided venous obstruction on MR venogram. In addition there was a high correlation between elevated CSF opening pressures and dominant-sided venous sinus obstruction. This correlation was further supported by evidence of collateral recanalization in patients with elevated CSF pressures and dominant-sided venous obstruction. A control group of 50 MR venograms indicated that dominant-sided venous outflow obstruction is an unlikely incidental finding, and a highly statistically significant difference was found between rates of obstruction in the suspected IIH and control groups.

Increased incidence of perforated appendicitis in children with obesity

Based on their clinical impression, the authors hypothesized that children with obesity may more commonly present with perforated appendicitis. Therefore, the authors reviewed their experience from 2008 to 2010 to determine whether obesity affected the clinical presentation of appendicitis. Variables studied were height, weight, use of diagnostic imaging, and clinical findings of appendicitis at presentation. Outcomes assessed were length of stay and complication rate. The study identified 319 patients with appendicitis. Children with obesity were more likely (P = .026) to present with perforation (28/62, 45%) than nonobese patients (78/257, 30%). Neither length of stay nor complication rate was affected by the presence of obesity. The data suggest that children with obesity are more likely to present with perforated appendicitis. This finding suggests that the diagnosis of appendicitis may be more difficult in obese patients or their presentation may be delayed. Practitioners should have heightened awareness in children with obesity and symptoms of abdominal pain.

Pediatric idiopathic intracranial hypertension and extreme childhood obesity

OBJECTIVE

To estimate the magnitude of the association between overweight, moderate, and extreme childhood obesity and the risk of idiopathic intracranial hypertension (IIH).

STUDY DESIGN

Risk estimates were obtained from the Kaiser Permanente Southern California Children's Health Study (n = 913 178). Weight classes were assigned by body mass index specific for age and sex. A combination of electronic database searches followed by complete medical records review was used to identify all children diagnosed with IIH between 2006 and 2009.

RESULTS

We identified 78 children with IIH, the majority of whom were girls (n = 66, 84.5%), age 11-19 (n = 66, 84.5%), non-Hispanic Whites (n = 37, 47.4%), and overweight or obese (n = 57, 73.1%). The adjusted ORs and 95% CIs of IIH with increasing weight class were 1.00, 3.56 (1.72-7.39), 6.45 (3.10-13.44), and 16.14 (8.18-31.85) for underweight/normal weight (reference category), overweight, moderately obese and extremely obese 11-19 year olds, respectively (P for trend < .001). Other independent IIH risk factors included White non-Hispanic race/ethnicity for all age groups and female sex, but only in older children. Overweight/obese children also had more IIH symptoms at onset than normal weight children.

CONCLUSIONS

We found that childhood obesity is strongly associated with an increased risk of pediatric IIH in adolescents. Our findings suggest that the childhood obesity epidemic is likely to lead to increased morbidity from IIH particularly among extremely obese, White non-Hispanic teenage girls. Our findings also suggest careful screening of these at risk individuals may lead to earlier detection and opportunity for treatment of IIH.

Overview of paediatric obesity for the paediatric mental health provider

Childhood obesity represents a significant challenge for paediatric healthcare delivery. As obesity rates increase, obese children and adolescents are at significant risk for the development of a myriad of medical and surgical problems as well as mental health problems. Moreover, children with mental health problems are increasingly presenting to their psychiatrists with obesity. Treatment of paediatric obesity requires a multidisciplinary approach with incorporation of the family into the treatment plan although still typically only offering suboptimal results. Paediatric providers from all disciplines should focus efforts primarily on obesity prevention and encouragement of healthy lifestyles, while incorporating treatment for obesity when such efforts fail. The goals of this article are to provide an overview of the epidemiology, pathophysiology, genetics, clinical features and treatment strategies for paediatric obesity.