Idiopathic intracranial hypertension in children: the Iowa experience

Elevated systemic venous pressures as a possible pathology in prepubertal pediatric idiopathic intracranial hypertension

BACKGROUND

Pediatric idiopathic intracranial hypertension (IIH) is a rare and challenging condition. As implied by the nomenclature, the etiologies remain unknown, and multiple etiologies are being investigated. In this study, we explored the potential role of increased systemic or cerebral venous pressure in the pathogenesis.

METHOD

An observational cohort study following the STROBE guidelines, including prepubertal children with clinical symptoms and imaging findings consistent with IIH referred to the neurosurgical department, was conducted. The patients underwent a comprehensive diagnostic protocol, including MRI, continuous intracranial pressure (ICP) monitoring, and endovascular venography with venous pressure measurements.

RESULTS

The study included 11 consecutive patients (six boys and five girls) with an average age of 2.3 years, and an average BMI of 18.4. Among these, one patient was found to have venous stenosis with a gradient; the other 10 patients presented with normal intracranial anatomy. All patients exhibited elevated venous pressures, with an average superior sagittal sinus pressure of 18.9 mmHg, average internal jugular vein pressure of 17.0 mmHg, and average central venous pressure of 15.9 mmHg. Daytime ICP averaged 12.9 mmHg, whereas nighttime ICP averaged 17.2 mmHg with either A- or B-waves in 10 of the 11 patients. Despite pathological ICP, only three patients had papilledema.

CONCLUSIONS

All patients had an increased systemic venous pressure, indicating a possible pathological factor for prepubertal IIH. Additionally, our findings show that young children often only partly meet the Friedman criteria due to a lack of papilledema, emphasizing the need for pediatric-specific diagnostic criteria. Further large-scale studies are needed to confirm these findings and to explore the underlying reasons for this increase in venous pressure and potential new treatment avenues.

The diagnostic value of MRI findings in pediatric idiopathic intracranial hypertension: a case-control study

BACKGROUND

Idiopathic intracranial hypertension (IIH) is a rare medical condition in children. Based on the different radiological findings reported in various studies in pediatric IIH, this study was conducted to determine the diagnostic value of MRI findings in diagnosing IIH in children.

METHODS

In this retrospective study, the medical records of all children aged 1 to 18 years who visited Ghaem Hospital in Mashhad, Iran, between 2012 and 2022 and were diagnosed with IIH were gathered. Forty-nine cases of children with IIH and 48 control cases of children with the first unprovoked seizure with no indications of increased intracranial pressure for comparison were selected. Patient demographic information and MRI findings were extracted. The comparison between different MRI findings in the case and control groups was conducted using statistical tests.

RESULTS

In the case group, the mean diameter of the subarachnoid space expansion around the optic nerve was 5.96 ± 1.21, compared to 4.79 ± 0.33 in the control group, with statistically significant difference (P < 0.001). All the patients with flattening of the posterior globe or transverse sinus stenosis were in the case group, and the frequency of these findings in the case group was significantly higher than in the control group (P < 0.001). The majority of patients (95.5%) classified under category 3 and 4 of empty sella were part of the case group, and the statistical test results indicated a significant difference between the two groups (P < 0.001). The optic nerve sheath diameter cut-off of 5.35 mm, when used for expansion of the subarachnoid space around the optic nerve, with a sensitivity of 82% and a specificity of 100% in diagnosing IIH.

CONCLUSION

The most reliable diagnostic indicators for diagnosing IIH in children are perioptic subarachnoid space expansion with high sensitivity, and posterior globe flattening and transverse sinus stenosis with high specificity.

Undiagnosed sagittal synostosis as cause of "idiopathic" intracranial hypertension

PURPOSE

Idiopathic intracranial hypertension (IIH) is a rare condition in children, but if diagnosed needs to be promptly treated to avoid clinical sequalae. The main purpose of this paper was to test our clinical experience with a cohort of normocephalic children with craniosynostosis who do not present in the routine way to craniofacial services, due to the normal head shape and age, diagnosed with IIH.

METHODS

We retrospectively reviewed all children who were referred to neurosurgery from 2012 to 2022 for management of IIH on our prospectively kept database. We determined what treatments were offered and if there was an associated craniosynostosis.

RESULTS

In total, 19 children were identified with an average age at referral of 11.5 years (st dev 4.0 years) with 11 male and 8 female. The most common presenting symptoms and signs were papilloedema (18/19), headaches (15/19), visual deterioration (9/19), nausea and vomiting (7/19) and diplopia (4/19). Five out of 19 children (26.3%) had a sagittal suture fused that was not identified at the time of treatment and all children were normocephalic.

CONCLUSION

There is a cohort of children with IIH who will have concomitant craniosynostosis and ideally would benefit from cranial vault expansion as primary surgery rather than cerebrospinal fluid (CSF) diversion. We suggest all children with IIH requiring neurosurgical intervention have cross-sectional imaging to look for occult craniosynostosis prior to intervention.

Pseudotumor cerebri with status epilepticus in a child: A rare presentation of vitamin D deficiency

Pseudotumor cerebri (PTC) encompasses a constellation of symptoms caused by elevated intracranial pressure of unclear etiology. Various associations have been described, rarely hypovitaminosis D. Vitamin D deficiency should be considered as a potential etiology of neurological manifestations like PTC and seizures in children. Early diagnosis and correction of vitamin D deficiency is key to preventing morbidity and achieving good outcomes.

New-Onset Vision Impairment in Children: Magnetic Resonance Imaging Findings by Age Groups

INTRODUCTION

Non-traumatic visual impairment is rare in the pediatric population, but early diagnosis and treatment of the cause is crucial to prevent long-term consequences affecting children's neurocognitive development. The authors aim to determine the most common causes of non-traumatic visual impairment in pediatric patients according to age groups by magnetic resonance imaging (MRI).

METHODS

Images of patients who underwent contrast-enhanced cranial and orbital MRI for new-onset visual impairment between June 2019 and June 2022 were retrospectively reviewed. MRI findings were categorized as tumors, idiopathic intracranial hypertension, demyelinating disorders, infections, isolated optic neuritis, and others. The patients were grouped according to age as preschoolers, schoolchildren, and adolescents. Demographic features of patients and MRI findings were collected and compared among age groups.

RESULTS

One hundred seventeen of the 238 patients had pathologic MRI findings. The most common pathologies were tumors (26.4%), idiopathic intracranial hypertension (24.7%), demyelinating disorders (18.8%), infections (11.1%), and isolated optic neuritis (7.6%). Tumors (69.2%) in preschool children, idiopathic intracranial hypertension (36.3%) in schoolchildren, and demyelinating disorders (32.7%) in adolescents were the most common cause of vision impairment by age group.

CONCLUSION

Children with acute vision impairment could have severe pathologies. Tumors in preschool children, idiopathic intracranial hypertension in schoolchildren, and demyelinating disorders in adolescents were the most common causes of new-onset vision impairment detected with MRI. Because of the difficulty of performing optimal ophthalmologic and neurologic examinations, especially in young children, cranial and orbital MRI should be considered to detect life-threatening pathologies.

Effect of Inhaled Sevoflurane on Pediatric Cerebrospinal Fluid Pressure During Lumbar Puncture; Implications for Intracranial Hypertension

Objective: To determine influence of sevoflurane on changes in cerebrospinal fluid pressure in children presenting for lumbar puncture. Methods: Cerebrospinal fluid pressure, end tidal carbon dioxide, and end tidal sevoflurane concentration measurements were obtained at 2-minute intervals for a total of 10 minutes (T0 to T5). Because of concerns regarding patient safety and comfort, the study measurements were completed at the end of the lumbar procedure, starting with the closing pressure and when sevoflurane was stopped. Results: As end tidal sevoflurane concentration decreased, cerebrospinal fluid pressure initially increased up to T2 before decreasing back to around the initial point. There was no significant correlation between sevoflurane level and cerebrospinal fluid pressure. Both weight status and presence or absence of optic edema did not have a significant impact on pressure over time. However, there was a statistically significant difference in the cerebrospinal fluid pressure over time between those with spontaneous respirations compared to those without. Conclusions: There was no significant correlation between the end tidal sevoflurane concentration and cerebrospinal fluid pressure. Assisted ventilation did produce a statistically significant increase in cerebrospinal fluid pressure and suggests that the most accurate measurements are in those with spontaneous respirations.

A Systematic Review on Whether an Association Exists Between Adolescent Obesity and Idiopathic Intracranial Hypertension

Pseudotumor cerebri syndrome (PTCS)/idiopathic intracranial hypertension (IIH) is a clinical presentation appertaining to signs/symptoms of raised intracranial pressure, like headache and papilledema. It is an uncommon but clinically significant cause of morbidity such as permanent vision loss. It is crucial to understand if idiopathic intracranial hypertension (IIH) is on the rise in adolescents, it is probably due to the rising prevalence of obesity worldwide. Our study aimed to find an association between obesity and IIH in adolescents. We utilized Preferred Reporting Items for Systematic Review and Meta-Analysis 2020 (PRISMA) guidelines to run this systematic review. Many publications related to the topic in the discussion were scrutinized through a comprehensive database search. We filtered them down to a final count of 10 articles after utilizing our inclusion/exclusion criteria and assessing the quality of work. In these final papers, we identified several possibilities to explain the link between obesity and IIH in adolescents. Overweight and obese adolescents were found to have a significantly increased risk of IIH development, with a more severe clinical picture seen in morbidly obese female patients.

Idiopathic Intracranial Hypertension: Incidental Discovery Versus Symptomatic Presentation

BACKGROUND

We aim to compare the clinical characteristics, disease course and visual outcomes between Canadian patients with idiopathic intracranial hypertension (IIH) who were incidentally discovered and those who sought care due to symptoms of IIH.

METHODS

Retrospective chart review of consecutive IIH patients conducted at tertiary neuro-ophthalmology clinics. Patients were divided into Group 1 (incidentally discovered disease) and Group 2 (patients seeking medical care due to symptoms of intracranial hypertension).

RESULTS

One hundred eighty-six patients were included in the study; of which, 75 (40.3%; Group-1) were incidentally discovered and 111 presented due to symptoms of IIH (Group-2). There were no differences in proportion of females (P = 0.101), age (P = 0.450), body mass index (P = 0.386), MRI findings of empty or partially empty sella (P = 0.41), and sella grade (P = 0.704). Group-1 patients were less likely to have experienced headache (P = 0.001), transient visual obscurations (P < 0.001), and diplopia (P = 0.026) at presentation. Group-1 patients were less likely to receive medical (P < 0.001) and surgical (P = 0.004) treatment. There was no difference in proportion of patients who lost weight between the groups (P = 0.848). At baseline, Group-1 patients exhibited better visual acuity (P = 0.001), Humphrey mean deviation (P < 0.001) and retinal nerve fiber layer thickness (P < 0.001). Group-1 patients continued to have better visual acuity (P = 0.002) and Humphrey mean deviation (P < 0.001) at final follow-up.

CONCLUSIONS

A significant portion of IIH patients were incidentally discovered. This group exhibited a favorable prognosis and only a minority of these patients required treatment. The way in which patients enter the medical system may be a valuable way to risk stratify IIH patients.

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

INTRODUCTION

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

METHODS AND ANALYSIS

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

ETHICS AND DISSEMINATION

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

TRIAL REGISTRATION NUMBER

ISRCTN52858719.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Clinical features and the role of magnetic resonance imaging in pediatric patients with intracranial hypertension

Increased intracranial hypertension (IIH) is a defined clinical condition; however, an unsolved pathophysiologic background usually creates problems in its diagnosis and proper approach. The aim of this study was to emphasize the clinical conditions and brain magnetic resonce imaging (MRI) clues of pediatric patients, especially this clinical entity with high morbidity. Here, we review the etiology, clinical presentation, brain MRI findings, and prognosis of IIH in children. The symptoms' onset age ranged from 9 months to 16 years. Headache (81%), vomiting (37%), and diplopia (33.3%) were the most frequent symptoms. The most common etiologic factors were found to be obesity and dural venous sinus thrombosis. Cerebrospinal fluid (CSF) opening pressure had mean a mean value of 615.2 ± 248 mm H₂O. A significant relationship was found between visual field impairment and height of CSF pressure (p < 0.001). Optic nerve sheath enlargement (88.8%) and optic nerve tortuosity (85.1%) were found as the most common brain MRI findings. Slit-like ventricle (37%), venous sinus thrombosis (29.6%), posterior globe sclera flattening (29.6%), empty sella (25.9%), and intraocular protrusion of the optic nerve (14.8%) were the other findings. A significant relationship was found between CSF opening pressure and the presence of optic nerve tortuosity (p = 0.002), and distension of the optic nerve sheath (p = 0.006). All patients received acetazolamide, only one patient underwent lumboperitoneal shunt, and only one received steroids. In children, IIH can present with different etiologies and symptoms. Brain MRI provides crucial clues in diagnosis. Urgent diagnosis and treatment planning are required to protect vision functions.

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

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

Atypical presentations of idiopathic intracranial hypertension

Idiopathic intracranial hypertension (IIH) is a disorder of unknown etiology that results in isolated raised intracranial pressure. Classic symptoms and signs of IIH include headache, papilledema, diplopia from sixth nerve palsy and divergence insufficiency, and pulsatile tinnitus. Atypical presentations include: (1) highly asymmetric or even unilateral papilledema, and IIH without papilledema; (2) ocular motor disturbances from third nerve palsy, fourth nerve palsy, internuclear ophthalmoplegia, diffuse ophthalmoplegia, and skew deviation; (3) olfactory dysfunction; (4) trigeminal nerve dysfunction; (5) facial nerve dysfunction; (6) hearing loss and vestibular dysfunction; (7) lower cranial nerve dysfunction including deviated uvula, torticollis, and tongue weakness; (8) spontaneous skull base cerebrospinal fluid leak; and (9) seizures. Although atypical findings should raise a red flag and prompt further investigation for an alternative etiology, clinicians should be familiar with these unusual presentations.

Pseudotumor cerebri in patient on leuprolide acetate for central precocious puberty

BACKGROUND

Gonadotropin releasing hormone agonists (GnRHa) are well established as a standard of care for the treatment of central precocious puberty (CPP) worldwide. While numerous delivery systems and routes of administration exist, depot intramuscular injections or sustained-release preparations have been most widely used. Leuprolide acetate is well tolerated among children though some can develop some complications.

CASE PRESENTATION

We present a case report of a 6.5 year old girl with central precocious puberty who developed signs of pseudotumor cerebri after 2 doses of leuprolide acetate 3.75 mg given monthly. Systemic exam and other tests to look for the cause did not yield anything. However, fundoscopy showed marked papilloedema with blurred disc margins. After six weeks' treatment with acetazolamide and withdrawal of the GRNHa the papilloedema resolved.

CONCLUSIONS

If a patient presents with complaints such as headache, nausea, vomiting, and double vision in pediatric patients treated with GnRH analogue one should highly consider the presence of pseudotumor cerebri and fundus examination be performed.

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.

Dural venous sinus stenting for treatment of pediatric idiopathic intracranial hypertension

BACKGROUND

Dural venous sinus stenting (VSS) is an effective treatment for idiopathic intracranial hypertension (IIH) in adult patients. There are no published series to date evaluating safety and efficacy of VSS in pediatric patients.

OBJECTIVE

To report on procedural device selection and technique as well as safety and efficacy of VSS for pediatric patients with medically refractory IIH due to underlying venous sinus stenosis.

METHODS

A multi-institutional retrospective case series identified patients with medically refractory IIH aged less than 18 years who underwent VSS.

RESULTS

14 patients were identified at four participating centers. Patient ages ranged from 10 to 17 years, and 10 patients (71.4%) were female. Mean body mass index was 25.7 kg/m² (range 15.8-34.6 kg/m²). Stenting was performed under general endotracheal anesthesia in all except two patients. The average trans-stenotic gradient during diagnostic venography was 10.6 mm Hg. Patients had stents placed in the superior sagittal sinus, transverse sinus, sigmoid sinus, occipital sinus, and a combination. Average follow-up was 1.7 years after stenting. Six patients out of 10 (60%) had reduced medication dosing, 12 of 14 patients (85.7%) had improvements in headaches, two patients (100%) with pre-stent tinnitus had resolution of symptoms, and four (80%) of five patients with papilledema had improvement on follow-up ophthalmological examinations. Two patients (14.3%) developed postprocedural groin hematomas, one patient (7.1%) developed a groin pseudoaneurysm, and one patient (7.1%) had postprocedural groin bleeding. No other procedural complications occurred. Four patients (28.6%) required further surgical treatment (cerebrospinal shunting and/or stenting) after their first stenting procedure.

CONCLUSIONS

This series suggests that VSS is feasible in a pediatric population with IIH and has a low complication rate and good clinical outcomes.

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

INTRODUCTION

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

METHODS AND ANALYSIS

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

ETHICS AND DISSEMINATION

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

PROSPERO REGISTRATION NUMBER

CRD42019154254.

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

INTRODUCTION

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

METHODS

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

RESULTS

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

CONCLUSION

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

Idiopathic intracranial hypertension in pediatric and adolescent patients

Objectives

Pediatric idiopathic intracranial hypertension is a rare condition, but inappropriate diagnosis and management may lead to devastating outcome with loss of vision and lifelong handicap. Dandy criteria are used for diagnosis of idiopathic intracranial hypertension (IIH) in adult, but these criteria cannot be applied in all pediatric patients.

The aim of this study is to evaluate the diagnostic criteria and outcome of management of IIH in pediatric patients.

Methods

Nineteen patients with IIH and age less than 16 years old have been evaluated for the diagnostic criteria and outcome of management. The patients were classified according to the secondary sexual criteria into adolescent IIH and pediatric IIH. Full neurological and ophthalmological evaluation was completed in all patients. The patients were managed and followed up for a mean period of 12 ± 8.6 months at Zagazig University hospitals or Kingdom Hospital in the time period from 2009 to 2018.

Results

Nineteen patients (16 females and 3 males) had been diagnosed and treated with idiopathic intracranial hypertension, their age is between 4 and 15 years, and the patients have been divided into two groups. Group I (pediatric IIH) involved 9 patients (6 females and 3 males), and their age is ranging between 4 and 9 years with mean age 5.56 ± 1.9 years while group II (adolescent IIH) involved 10 patients, all of them are females and their age ranges between 12 and 15 years with mean age 13.5 ± 1.3. Diagnostic criteria of the patients are papilledema, symptoms and signs of intracranial hypertension, and elevated CSF opening pressure with normal MRI. Headache, delayed school performance, and sixth nerve palsy are the most common clinical finding in the patients of group I while headache is the most common presenting symptom in group II. Anemia and otitis media are the most common associated risk factors in group I while obesity and female gender were the most common associated risk factors in group II. The minimum value for opening pressure in group I is 180 mmH2O while the minimum value in group II is 250 mm. 16 patients improved after the first lumbar puncture and drainage of CSF; two patients improved after repeated lumbar puncture while lumbo-peritoneal shunt was inserted for two patients, both of them were in group II. Recurrence was diagnosed in four patients (21%), one of them (11.1%) was in group I while three of them (30%) were in group II.

Conclusion

Pediatric idiopathic intracranial hypertension can be classified into two subtypes: pediatric type and adolescent type according to the secondary sexual criteria.

Modified Dandy criteria can be applied for the diagnosis of adolescent type, but pediatric type is not associated with obesity, has no female predominance, and usually responds to the initial lumbar puncture with a low rate of recurrence.

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Venous pathologies in paediatric neuroradiology: from foetal to adolescent life

The interpretation of cerebral venous pathologies in paediatric practice is challenging as there are several normal anatomical variants, and the pathologies are diverse, involving the venous system through direct and indirect mechanisms. This paper aims to provide a comprehensive review of these entities, as their awareness can avoid potential diagnostic pitfalls. We also propose a practical classification system of paediatric cerebral venous pathologies, which will enable more accurate reporting of the neuroimaging findings, as relevant to the underlying pathogenesis of these conditions. The proposed classification system comprises of the following main groups: arterio-venous shunting-related disorders, primary venous malformations and veno-occlusive disorders. A multimodal imaging approach has been included in the relevant subsections, with a brief overview of the modality-specific pitfalls that can also limit interpretation of the neuroimaging. The article also summarises the current literature and international practices in terms of management options and outcomes in specific disease entities.

Asymptomatic Versus Symptomatic Idiopathic Intracranial Hypertension in Children

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

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.

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

OBJECTIVES

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

METHOD

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

RESULTS

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

CONCLUSIONS

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

Pseudotumor cerebri in childhood and adolescence: data from a specialized service

ABSTRACT Objective: To report cases of children and adolescents diagnosed with pseudotumor cerebri associated or not with rheumatic disease. Methods: This was a retrospective study based on medical reports of 29 patients, up to 18 years of age and diagnosed with pseudotumor cerebri, followed up in the Pediatric Rheumatology and Neurology outpatient clinics of a tertiary hospital, until December 2016. Results: Among the 29 patients diagnosed with pseudotumor cerebri, 51.7% were girls and the mean age at the disease onset was 12.3 years. In 18 patients (62%) where an etiology was found, four were associated with a rheumatic disease. The most common symptom was headache (69%) and acetazolamide was the most used medication (69%). Two patients developed blindness and 10 are still being followed up. Conclusion: Although rare, pseudotumor cerebri should be considered in children with headaches, especially in patients with rheumatic disease.

Life-Threatening Headaches in Children: Clinical Approach and Therapeutic Options

Life-threatening headaches in children can present in an apoplectic manner that garners immediate medical attention, or in an insidious, more dangerous form that may go unnoticed for a relatively long period of time. The recognition of certain clinical characteristics that accompany the headache should prompt recognition and referral to an institution equipped with neuroimaging facilities, pediatric neurosurgeons, and neurologists. Thunderclap headaches, which reach a peak within a very short period of time, may be the presenting feature of conditions such as arterial dissection, venous sinus thrombosis, and reversible cerebral vasoconstriction syndrome, which can be addressed by specific pharmacological options instituted in an intensive care setting. On the other hand, subacute to chronic headaches that are accompanied by focal neurological signs, such as abducens nerve palsy, restriction of upward gaze, or papilledema, may be indicative of the need for urgent imaging and neurosurgical referral. [Pediatr Ann. 2018;47(2):e74-e80.].

An update on idiopathic intracranial hypertension

BACKGROUND

Idiopathic intracranial hypertension (IIH) is still a grey area in the knowledge of the aetiology, diagnosis and management of neurosurgical diseases. The definition of IIH has been reviewed over time and many hypotheses have been expressed as cause of the disease. The literature supplies very little evidence-based information to guide our decision-making process when it comes to treat the disease. In this review we sum up the latest information regarding the aetiology and therapy of IIH. Additionally, we make an attempt to unify the diagnostic criteria of Dandy, Friedman and Wall established from 1937 to date.

METHOD

In this narrative review, we attempt to update the current standpoint to IIH, evaluate the input until now and consider future directions for research. The vast majority of the literature consisted of cohort studies, case control studies, systematic reviews and other narrative reviews.

RESULTS

Pathophysiology: The incidence of IIH is steadily increasing. Several pathophysiological theories have been proposed in the literature based on the flow of cerebrospinal fluid.

DIAGNOSIS

We attempt to fuse all the three diagnostic approaches published in the literature that detect IIH, while preserving the individual characteristics of each approach.

TREATMENT

Based on evidence-based trials, the current use of acetazolamide in comparison with placebo or with topiramate has been evaluated. In the interventions' field, there seems to be a consonance about the alarming symptoms and what the most suitable operation is in each case. There is some disagreement about the indications for venous sinus transversus stenting and its risk/benefit ratio.

CONCLUSIONS

Until now there is no class I guideline to which our decision-making can be based on for the management of IIH. A lack of systematic reviews and randomised control trials has been noted. If we focused our research on that, we could develop a standardised treatment protocol.

Probable pseudotumor cerebri complex in 25 children. Further support of a concept

BACKGROUND

Cerebrospinal fluid (CSF) opening pressure (OP) of ≥28 cm H₂O is now considered a diagnostic criterion for Pseudotumor cerebri syndrome (PTCS) in children. However, it has been proposed that a diagnosis of "probable" PTCS can be made with an OP < 28 cm H₂O if other diagnostic criteria are met. We report a group of children with probable PTCS.

METHODS

Retrospective analysis of 25 children diagnosed with PTCS but with a CSF OP below 28 cm H₂O. Eleven patients were identified during a nation-wide, prospective, active hospital-based surveillance, and additional 14 patients from our own institution. An extensive chart review of these cases was performed in order to identify signs and symptoms supportive of PTCS.

RESULTS

Of these 25 patients 23 were treated with acetazolamide. Five children required escalation of medical treatment. Findings supportive of PTCS in the absence of an abnormal OP were: papilledema (n = 24), abducens nerve palsy (n = 7), without papilledema in one of them, headache (n = 15). Six patients had a relapse. A second lumbar puncture (LP) documented an opening pressure of >30 cm H₂O in seven children. MRI findings supportive of PTCS were seen in eight patients.

CONCLUSIONS

The diagnosis of probable PTCS as a subgroup of PTCS can be convincingly made in children with an OP < 28 cm H₂O. Results of opening pressure measurement always need to be interpreted within the whole clinical context. Treatment decisions in patients with "probable" PTCS should follow the same stage-based principles as for "proven" PTCS.

Outcomes of ventriculoperitoneal shunt insertion in the management of idiopathic intracranial hypertension in children

PURPOSE

The ventriculoperitoneal (VP) shunt has become the procedure of choice for treatment of idiopathic intracranial hypertension (IIH). We aimed to assess the efficacy of frameless stereotactic placement of VP shunts for the management of medically resistant IIH in children and to assess the role of gender and obesity in the aetiology of the condition.

METHODS

This is a retrospective analysis of the case notes of 10 patients treated surgically at the University Hospital of Wales in Cardiff, from May 2006 to September 2012.

RESULTS

VP shunts were successful in relieving headache, papilloedema and stabilising vision. No sex predilection was identified, and increased BMI was a feature throughout the population, regardless of age.

CONCLUSIONS

Neuronavigated VP shunt insertion is an effective mode of treatment for medically resistant IIH in children. The aetiological picture in children does not seem to be dominated by obesity, as in adults. Literature on childhood IIH is sparse, and larger scale, comparative studies would be of benefit to treating clinicians.

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.

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.

Acute Abducens Nerve Paralysis in the Pediatric Emergency Department: Analysis of 14 Patients

OBJECTIVES

Sixth cranial nerve (SCN) palsy is an uncommon but important neurological problem in patients admitted to pediatric emergency department. The underlying etiology of SCN palsy has a wide range from viral infections to intracranial tumors; therefore, a careful and systematic approach is necessary while examining these patients.

METHODS

Fourteen patients who presented with acute SCN paralysis to pediatric emergency department during the last 10 years were examined.

RESULTS

The age at the time of admission ranged between 14 months and 16 years (median, 9.5 years). Of the 14 patients, 5 were girls and 9 were boys. A total of 3 of the 14 patients had bilateral cranial nerve VI paralysis, and 9 patients had additional abnormal findings on neurological examination. Neuroimaging studies included cranial tomography (n = 3) and brain magnetic resonance imaging in all patients. The underlying etiology was malignancy (n = 3); glioma, medulloblastoma, acute lymphoblastic leukemia, and dural sinus thrombosis (n = 2); as well as Guillain-Barre syndrome (n = 2), multiple sclerosis (n = 1), pseudotumor cerebri (n = 1), and meningitis (n = 1). The remaining 4 patients had miscellaneous benign etiologies.

CONCLUSIONS

Other lesions of primary brain tumors causing increased intracranial pressure constitute 50% of the underlying etiology, followed by Guillain-Barre syndrome (14.2%). However, these patients had neurological symptoms signs, in addition to diplopia or SCN paralysis. Patients admitted to pediatric emergency department with acute SCN paralysis should be examined in detail to disclose the underlying etiology especially if they present with additional clinical signs or symptoms.

Idiopathic Intracranial Hypertension in a Prepubertal Pediatric Japanese Patient Complicated by Severe Papilledema

Purpose

To report a rare case of idiopathic intracranial hypertension (IIH) in a prepubertal pediatric patient.

Case Report

The patient was an 11-year-old Japanese boy. Initially, an ophthalmologist found severe papilledema, and the patient was diagnosed with IIH. He was unresponsive to conservative therapy, and a ventriculoperitoneal shunt was inserted in the Neurosurgery Department because the visual impairment was severe. Twelve months after the shunt, the improvement in vision was limited due to optic disc atrophy.

Conclusion

Ophthalmologists need to be more aware of II, especially in cases with severe papilledema that can lead to permanent reduction of vision.

Sixth Nerve Palsy in Paediatric Intracranial Hypertension

The purpose of this study was to report the incidence and describe the characteristics of sixth cranial nerve (CN VI) palsy in paediatric patients with intracranial hypertension (IH). A retrospective chart review of central Ohio children diagnosed with IH over the 3-year period from 2010 to 2013 was conducted. IH without identifiable cause was defined as idiopathic intracranial hypertension (IIH), whereas IH with identifiable pathologic aetiology was deemed secondary intracranial hypertension (SIH). A subset of patients with CN VI palsy was identified. Data collected included patient age, gender, past medical history, aetiology of SIH, ophthalmic examination, lumbar puncture results, neuroimaging results, and response to treatment. Seventy-eight children with intracranial hypertension were included in the study. Nine (11.5%) children (four males, five females; median age 14, range: 3-18) were found to have a unilateral (n = 2) or bilateral (n = 7) CN VI palsy. Five children had IIH; the remaining four had SIH from cerebral venous sinus thrombosis (n = 2) and infection (n = 2). The mean lumbar puncture opening pressure for the nine patients with CN VI palsy was 40 cm H₂O (range: 21-65 cm H₂O). Papilloedema was present in 8/9 (89%) patients. One patient required a lumboperitoneal shunt, and two others required optic nerve sheath fenestrations in addition to medical management. All cases of CN VI palsy resolved with treatment. In our primary service area, the incidence of CN VI palsy is approximately 12% among paediatric IH patients. The majority of cases with CN VI palsy presented with papilloedema and all cases resolved with treatment of intracranial hypertension.

Pseudotumor Cerebri in a Child with Idiopathic Growth Hormone Insufficiency Two Months after Initiation of Recombinant Human Growth Hormone Treatment

Purpose. To report a rare case of pseudotumor cerebri (PTC) in a child two months after receiving treatment with recombinant human growth hormone (rhGH) and to emphasize the need of close collaboration between ophthalmologists and pediatric endocrinologists in monitoring children receiving rhGH. Methods. A 12-year-old boy with congenital hypothyroidism started treatment with rhGH on a dose of 1,5 mg/daily IM (4.5 IU daily). Eight weeks later, he was complaining of severe headache without any other accompanying symptoms. The child was further investigated with computed tomography scan and lumbar puncture. Results. Computed tomography scan showed normal ventricular size and lumbar puncture revealed an elevated opening pressure of 360 mm H₂O. RhGH was discontinued and acetazolamide 250 mg per os twice daily was initiated. Eight weeks later, the papilledema was resolved. Conclusions. There appears to be a causal relationship between the initiation of treatment with rhGH and the development of PTC. All children receiving rhGH should have a complete ophthalmological examination if they report headache or visual disturbances shortly after the treatment. Discontinuation of rhGH and initiation of treatment with acetazolamide may be needed and regular follow-up examinations by an ophthalmologist should be recommended.

Malignant Hypertensive Retinopathy in an Infant with Mid-Aortic Occlusion

Purpose. Case report describing an eight-month-old infant presenting with intermittent esotropia and irritability who was found to have malignant (grade 4) hypertensive retinopathy and mid-aortic syndrome. Methods. Visual acuity was 6/140 in the right eye and not recordable in the left eye. Blood pressure was as high as 230/120 mmHg. Fundoscopy revealed bilateral optic disc swelling, macular stars, and serous retinal detachment in the left eye, findings that are consistent with malignant (grade 4) hypertensive retinopathy. CT abdominal angiogram revealed a severe mid-aortic syndrome with occlusion of the abdominal aorta at T12. Results. The patient was treated with medical management of his hypertension, improving the subretinal exudate. Binocular visual acuity improved to 6/9.5 over 9 months. There was a persistent left relative afferent pupillary defect and moderate left esotropia. Conclusion. This is the first reported case of malignant hypertensive retinopathy in an infant with concomitant mid-aortic occlusion. The authors emphasize the need for an ophthalmological and pediatric examination in a child presenting with intermittent squint and irritability. The esotropia was found to be a false localizing sign of raised intracranial pressure secondary to the severe mid-aortic syndrome.

A baby with a lot of nerve

An infant presented with bilateral disk edema and an acute left sixth cranial nerve (CN VI) palsy because of pseudotumor cerebri (PTC). PTC is rare in infants where it is often associated with endocrine abnormalities, medications, viral infections, systemic conditions, and nutritional etiologies such as vitamin A toxicity. We report a case of PTC in an infant associated with hypervitaminosis A with an unlikely source-a common prenatal vitamin.

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.

Visual Outcome and Recurrence Rate in Children With Idiopathic Intracranial Hypertension

The purpose of this retrospective study was to evaluate the visual outcome and recurrence rate of idiopathic intracranial hypertension in children. The study included 68 patients who were diagnosed with idiopathic intracranial hypertension according to the modified Dandy criteria. Permanent visual impairment was rare. Three percent remained with mild visual impairment, 4% with minimal visual field defects, and only 1 patient had severe visual impairment. However, 26% had either a prolonged course of disease or a recurring condition. Higher cerebrospinal fluid opening pressure was the only clinical predictor at presentation (P = .04). Recurrence rate was 18%, and in most cases, the second episode occurred during the first year after remission. There was no significant difference between the group of patients with only 1 episode and the group of patients with more than 1 episode. We suggest long-term follow-up after remission, for at least a year, for all children with idiopathic intracranial hypertension.

Intracranial hypertension without headache in children

We aimed to determine the frequency of intracranial hypertension without headache in children. We retrospectively analyzed patients evaluated in a pediatric intracranial hypertension referral center. Patients were divided into 2 groups depending on whether they complained of headache 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 .05 was considered significant. A total of 228 charts were reviewed; 152 patients met the criteria for intracranial hypertension and 22/152 patients (14.5%) met the criteria of optic nerve edema without headache. There were clinically significant differences in age and body mass index between the 2 groups. The group without headache was typically younger and not obese. The opening pressure and modified opening pressure were not clinically significant between the 2 groups.

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.