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Moreno-Gómez LA, Quintero-Pulgarín D, Espitia Segura OM, Chiquiza-Garzón LC, Farfán-Albarracín JD, Ramírez-Sierra CL, Zuñiga-Zambrano YC, Ceballos-Inga LA. Magnetic resonance signs of intracranial hypertension in children: a retrospective case-control study. Eur J Pediatr 2025; 184:218. [PMID: 40024938 PMCID: PMC11872764 DOI: 10.1007/s00431-025-06025-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/31/2024] [Revised: 01/27/2025] [Accepted: 01/29/2025] [Indexed: 03/04/2025]
Abstract
The diagnostic accuracy of magnetic resonance (MRI) signs of intracranial hypertension (ICH) in children remains unclear. This study aims to assess how brain MRI signs of ICH correlate with cerebrospinal fluid opening pressure (CSFOP). A retrospective case-control study was conducted with 77 children aged 1 to 18 years, who underwent brain MRI and lumbar puncture with CSFOP measurement. A blinded radiologist evaluated key ICH signs, including distension of the perioptic subarachnoid space, optic nerve (ON) tortuosity, posterior scleral flattening, intraocular protrusion, and enhancement of the prelaminar ON, among others. Odds ratios, likelihood ratios, predictive values, sensitivity, specificity, and the area under the ROC curve (AUROC), were calculated in relation to CSFOP, adjusted for age and sex. The ICH group included 38 patients (49.3%) and the control group 39 (50.7%). The presence of four or more MRI signs of ICH provided the best diagnostic performance (specificity 92%, sensitivity 40%, AUROC 0.759) for identifying elevated CSFOP, particularly with intraocular protrusion of the prelaminar ON (p = 0.006, median CSFOP 49.6 cm H2O, p < .001) and papilledema (p = 0.042). CONCLUSION The presence of four or more MRI signs is associated with elevated CSFOP in children with non-structural ICH. WHAT IS KNOWN • The diagnostic accuracy of magnetic resonance imaging (MRI) signs of intracranial hypertension (ICH) in children remains unclear. • In children, there is no consensus about the most appropriate diagnostic criteria or robust evidence regarding the diagnostic performance of imaging signs for ICH. WHAT IS NEW • The presence of four or more MRI signs is associated with elevated cerebrospinal fluid opening pressure (CSFOP) in children with non-structural ICH. • Intraocular protrusion of the prelaminar ON, and papilledema are particularly relevant signs for identifying elevated CSFOP.
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Affiliation(s)
- Luz Angela Moreno-Gómez
- Department of Pediatric Radiology, HOMI Fundación Hospital Pediátrico la Misericordia, Bogotá, Colombia.
- School of Medicine, Universidad Nacional de Colombia, Bogotá, Colombia.
| | - Daniel Quintero-Pulgarín
- Department of Pediatric Radiology, HOMI Fundación Hospital Pediátrico la Misericordia, Bogotá, Colombia
- School of Medicine, Universidad Nacional de Colombia, Bogotá, Colombia
| | - Oscar Mauricio Espitia Segura
- Qualitative and Quantitative Research Network in Child Neurology (RICCNeP), Bogotá, Colombia
- Department of Child Neurology, HOMI Fundación Hospital Pediátrico la Misericordia, Bogotá, Colombia
| | | | - Juan David Farfán-Albarracín
- Qualitative and Quantitative Research Network in Child Neurology (RICCNeP), Bogotá, Colombia
- Department of Child Neurology, HOMI Fundación Hospital Pediátrico la Misericordia, Bogotá, Colombia
- School of Medicine, Universidad de Antioquia, Medellín, Colombia
| | - Cristina Lorena Ramírez-Sierra
- Qualitative and Quantitative Research Network in Child Neurology (RICCNeP), Bogotá, Colombia
- School of Medicine, Universidad Nacional de Colombia, Bogotá, Colombia
- Department of Child Neurology, Clínica Infantil Santa María del Lago - Clínica Colsanitas, Bogotá, Colombia
| | - Yenny Carolina Zuñiga-Zambrano
- Qualitative and Quantitative Research Network in Child Neurology (RICCNeP), Bogotá, Colombia
- Department of Child Neurology, HOMI Fundación Hospital Pediátrico la Misericordia, Bogotá, Colombia
| | - Leydi Alexandra Ceballos-Inga
- Qualitative and Quantitative Research Network in Child Neurology (RICCNeP), Bogotá, Colombia
- Department of Child Neurology, HOMI Fundación Hospital Pediátrico la Misericordia, Bogotá, Colombia
- School of Medicine, Universidad Nacional de Colombia, Bogotá, Colombia
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Pabst L, Aylward BS, Rogers DL, Aylward SC. Persistent Elevation of Opening Pressure Despite Treatment and Symptom Resolution in Pediatric Intracranial Hypertension. Pediatr Neurol 2024; 153:92-95. [PMID: 38354628 DOI: 10.1016/j.pediatrneurol.2023.12.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/23/2022] [Revised: 11/04/2023] [Accepted: 12/18/2023] [Indexed: 02/16/2024]
Abstract
BACKGROUND Currently no guidelines for repeating a lumbar puncture to guide management in primary intracranial hypertension (PIH) exist. METHODS An institutional database of patients 18 years and younger followed in the institution's pediatric intracranial hypertension clinic was examined for opening pressure changes in PIH at diagnosis, before medication wean, and following medication wean, as well as to examine whether measurements at the time of diagnosis differed between those with and without disease recurrence. RESULTS Forty-two patients were included in this study; 36% were male and the mean age at diagnosis was 11.01 years. Treatment duration averaged 9.68 months in those without recurrence and 8.5 months in those with recurrence. Average body mass index percentile of patients with disease recurrence was 83.7 and 72.1 in those without recurrence (P = 0.16). Average opening pressure values of all patients at diagnosis, prewean, and postwean was 36.53 cm H2O, 30.7 cm H2O, and 31.1 cm H2O, respectively. There was no statistically significant difference in opening pressures across these time points (P = 0.14). The change in opening pressure from diagnosis to postwean was statistically significant with a reduction of 5.18 cm H2O (P = 0.04). There was no statistical difference between change in opening pressure at diagnosis versus postwean between those with and without recurrence (P = 0.17). CONCLUSIONS This clinical observational study suggests that mean opening pressure measurements in patients with PIH remain elevated both before and after medication wean despite papilledema resolution and patient-reported PIH symptoms. Clinically, this suggests that other features such as signs of optic disc edema and symptoms should be used to inform a clinical determination of disease recurrence and treatment course.
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Affiliation(s)
- Lisa Pabst
- Department of Neurology, Nationwide Children's Hospital, Columbus, Ohio
| | - Brandon S Aylward
- RTI Health Advance, RTI International, Research Triangle Park, North Carolina
| | - David L Rogers
- Department of Ophthalmology, Nationwide Children's Hospital, Columbus, Ohio
| | - Shawn C Aylward
- Department of Neurology, Nationwide Children's Hospital, Columbus, Ohio.
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Nitzan-Luques A, Bulkowstein Y, Barnoy N, Aran A, Reif S, Gilboa T. Improving pediatric idiopathic intracranial hypertension care: a retrospective cohort study. Sci Rep 2022; 12:19218. [PMID: 36357479 PMCID: PMC9649632 DOI: 10.1038/s41598-022-23960-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2022] [Accepted: 11/08/2022] [Indexed: 11/12/2022] Open
Abstract
To describe the clinical course and prognosis of pediatric idiopathic intracranial hypertension (IIH) and examine the preferred management setting. IIH is characterized by increased intracranial pressure and is often associated with headaches and visual complaints. IIH is a preventable cause of vision loss in children. Hence, a rapid diagnosis followed by prompt treatment and follow-up is essential. However, standardization of the management of IIH in the pediatric population is not well established. Computerized medical charts of all 82 pediatric (< 18 years) patients diagnosed with IIH between 2007 and 2018 in the metropolitan area of Jerusalem were reviewed. Comparison was made between children followed in a multidisciplinary clinic in tertiary centers and those followed elsewhere. Detailed demographic and clinical data, as well as data regarding the follow-up setting and clinical course of the disease, were collected and analyzed. Recurrent IIH-related hospital returns were selected as a measurable marker for the uncontrolled disease. Recurrent IIH-related hospital return rate was significantly lower and occurred later among children followed by multidisciplinary teams compared to individual experts. Follow-up in multidisciplinary clinics improve the quality of life, and financial burden and may prevent permanent visual impairment in children with IIH.
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Affiliation(s)
- Adi Nitzan-Luques
- Pediatric Department, Hadassah Medical Center, Ein-Kerem Campus, Jerusalem, Israel
- Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
- Pediatric Hemato-Oncology Department, Hadassah Medical Center, Ein-Kerem Campus, Jerusalem, Israel
| | - Yarden Bulkowstein
- Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
- Pediatric department, Schneider Children's Medical Center of Israel, Petah Tikva, Israel
| | - Noa Barnoy
- Pediatric Neurology Unit, Shaare Zedek Medical Center, Jerusalem, Israel
| | - Adi Aran
- Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
- Pediatric Neurology Unit, Shaare Zedek Medical Center, Jerusalem, Israel
| | - Shimon Reif
- Pediatric Department, Hadassah Medical Center, Ein-Kerem Campus, Jerusalem, Israel
- Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Tal Gilboa
- Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel.
- Pediatric Neurology Unit, Hadassah Medical Center, Jerusalem, Israel.
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4
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[Pseudotumor cerebri in children and adolescents at the Saarland University Medical Center: a retrospective study]. Wien Med Wochenschr 2022; 173:173-181. [PMID: 35939217 DOI: 10.1007/s10354-022-00950-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2021] [Accepted: 06/14/2022] [Indexed: 11/27/2022]
Abstract
Pseudotumor cerebri (PTC) is defined as a rare disease with a pathological increase in intracranial pressure of unknown origin. The aim of this retrospective study was to establish a uniform diagnostic and therapeutic protocol for children and adolescents for the Saarland University Medical Center. Data from 28 patients with pseudotumor cerebri aged 0-17 years in the period 2008-2018 were retrospectively collected and statistically analyzed. The purpose of this study was to generate a better understanding of the clinical entity of pseudotumor cerebri in children and adolescents. Distinctive features, such as pubertal or adolescent age, female gender and obesity could be highlighted. The data collected in this study were used to develop an in-house standard for the diagnosis and treatment of children and adolescents with pseudotumor cerebri.
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Alex AA, Jordan CO, Benedict JA, Aylward SC, Rogers DL, Inger HE. Intracranial Hypertension Recurrence Risk After Wean of Intracranial Pressure-Lowering Medication. Pediatr Neurol 2021; 121:40-44. [PMID: 34153813 DOI: 10.1016/j.pediatrneurol.2021.05.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2020] [Revised: 04/18/2021] [Accepted: 05/01/2021] [Indexed: 11/17/2022]
Abstract
BACKGROUND The proportion of children with recurrent signs and symptoms of intracranial hypertension after medication wean has been reported to be between 18% and 50%. Few studies have reported intracranial hypertension recurrence risk in children while adjusting for each individual's observed follow-up time after medication wean. In addition, the role of intracranial hypertension etiology on the risk of disease recurrence has not been widely studied. METHODS The medical charts of patients with intracranial hypertension treated with intracranial pressure-lowering medication were analyzed retrospectively for disease recurrence. Baseline characteristics from diagnosis were recorded in addition to information regarding duration of therapy, medication wean, and recurrence. Survival analyses as well as Poisson regression models with time under observation as an offset were performed. RESULTS One hundred and thirty-three patients were included in the study. The cumulative risk of intracranial hypertension recurrence increased rapidly within the first six months after medication wean and was 1.5% at one month, 9.5% at three months, and 20% at six months. This risk leveled off near 12 to 18 months. CONCLUSIONS While the cumulative risk of intracranial hypertension recurrence increases most dramatically within the first six months after medication wean, it does not appear to taper until 12 to 18 months. Given the possibility of delayed or asymptomatic recurrences, long-term follow-up is ideal, although patients can likely be seen less frequently after the first 12 to 18 months after medication wean.
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Affiliation(s)
- Anastasia A Alex
- Department of Ophthalmology, Havener Eye Institute, The Ohio State University, Columbus, Ohio
| | - Catherine O Jordan
- Department of Ophthalmology, Nationwide Children's Hospital, Columbus, Ohio
| | - Jason A Benedict
- Department of Bioinformatics, Center for Biostatistics, The Ohio State University, Columbus, Ohio
| | - Shawn C Aylward
- Department of Neurology, Nationwide Children's Hospital, Columbus, Ohio
| | - David L Rogers
- Department of Ophthalmology, Nationwide Children's Hospital, Columbus, Ohio
| | - Hilliary E Inger
- Department of Ophthalmology, Nationwide Children's Hospital, Columbus, Ohio.
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Martín-Begué N, Mogas E, Dod CW, Alarcón S, Clemente M, Campos-Martorell A, Fábregas A, Yeste D. Growth Hormone Treatment and Papilledema: A Prospective Pilot Study. J Clin Res Pediatr Endocrinol 2021; 13:146-151. [PMID: 33006547 PMCID: PMC8186341 DOI: 10.4274/jcrpe.galenos.2020.2020.0007] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2020] [Accepted: 09/16/2020] [Indexed: 12/01/2022] Open
Abstract
Objective To investigate the incidence of pseudotumor cerebri syndrome (PTCS) in children treated with growth hormone (GH) in a paediatric hospital and to identify risk factors for this complication. Methods Prospective pilot study of paediatric patients treated with recombinant human GH, prescribed by the Paediatric Endocrinology Department, between February 2013 and September 2017. In all these patients, a fundus examination was performed before starting treatment and 3-4 months later. Results Two hundred and eighty-nine patients were included, of whom 244 (84.4%) had GH deficiency, 36 (12.5%) had short stature associated with small for gestational age, six (2.1%) had a mutation in the SHOX gene and three (1.0%) had Prader-Willi syndrome. Five (1.7%) developed papilledema, all were asymptomatic and had GH deficiency due to craniopharyngioma (n=1), polymalformative syndrome associated with hypothalamic-pituitary axis anomalies (n=2), a non-specified genetic disease with hippocampal inversion (n=1) and one with normal magnetic resonance imaging who had developed a primary PTCS years before. Conclusion GH treatment is a cause of PTCS. In our series, at risk patients had GH deficiency and hypothalamic-pituitary anatomic anomalies or genetic or chromosomal diseases. Fundus examination should be systematically screened in all patients in this at-risk group, irrespective of the presence or not of symptoms.
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Affiliation(s)
- Nieves Martín-Begué
- Hospital Universitari Vall d’Hebron, Department of Paediatric Ophthalmology, Barcelona, Spain
| | - Eduard Mogas
- Hospital Universitari Vall d’Hebron, Department of Paediatric Endocrinology, Barcelona, Spain
| | - Charlotte Wolley Dod
- Hospital Universitari Vall d’Hebron, Department of Paediatric Ophthalmology, Barcelona, Spain
| | - Silvia Alarcón
- Hospital Universitari Vall d’Hebron, Department of Paediatric Ophthalmology, Barcelona, Spain
| | - María Clemente
- Hospital Universitari Vall d’Hebron, Department of Paediatric Endocrinology, Barcelona, Spain
- Universitat Autònoma de Barcelona (UAB), Barcelona, Spain
- Centro de Investigación Biomédica en Red: Enfermedades Raras (CIBERER), Madrid, Spain
| | - Ariadna Campos-Martorell
- Hospital Universitari Vall d’Hebron, Department of Paediatric Endocrinology, Barcelona, Spain
- Universitat Autònoma de Barcelona (UAB), Barcelona, Spain
| | - Ana Fábregas
- Hospital Universitari Vall d’Hebron, Department of Paediatric Endocrinology, Barcelona, Spain
| | - Diego Yeste
- Hospital Universitari Vall d’Hebron, Department of Paediatric Endocrinology, Barcelona, Spain
- Universitat Autònoma de Barcelona (UAB), Barcelona, Spain
- Centro de Investigación Biomédica en Red: Enfermedades Raras (CIBERER), Madrid, Spain
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Polemikos M, Hermann EJ, Heissler HE, Hartmann H, Krauss JK. Pseudotumor cerebri syndrome in a child with Alagille syndrome: intracranial pressure dynamics and treatment outcome after ventriculoperitoneal shunting. Childs Nerv Syst 2021; 37:2899-2904. [PMID: 33555437 PMCID: PMC8423640 DOI: 10.1007/s00381-021-05043-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2020] [Accepted: 01/14/2021] [Indexed: 12/01/2022]
Abstract
Alagille syndrome (AS) is a rare multisystem disease of the liver, heart, eyes, face, skeleton, kidneys, and vascular system. The occurrence of pseudotumor cerebri syndrome (PTCS) in patients with AS has been reported only exceptionally. Owning to its rarity and a mostly atypical presentation, the diagnosis and natural history of affected patients remain uncertain. We report an atypical case of PTCS in a 4-year-old boy with a known history of AS who presented with bilateral papilledema (PE) on a routine ophthalmological examination. Visual findings deteriorated after treatment with acetazolamide. Continuous intracranial pressure (ICP) monitoring was then utilized to investigate ICP dynamics. Successful treatment with resolution of PE was achieved after ventriculoperitoneal shunting but relapsed due to growth-related dislocation of the ventricular catheter. This report brings new insights into the ICP dynamics and the resulting treatment in this possibly underdiagnosed subgroup of PTCS patients. It also demonstrates that ventriculoperitoneal shunting can provide long-term improvement of symptoms for more than 10 years.
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Affiliation(s)
- Manolis Polemikos
- Department of Neurosurgery, Hannover Medical School, MHH, Carl-Neuberg-Str. 1, DE-30625, Hannover, Germany.
| | - Elvis J. Hermann
- Department of Neurosurgery, Hannover Medical School, MHH, Carl-Neuberg-Str. 1, DE-30625 Hannover, Germany
| | - Hans E. Heissler
- Department of Neurosurgery, Hannover Medical School, MHH, Carl-Neuberg-Str. 1, DE-30625 Hannover, Germany
| | - Hans Hartmann
- Clinic for Paediatric Nephrology, Hepatology and Metabolic Disorders, Hannover Medical School, Hannover, Germany
| | - Joachim K. Krauss
- Department of Neurosurgery, Hannover Medical School, MHH, Carl-Neuberg-Str. 1, DE-30625 Hannover, Germany
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Mahajnah M, Genizi J, Zahalka H, Andreus R, Zelnik N. Pseudotumor Cerebri Syndrome: From Childhood to Adulthood Risk Factors and Clinical Presentation. J Child Neurol 2020; 35:311-316. [PMID: 31928127 DOI: 10.1177/0883073819895179] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
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.
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Affiliation(s)
- Muhammad Mahajnah
- Child Neurology and Development Center, Hillel-Yaffe Medical Center, Hadera, Israel.,The Ruth and Bruce Rappaport Faculty of Medicine, Technion, Haifa, Israel
| | - Jacob Genizi
- The Ruth and Bruce Rappaport Faculty of Medicine, Technion, Haifa, Israel.,Child Neurology Unit, Bnai-Zion Medical Center, Haifa, Israel
| | - Hazar Zahalka
- Child Neurology and Development Center, Hillel-Yaffe Medical Center, Hadera, Israel
| | - Ronza Andreus
- Child Neurology and Development Center, Carmel Medical Center & Clalit Health Services, Haifa District, Israel
| | - Nathanel Zelnik
- The Ruth and Bruce Rappaport Faculty of Medicine, Technion, Haifa, Israel.,Child Neurology and Development Center, Carmel Medical Center & Clalit Health Services, Haifa District, Israel
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Hilely A, Hecht I, Goldenberg-Cohen N, Leiba H. Long-Term Follow-up of Pseudotumor Cerebri Syndrome in Prepubertal Children, Adolescents, and Adults. Pediatr Neurol 2019; 101:57-63. [PMID: 31604646 DOI: 10.1016/j.pediatrneurol.2019.04.018] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/30/2018] [Revised: 01/12/2019] [Accepted: 04/21/2019] [Indexed: 10/26/2022]
Abstract
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.
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Affiliation(s)
- Assaf Hilely
- Department of Ophthalmology, Kaplan Medical Center, Rehovot, Israel; The Hebrew University of Jerusalem, Jerusalem, Israel.
| | - Idan Hecht
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Nitza Goldenberg-Cohen
- Department of Ophthalmology, Bnai Zion Medical Center, Haifa, Israel; Krieger Eye Research Laboratory, Felsenstein Medical Research Center, Tel Aviv University, Rabin Campus, Petach Tikva, Israel; The Bruce and Ruth Rappaport, Faculty of Medicine, Technion, Israel Institute of Technology, Haifa, Israel
| | - Hana Leiba
- Department of Ophthalmology, Kaplan Medical Center, Rehovot, Israel; The Hebrew University of Jerusalem, Jerusalem, Israel
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Boles S, Martinez-Rios C, Tibussek D, Pohl D. Infantile Idiopathic Intracranial Hypertension: A Case Study and Review of the Literature. J Child Neurol 2019; 34:806-814. [PMID: 31309848 DOI: 10.1177/0883073819860393] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
Idiopathic intracranial hypertension, or pseudotumor cerebri, is an increase in cerebrospinal fluid pressure of unknown etiology. It is mostly seen in adults, less frequently in adolescents, rarely in younger children. Only 5 infants meeting idiopathic intracranial hypertension criteria have been mentioned in the literature. We report a case of a previously healthy 9-month-old boy who presented with irritability, decreased appetite, and a bulging fontanelle. Computed tomography (CT) head imaging and cerebrospinal fluid studies revealed normal results. The patient's symptoms transiently resolved after the initial lumbar puncture, but 11 days later, his fontanelle bulged again. A second lumbar puncture revealed an elevated opening pressure of 35 cmH2O and led to a diagnosis of idiopathic intracranial hypertension in accordance with the modified Dandy Criteria. Treatment with acetazolamide at a dose of 25 mg/kg/d was initiated and the patient remained symptom-free for 6 weeks, followed by another relapse. His acetazolamide dose was increased to 37 mg/kg/d, with no further relapses to date. A diagnosis of idiopathic intracranial hypertension is challenging in infants, because the patients cannot yet verbalize typical idiopathic intracranial hypertension-related symptoms such as positional headaches, diplopia, or pulsatile tinnitus. Furthermore, it is more difficult to assess papilledema in that age group. If undetected and untreated, idiopathic intracranial hypertension may result in permanent visual deficits. Little is known about idiopathic intracranial hypertension in infants, and age-specific treatment guidelines are lacking. We discuss this rare case of infantile idiopathic intracranial hypertension and provide a review of the literature, including an overview of disease characteristics and outcomes of idiopathic intracranial hypertension in this very young age group.
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Affiliation(s)
- Sama Boles
- University of Ottawa, Ottawa, Ontario, Canada
| | - Claudia Martinez-Rios
- Department of Medical Imaging, Children's Hospital of Eastern Ontario, University of Ottawa, Ottawa, Ontario, Canada
| | - Daniel Tibussek
- Department of General Pediatrics, Neonatology and Pediatric Cardiology, University Children's Hospital, Heinrich-Heine-University, Düsseldorf, Germany
| | - Daniela Pohl
- Division of Neurology, Children's Hospital of Eastern Ontario, University of Ottawa, Ottawa, Ontario, Canada
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De Simone R, Ranieri A, Sansone M, Marano E, Russo CV, Saccà F, Bonavita V. Dural sinus collapsibility, idiopathic intracranial hypertension, and the pathogenesis of chronic migraine. Neurol Sci 2019; 40:59-70. [PMID: 30838545 DOI: 10.1007/s10072-019-03775-w] [Citation(s) in RCA: 30] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
Available evidences suggest that a number of known assumption on idiopathic intracranial hypertension (IIH) with or without papilledema might be discussed. These include (1) the primary pathogenetic role of an excessive dural sinus collapsibility in IIH, allowing a new relatively stable intracranial fluids pressure balance at higher values; (2) the non-mandatory role of papilledema for a definite diagnosis; (3) the possibly much higher prevalence of IIH without papilledema than currently considered; (4) the crucial role of the cerebral compliance exhaustion that precede the raise in intracranial pressure and that may already be pathologic in cases showing a moderately elevated opening pressure; (5) the role as "intracranial pressure sensor" played by the trigeminovascular innervation of dural sinuses and cortical bridge veins, which could represent a major source of CGRP and may explain the high comorbidity and the emerging causative link between IIHWOP and chronic migraine (CM). Accordingly, the control of intracranial pressure is to be considered a promising new therapeutic target in CM.
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Affiliation(s)
- Roberto De Simone
- Department of Neuroscience, Reproductive Sciences and Odontostomatology, Headache Centre, University Federico II of Naples, Via Pansini, 5, 80122, Naples, Italy.
| | - Angelo Ranieri
- Division of Neurology and Stroke Unit, Hospital A. Cardarelli, Naples, Italy
| | - Mattia Sansone
- Department of Neuroscience, Reproductive Sciences and Odontostomatology, Headache Centre, University Federico II of Naples, Via Pansini, 5, 80122, Naples, Italy
| | - Enrico Marano
- Department of Neuroscience, Reproductive Sciences and Odontostomatology, Headache Centre, University Federico II of Naples, Via Pansini, 5, 80122, Naples, Italy
| | - Cinzia Valeria Russo
- Department of Neuroscience, Reproductive Sciences and Odontostomatology, Headache Centre, University Federico II of Naples, Via Pansini, 5, 80122, Naples, Italy
| | - Francesco Saccà
- Department of Neuroscience, Reproductive Sciences and Odontostomatology, Headache Centre, University Federico II of Naples, Via Pansini, 5, 80122, Naples, Italy
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Agraz D, Morgan LA, Fouzdar Jain S, Suh DW. Clinical features of pediatric idiopathic intracranial hypertension. Clin Ophthalmol 2019; 13:881-886. [PMID: 31213758 PMCID: PMC6538838 DOI: 10.2147/opth.s183087] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2018] [Accepted: 02/28/2019] [Indexed: 11/23/2022] Open
Abstract
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.
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Affiliation(s)
- Daniel Agraz
- College of Medicine, University of Nebraska Medical Center, Omaha, NE, USA
| | - Linda A Morgan
- Department of Pediatric Ophthalmology, Children's Hospital and Medical Center, Omaha, NE, USA
| | - Samiksha Fouzdar Jain
- College of Medicine, University of Nebraska Medical Center, Omaha, NE, USA.,Department of Pediatric Ophthalmology, Children's Hospital and Medical Center, Omaha, NE, USA
| | - Donny W Suh
- College of Medicine, University of Nebraska Medical Center, Omaha, NE, USA.,Department of Pediatric Ophthalmology, Children's Hospital and Medical Center, Omaha, NE, USA
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Bhalla S, Nickel NE, Mutchnick I, Ziegler C, Sowell M. Demographics, clinical features, and response to conventional treatments in pediatric Pseudotumor Cerebri syndrome: a single-center experience. Childs Nerv Syst 2019; 35:991-998. [PMID: 31025099 DOI: 10.1007/s00381-019-04150-y] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/10/2018] [Accepted: 04/03/2019] [Indexed: 12/20/2022]
Abstract
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.
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Affiliation(s)
- Sonam Bhalla
- Division of Child Neurology, Department of Neurology, Columbia University Medical Center, New York, NY, USA.
| | - Noura Estephane Nickel
- Department of Pediatrics, Johns Hopkins All Children's Hospital, St. Petersburg, FL, USA
| | - Ian Mutchnick
- Division of Pediatric Neurosurgery, Norton Neuroscience Institute, Norton Children's Hospital and University of Louisville School of Medicine, Louisville, KY, USA
| | - Craig Ziegler
- University of Louisville Office of Graduate Medical Education, Louisville, KY, USA
| | - Michael Sowell
- Division of Child Neurology, Department of Neurology, University of Louisville School of Medicine, Louisville, KY, USA
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14
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Balbi GGM, Matas SL, Len CA, Fraga MM, Sousa IO, Terreri MT. Pseudotumor cerebri in childhood and adolescence: data from a specialized service. ARQUIVOS DE NEURO-PSIQUIATRIA 2018; 76:751-755. [DOI: 10.1590/0004-282x20180131] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/24/2018] [Accepted: 08/15/2018] [Indexed: 11/21/2022]
Abstract
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.
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15
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Abstract
PURPOSE OF REVIEW The purpose of this review is to provide an update on pediatric intracranial hypertension. RECENT FINDINGS The annual pediatric incidence is estimated at 0.63 per 100,000 in the USA and 0.71 per 100,000 in Britain. The Idiopathic Intracranial Hypertension Treatment Trial found improvement in visual fields, optical coherence tomography, Frisen grade, and quality of life with acetazolamide compared to placebo in adult patients, and these findings have been translated to the pediatric population. Pediatric intracranial hypertension is a disorder that if left untreated can lead to poor quality of life and morbidity. There are no current treatment studies in pediatrics, but adult data suggests acetazolamide remains an acceptable first-line medication.
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Affiliation(s)
- Shawn C Aylward
- Department of Neurology, Nationwide Children's Hospital, The Ohio State University College of Medicine, 700 Children's Drive, Columbus, OH, 43205, USA.
| | - Amanda L Way
- Department of Ophthalmology, Nationwide Children's Hospital, Columbus, OH, USA
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16
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17
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Fernández-García MÁ, Cantarín-Extremera V, Andión-Catalán M, Duat-Rodríguez A, Jiménez-Echevarría S, Bermejo-Arnedo I, Hortigüela-Saeta M, Rekarte-García S, Babín-López L, Ruano Domínguez D. Secondary Intracranial Hypertension in Pediatric Patients With Leukemia. Pediatr Neurol 2017; 77:48-53. [PMID: 29097019 DOI: 10.1016/j.pediatrneurol.2017.08.013] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/02/2017] [Revised: 08/21/2017] [Accepted: 08/24/2017] [Indexed: 10/18/2022]
Abstract
BACKGROUND We investigated the clinical characteristics of a pediatric population with hemato-oncological disease and intracranial hypertension, analyze the therapeutic response and outcome, and compare its characteristics with respect to a control group with idiopathic intracranial hypertension. METHODS We retrospectively analyzed patients with hemato-oncological disease and secondary intracranial hypertension in our center during the past five years. We compared these individuals with a historical cohort with idiopathic intracranial hypertension from our institution (control group). RESULTS We identified eight patients, all with leukemia, and 21 controls. Mean age at diagnosis was 10.6 years, and 62% of individuals were female. Most of them were under treatment with drugs (62% corticosteroids, 75% active chemotherapy). Mean opening pressure of cerebrospinal fluid was 35 cm H2O. All had headache, but only 28% complained of visual symptoms. Only 12.5% exhibited papilledema at the time of diagnosis (versus 71% in controls). All of them were treated with acetazolamide, with average therapy duration of nine months, and all had a favorable outcome (versus 57% of controls who needed second-line treatment). None of them showed long-term visual complications (versus 20% of controls). CONCLUSIONS Patients with hemato-oncological disease and secondary intracranial hypertension may not develop typical symptomatology. Thus, diagnosis and recognition of this entity among this cohort may be difficult. Associated factors are diverse and do not show an obvious causal relationship. A high index of suspicion must be maintained for diagnosis, because a favorable outcome is expected with prompt treatment. Acetazolamide is effective as a first-line therapy and caused few side effects.
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Affiliation(s)
| | | | - Maitane Andión-Catalán
- Pediatric Hemato-Oncology Section, Hospital Infantil Universitario Niño Jesús, Madrid, Spain
| | - Anna Duat-Rodríguez
- Pediatric Neurology Section, Hospital Infantil Universitario Niño Jesús, Madrid, Spain
| | | | | | | | - Saray Rekarte-García
- Pediatric Neurology Section, Hospital Infantil Universitario Niño Jesús, Madrid, Spain
| | - Lara Babín-López
- Pediatric Neurology Section, Hospital Infantil Universitario Niño Jesús, Madrid, Spain
| | - David Ruano Domínguez
- Pediatric Hemato-Oncology Section, Hospital Infantil Universitario Niño Jesús, Madrid, Spain
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18
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Tibussek D, Distelmaier F, Karenfort M, Harmsen S, Klee D, Mayatepek E. Probable pseudotumor cerebri complex in 25 children. Further support of a concept. Eur J Paediatr Neurol 2017; 21:280-285. [PMID: 27825557 DOI: 10.1016/j.ejpn.2016.10.004] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2016] [Revised: 09/25/2016] [Accepted: 10/17/2016] [Indexed: 11/18/2022]
Abstract
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.
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Affiliation(s)
- Daniel Tibussek
- Department of General Pediatrics, Neonatology and Pediatric Cardiology, University Children's Hospital, Heinrich-Heine-University, Moorenstrasse 5, 40225 Düsseldorf, Germany.
| | - Felix Distelmaier
- Department of General Pediatrics, Neonatology and Pediatric Cardiology, University Children's Hospital, Heinrich-Heine-University, Moorenstrasse 5, 40225 Düsseldorf, Germany.
| | - Michael Karenfort
- Department of General Pediatrics, Neonatology and Pediatric Cardiology, University Children's Hospital, Heinrich-Heine-University, Moorenstrasse 5, 40225 Düsseldorf, Germany.
| | - Stefani Harmsen
- Department of General Pediatrics, Neonatology and Pediatric Cardiology, University Children's Hospital, Heinrich-Heine-University, Moorenstrasse 5, 40225 Düsseldorf, Germany
| | - Dirk Klee
- Department of Diagnostic and Interventional Radiology, Medical Faculty, University Dusseldorf, Moorenstrasse 5, 40225 Düsseldorf, Germany.
| | - Ertan Mayatepek
- Department of General Pediatrics, Neonatology and Pediatric Cardiology, University Children's Hospital, Heinrich-Heine-University, Moorenstrasse 5, 40225 Düsseldorf, Germany.
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Aylward SC, Reem RE. Pediatric Intracranial Hypertension. Pediatr Neurol 2017; 66:32-43. [PMID: 27940011 DOI: 10.1016/j.pediatrneurol.2016.08.010] [Citation(s) in RCA: 46] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/22/2016] [Revised: 08/08/2016] [Accepted: 08/10/2016] [Indexed: 10/21/2022]
Abstract
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.
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Affiliation(s)
- Shawn C Aylward
- Department of Neurology, Nationwide Children's Hospital, Columbus, Ohio.
| | - Rachel E Reem
- Department of Ophthalmology, Nationwide Children's Hospital, Columbus, Ohio
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20
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Gül Ü, Kaçar Bayram A, Kendirci M, Hatipoğlu N, Okdemir D, Gümüş H, Kurtoğlu S. Pseudotumour Cerebri Presentation in a Child Under the Gonadotropin-Releasing Hormone Agonist Treatment. J Clin Res Pediatr Endocrinol 2016; 8:365-7. [PMID: 27087351 PMCID: PMC5096505 DOI: 10.4274/jcrpe.2212] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
Abstract
Gonadotropin-releasing hormone analogues are common treatment option in central precocious puberty in childhood as well as in endometriosis, infertility, and prostate cancer in adults. Pseudotumor cerebri is a rare side effect observed in adults. We present the case of a girl with precocious puberty treated with triptorelin acetate who developed pseudotumor cerebri after the 4th dose. She had headaches, and her blood pressure was detected to be above the 99 percentile. There were no causes underlying of hypertension such as cardiac, renal, or endocrine. Neurological examination was normal except bilateral papilledema. Cranial magnetic resonance imaging was normal. Cerebrospinal fluid (CSF) opening pressure was elevated. Triptorelin therapy was ceased and acetazolamide was applied; CSF pressure returned to normal. We observed pseudotumor cerebri after precocious puberty treatment, a finding for the first time ever seen in childhood.
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Affiliation(s)
- Ülkü Gül
- Erciyes University Faculty of Medicine, Department of Pediatric Endocrinology, Kayseri, Turkey, Phone: +90 352 437 49 31 E-mail:
| | - Ayşe Kaçar Bayram
- Erciyes University Faculty of Medicine, Department of Pediatric Neurology, Kayseri, Turkey
| | - Mustafa Kendirci
- Erciyes University Faculty of Medicine, Department of Pediatric Endocrinology, Kayseri, Turkey
| | - Nihal Hatipoğlu
- Erciyes University Faculty of Medicine, Department of Pediatric Endocrinology, Kayseri, Turkey
| | - Deniz Okdemir
- Erciyes University Faculty of Medicine, Department of Pediatric Endocrinology, Kayseri, Turkey
| | - Hakan Gümüş
- Erciyes University Faculty of Medicine, Department of Pediatric Neurology, Kayseri, Turkey
| | - Selim Kurtoğlu
- Erciyes University Faculty of Medicine, Department of Pediatric Endocrinology, Kayseri, Turkey
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21
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Aylward SC, Waslo CS, Au JN, Tanne E. Manifestations of Pediatric Intracranial Hypertension From the Intracranial Hypertension Registry. Pediatr Neurol 2016; 61:76-82. [PMID: 27255412 DOI: 10.1016/j.pediatrneurol.2016.04.007] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/01/2015] [Revised: 04/06/2016] [Accepted: 04/09/2016] [Indexed: 11/26/2022]
Abstract
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.
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Affiliation(s)
- Shawn C Aylward
- Department of Neurology, Nationwide Children's Hospital, Columbus, Ohio.
| | - Carin S Waslo
- Casey Eye Institute, Department of Ophthalmology, Intracranial Hypertension Registry, Oregon Health & Science University, Portland, Oregon
| | - Johnathan N Au
- Chicago Medical School, Rosalind Franklin University of Medicine and Science, Chicago, Illinois
| | - Emanuel Tanne
- Casey Eye Institute, Department of Ophthalmology, Intracranial Hypertension Registry, Oregon Health & Science University, Portland, Oregon; Casey Eye Institute, Oregon Health & Science University, Portland, Oregon
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22
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Aylward SC, Aronowitz C, Roach ES. Intracranial Hypertension Without Papilledema in Children. J Child Neurol 2016; 31:177-83. [PMID: 26012507 DOI: 10.1177/0883073815587029] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/12/2015] [Accepted: 04/21/2015] [Indexed: 11/16/2022]
Abstract
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.
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Affiliation(s)
- Shawn C Aylward
- Department of Neurology, Nationwide Children's Hospital, Ohio State University College of Medicine, Columbus, OH, USA
| | | | - E Steve Roach
- Department of Neurology, Nationwide Children's Hospital, Ohio State University College of Medicine, Columbus, OH, USA
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23
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Reid JE, Reem RE, Aylward SC, Rogers DL. Sixth Nerve Palsy in Paediatric Intracranial Hypertension. Neuroophthalmology 2016; 40:23-27. [PMID: 27928378 DOI: 10.3109/01658107.2015.1117498] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2015] [Revised: 11/04/2015] [Accepted: 11/04/2015] [Indexed: 11/13/2022] Open
Abstract
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.
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Affiliation(s)
- Julia E Reid
- Department of Ophthalmology, The Ohio State University , Columbus, Ohio, USA
| | - Rachel E Reem
- Department of Ophthalmology, Nationwide Children's Hospital , Columbus, Ohio, USA
| | - Shawn C Aylward
- Department of Neurology, Nationwide Children's Hospital , Columbus, Ohio, USA
| | - David L Rogers
- Department of Ophthalmology, Nationwide Children's Hospital , Columbus, Ohio, USA
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24
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Ravid S, Shahar E, Schif A, Yehudian S. Visual Outcome and Recurrence Rate in Children With Idiopathic Intracranial Hypertension. J Child Neurol 2015; 30:1448-52. [PMID: 25713004 DOI: 10.1177/0883073815569306] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/15/2014] [Accepted: 01/03/2015] [Indexed: 11/15/2022]
Abstract
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.
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Affiliation(s)
- Sarit Ravid
- Child Neurology Unit, Meyer Children's Hospital, Rambam Health Care Campus, Haifa, Israel
| | - Eli Shahar
- Child Neurology Unit, Meyer Children's Hospital, Rambam Health Care Campus, Haifa, Israel
| | - Aharon Schif
- Child Neurology Unit, Meyer Children's Hospital, Rambam Health Care Campus, Haifa, Israel
| | - Shawn Yehudian
- Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel
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25
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Aylward SC, Aronowitz C, Reem R, Rogers D, Roach ES. Intracranial hypertension without headache in children. J Child Neurol 2015; 30:703-6. [PMID: 25038131 DOI: 10.1177/0883073814540522] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/21/2014] [Accepted: 05/22/2014] [Indexed: 11/16/2022]
Abstract
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.
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Affiliation(s)
- Shawn C Aylward
- Department of Neurology, Nationwide Children's Hospital, Columbus, OH, USA
| | | | - Rachel Reem
- Department of Ophthalmology, Nationwide Children's Hospital, Columbus, OH, USA
| | - David Rogers
- Department of Ophthalmology, Nationwide Children's Hospital, Columbus, OH, USA
| | - E Steve Roach
- Department of Neurology, Nationwide Children's Hospital, Columbus, OH, USA
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26
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Pérez Casaseca C, Nievas Gómez T, Fernández-Baca Vaca G. Manifestaciones oftalmológicas de la hipertensión intracraneal idiopática en la infancia. A propósito de un caso. REVISTA MEXICANA DE OFTALMOLOGÍA 2015. [DOI: 10.1016/j.mexoft.2015.01.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
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Abstract
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.
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Değerliyurt A, Teber S, Karakaya G, Güven A, Şeker ED, Arhan EP, Şayli TR. Pseudotumor cerebri/idiopathic intracranial hypertension in children: an experience of a tertiary care hospital. Brain Dev 2014; 36:690-9. [PMID: 24139858 DOI: 10.1016/j.braindev.2013.09.007] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/06/2013] [Revised: 09/16/2013] [Accepted: 09/20/2013] [Indexed: 10/26/2022]
Abstract
OBJECTIVE Pseudotumor cerebri (PTC) is diagnosed at increasing rates probably due to the increase in obesity prevalence all over the world and awareness about the disease. Our aim in this study was to evaluate the PTC clinical picture and etiological factors in children at the present time. METHOD The records of 53 patients with 32 females, who were diagnosed with PTC in a child neurology department between the years of 2005 and 2012 were retrospectively analyzed. RESULTS The mean age at presentation was 10.9 years (3-17 years) and approximately half of patients were aged of 11 years or less. While more than half of prepubertal patients were male, girls rate reaches 74% at puberty. An etiological factor such as venous sinus thrombosis, infections, anemia, steroid discontinuation, drugs, slit ventricle syndrome and minor head injury causing the PTC was identified in 43% of the patients. The mean duration of treatment was 6.4 months (3-24 months) and the mean follow-up duration 16.5 months (3-52 months). Visual field constriction was moderate in only two pubertal and obese female patients and mild in four patients. CONCLUSIONS PTC is seen in prepubertal children as often as in puberty. An etiological factor causing PTC is present in about half the patients in childhood. The main etiological factors of the disease currently consist of cranial venous thrombosis, infections, anemia and drugs. Malnutrition, renutrition and related vitamin deficiencies or excesses commonly seen previously have become less important in PTC etiology. PTC is a disease that requires long-term treatment and follow-up but the prognosis is good in patients who are diagnosed early, receive appropriate treatment and show good compliance with the treatment.
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Affiliation(s)
- Aydan Değerliyurt
- Department of Pediatric Neurology, Ankara Pediatrics, Hematology-Oncology Training and Research Hospital, Ankara, Turkey.
| | - Serap Teber
- Department of Pediatric Neurology, Ankara Pediatrics, Hematology-Oncology Training and Research Hospital, Ankara, Turkey
| | - Gülhan Karakaya
- Department of Pediatrics, Ankara Pediatrics, Hematology-Oncology Training and Research Hospital, Ankara, Turkey
| | - Alev Güven
- Department of Pediatric Neurology, Ankara Pediatrics, Hematology-Oncology Training and Research Hospital, Ankara, Turkey
| | - Esra Dağ Şeker
- Department of Ophthalmology, Ankara Pediatrics, Hematology-Oncology Training and Research Hospital, Ankara, Turkey
| | - Ebru Petek Arhan
- Department of Pediatric Neurology, Ankara Pediatrics, Hematology-Oncology Training and Research Hospital, Ankara, Turkey
| | - Tülin Revide Şayli
- Department of Pediatrics, Ankara Pediatrics, Hematology-Oncology Training and Research Hospital, Ankara, Turkey
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Childhood overweight or obesity increases the risk of IIH recurrence fivefold. Int J Obes (Lond) 2014; 38:1475-7. [PMID: 24638200 DOI: 10.1038/ijo.2014.44] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/03/2013] [Revised: 02/26/2014] [Accepted: 03/06/2014] [Indexed: 11/08/2022]
Abstract
Overweight and obesity are less closely associated with idiopathic intracranial hypertension (IIH) in young children than in post-pubescent children and adults. We examined the hypothesis that being overweight or obese (body mass index (BMI) ⩾ 85th percentile) in children is a risk factor for IIH recurrence. A total of 43 children with IIH who were followed up for an average of 9 ± 3.4 years were evaluated in a retrospective case-control series. The rate of IIH recurrence was compared between children of healthy weight and children presenting with overweight or obesity, using survival curve analysis. The overall risk for long-term IIH recurrence in children is ~20%. Following weight stratification, the risk for IIH recurrence in our cohort was fivefold higher in children with a BMI ⩾ 85th percentile (57%) than in healthy weight children (11%; log-rank test P = 0.04). Pediatricians may consider counseling families that weight control may be a means of decreasing the risk of IIH recurrence.
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Clinical spectrum of the pseudotumor cerebri in children: etiological, clinical features, treatment and prognosis. Brain Dev 2013; 35:561-8. [PMID: 22981259 DOI: 10.1016/j.braindev.2012.08.008] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/27/2012] [Revised: 08/15/2012] [Accepted: 08/16/2012] [Indexed: 11/21/2022]
Abstract
OBJECTIVE Pseudotumor cerebri (PTC) is a clinical condition characterized by signs and symptoms of increased intracranial pressure, such as headache and papilledema. Our aim was to investigate the etiological and clinical features of pseudotumor cerebri (PTC) in children. MATERIALS AND METHOD We performed a comprehensive analysis of epidemiology, diagnostic work-up, therapy, and clinical follow-up in 42 consecutive patients. RESULTS Totally 42 patients diagnosed with PTC [27 (64.3%) females and 15 (35.7%) males] were included in the study. The average age of the symptoms onset was 10.79±3.43 years (range from 12 months to 17 years). Obesity was found in eleven (26.2%) of them. Two of the patients had familial mediterranean fever, two of them had posttraumatic PTC. The following diseases were one patient, respectively; mycophenolate mofetil-induced PTC, hypervitaminosis A induced PTC, corticosteroid induced withdrawal due to nephritic syndrome, use of oral contraceptives, Guillain-Barre syndrome, urinary tract infection, varicella-zoster virus infection and dural venous sinus thrombosis associated with otitis media. The most common symptom was headache, recorded in 76.2% of the patients. All patients were treated medically. Three patients in our group also required a ventriculoperitoneal shunt. CONCLUSION Pseudotumor cerebri is an avoidable cause of visual loss, both in adults and children. Pre-pubertal obese girls are more common. Medical therapy appeared to be successful in treating pediatric PTC in most patients. Nevertheless, despite adequate treatment, children can rarely experience loss of visual field and acuity; thus, prompt diagnosis and management are important.
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31
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Diagnosis and Treatment of Idiopathic Intracranial Hypertension (IIH) in Children and Adolescents. Curr Neurol Neurosci Rep 2013; 13:336. [DOI: 10.1007/s11910-012-0336-x] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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32
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Caviness V, Ebinger F. Headache in pediatric practice. HANDBOOK OF CLINICAL NEUROLOGY 2013; 112:827-838. [PMID: 23622290 DOI: 10.1016/b978-0-444-52910-7.00002-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/02/2023]
Affiliation(s)
- V Caviness
- Department of Neurology, Massachusetts General Hospital, Boston, MA, USA.
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33
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Peng KP, Fuh JL, Wang SJ. High-pressure headaches: idiopathic intracranial hypertension and its mimics. Nat Rev Neurol 2012; 8:700-10. [DOI: 10.1038/nrneurol.2012.223] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
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34
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Pseudotumor cerebri bei Neuroborreliose. Monatsschr Kinderheilkd 2012. [DOI: 10.1007/s00112-011-2595-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
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Chern JJ, Tubbs RS, Gordon AS, Donnithorne KJ, Oakes WJ. Management of pediatric patients with pseudotumor cerebri. Childs Nerv Syst 2012; 28:575-8. [PMID: 22258754 DOI: 10.1007/s00381-011-1657-9] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/23/2011] [Accepted: 12/06/2011] [Indexed: 11/26/2022]
Abstract
INTRODUCTION The care of patients with pseudotumor cerebri (idiopathic intracranial hypertension) involves ophthalmologists, neurologists and neurosurgeons. Its clinical characteristics in the pediatric population are distinct from those in adult patients. PATIENTS AND METHODS Fifty-nine patients diagnosed with pseudotumor cerebri were identified from the neurosurgery and neurology databases at Children's Hospital, Birmingham, AL, USA. Clinical data were collected from the ophthalmology, neurology and neurosurgery departments. RESULTS The average age of patients at diagnosis was 11.4 years (range 3-17). The average opening pressure of lumbar puncture (LP) was 37 cm of water. Most of the patients responded well to therapeutic LPs and medical management. Neurosurgical interventions included intracranial pressure monitoring and shunt insertion in nine patients. In three patients who presented with acute visual decline, two recovered and one remains legally blind. CONCLUSIONS The care of patients with pseudotumor cerebri requires a multiple-disciplinary approach. Neurosurgical interventions are sometimes needed for diagnostic and treatment purpose. Prompt and accurate communication among specialists is necessary to ensure timely treatment and optimal outcomes.
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Affiliation(s)
- Joshua J Chern
- Department of Pediatric Neurosurgery, Children's Hospital, Birmingham, AL, USA.
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36
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Dolinsky DH, Armstrong S. An 8-year-old girl with headache and syncope. Pediatr Ann 2011; 40:594-7. [PMID: 22148273 DOI: 10.3928/00904481-20111103-04] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Affiliation(s)
- Diana H Dolinsky
- Department of Pediatrics, Duke University Medical Center, NC, USA.
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Soiberman U, Stolovitch C, Balcer LJ, Regenbogen M, Constantini S, Kesler A. Idiopathic intracranial hypertension in children: visual outcome and risk of recurrence. Childs Nerv Syst 2011; 27:1913-8. [PMID: 21538129 DOI: 10.1007/s00381-011-1470-5] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2011] [Accepted: 04/15/2011] [Indexed: 11/26/2022]
Abstract
PURPOSE Idiopathic intracranial hypertension (IIH) is a disorder associated with increased intracranial pressure without evidence of a space-occupying lesion and with normal cerebrospinal fluid constituents. The disease is rare in the pediatric population. In this study, we assessed the visual outcome of children with IIH and the risk of recurrence. METHODS This single-center observational retrospective cohort study included 90 children younger than 18 years of age who satisfied the modified Dandy criteria for the diagnosis of IIH. Upon follow-up, the treatment was discontinued when patients were free of symptoms such as headaches, transient visual obscurations or tinnitus, and when examination revealed no evidence of papilledema. The main outcome measures were visual acuity and visual field outcomes as well as risk of recurrence. RESULTS The mean follow-up was 30.65 months (range 1.15-172.6 months, standard deviation 27.47 months). Special grading scales were devised for visual acuity and visual field scores. The mean visual acuity score improved from 4.7 ± 0.62 to 4.87 ± 0.44 (p = 0.003).The mean visual field score improved from 3.41 ± 0.8 to 3.52 ± 0.75 (p = 0.21). The recurrence rate was 23.7%, and the risk of recurrence was highest within the first 18 months after diagnosis of IIH. CONCLUSIONS These study results suggest that pediatric patients with IIH have a favorable visual outcome in terms of both visual acuity and visual field. If there is any recurrence, it is most likely to occur during the first 18 months after diagnosis.
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Affiliation(s)
- Uri Soiberman
- Neuro-Opthalmology Unit, Department of Ophthalmology, Tel Aviv Medical Center, Tel Aviv, Israel.
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38
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Honorat R, Marchandot J, Tison C, Cances C, Chaix Y. [Treatment and prognosis of idiopathic intracranial hypertension in children. Retrospective study (1995-2009) and literature review]. Arch Pediatr 2011; 18:1139-47. [PMID: 21992894 DOI: 10.1016/j.arcped.2011.08.017] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2010] [Revised: 07/12/2011] [Accepted: 08/10/2011] [Indexed: 11/30/2022]
Abstract
AIM Idiopathic intracranial hypertension (IIH) may cause severe visual loss due to the optic nerve damage. Routine management involves mainly medical treatment. The aim of this study was to improve diagnosis and management of IIH in children. METHODS The medical records of all patients with definite IIH seen at the children's hospital of Toulouse between 1995 and 2009 were reviewed. Cases of secondary intracranial hypertension were included because they did not present any cerebral lesions and underwent a similar therapeutic approach. The clinical and ophthalmological data at the beginning and at the end of their treatment was collected. RESULTS Eighteen children were included in this study. The average age was 10 years and the sex-ratio was equal to 1. There were 3 cases of secondary idiopathic intracranial hypertension in this pediatric group. The main features encountered were headache (15 children) and diplopia (8 children). Abnormal neurological examination was found for 11 patients with abducens nerve paresis in 8 cases, rachialgia in 6 cases, and neurogenic pains (neuralgia, dysesthesia, paresthesia, hyperesthesia) in the other cases. Papilledema was noted in 16 patients. At the initial phase, loss of visual acuity was documented in 6 patients and altered visual field in nine patients. All patients had a medical treatment. When recurrence occurred, each new treatment was documented, for a total of 23 treatments analyzed. Lumbar puncture was the only treatment for 2 patients. In 16 cases, first-line treatment was acetazolamide and it was the second choice in 1 case, with an average dosage of 11.2mg/kg and a mean duration of 2.5 months (15 treatments could be analyzed). This treatment was effective in 11 cases out of 15. Steroids were the initial treatment in 4 cases and second-line treatment in 4 cases (after failed acetazolamide therapy). The dosage was 1.5-2mg/kg for a mean duration of 1.5 months (6 treatments could be analyzed). This treatment was effective in 5 patients out of 6. One patient had dual therapy. No surgical procedure was necessary in this pediatric cohort. Three patients presented relapses of IIH. The outcome was good with no residual visual impairment in the 13 patients analyzed. One patient was still under medication. COMMENTS Therapeutic management of IIH in a pediatric population is essentially medical, in some cases limited to lumbar puncture. The first-line treatment is acetazolamide, but this study shows that low doses and short duration are usually chosen. Doses must be increased and treatment prolonged to avoid the use of corticosteroids as a second-line treatment and prevent possible relapses that require close monitoring of visual function. CONCLUSION The visual prognosis is generally better for this age group compared to adults and no risk factors for visual sequelae were identified. A standardized protocol for management of IIH was proposed.
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Affiliation(s)
- R Honorat
- Unité de neurologie pédiatrique, hôpital des enfants, CHU de Toulouse, 330, avenue de Grande-Bretagne, 31059 Toulouse cedex 09, France.
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Yilmaz S, Serdaroglu G, Unver H, Akcay A, Gokben S, Tekgul H. Recurrent pseudotumor cerebri in childhood: a case of neuro-Behçet disease complicated with thrombotic risk factors. J Child Neurol 2011; 26:881-4. [PMID: 21498791 DOI: 10.1177/0883073810391905] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Pseudotumor cerebri with or without venous sinus thrombosis is a rare clinical presentation of Behçet disease in childhood. We present here a case of childhood pseudotumor cerebri without a previous diagnosis of Behçet disease. The detailed history and physical examination of the case led to the diagnosis of neuro-Behçet disease. The investigation of predisposition to thrombosis revealed heterozygous factor V Leiden mutation along with the high lipoprotein(a) level. The symptoms resolved dramatically by treatment with the combination of immunosuppression and anticoagulation with regard to the detected factor V Leiden mutation and high lipoprotein(a) level. After a symptom-free period of 9 months, the cerebral vein thrombosis recurred. We present this case to draw attention to this rare cause of pseudotumor cerebri in childhood and to emphasize the importance of additional thrombotic risk factors regarding the potential recurrence of thrombotic events in Behçet disease.
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Affiliation(s)
- Sanem Yilmaz
- Division of Child Neurology, Department of Pediatrics, Ege University Medical School, Bornova-Izmir, Turkey.
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40
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Mycophenolate mofetil-induced pseudotumor cerebri in a boy with autoimmune lymphoproliferative disease. Childs Nerv Syst 2011; 27:853-5. [PMID: 21305306 DOI: 10.1007/s00381-011-1402-4] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/07/2010] [Accepted: 01/19/2011] [Indexed: 10/18/2022]
Abstract
INTRODUCTION Pseudotumor cerebri (PTC) is a syndrome characterized with increased intracranial pressure, normal cerebrospinal fluid content (CSF), and a normal brain on imaging studies. In this case report, PTC has been linked to mycophenolate mofetil (MMF) that has been used for autoimmune lymphoproliferative syndrome (ALPS). CASE REPORT A 5-year-old boy, who was using MMF for 4 months because of the ALPS, suffered from occipital headache and vomiting with no other symptom. The initial physical examination was normal expect bilateral papilledema. The patient underwent a lumbar puncture which showed elevated opening pressure (590 mmH₂O) but no laboratory abnormalities of the CSF. A diagnosis of PTC was established. MMF was stopped, and the child was started on an acetazolamide treatment for 2 weeks. His symptoms and complaints recovered after this treatment. DISCUSSION According to our knowledge, we report the first case of MMF-induced PTC in a boy with ALPS. This case illustrates that despite the rarity of MMF-induced PTC, the physicians should be aware of this possibility. Furthermore, in the setting of new-onset headaches or visual changes, early ophthalmologic examination for papilledema is recommended for early diagnosis.
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Spennato P, Ruggiero C, Parlato RS, Buonocore MC, Varone A, Cianciulli E, Cinalli G. Pseudotumor cerebri. Childs Nerv Syst 2011; 27:215-35. [PMID: 20721668 DOI: 10.1007/s00381-010-1268-x] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/23/2010] [Accepted: 08/03/2010] [Indexed: 11/26/2022]
Abstract
INTRODUCTION Pseudotumor cerebri is a condition characterized by raised intracranial pressure, normal CSF contents, and normal brain with normal or small ventricles on imaging studies. It affects predominantly obese women of childbearing age; however, its incidence seems to be increasing among adolescent and children. While among older children the clinical picture is similar to that of adults, younger children present demographic and clinical peculiarities. Different diagnostic criteria for adults and pre-pubertal children have been proposed. Etiology and pathogenesis are still unclear, particular concerning the role of obstruction to venous outflow. METHODS An extensive literature review concerning all the aspects of pseudotumor cerebri has been performed, both among adults and pre-pubertal children. CONCLUSION Pseudotumor cerebri is an avoidable cause of visual loss, both in adults and children. Few diagnostic measures are usually sufficient to determine the correct diagnosis. Since pseudotumor cerebri is a diagnosis of exclusion, the differential diagnosis work out is of special importance. Modern neuroimaging techniques, especially magnetic resonance imaging and magnetic resonance venography may clarify the role of obstruction to venous outflow in each case. Various therapeutic options are available: medical, surgical, and endovascular procedures may be used to prevent irreversible visual loss. Treatment is usually effective, and most patients will experience complete resolution of symptoms without persistent deficits.
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Affiliation(s)
- Pietro Spennato
- Department of Neurosurgery, Santobono-Paulipon Pediatric Hospital, Via Mario Fiore 6, Naples, Italy.
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Tzoufi M, Makis A, Grammeniatis V, Nakou I, Exarchakos G, Asproudis I, Zikou A, Argyropoulou M, Siamopoulou-Mavridou A. Idiopathic intracranial hypertension and facial palsy: case report and review of the literature. J Child Neurol 2010; 25:1529-34. [PMID: 20921567 DOI: 10.1177/0883073810375849] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
We present the case of an 11-year-old obese girl who presented with idiopathic intracranial hypertension affecting first the lateral abducens nerve. She received acetazolamide, but 5 days later she developed lateral, peripheral facial palsy. Imaging evaluation was normal, which primarily excluded cerebral venous thrombosis and sustained the initial diagnosis. Despite some complicating factors (obesity, elevated intracranial pressure), prednisolone was administered for a short-term period to counteract the facial palsy. Ophthalmological residuals resolved within almost 1.5 months, while facial palsy receded after 4 months. Peripheral facial palsy is an extremely rare, but not unknown condition in idiopathic intracranial hypertension. As a symptom, it should be investigated thoroughly, primarily to exclude cerebral venous sinus thrombosis, before it can be attributed to idiopathic intracranial hypertension. As far as treatment is concerned, corticosteroids can be added to the initial treatment with acetazolamide, without worsening already elevated intracranial hypertension or ophthalmologic findings.
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Affiliation(s)
- Meropi Tzoufi
- Department of Child Health, the University of Ioannina Medical School, Ioannina, Greece.
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Izci Y, Kırık A, Mutlu FM. Transient unilateral ophthalmoplegia without papilledema in a child with intracranial hypertension. Saudi J Ophthalmol 2010; 24:159-62. [PMID: 23960895 DOI: 10.1016/j.sjopt.2010.04.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2010] [Revised: 04/26/2010] [Accepted: 04/27/2010] [Indexed: 11/17/2022] Open
Abstract
Intracranial hypertension is usually presented with papilledema and headache. Complete ophthalmoplegia without papilledema is a very rare finding of intracranial hypertension in children. A 5-year-old male patient with unilateral ophthalmoplegia due to increased intracranial pressure is presented. The fundoscopic examination and the magnetic resonance imaging of the brain were normal. He underwent lumboperitoneal shunt insertion for intracranial hypertension and the ophthalmoplegia was resolved one month later. Complete ophthalmoplegia without papilledema may occur following intracranial hypertension. Prompt and accurate diagnosis should be done and appropriate treatment to reduce the pressure should be performed to save the life of the children.
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Affiliation(s)
- Yusuf Izci
- Department of Neurosurgery, Gulhane Military Medical Academy, Ankara, Turkey
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De Simone R, Ranieri A, Bonavita V. Advancement in idiopathic intracranial hypertension pathogenesis: focus on sinus venous stenosis. Neurol Sci 2010; 31 Suppl 1:S33-9. [PMID: 20464580 DOI: 10.1007/s10072-010-0271-z] [Citation(s) in RCA: 55] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Affiliation(s)
- Roberto De Simone
- Department of Neurological Sciences, Headache Centre, University of Naples Federico II, via Pansini, 5, 80131, Naples, Italy.
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