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Kim JA, Park C, Hur MH, David H. The Red-Flag Paradox of Clinical Signs Synonymous With Intracranial Hypertension in Children. Pediatr Neurol 2025; 168:17-22. [PMID: 40378684 DOI: 10.1016/j.pediatrneurol.2025.04.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/31/2024] [Revised: 02/17/2025] [Accepted: 04/07/2025] [Indexed: 05/19/2025]
Abstract
BACKGROUND Intracranial hypertension (IH) is well-documented in children but remains challenging to clinicians because patients often present with nonspecific symptoms. Clinical features concerning for "red-flag signs" in headache could be representative of IH; however, the incidence or predictive value of these features is not well reported in children. METHODS We evaluated the headache characteristics concerning for "red flags" among children with IH syndrome. By retrospective chart review, a total of 78 patients who underwent lumbar puncture to evaluate IH were analyzed. RESULTS Among 78 patients, 54 had confirmed IH (37 primary, 17 secondary) and in 24 IH was ruled out. Forty-two of 54 patients with IH and 23 of 24 non-IH patients presented with headache. Eleven of these 42 with IH (26%) presenting with headache complained of worsening headache in the supine position, and four of the 23 non-IH (17%) complained of worsening headache in the supine position. There was paradoxical positional headache (worse when upright) reported in both the IH and non-IH groups as 14% (six of 42) and 13% (three of 23), respectively. Within the IH group was significantly higher opening pressure in patients with neck/shoulder pain compared with patients without pain (P < 0.01). CONCLUSIONS Positional headache is an important clinical feature, but it should be considered that patients with IH can present with paradoxical positional headache. Neck and shoulder pain should be considered a symptom of IH as well. A larger cohort investigating IH in children to identify signs and symptoms will be helpful.
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Affiliation(s)
- Jeong A Kim
- Department of Child and Adolescent Neurology, Nemours Children's Health, Jacksonville, Florida
| | - Carol Park
- Department of Child and Adolescent Neurology, University of Chicago, Chicago, Illinois
| | - Moon Hee Hur
- Department of Child and Adolescent Neurology, University of Chicago, Chicago, Illinois
| | - Henry David
- Department of Child and Adolescent Neurology, University of Chicago, Chicago, Illinois.
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2
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Kerscher SR, Zipfel J, Haas-Lude K, Bevot A, Schuhmann MU. Ultrasound-guided initial diagnosis and follow-up of pediatric idiopathic intracranial hypertension. Pediatr Radiol 2024; 54:1001-1011. [PMID: 38506946 PMCID: PMC11111542 DOI: 10.1007/s00247-024-05905-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/14/2023] [Revised: 03/04/2024] [Accepted: 03/05/2024] [Indexed: 03/22/2024]
Abstract
BACKGROUND Idiopathic intracranial hypertension in children often presents with non-specific symptoms found in conditions such as hydrocephalus. For definite diagnosis, invasive intracranial pressure measurement is usually required. Ultrasound (US) of the optic nerve sheath diameter provides a non-invasive method to assess intracranial pressure. Transtemporal US allows imaging of the third ventricle and thus assessment for hydrocephalus. OBJECTIVE To investigate whether the combination of US optic nerve sheath and third ventricle diameter can be used as a screening tool in pediatric idiopathic intracranial hypertension to indicate elevated intracranial pressure and exclude hydrocephalus as an underlying pathology. Further, to analyze whether both parameters can be used to monitor treatment outcome. MATERIALS AND METHODS We prospectively included 36 children with idiopathic intracranial hypertension and 32 controls. Using a 12-Mhz linear transducer and a 1-4-Mhz phased-array transducer, respectively, optic nerve sheath and third ventricle diameters were determined initially and during the course of treatment. RESULTS In patients, the mean optic nerve sheath diameter was significantly larger (6.45±0.65 mm, controls: 4.96±0.32 mm) and the mean third ventricle diameter (1.69±0.65 mm, controls: 2.99±1.31 mm) was significantly smaller compared to the control group, P<0.001. Optimal cut-off values were 5.55 mm for the optic nerve sheath and 1.83 mm for the third ventricle diameter. CONCLUSIONS The combined use of US optic nerve sheath and third ventricle diameter is an ideal non-invasive screening tool in pediatric idiopathic intracranial hypertension to indicate elevated intracranial pressure while ruling out hydrocephalus. Treatment can effectively be monitored by repeated US, which also reliably indicates relapse.
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Affiliation(s)
- Susanne Regina Kerscher
- Department of Diagnostic and Interventional Radiology, University Hospital of Ulm, Albert-Einstein-Allee 23, 89081, Ulm, Germany.
- Department of Neurosurgery, Division of Pediatric Neurosurgery, University Hospital of Tuebingen, Tuebingen, Germany.
| | - Julian Zipfel
- Department of Neurosurgery, Division of Pediatric Neurosurgery, University Hospital of Tuebingen, Tuebingen, Germany
| | - Karin Haas-Lude
- Department of Pediatric Neurology and Developmental Medicine, University Children's Hospital of Tuebingen, Tuebingen, Germany
| | - Andrea Bevot
- Department of Pediatric Neurology and Developmental Medicine, University Children's Hospital of Tuebingen, Tuebingen, Germany
| | - Martin Ulrich Schuhmann
- Department of Neurosurgery, Division of Pediatric Neurosurgery, University Hospital of Tuebingen, Tuebingen, Germany
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3
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Kerscher SR, Zipfel J, Bevot A, Sollmann N, Haas-Lude K, Tellermann J, Schuhmann MU. Non-Invasive Quantitative Approximation of Intracranial Pressure in Pediatric Idiopathic Intracranial Hypertension Based on Point-of-Care Ultrasound of the Optic Nerve Sheath Diameter. Brain Sci 2023; 14:32. [PMID: 38248247 PMCID: PMC10812972 DOI: 10.3390/brainsci14010032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2023] [Revised: 12/22/2023] [Accepted: 12/25/2023] [Indexed: 01/23/2024] Open
Abstract
BACKGROUND To investigate whether ultrasound-based optic nerve sheath diameter (US-ONSD) is a reliable measure to follow up children with idiopathic intracranial hypertension (IIH). In addition, to analyze the inter- and intra-individual relationships between US-ONSD and intracranial pressure (ICP), and to investigate whether an individualized mathematical regression equation obtained from two paired US-ONSD/ICP values can be used to approximate ICP from US-ONSD values. METHODS 159 US examinations and 53 invasive ICP measures via lumbar puncture (LP) were performed in 28 children with IIH. US-ONSD was measured using a 12 Mhz linear transducer and compared to ICP values. In 15 children, a minimum of 2 paired US-ONSD/ICP determinations were performed, and repeated-measures correlation (rmcorr) and intra-individual correlations were analyzed. RESULTS The cohort correlation between US-ONSD and ICP was moderate (r = 0.504, p < 0.01). Rmcorr (r = 0.91, p < 0.01) and intra-individual correlations (r = 0.956-1) of US-ONSD and ICP were excellent. A mathematical regression equation can be calculated from two paired US-ONSD/ICP values and applied to the individual patient to approximate ICP from US-ONSD. CONCLUSIONS Related to excellent intra-individual correlations between US-ONSD and ICP, an individualized regression formula, created from two pairs of US-ONSD/ICP values, may be used to directly approximate ICP based on US-ONSD values. Hence, US-ONSD may become a non-invasive and reliable measure to control treatment efficacy in pediatric IIH.
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Affiliation(s)
- Susanne Regina Kerscher
- Department of Diagnostic and Interventional Radiology, University Hospital Ulm, 89081 Ulm, Germany;
- Department of Neurosurgery and Neurotechnology, Division of Pediatric Neurosurgery, University Hospital of Tuebingen, 72076 Tuebingen, Germany; (J.Z.); (J.T.); (M.U.S.)
| | - Julian Zipfel
- Department of Neurosurgery and Neurotechnology, Division of Pediatric Neurosurgery, University Hospital of Tuebingen, 72076 Tuebingen, Germany; (J.Z.); (J.T.); (M.U.S.)
| | - Andrea Bevot
- Department of Pediatric Neurology and Developmental Medicine, University Children’ s Hospital of Tuebingen, 72076 Tuebingen, Germany; (A.B.); (K.H.-L.)
| | - Nico Sollmann
- Department of Diagnostic and Interventional Radiology, University Hospital Ulm, 89081 Ulm, Germany;
- Department of Diagnostic and Interventional Neuroradiology, School of Medicine, Klinikum rechts der Isar, Technical University of Munich, 81675 Munich, Germany
- TUM-Neuroimaging Center, Klinikum rechts der Isar, Technical University of Munich, 81675 Munich, Germany
| | - Karin Haas-Lude
- Department of Pediatric Neurology and Developmental Medicine, University Children’ s Hospital of Tuebingen, 72076 Tuebingen, Germany; (A.B.); (K.H.-L.)
| | - Jonas Tellermann
- Department of Neurosurgery and Neurotechnology, Division of Pediatric Neurosurgery, University Hospital of Tuebingen, 72076 Tuebingen, Germany; (J.Z.); (J.T.); (M.U.S.)
| | - Martin Ulrich Schuhmann
- Department of Neurosurgery and Neurotechnology, Division of Pediatric Neurosurgery, University Hospital of Tuebingen, 72076 Tuebingen, Germany; (J.Z.); (J.T.); (M.U.S.)
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Senderowich N, Bachar-Zipori A, Mitelpunkt A, Latzer IT, Klein A, Mezad-Koursh D, Fattal-Valevski A, Hausman-Kedem M. Predictors of disease course and long-term outcomes of idiopathic intracranial hypertension in children and adolescents. Eur J Pediatr 2023; 182:5137-5147. [PMID: 37691042 DOI: 10.1007/s00431-023-05173-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2023] [Revised: 08/20/2023] [Accepted: 08/22/2023] [Indexed: 09/12/2023]
Abstract
This study aimed to identify predictors for unfavorable disease course and clinical and visual outcomes in pediatric patients with idiopathic intracranial hypertension (IIH). Employing a multi-tiered approach, we retrospectively analyzed clinical, ophthalmic, and neuroimaging data from patients diagnosed with IIH between 2003 and 2021. Of the 97 patients included, 56 (58%) were females. The median age was 12 years [Interquartile range (IQR) 9, 14], and the median follow-up time was 39.0 months (IQR 14.8, 90.9). Forty-two (43%) patients had an unfavorable disease course, 28 (29%) had persistence of headache at last follow-up, and 16 (18%) had a poor visual outcome, most of them with mild visual disturbances. Poor visual outcome was more common in females compared to males [16/47 (34%) vs. 0/39, p < 0.001)]. On multivariate regression analysis, female sex and disease recurrence were significantly associated with poor visual outcomes (OR: 18.5, CI:1.3-270, P = 0.03, and OR: 5.1, CI: 1.2-22.5, P = 0.03, respectively). Patients with persistent headaches exhibited lower incidence of papilledema, lower opening pressure, and fewer neuroimaging markers indicating elevated intracranial pressure. CONCLUSIONS This study provides insights into predictive factors for an unfavorable disease course, persistent headaches, and poor visual outcomes in patients with childhood IIH. Patients with persistent headaches may have a variant of a chronic pain syndrome warranting a different therapeutic approach. WHAT IS KNOWN • Childhood-onset Idiopathic Intracranial hypertension (IIH) is a heterogenous disease. The knowledge on disease trajectory and long-term outcomes and its predictors is limited. WHAT IS NEW • A higher opening pressure and factors suggestive of the metabolic syndrome predict an unfavorable disease course whereas female sex and disease recurrence are significantly associated with poor visual outcomes • A third of the patients diagnosed with IIH experience ongoing headaches despite achieving favorable visual outcomes. This subset, characterized by lower disease-severity indicators at onset may represent a distinct subgroup warranting a different therapeutic approach.
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Affiliation(s)
| | - Anat Bachar-Zipori
- Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
- Ophthalmology Division, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
| | - Alexis Mitelpunkt
- Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
- Pediatric Neurology Institute, Dana-Dwek Children's Hospital, Tel Aviv Sourasky Medical Center, 6 Weizmann Street, Tel Aviv, 6423906, Israel
| | - Itay Tokatly Latzer
- Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
- Pediatric Neurology Institute, Dana-Dwek Children's Hospital, Tel Aviv Sourasky Medical Center, 6 Weizmann Street, Tel Aviv, 6423906, Israel
| | - Ainat Klein
- Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
- Ophthalmology Division, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
| | - Daphna Mezad-Koursh
- Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
- Ophthalmology Division, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
| | - Aviva Fattal-Valevski
- Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
- Pediatric Neurology Institute, Dana-Dwek Children's Hospital, Tel Aviv Sourasky Medical Center, 6 Weizmann Street, Tel Aviv, 6423906, Israel
| | - Moran Hausman-Kedem
- Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.
- Pediatric Neurology Institute, Dana-Dwek Children's Hospital, Tel Aviv Sourasky Medical Center, 6 Weizmann Street, Tel Aviv, 6423906, Israel.
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Lyons HS, Mollan SLP, Liu GT, Bowman R, Thaller M, Sinclair AJ, Mollan SP. Different Characteristics of Pre-Pubertal and Post-Pubertal Idiopathic Intracranial Hypertension: A Narrative Review. Neuroophthalmology 2022; 47:63-74. [PMID: 36891406 PMCID: PMC9988343 DOI: 10.1080/01658107.2022.2153874] [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: 09/13/2022] [Revised: 11/10/2022] [Accepted: 11/20/2022] [Indexed: 12/23/2022] Open
Abstract
Idiopathic intracranial hypertension (IIH) affects both children and adults. There are currently no clinical trials in IIH for those who are adolescents or children. The aims of this narrative review were to characterise the differences between pre- and post-pubertal IIH and to highlight the need to be more inclusive in clinical trial planning and recruitment. A detailed search of the scientific literature was performed using the PubMed database, from inception until 30 May 2022 using keywords. This included English language papers only. The abstracts and full texts were reviewed by two independent assessors. The literature revealed that the pre-pubertal group had a more variable presentation. The presenting features in the post-pubertal paediatric group were more akin to adults with headache as the dominant feature. They were also more likely to be female and have an increased body mass index. A clear limitation of the literature was that a number of paediatric studies had variable inclusion criteria, including secondary causes of raised intracranial pressure. Pre-pubertal children do not display the same predilection towards the female sex and obesity as post-pubertal children, who have a similar phenotype to the adult cohort. Inclusion of adolescents in clinical trials should be considered given the similar phenotype to adults. There is a lack of consistency in the definition of puberty, making the IIH literature difficult to compare. Inclusion of secondary causes of raised intracranial pressure has the potential to confound the accuracy of analysis and interpretation of the results.
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Affiliation(s)
- Hannah S. Lyons
- Translational Brain Science, Institute of Metabolism and Systems Research, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
- Department of Neurology, University Hospitals Birmingham NHS Foundation Trust, Queen Elizabeth Hospital, Birmingham, UK
- Centre for Endocrinology, Diabetes and Metabolism, Birmingham Health Partners, Birmingham, UK
| | | | - Grant T. Liu
- Children's Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Richard Bowman
- Ophthalmology Department, Great Ormond Street Children’s Hospital, London, UK
| | - Mark Thaller
- Translational Brain Science, Institute of Metabolism and Systems Research, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
- Department of Neurology, University Hospitals Birmingham NHS Foundation Trust, Queen Elizabeth Hospital, Birmingham, UK
- Centre for Endocrinology, Diabetes and Metabolism, Birmingham Health Partners, Birmingham, UK
| | - Alexandra J. Sinclair
- Translational Brain Science, Institute of Metabolism and Systems Research, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
- Department of Neurology, University Hospitals Birmingham NHS Foundation Trust, Queen Elizabeth Hospital, Birmingham, UK
- Centre for Endocrinology, Diabetes and Metabolism, Birmingham Health Partners, Birmingham, UK
| | - Susan P. Mollan
- Translational Brain Science, Institute of Metabolism and Systems Research, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
- Birmingham Neuro-Ophthalmology, University Hospitals Birmingham NHS Foundation Trust, Queen Elizabeth Hospital, Birmingham, UK
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6
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Lin LY, Pan W, Ying GS, Binenbaum G. Ocular Findings in Children with Headache. Ophthalmic Epidemiol 2022:1-8. [PMID: 36125107 DOI: 10.1080/09286586.2022.2125019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2022]
Abstract
PURPOSE To determine the prevalence of ophthalmological findings suggesting an ocular cause for headache or occult neurological disease, among children with headache. METHODS Retrospective cross-sectional study on children with headache at a tertiary outpatient ophthalmology clinic. All children underwent sensorimotor, anterior segment, and dilated fundoscopic examinations, with or without cycloplegic refraction. Prevalence of one or more new findings of ocular or occult neurological cause of headache, including glaucoma, uveitis, optic nerve elevation, or possible asthenopia from strabismus or refractive issues. Headache characteristics and associated symptoms were evaluated as risk factors for ocular findings. RESULTS Among 1,878 children with headache (mean age 10 yrs, range 2-18), 492 (26.1%, 95% CI 24.3-28.2%) children had one or more new ocular findings that could cause headache or indicate intracranial disease: refractive issues (342, 18.2%), strabismus (83, 4.4%), optic nerve elevation (51, 2.7%; 26 with papilledema, 25 with pseudopapilledema), uveitis (6, 0.3%), and glaucoma (2, 0.1%). Shorter headache duration was associated with ocular findings (p = .047), but headache frequency, photophobia, nausea/vomiting, and visual changes were not. In univariable analysis, visual changes (p ≤ .001), nausea/vomiting (p ≤ .002), and morning headache (p = .02) were associated with optic nerve elevation. CONCLUSION An ophthalmologic examination including cycloplegic refraction is indicated in children with headache, as one-quarter have a treatable ocular condition, which may be related to the headache, or sign of intracranial pathology. While nausea, visual changes, or morning headache should raise concern, coincident visual, ocular, or systemic symptoms are not reliable predictors of discovering ocular pathology in a child with headache.
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Affiliation(s)
- Lisa Y Lin
- Department of Ophthalmology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA.,Department of Ophthalmology, Massachusetts Eye and Ear, Harvard Medical School, Boston, Massachusetts, USA
| | - Wei Pan
- Scheie Eye Institute, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Gui-Shuang Ying
- Scheie Eye Institute, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Gil Binenbaum
- Department of Ophthalmology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA.,Scheie Eye Institute, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
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7
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Masri A, Al Jaberi M, Shihadat R, Rayyan A, AlMasri M, Abuna'meh L, Ali M, Al Ryalat N, Hadidy A, Al-Shakkah AA. Pseudotumor cerebri syndrome in children: Clinical characteristic and re-classification. Brain Dev 2022; 44:446-453. [PMID: 35393129 DOI: 10.1016/j.braindev.2022.03.006] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/14/2022] [Revised: 03/14/2022] [Accepted: 03/22/2022] [Indexed: 11/28/2022]
Abstract
AIM To describe the clinical characteristics of children with pseudotumor cerebri syndrome (PTCS) who were diagnosed according to the modified Dandy criteria and to reclassify them according to the newly proposed diagnostic criteria by Freidman. METHODOLOGY This retrospective study included the period from January 2016-to July 2021. RESULTS 50 patients were included; 34 males and 16 females with a male to female ratio of 2.1:1. The average age at onset of symptoms was 8 years. Obesity was noticed in 6 (12%) patients; 34 (68%) had symptoms upon presentation. The most common presenting symptom was headache (28 patients; 56%), papilledema was present in 33 (66%) patients. Most patients (37; 74%) had an initial cerebrospinal fluid (CSF) pressure ≥280 mmH2O. At last follow-up, papilledema resolved in 11/32 (34.3%) patients, and headache resolved in 17/23 (74%) patients. 22/50 (44%) patients fulfilled the definite criteria proposed by Freidman, 11/50 (22%) fulfilled the probable, 10/50 (20%) were categorized as possible, and 7 (14%) patients were categorized as unmet. CONCLUSION PTCS is a chronic condition. Managing patients who do not have papilledema or who do not meet the newly proposed higher CSF pressure is challenging. Although, applying the newly proposed criteria captured most of our patients, however, around one quarter were managed based on clinical experience. This study indicates a strong need for future guidelines tailored specifically for children, taking into consideration that the cut-off point of CSF pressure might not be similar for all populations.
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Affiliation(s)
- Amira Masri
- Department of Paediatrics,division of child neurology , Faculty of Medicine, The University of Jordan.
| | | | | | | | | | - Lina Abuna'meh
- Department of Paediatrics,division of child neurology , Faculty of Medicine, The University of Jordan
| | - Majd Ali
- Department of Paediatrics,division of child neurology , Faculty of Medicine, The University of Jordan
| | - Nosaiba Al Ryalat
- Department of Radiology, Faculty of Medicine, The University of Jordan
| | - Azmy Hadidy
- Department of Radiology, Faculty of Medicine, The University of Jordan
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Aragão MDFVV, Araújo LC, Valença MM. Headache and neuroimaging findings in conditions of cerebrospinal fluid (CSF) circulation disorders: in hydrocephalus, pseudotumor cerebri, and CSF hypotension syndrome. HEADACHE MEDICINE 2022. [DOI: 10.48208/headachemed.2021.47] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022] Open
Abstract
The authors wish in this narrative minireview show and comment on some neuroimaging findings encountered in patients with conditions of cerebrospinal fluid circulation disorders, such as in the hydrocephalus, pseudotumor cerebri, and CSF hypotension syndrome. The MRI of a young woman with a clinical diagnosis of post-dural puncture headache, performed on the fourth postpartum day after cesarean delivery, evolving with headache and diplopia, is shown. Non-contrast-enhanced sagittal T1 magnetic resonance imaging shows that the cerebellar tonsils are at the level of the foramen magnum, therefore still within normal limits, but, despite that, the opening of the cerebral aqueduct in the third ventricle is below the imaginary line connecting the anterior clinoid to the vein of Galen, therefore considered abnormally lower than the expected anatomical position. The axial T1-weighted images with post-contrast fat suppression also show impregnation and thickening of the dura mater. There is also mild engorgement of the cerebral venous sinuses, best demonstrated on T1 with post-contrast fat suppression, which is also identified on post-contrast magnetic resonance angiography, with no signs of venous thrombosis. We conclude that the diagnosis of a patient with intracranial hypotension syndrome can be suspected or confirmed with typical neuroimaging findings.
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Del Monte F, Bucchino L, Versace A, Tardivo I, Castagno E, Pieri G, Pilloni G, Felici E, Urbino AF. Infantile idiopathic intracranial hypertension: case report and review of the literature. Ital J Pediatr 2022; 48:3. [PMID: 35012609 PMCID: PMC8743694 DOI: 10.1186/s13052-021-01191-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/22/2021] [Accepted: 12/01/2021] [Indexed: 11/10/2022] Open
Abstract
Background Idiopathic intracranial hypertension is an infrequent condition of childhood, and is extremely rare in infants, with only 26 cases described. The etiology is still unknown. Typical clinical manifestations change with age, and symptoms are atypical in infants, thus the diagnosis could be late. This is based on increased opening pressure at lumbar puncture, papilloedema and normal cerebral MRI. The measurement of cerebrospinal fluid opening pressure in infants is an issue because many factors may affect it, and data about normal values are scanty. The mainstay of treatment is acetazolamide, which allows to relieve symptoms and to avoid permanent visual loss if promptly administered. Case presentation We report the case of an 8-month-old infant admitted because of vomit, loss of appetite and irritability; later, also bulging anterior fontanel was observed. Cerebral MRI and cerebrospinal fluid analysis resulted negative and after two lumbar punctures he experienced initial symptom relief. Once the diagnosis of idiopathic intracranial hypertension was made, he received oral acetazolamide, and corticosteroids, with progressive symptom resolution. Conclusions Infantile idiopathic intracranial hypertension is extremely rare, and not well described yet. Bulging anterior fontanel in otherwise healthy infants with normal neuroimaging should be always considered suggestive, but can be a late sign, while irritability and anorexia, especially if associated with vomiting, may represent an early sign. In such cases, lumbar puncture should be always done, hopefully with cerebrospinal fluid opening pressure measurement, which is among coded diagnostic criteria, but whose threshold is controversial in infants. Early diagnosis, timely treatment and strict follow-up help to prevent vision loss or death of affected infants.
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Affiliation(s)
- Francesco Del Monte
- Department of Public Health and Pediatrics, University of Turin, Regina Margherita Children's Hospital, A.O.U. Città della Salute e della Scienza di Torino, Piazza Polonia 94, 10126, Turin, Italy.
| | - Laura Bucchino
- Division of Pediatrics, Department of Health Science, University of Piemonte Orientale, Novara, Italy
| | - Antonia Versace
- Department of Pediatric Emergency, Regina Margherita Children's Hospital, A.O.U. Città della Salute e della Scienza di Torino, Turin, Italy
| | - Irene Tardivo
- Department of Pediatric Emergency, Regina Margherita Children's Hospital, A.O.U. Città della Salute e della Scienza di Torino, Turin, Italy
| | - Emanuele Castagno
- Department of Pediatric Emergency, Regina Margherita Children's Hospital, A.O.U. Città della Salute e della Scienza di Torino, Turin, Italy
| | - Giovanni Pieri
- Pediatrics and Pediatric Emergency Unit, The Children's Hospital, AO SS Antonio e Biagio e C. Arrigo, Alessandria, Italy
| | - Giulia Pilloni
- Division of Pediatric Neurosurgery, Regina Margherita Children's Hospital, A.O.U. Città della Salute e della Scienza di Torino, Turin, Italy
| | - Enrico Felici
- Pediatrics and Pediatric Emergency Unit, The Children's Hospital, AO SS Antonio e Biagio e C. Arrigo, Alessandria, Italy
| | - Antonio Francesco Urbino
- Department of Pediatric Emergency, Regina Margherita Children's Hospital, A.O.U. Città della Salute e della Scienza di Torino, Turin, Italy
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Talukder NT, Clorfeine AH, Black MK, Moody SB. Atypical idiopathic intracranial hypertension presenting as cyclic vomiting syndrome: a case report. J Med Case Rep 2021; 15:440. [PMID: 34461990 PMCID: PMC8405252 DOI: 10.1186/s13256-021-03068-x] [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] [Subscribe] [Scholar Register] [Received: 03/31/2021] [Accepted: 08/14/2021] [Indexed: 11/21/2022] Open
Abstract
Background Idiopathic intracranial hypertension is a disorder of increased intracranial pressure in the absence of cerebrospinal outflow obstruction, mass lesion, or other underlying cause. It is a rare phenomenon in prepubertal children and is most typically found in women of childbearing age. The classic presentation consists of headaches, nausea, vomiting, and visual changes; however, children present more atypically. We report a case of idiopathic intracranial hypertension in an otherwise healthy, 4-year-old child with atypical symptoms resembling those of cyclic vomiting syndrome. Case presentation A 4-year-old Caucasian, otherwise healthy, male child presented to our emergency department with episodic intermittent early-morning vomiting occurring once every 1–3 weeks without interepisodic symptoms, starting 10 months prior. With outpatient metabolic, autoimmune, endocrine, allergy, and gastroenterology work-up all unremarkable, he was initially diagnosed with cyclic vomiting syndrome. Discovery of mild optic nerve sheath distension on magnetic resonance imaging of the brain 10 months after symptom onset led to inpatient admission and a lumbar puncture notable for an opening pressure of 47 mmHg, with normal cell count and protein levels. He had no changes in visual acuity or optic disc edema on dilated fundoscopic examination. The patient was started on acetazolamide, with resolution of episodic emesis at his last follow-up visit 12 weeks after discharge. Conclusions Idiopathic intracranial hypertension presents atypically in prepubescent children, with about one-fourth presenting asymptomatically, and only 13–52% presenting with “classic” symptoms. With a prevalence of only 0.6–0.7 per 100,000, much remains unknown regarding the underlying pathophysiology in this demographic. Cyclic vomiting syndrome, however, has a much higher prevalence in this age group, with a prevalence of 0.4–1.9 per 100. It is thought to be an idiopathic, periodic disorder of childhood, often linked to neurological conditions such as abdominal migraines, epilepsy, mitochondrial disorders, and structural lesions such as chiari malformation and posterior fossa tumors. While cyclic vomiting syndrome is thought to have a benign course, untreated idiopathic intracranial hypertension can have long-term detrimental effects, such as visual loss or even blindness. We present a case of idiopathic intracranial hypertension presenting with symptoms resembling cyclic vomiting syndrome in a 4-year-old child, diagnosed 10 months after initial onset of symptoms. We aim to demonstrate the need for a high level of clinical suspicion and the need for further investigation into underlying pathophysiology in this vulnerable population.
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Affiliation(s)
- Nafee T Talukder
- Department of Neurology, Children's Memorial Hermann Hospital, 6410 Fannin St., Ste 1014, Houston, TX, 77030, USA. .,University of Texas Health Science Center, Houston, TX, USA.
| | - Amanda H Clorfeine
- Department of Neurology, Children's Memorial Hermann Hospital, 6410 Fannin St., Ste 1014, Houston, TX, 77030, USA.,University of Texas Health Science Center, Houston, TX, USA
| | - Moira K Black
- Department of Neurology, Children's Memorial Hermann Hospital, 6410 Fannin St., Ste 1014, Houston, TX, 77030, USA.,University of Texas Health Science Center, Houston, TX, USA
| | - Shade B Moody
- Department of Neurology, Children's Memorial Hermann Hospital, 6410 Fannin St., Ste 1014, Houston, TX, 77030, USA.,University of Texas Health Science Center, Houston, TX, USA
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11
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Mollan SP, Chong YJ, Grech O, Sinclair AJ, Wakerley BR. Current Perspectives on Idiopathic Intracranial Hypertension without Papilloedema. Life (Basel) 2021; 11:472. [PMID: 34073844 PMCID: PMC8225003 DOI: 10.3390/life11060472] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2021] [Revised: 05/16/2021] [Accepted: 05/18/2021] [Indexed: 02/07/2023] Open
Abstract
The pseudotumor cerebri syndrome embraces disorders characterised by raised intracranial pressure, where the commonest symptom is headache (90%). Idiopathic intracranial hypertension without papilloedema (IIHWOP) is increasingly recognised as a source of refractory headache symptoms and resultant neurological disability. Although the majority of patients with IIHWOP are phenotypically similar to those with idiopathic intracranial hypertension (IIH), it remains uncertain as to whether IIHWOP is nosologically distinct from IIH. The incidence, prevalence, and the degree of association with the world-wide obesity epidemic is unknown. Establishing a diagnosis of IIHWOP can be challenging, as often lumbar puncture is not routinely part of the work-up for refractory headaches. There are published diagnostic criteria for IIHWOP; however, some report uncertainty regarding a pathologically acceptable cut off for a raised lumbar puncture opening pressure, which is a key criterion. The literature provides little information to help guide clinicians in managing patients with IIHWOP. Further research is therefore needed to better understand the mechanisms that drive the development of chronic daily headaches and a relationship to intracranial pressure; and indeed, whether such patients would benefit from therapies to lower intracranial pressure. The aim of this narrative review was to perform a detailed search of the scientific literature and provide a summary of historic and current opinion regarding IIHWOP.
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Affiliation(s)
- Susan P. Mollan
- Birmingham Neuro-Ophthalmology Unit, University Hospitals Birmingham NHS Foundation Trust, Birmingham B15 2TH, UK;
| | - Yu Jeat Chong
- Birmingham Neuro-Ophthalmology Unit, University Hospitals Birmingham NHS Foundation Trust, Birmingham B15 2TH, UK;
| | - Olivia Grech
- Metabolic Neurology, Institute of Metabolism and Systems Research, University of Birmingham, Edgbaston B15 2TT, UK; (O.G.); (A.J.S.); (B.R.W.)
- Centre for Endocrinology, Diabetes and Metabolism, Birmingham Health Partners, Birmingham B15 2TH, UK
| | - Alex J. Sinclair
- Metabolic Neurology, Institute of Metabolism and Systems Research, University of Birmingham, Edgbaston B15 2TT, UK; (O.G.); (A.J.S.); (B.R.W.)
- Centre for Endocrinology, Diabetes and Metabolism, Birmingham Health Partners, Birmingham B15 2TH, UK
- Department of Neurology, University Hospitals Birmingham NHS Foundation Trust, Birmingham B15 2TH, UK
| | - Benjamin R. Wakerley
- Metabolic Neurology, Institute of Metabolism and Systems Research, University of Birmingham, Edgbaston B15 2TT, UK; (O.G.); (A.J.S.); (B.R.W.)
- Centre for Endocrinology, Diabetes and Metabolism, Birmingham Health Partners, Birmingham B15 2TH, UK
- Department of Neurology, University Hospitals Birmingham NHS Foundation Trust, Birmingham B15 2TH, UK
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12
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Yamamoto E, Farber D, Rothner D, Moodley M. Assessment of Pediatric Pseudotumor Cerebri Clinical Characteristics and Outcomes. J Child Neurol 2021; 36:341-349. [PMID: 33148096 DOI: 10.1177/0883073820972231] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Pseudotumor cerebri also known as idiopathic intracranial hypertension is a relatively uncommon disorder of unknown pathophysiology. Although pseudotumor cerebri occurs in both children and adults, the pseudotumor cerebri literature is heavily dominated by adult studies. The aim of this study is to retrospectively describe the clinical presentation, imaging, treatment, and outcomes of a large pediatric pseudotumor cerebri population over a 23-year period. We also discuss secondary pseudotumor cerebri (44%) as well as the increasingly recognized patient subgroups without headache (13.3%) and without papilledema (7.3%). Female sex, obesity, and initial symptoms were consistent with the literature; however radiographic findings were surprisingly low in this cohort. Headache outcomes at 1 week, 1 month, and 3 months following initial lumbar puncture/treatment and visual function outcomes are reported.
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Affiliation(s)
- Erin Yamamoto
- 443553Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, OH, USA
| | - Darren Farber
- Norton Children's Medical Group, 204841The University of Louisville, Louisville, KY, USA
| | - David Rothner
- 443553Cleveland Clinic, Neurological Institute, Center for Pediatric Neurology, Cleveland, OH, USA
| | - Manikum Moodley
- 443553Cleveland Clinic, Neurological Institute, Center for Pediatric Neurology, Cleveland, OH, USA
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13
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Türay S, Kabakuş N, Hancı F, Ulaş F, Dilek M, Cihan B. The role of clinical signs in the diagnosis of papilledema: development of an algorithm. Childs Nerv Syst 2021; 37:599-605. [PMID: 32839852 DOI: 10.1007/s00381-020-04869-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/17/2020] [Accepted: 08/20/2020] [Indexed: 11/25/2022]
Abstract
PURPOSE The aim of this study was not only to emphasize the role of clinical signs as well as ophthalmologic evaluation for accurate and differential diagnosis of papilledema (PE), but also to present an instructive algorithm that would help to eliminate unnecessary examinations and treatments. METHOD The files of 43 patients (ages 0-18) diagnosed with PE were retrospectively reviewed. The study included 25 patients from our pediatric neurology outpatient clinic, who were thought to have PE, and 18 patients, who were referred from the external centers to our hospital with a pre-diagnosis of PE. RESULTS Of the 43 patients, 28 had PE, 8 had pseudopapilledema (PPE), and 7 had optic nerve pathologies (ONP). For patients who applied directly to our pediatric neurology unit, a margin of error of 8% was detected based on only a simple ophthalmologic examination and an evaluation of clinical findings. For the patients who were forwarded to our pediatric neurology unit from the external centers without examining any clinical findings and with no details, the margin of error was 72%. CONCLUSION For patients with suspected PE, advanced ophthalmologic opinion is a necessary requirement before invasive radiological examinations are used. When the ophthalmologic evaluation is properly elaborated, the distinction can be made more clearly by using noninvasive methods. In order to determine the gold standard in terms of the methods used in the evaluation of patients who are not clinically diagnosed, new prospective studies with more patients should be planned.
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Affiliation(s)
- Sevim Türay
- Department of Pediatric Neurology, Faculty of Medicine, Abant Izzet Baysal University, Bolu, Turkey.
| | - Nimet Kabakuş
- Department of Pediatric Neurology, Faculty of Medicine, Abant Izzet Baysal University, Bolu, Turkey
| | - Fatma Hancı
- Department of Pediatric Neurology, Faculty of Medicine, Abant Izzet Baysal University, Bolu, Turkey
| | - Fatih Ulaş
- Department of Ophthalmology, Faculty of Medicine, Abant Izzet Baysal University, Bolu, Turkey
| | - Mustafa Dilek
- Department of Pediatrics, Faculty of Medicine, Abant Izzet Baysal University, Bolu, Turkey
| | - Büşra Cihan
- Department of Pediatrics, Faculty of Medicine, Abant Izzet Baysal University, Bolu, Turkey
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14
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Abstract
PURPOSE OF REVIEW Pseudotumor cerebri syndrome (PTCS) may affect both children and adults; however, the risk factors and clinical presentation vary greatly between these populations. This review aims to highlight the entity of PTCS in children and the unique considerations in this population; review the epidemiology and demographics; discuss the clinical presentation, revised diagnostic criteria, and approach to evaluation; review management strategies; and discuss the prognosis and long-term outcomes in children with PTCS. RECENT FINDINGS Clinical presentation can be variable in children and may be less obvious than in their adult counterparts. Papilledema can also be challenging to diagnose in this population. The upper limits for opening pressure on lumbar puncture differ in children, with a cut-off of 25 cm H20 (or 28 cm H2O in a sedated or obese child). Morbidity related to visual loss, pain and reduced quality of life lends urgency towards accurately identifying, evaluating and managing children with PTCS. There are no randomised controlled studies to allow for evidence-based recommendations for the management of PTCS in children. Further studies are needed to clarify and consolidate management approaches in this population.
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Affiliation(s)
- Rebecca Barmherzig
- Division of Neurology, Women's College Hospital Centre for Headache, University of Toronto, Toronto, Canada.,Division of Neurology, Department of Pediatrics, The Hospital for Sick Children, Toronto, Canada
| | - Christina L Szperka
- Pediatric Headache Program, Division of Neurology, Children's Hospital of Philadelphia, Philadelphia, PA, USA. .,Department of Neurology, Perelman School of Medicine, University of Pennsylvania, CTRB 10019 3501 Civic Center Blvd., Philadelphia, PA, 19104, USA.
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15
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Abstract
PURPOSE OF REVIEW To review the most relevant developments in the understanding of headache in idiopathic intracranial hypertension (IIH). RECENT FINDINGS The phenotype of the typical IIH headache is diverging from the historical thinking of a raised intracranial pressure headache, with the majority being classified as having migraine. A larger proportion of those with IIH have a past medical history of migraine, compared with the general population, highlighting the importance of re-examining those who have a change or escalation in their headache. The mechanisms underlying headache in IIH are not understood. Additionally, factors which confer a poor headache prognosis are not established. It is clear, however, that headache has a detrimental effect on all aspects of the patient's quality of life and is currently ranked highly as a research priority by IIH patients to better understand the pathophysiology of headache in IIH and identification of potential headache specific therapeutic agents. SUMMARY Headache remains the predominate morbidity in the majority of those with IIH. Headache management is an unmet need in IIH and future studies are required to investigate the probable complex mechanisms, as well as effective management.
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Affiliation(s)
- Susan P. Mollan
- Birmingham Neuro-Ophthalmology, University Hospitals Birmingham, NHS Foundation Trust, Queen Elizabeth Hospital, Birmingham
| | - Jan Hoffmann
- Basic and Clinical Neuroscience, Institute of Psychiatry, Psychology and Neuroscience, Wellcome Foundation Building, Denmark Hill Campus, King's College London, London
| | - Alexandra J. Sinclair
- Metabolic Neurology, Institute of Metabolism and Systems Research, University of Birmingham, Edgbaston
- Department of Neurology, University Hospitals Birmingham, Queen Elizabeth Hospital, Birmingham
- Centre for Endocrinology, Diabetes and Metabolism, Birmingham Health Partners, Birmingham, UK
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