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Costello F, Hamann S. Advantages and Pitfalls of the Use of Optical Coherence Tomography for Papilledema. Curr Neurol Neurosci Rep 2024; 24:55-64. [PMID: 38261144 DOI: 10.1007/s11910-023-01327-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/11/2023] [Indexed: 01/24/2024]
Abstract
PURPOSE OF REVIEW Papilledema refers to optic disc swelling caused by raised intracranial pressure. This syndrome arises from numerous potential causes, which may pose varying degrees of threat to patients. Manifestations of papilledema range from mild to severe, and early diagnosis is important to prevent vision loss and other deleterious outcomes. The purpose of this review is to highlight the role of optical coherence tomography (OCT) in the diagnosis and management of syndromes of raised intracranial pressure associated with papilledema. RECENT FINDINGS Ophthalmoscopy is an unreliable skill for many clinicians. Optical coherence tomography is a non-invasive ocular imaging technique which may fill a current care gap, by facilitating detection of papilledema for those who cannot perform a detailed fundus examination. Optical coherence tomography may help confirm the presence of papilledema, by detecting subclinical peripapillary retinal nerve fiber layer (pRNFL) thickening that might otherwise be missed with ophthalmoscopy. Enhanced depth imaging (EDI) and swept source OCT techniques may identify optic disc drusen as cause of pseudo-papilledema. Macular ganglion cell inner plexiform layer (mGCIPL) values may provide early signs of neuroaxonal injury in patients with papilledema and inform management for patients with syndromes of raised intracranial pressure. There are well-established advantages and disadvantages of OCT that need to be fully understood to best utilize this method for the detection of papilledema. Overall, OCT may complement other existing tools by facilitating detection of papilledema and tracking response to therapies. Moving forward, OCT findings may be included in deep learning models to diagnose papilledema.
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Affiliation(s)
- Fiona Costello
- Department of Clinical Neurosciences, Cumming School of Medicine, University of Calgary, Alberta, Canada.
- Department of Surgery, Cumming School of Medicine, University of Calgary, Alberta, Canada.
| | - Steffen Hamann
- Department of Ophthalmology, Rigshospitalet, University of Copenhagen, Glostrup, Denmark
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Asal N, Bayar Muluk N, Özdemir A, Say B. Evaluation of peripheral and central olfactory regions by MRI in patients with idiopathic intracranial hypertension. Neurol Res 2023; 45:346-353. [PMID: 36373831 DOI: 10.1080/01616412.2022.2146261] [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: 11/16/2022]
Abstract
OBJECTIVES We investigated the peripheral and central smell regions in patients with idiopathic intracranial hypertension (IIH) by cranial MRI. METHODS In this retrospective study, cranial MRI images of 43 adult patients with IIH (Group 1) and 43 healthy adults without IIH (Group 2) were included. In both groups, peripheral [Olfactory bulb (OB) volume and Olfactory sulcus (OS) depth] and central smell regions (insular gyrus and corpus amygdala area, and thalamus volume) were measured in cranial MRI. RESULTS Bilateral OB volume and insular gyrus area, and right corpus amygdala and thalamus volumes of the IIH group were significantly lower than those of the control group (p < 0.05). In the IIH group, OB volume of the right side was significantly lower, and insular gyrus area of the right side was significantly higher than those of the left side (p < 0.05). In the IIH group, there were positive correlations between OB volumes; OS depths; insular gyrus areas; corpus amygdala areas; and thalamus volumes bilaterally (p < 0.05). In older patients, right OS depth and right corpus amygdala area decreased (p < 0.05). CONCLUSION In conclusion, IIH may be related to olfactory impairment. Cranial MRI images showed a decrease in peripheral (OB volume) and central (insular gyrus and corpus amygdala area and thalamus volume) smell regions. To prevent olfactory impairment in IIH patients, treatment should be done in IIH patients to decrease intracranial pressure. It is very important to prevent the circulation of CSF with increased pressure between the sheets of the olfactory nerve in IIH patients.
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Affiliation(s)
- Neşe Asal
- Faculty of Medicine, Radiology Department, Kırıkkale University, Kırıkkale, Turkey
| | - Nuray Bayar Muluk
- Faculty of Medicine, ENT Department, Kırıkkale University, Kırıkkale, Turkey
| | - Adnan Özdemir
- Faculty of Medicine, Radiology Department, Kırıkkale University, Kırıkkale, Turkey
| | - Bahar Say
- Faculty of Medicine, Neurology Department, Kırıkkale University, Kırıkkale, Turkey
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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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Zafar S, Panthangi V, Cyril Kurupp AR, Raju A, Luthra G, Shahbaz M, Almatooq H, Foucambert P, Esbrand FD, Khan S. A Systematic Review on Whether an Association Exists Between Adolescent Obesity and Idiopathic Intracranial Hypertension. Cureus 2022; 14:e28071. [PMID: 36127965 PMCID: PMC9477550 DOI: 10.7759/cureus.28071] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2022] [Accepted: 08/16/2022] [Indexed: 11/19/2022] Open
Abstract
Pseudotumor cerebri syndrome (PTCS)/idiopathic intracranial hypertension (IIH) is a clinical presentation appertaining to signs/symptoms of raised intracranial pressure, like headache and papilledema. It is an uncommon but clinically significant cause of morbidity such as permanent vision loss. It is crucial to understand if idiopathic intracranial hypertension (IIH) is on the rise in adolescents, it is probably due to the rising prevalence of obesity worldwide. Our study aimed to find an association between obesity and IIH in adolescents. We utilized Preferred Reporting Items for Systematic Review and Meta-Analysis 2020 (PRISMA) guidelines to run this systematic review. Many publications related to the topic in the discussion were scrutinized through a comprehensive database search. We filtered them down to a final count of 10 articles after utilizing our inclusion/exclusion criteria and assessing the quality of work. In these final papers, we identified several possibilities to explain the link between obesity and IIH in adolescents. Overweight and obese adolescents were found to have a significantly increased risk of IIH development, with a more severe clinical picture seen in morbidly obese female patients.
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Apperley L, Kumar R, Senniappan S. Idiopathic intracranial hypertension in children with obesity. Acta Paediatr 2022; 111:1420-1426. [PMID: 35318727 DOI: 10.1111/apa.16343] [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: 12/09/2021] [Revised: 03/16/2022] [Accepted: 03/21/2022] [Indexed: 11/28/2022]
Abstract
AIM Obesity is an under-recognised risk factor for raised intracranial pressure in the paediatric population. The pathophysiology remains unclear. The aim of our study was to investigate the association between idiopathic intracranial hypertension (IIH) and weight in children. METHODS Patients diagnosed with IIH at a tertiary children's hospital were retrospectively identified between April 2017 and April 2019. Information regarding the patients' body mass index, presentation, investigation and treatment was collected and analysed. RESULTS In total, 18 patients (M:F 7:11) were identified with a mean age of 11 years (±3.3SD; range: 6-15 years). The mean BMI was 30.3 kg/m2 and mean BMI SDS was +2.5. Twelve (66.6%) patients presented with both headaches and eye signs. Three patients were asymptomatic, with papilloedema noted on routine optician review. Of the 18 patients, 15 were treated medically, two had long-term neurosurgical interventions and one patient was managed conservatively. CONCLUSION The results show that the majority of children with obesity who develop IIH were female. Awareness regarding IIH secondary to obesity needs to be highlighted to ensure detailed clinical evaluation takes place so that raised intracranial pressure can be diagnosed and managed earlier, to avoid more serious complications such as permanent visual loss.
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Affiliation(s)
- Louise Apperley
- Department of Paediatric Endocrinology Alder Hey Children’s Hospital Liverpool UK
| | - Ram Kumar
- Department of Paediatric Neurology Alder Hey Children’s Hospital Liverpool UK
| | - Senthil Senniappan
- Department of Paediatric Endocrinology Alder Hey Children’s Hospital Liverpool UK
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Thanki S, Guerrero W, Mokin M. Treatment of Pseudotumor Cerebri (Sinus Stenosis). Neurosurg Clin N Am 2022; 33:207-214. [DOI: 10.1016/j.nec.2021.11.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Rohit W, Rajesh A, Mridula R, Jabeen SA. Idiopathic Intracranial Hypertension - Challenges and Pearls. Neurol India 2022; 69:S434-S442. [PMID: 35103000 DOI: 10.4103/0028-3886.332276] [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: 11/04/2022]
Abstract
Idiopathic intracranial hypertension (IIH) is defined as a syndrome of raised intracranial pressure with normal imaging of the brain and cerebrospinal fluid (CSF) composition. There is a rising incidence and prevalence of this disease related to the increased prevalence of obesity. It typically affects women of working age, and headache is the predominant morbidity in over 90%. The disease is also more prevalent in young males. There are many controversies and myths that surround IIH. There are currently few treatment options for IIH, management is typically medical with those experiencing progressive visual loss undergoing surgical procedures. Weight loss and venous sinus stenting are a few therapies directed at the etiology.
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Affiliation(s)
- Wadikhaye Rohit
- RVM Institute of Medical Science and Research Centre, Hyderabad, Telangana, India
| | - Alugolu Rajesh
- Department of Neurosurgery, Nizam's Institute of Medical Sciences, Hyderabad, Telangana, India
| | - Rukmini Mridula
- Department of Neurology, Nizam's Institute of Medical Sciences, Hyderabad, Telangana, India
| | - Shaik A Jabeen
- Department of Neurology, Nizam's Institute of Medical Sciences, Hyderabad, Telangana, India
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How do presentation age and CSF opening pressure level affect long-term prognosis of pseudotumor cerebri syndrome in children? Experience of a single tertiary clinic. Childs Nerv Syst 2022; 38:95-102. [PMID: 34568960 DOI: 10.1007/s00381-021-05365-8] [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: 08/18/2021] [Accepted: 09/14/2021] [Indexed: 10/20/2022]
Abstract
BACKGROUND Diagnosis and treatment of pseudotumor cerebri syndrome in children is still a challenge for clinicians. The aim of this study is to reveal the influence of presentation age and CSF opening pressure on long-term prognosis of pseudotumor cerebri and share our clinical data of the very young age (≤ 5-year) group. METHOD This retrospective study includes the patients followed by the Marmara University Pediatric Neurology Clinic between years 2012 and 2020 diagnosed with definite, probable, or suggestive pseudotumor cerebri syndrome according to modified Friedman criteria. Patients were classified into three groups according to presentation age: group 1: ≤ 5 years old; group 2: 6-10 years; and group 3 > 10 years old. CSF opening pressure was also categorized into three groups as CSF < 20 cmH20; CSF 20-30 cmH20; and CSF > 30 cmH20. RESULTS One hundred three patients, 62.1% female (n = 64), were enrolled in the study. Group 1 consisted of 16 patients (60% male), group 2 consisted of 30 patients (63.3% female), and group 3 consisted of 57 patients (66.7% female). The mean CSF opening pressure did not differ between the three age groups in our study (p > 0.05). Treatment response was not correlated with CSF opening pressure. Papilledema presence and level of CSF opening pressure were independent of age (p > 0.05). CONCLUSIONS Age at presentation and CSF opening pressure at diagnosis are not any predictive factors that influence long-term prognosis of pseudotumor cerebri syndrome in children. Evaluation and follow-up of children should be done in personalized approach.
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A rare patient with idiopathic intracranial hypertension without papilledema presenting with tinnitus. Neurol Sci 2021; 42:3879-3881. [PMID: 33993355 DOI: 10.1007/s10072-021-05275-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2021] [Accepted: 04/19/2021] [Indexed: 10/21/2022]
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10
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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: 2.0] [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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Zhou S, Zhang M, Wu H, Liu G, Wang Y, Bao Y. Vision treatment strategy for acute blindness in adolescent female with diffuse leptomeningeal glioneuronal tumor. Int J Neurosci 2020; 130:1170-1173. [PMID: 32067532 DOI: 10.1080/00207454.2020.1730364] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
Diffuse leptomeningeal glioneuronal tumor with the first symptom of acute rapid blindness in both eyes are rare in adolescents. We present a case of an adolescent female without a history of cancer who developed a dramatic loss of vision and eventually blindness, and was diagnosed as diffuse leptomeningeal glioneuronal tumor by cerebrospinal fluid cytology and enhanced MRI. In order to save vision, under the condition of ineffective dehydration treatment, timely emergency surgery to implant Ommaya sac drainage cerebrospinal fluid. According to the pathophysiological mechanism of cerebral edema, we added Edaravone to scavenge oxygen free radicals, Alprostadil to improve microcirculation, Monosialotetrahexosylganglioside nutrient nerve, Butylphthalide to promote collateral circulation, combined with hyperbaric oxygen and acupoint injection of Anisodine. Finally, the patient's vision returned to normal. Conclusion: when dehydration treatment is ineffective, timely surgery to reduce intracranial pressure, combined with comprehensive treatment, can effectively save vision.
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Affiliation(s)
- Siqin Zhou
- Department of Neurology, Taihe Hospital Affiliated to Hubei University of Medicine, Shiyan City, Hubei, China
| | - Miao Zhang
- Department of Neurology, Taihe Hospital Affiliated to Hubei University of Medicine, Shiyan City, Hubei, China
| | - Huihui Wu
- Department of Neurology, Taihe Hospital Affiliated to Hubei University of Medicine, Shiyan City, Hubei, China
| | - Guangjian Liu
- Department of Neurology, Taihe Hospital Affiliated to Hubei University of Medicine, Shiyan City, Hubei, China
| | - Ying Wang
- Department of Neurology, Taihe Hospital Affiliated to Hubei University of Medicine, Shiyan City, Hubei, China
| | - Yi Bao
- Department of Neurology, Taihe Hospital Affiliated to Hubei University of Medicine, Shiyan City, Hubei, China
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Onyia CU, Ogunbameru IO, Dada OA, Owagbemi OF, Ige-Orhionkpaibima FS, Olarewaju OA, Komolafe EO. Idiopathic intracranial hypertension: Proposal of a stratification strategy for monitoring risk of disease progression. Clin Neurol Neurosurg 2019; 179:35-41. [PMID: 30818126 DOI: 10.1016/j.clineuro.2019.02.013] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2018] [Revised: 02/06/2019] [Accepted: 02/13/2019] [Indexed: 10/27/2022]
Abstract
OBJECTIVES A general consensus based on a multidisciplinary perspective involving an international panel was recently developed for management of patients with idiopathic intracranial hypertension (IIH). In this paper, the authors sought to develop further on the aspect of this consensus that concerns monitoring progression of the disease. PATIENTS AND METHODS A systematic literature review of previous publications on monitoring disease progression in IIH and a meta-analysis to examine efficacy of method of monitoring employed in each study. The authors present a brief descriptive analysis of challenges with monitoring progression of the disease and propose a risk stratification to aid monitoring. RESULTS Of a total of 382 publications identified from the literature search, only 8 studies (144 patients) satisfied inclusion criteria and were included for analysis. Among these, 3 were based on ICP monitoring while the remaining 5 focused on ophthamological evaluation. Interestingly, there were neither any studies on monitoring with progression of clinical features nor any study on monitoring with symptomatology associated with IIH among the selected studies. CONCLUSION There is a paucity of studies in the literature on methods of monitoring disease progression in IIH. Though close attention to adequate evaluation and proper care of patients with IIH remains the key in managing this problem, this proposed risk stratification will be an objective tool and useful guide to better monitor these patients according to their extent of risk from the disease and possibly for planning treatment and intervention.
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Affiliation(s)
| | - Ibironke O Ogunbameru
- Neurosurgery Division, Department of Surgery, Obafemi Awolowo University Teaching Hospitals Complex, Ile-Ife, Nigeria; Faculty of Clinical Sciences, Obafemi Awolowo University, Ile-Ife, Nigeria
| | - Oluwamuyiwa A Dada
- Neurosurgery Division, Department of Surgery, Obafemi Awolowo University Teaching Hospitals Complex, Ile-Ife, Nigeria
| | - Oluwafemi F Owagbemi
- Neurosurgery Division, Department of Surgery, Obafemi Awolowo University Teaching Hospitals Complex, Ile-Ife, Nigeria
| | - Fred S Ige-Orhionkpaibima
- Neurosurgery Division, Department of Surgery, Obafemi Awolowo University Teaching Hospitals Complex, Ile-Ife, Nigeria
| | - Oluseun A Olarewaju
- Department of Surgery, University of Calabar Teaching Hospital, Calabar, Nigeria
| | - Edward O Komolafe
- Neurosurgery Division, Department of Surgery, Obafemi Awolowo University Teaching Hospitals Complex, Ile-Ife, Nigeria; Faculty of Clinical Sciences, Obafemi Awolowo University, Ile-Ife, Nigeria
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Onder H, Aksoy M. Resolution of Idiopathic Intracranial Hypertension Symptoms by Surgery for Obstructive Sleep Apnea in a Pediatric Patient. J Pediatr Neurosci 2019; 14:110-112. [PMID: 31516635 PMCID: PMC6712914 DOI: 10.4103/jpn.jpn_30_19] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Affiliation(s)
- Halil Onder
- Department of Neurology, Neurology Clinic, Yozgat City Hospital, Yozgat, Turkey
| | - Mustafa Aksoy
- Department of Ophthalmology, Ophthalmology Clinic, Yozgat City Hospital, Yozgat, Turkey
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Moavero R, Sforza G, Papetti L, Battan B, Tarantino S, Vigevano F, Valeriani M. Clinical Features of Pediatric Idiopathic Intracranial Hypertension and Applicability of New ICHD-3 Criteria. Front Neurol 2018; 9:819. [PMID: 30356916 PMCID: PMC6190892 DOI: 10.3389/fneur.2018.00819] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2018] [Accepted: 09/10/2018] [Indexed: 12/31/2022] Open
Abstract
Idiopathic intracranial hypertension (IIH) is characterized by intracranial pressure >28 cmH2O in the absence of identifiable causes. Aim of this paper is to describe the clinical phenotype of pediatric IIH and to analyze the applicability of ICHD-3 criteria in comparison to the ICHD-2. We conducted a retrospective analysis of full clinical data of pediatric patients diagnosed with IIH between January 2007 and June 2018. Diagnostic evaluation included neuroimaging (all patients) and ultrasound-based optic nerve sheath diameter measurement (9 patients). Diagnosis of IIH was verified according to both ICHD-2 and ICHD-3 criteria for headache attributed to IIH, to verify the degree of concordance. We identified 41 subjects with suspected IIH; 14 were excluded due a diagnosis of secondary IH or lack of data. We therefore selected 27 subjects (age 4–15 years, mean 11). All patients presented with headache and bilateral papilloedema. Headache was daily in 22% cases, with diffuse gravative pain in 41%. In 4%, pain was exacerbated by cough, stress or tension. The most common presentation symptoms, in addition to headache, were blurred vision or diplopia (70%), vomiting (33%), and dizziness (15%). Twenty patients (74%) were obese. In 6 patients (22%) neuroimaging showed empty sella. Optic nerve sheath distension was detected in 6 out of 9 patients. Regarding the applicability of the ICHD-2 criteria, 18/27 (71%) patients have criterion A; 24/27 (89%) criterion B; 27/27 (100%) criterion C; 27/27 (100%) criterion D. When the ICHD-3 criteria were used, 27/27 (100%) fitted criterion A; 24/27 (89%) criterion B; 27/27 (100%) criterion C; and 27/27 (100%) criterion D. Our study suggests that, as compared with the ICHD-2, the new ICHD-3 criteria for headache attributed to IIH are better satisfied by pediatric patients with IIH. This is mainly due to the fact that qualitative headache characteristics are no longer considered in ICHD-3. Although the risk of under-rating the symptom of headache in IIH should not be disregarded, in pediatric population headache characteristics are usually less defined than in adults and obtaining a precise description of them is often very difficult.
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Affiliation(s)
- Romina Moavero
- Child Neurology Unit, Department of Neuroscience and Neurorehabilitation, Headache Center, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy.,Child Neurology and Psychiatry Unit, Tor Vergata University Hospital of Rome, Rome, Italy
| | - Giorgia Sforza
- Child Neurology and Psychiatry Unit, Tor Vergata University Hospital of Rome, Rome, Italy
| | - Laura Papetti
- Child Neurology Unit, Department of Neuroscience and Neurorehabilitation, Headache Center, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Barbara Battan
- Child Neurology Unit, Department of Neuroscience and Neurorehabilitation, Headache Center, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Samuela Tarantino
- Child Neurology Unit, Department of Neuroscience and Neurorehabilitation, Headache Center, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Federico Vigevano
- Child Neurology Unit, Department of Neuroscience and Neurorehabilitation, Headache Center, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Massimiliano Valeriani
- Child Neurology Unit, Department of Neuroscience and Neurorehabilitation, Headache Center, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy.,Center for Sensory Motor Interaction, Aalborg University, Aalborg, Denmark
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Hamedani AG, Witonsky KFR, Cosico M, Rennie R, Xiao R, Sheldon CA, Paley GL, McCormack SE, Liu GW, Friedman DI, Liu GT, Szperka CL. Headache Characteristics in Children With Pseudotumor Cerebri Syndrome, Elevated Opening Pressure Without Papilledema, and Normal Opening Pressure: A Retrospective Cohort Study. Headache 2018; 58:1339-1346. [PMID: 30137653 DOI: 10.1111/head.13362] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2016] [Revised: 08/22/2016] [Accepted: 05/18/2018] [Indexed: 11/27/2022]
Abstract
BACKGROUND Certain headache characteristics and associated symptoms are commonly attributed to increased intracranial pressure, but they have not been systematically studied among children in the context of revised diagnostic criteria for pseudotumor cerebri syndrome (PTCS). METHODS We performed a retrospective cohort study of patients treated for suspected or confirmed PTCS. Charts were reviewed for PTCS and headache diagnostic criteria and associated characteristics. Chi-squared or Fisher's exact tests were used to compare the frequency of headache characteristics between groups. RESULTS One hundred and twenty-seven individuals were identified: 61 had definite PTCS, 10 had probable PTCS, 31 had elevated opening pressure (OP) without papilledema, and 25 had normal OP without papilledema. Eleven children had no headache (6 with definite PTCS, 5 with probable PTCS). Headache pattern was episodic in 49% (95% CI: 34-64%) of those with definite PTCS, 18% (95% CI 6-37%) of those with elevated OP without papilledema, and 16% (5-36%) of those with normal OP without papilledema. Headache location was more likely to involve the head along with neck or shoulders in those with definite PTCS compared with elevated OP without papilledema (OR = 7.2, 95% CI: 1.9-27.6) and normal OP (OR = 4.5, 95% CI: 1.3-15.6) groups. DISCUSSION While missing data and small cohort size are limitations, this study suggests that headache in PTCS is more likely to involve the head along with neck/shoulders, and that headache in PTCS may be episodic or constant. Headache is occasionally absent in PTCS.
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Affiliation(s)
- Ali G Hamedani
- Department of Neurology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Kailyn F R Witonsky
- Division of Neurology, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Mahgenn Cosico
- Division of Neurology, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Robert Rennie
- Division of Neurology, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Riu Xiao
- Department of Biostatistics and Epidemiology, University of Pennsylvania, Philadelphia, PA, USA
| | - Claire A Sheldon
- Neuro-Ophthalmology Service, Division of Ophthalmology, Children's Hospital of Philadelphia, Philadelphia, PA, USA.,Department of Ophthalmology & Visual Sciences, University of British Columbia, Vancouver, CA, Canada
| | - Grace L Paley
- Neuro-Ophthalmology Service, Division of Ophthalmology, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Shana E McCormack
- Division of Endocrinology & Diabetes, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Geraldine W Liu
- Division of Neurology, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Deborah I Friedman
- Department of Neurology & Neurotherapeutics, University of Texas Southwestern Medical Center, Dallas, TX, USA.,Department of Ophthalmology, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Grant T Liu
- Department of Neurology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA.,Neuro-Ophthalmology Service, Division of Ophthalmology, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Christina L Szperka
- Department of Neurology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA.,Division of Neurology, Children's Hospital of Philadelphia, Philadelphia, PA, USA
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17
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Higgins JNP, Pickard JD, Lever AML. Chronic fatigue syndrome and idiopathic intracranial hypertension: Different manifestations of the same disorder of intracranial pressure? Med Hypotheses 2017; 105:6-9. [PMID: 28735654 DOI: 10.1016/j.mehy.2017.06.014] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2017] [Revised: 05/20/2017] [Accepted: 06/23/2017] [Indexed: 01/03/2023]
Abstract
Though not discussed in the medical literature or considered in clinical practice, there are similarities between chronic fatigue syndrome and idiopathic intracranial hypertension (IIH) which ought to encourage exploration of a link between them. The cardinal symptoms of each - fatigue and headache - are common in the other and their multiple other symptoms are frequently seen in both. The single discriminating factor is raised intracranial pressure, evidenced in IIH usually by the sign of papilloedema, regarded as responsible for the visual symptoms which can lead to blindness. Some patients with IIH, however, do not have papilloedema and these patients may be clinically indistinguishable from patients with chronic fatigue syndrome. Yet IIH is rare, IIH without papilloedema (IIHWOP) seems rarer still, while chronic fatigue syndrome is common. So are the clinical parallels spurious or is there a way to reconcile these conflicting observations? We suggest that it is a quirk of clinical measurement that has created this discrepancy. Specifically, that the criteria put in place to define IIH have led to a failure to appreciate the existence, clinical significance or numerical importance of patients with lower level disturbances of intracranial pressure. We argue that this has led to a grossly implausible distortion of the epidemiology of IIH such that the milder form of the illness (IIHWOP) is seen as less common than the more severe and that this would be resolved by recognising a connection with chronic fatigue syndrome. We hypothesise, therefore, that IIH, IIHWOP, lesser forms of IIH and an undetermined proportion of chronic fatigue cases are all manifestations of the same disorder of intracranial pressure across a spectrum of disease severity, in which this subset of chronic fatigue syndrome would represent the most common and least severe and IIH the least common and most extreme.
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Affiliation(s)
| | - John D Pickard
- Academic Department of Neurosurgery, Addenbrooke's Hospital, Cambridge, UK; University of Cambridge, UK
| | - Andrew M L Lever
- Department of Infectious Diseases, Addenbrooke's Hospital, Cambridge, UK; University of Cambridge, UK
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18
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Abstract
Headache represents the most common neurologic disorder in the general population including children and is increasingly being recognized as a major source of morbidity in youth related to missed school days and activities. In this article, we take a holistic approach to the child presenting with headache with a focus on the detailed headache history, physical and neurologic examinations, and diagnostic evaluation of these patients. Clinical presentations and classification schema of multiple primary and secondary headache types in children are discussed using the International Headache Criteria (IHCD-3) as a guide, and a summary provided of the various treatment modalities employed for pediatric headache including lifestyle modifications, behavioral techniques, and abortive and preventive medications.
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Affiliation(s)
- Raquel Langdon
- Center for Neurosciences and Behavioral Health, Children׳s National Medical Center, Washington, DC
| | - Marc T DiSabella
- Center for Neurosciences and Behavioral Health, Children׳s National Medical Center, Washington, DC
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19
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Effects of bisphosphonates on osteogenesis and osteoclastogenesis signaling during the endochondral ossification of growing rats. Cell Tissue Res 2017; 368:287-300. [DOI: 10.1007/s00441-017-2574-3] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2015] [Revised: 12/28/2016] [Accepted: 01/11/2017] [Indexed: 11/25/2022]
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20
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Albakr A, Hamad MH, Alwadei AH, Bashiri FA, Hassan HH, Idris H, Hassan S, Muayqil T, Altweijri I, Salih MA. Idiopathic intracranial hypertension in children: Diagnostic and management approach. Sudan J Paediatr 2016; 16:67-76. [PMID: 28096561 PMCID: PMC5237838] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
Abstract
Idiopathic intracranial hypertension (IIH) is a rare neurological disorder in children. It is characterized by raised intracranial pressure (ICP) in the absence of brain parenchymal lesion, vascular malformations, hydrocephalus, or central nervous system (CNS) infection. The diagnosis is usually confirmed by high opening pressure of cerebrospinal fluid (CSF) with exclusion of secondary causes of intracranial hypertension. If not treated properly, it may lead to severe visual dysfunction. Here we review the etiology, clinical presentation, diagnostic criteria and management of IIH in children through illustration of the clinical and radiological presentation of a 13-year-old overweight girl who presented with severe headache, diplopia and bilateral papilledema. Otherwise, she had unremarkable neurological and systemic examinations. Lumbar puncture showed a high CSF opening pressure (360-540 mmH2O). Her investigations showed normal complete blood count (CBC), normal renal, liver, and thyroid function tests. Cerebrospinal fluid (CSF) and blood chemistry were unremarkable. Magnetic resonant image (MRI) of the brain demonstrated empty sella turcica, tortuous optic nerves, and flattening of the posterior sclera. Magnetic resonant venography (MRV) showed focal narrowing of the distal transverse sinuses and absence of venous sinus thrombosis. She required treatment with acetazolamide and prednisolone. With medical treatment, weight reduction, and exercise, our patient had a remarkable improvement in her symptoms with resolution of papilledema in two months. This review highlights the importance of early recognition and management of IIH to prevent permanent visual loss.
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Affiliation(s)
- Abdulrahman Albakr
- Division of Neurosurgery, Department of Surgery, College of Medicine, King Saud University, Riyadh, Saudi Arabia
| | - Muddathir H Hamad
- Division of Neurology, Departments of Pediatrics, King Khalid University Hospital, College of Medicine, King Saud University, Riyadh, Saudi Arabia
| | - Ali H Alwadei
- Pediatric Neurology Department, National Neuroscience Institute, King Fahad Medical City, Riyadh, Saudi Arabia
| | - Fahad A Bashiri
- Division of Neurology, Departments of Pediatrics, King Khalid University Hospital, College of Medicine, King Saud University, Riyadh, Saudi Arabia
| | - Hamdy H Hassan
- Department of Radiology, College of Medicine, King Saud University, Riyadh, Saudi Arabia
| | - Hiyam Idris
- Division of Neurology, Departments of Pediatrics, King Khalid University Hospital, College of Medicine, King Saud University, Riyadh, Saudi Arabia
| | - Saeed Hassan
- Division of Neurology, Departments of Pediatrics, King Khalid University Hospital, College of Medicine, King Saud University, Riyadh, Saudi Arabia
| | - Taim Muayqil
- Division of Neurology, College of Medicine, King Saud University, Riyadh, Saudi Arabia
| | - Ikhlass Altweijri
- Division of Neurosurgery, Department of Surgery, College of Medicine, King Saud University, Riyadh, Saudi Arabia
| | - Mustafa A Salih
- Division of Neurology, Departments of Pediatrics, King Khalid University Hospital, College of Medicine, King Saud University, Riyadh, Saudi Arabia
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21
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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: 1.7] [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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22
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Andrews LE, Liu GT, Ko MW. Idiopathic intracranial hypertension and obesity. Horm Res Paediatr 2015; 81:217-25. [PMID: 24642712 DOI: 10.1159/000357730] [Citation(s) in RCA: 58] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2013] [Accepted: 12/04/2013] [Indexed: 11/19/2022] Open
Abstract
Idiopathic intracranial hypertension (IIH), also known as primary pseudotumor cerebri syndrome (PTCS), is a condition of unknown etiology which affects primarily overweight, reproductive-aged women and causes increased intracranial pressure (ICP). This review discusses the recently revised diagnostic criteria for PTCS for adults and children. Additionally, the role of obesity in the epidemiology, etiology, and management of IIH as well as the current knowledge of obesity profiles and markers in IIH are reviewed. We also highlight the emerging, unifying theory of the neuroendocrine effects on the mineralocorticoid receptor to explain a possible mechanism for the increased cerebrospinal fluid production and ICP in secondary PTCS.
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Affiliation(s)
- Laura E Andrews
- Department of Neurology, University Health Care Center, Syracuse, N.Y., USA
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23
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What do lumbar puncture and jugular venoplasty say about a connection between chronic fatigue syndrome and idiopathic intracranial hypertension? EJMINT : EUROPEAN JOURNAL OF MINIMALLY INVASIVE NEUROLOGICAL THERAPY 2014; 2014:1443000223. [PMID: 36698748 PMCID: PMC7614098] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
Introduction Similarities between chronic fatigue syndrome and idiopathic intracranial hypertension (IIH) invite speculation that they may be related. Cranial venous outflow obstruction plays a role in the development of IIH. Could it be a factor in chronic fatigue? This paper attempts to evaluate an investigative approach to chronic fatigue syndrome that allows for this possibility. Methods Since 2007, patients attending a specialist clinic at our institution diagnosed with chronic fatigue syndrome and with prominent headache have been offered CT venography, lumbar puncture and a trial of cerebrospinal fluid withdrawal looking for IIH. Also, if CT venography revealed focal narrowing of the jugular veins, patients were offered catheter cerebral venography and jugular venoplasty attempting to establish their clinical significance. Results In the 29 patients investigated to date, the mean cerebrospinal fluid (CSF) pressure was 19 cm H2O (range 12 - 41 cm H2O). Twenty-five patients responded positively to CSF withdrawal and in 5 the CSF pressures were high enough to allow an unequivocal diagnosis of IIH while in the remaining 20, symptoms improved with lumbar puncture even though CSF pressures were within the normal range. Twenty-one patients had focal narrowing of one or both internal jugular veins on CT venography. Fourteen of these have had jugular venoplasty, all of whom reported an improvement in symptoms afterwards lasting from a few minutes to more than 1 month. Conclusions Chronic fatigue syndrome may represent an incomplete form of IIH. Cranial venous outflow obstruction deserves further investigation as a possible aetiological factor.
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24
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Babiker MOE, Prasad M, MacLeod S, Chow G, Whitehouse WP. Fifteen-minute consultation: the child with idiopathic intracranial hypertension. Arch Dis Child Educ Pract Ed 2014; 99:166-72. [PMID: 24667890 DOI: 10.1136/archdischild-2013-305818] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
Idiopathic intracranial hypertension (IIH) is a rare condition where intracranial hypertension is found in the context of normal brain parenchyma and no mass lesion, ventriculomegaly, underlying infection, or malignancy. Our understanding of this condition has greatly improved in the recent years with neuroimaging features and normal values for lumbar puncture opening pressure now well defined. This article provides a review of IIH in children and revised diagnostic criteria based on recent evidence and published opinion. We have also presented an algorithmic approach to the child with possible IIH.
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Affiliation(s)
- Mohamed O E Babiker
- Fraser of Allander Neurosciences Unit, Royal Hospital of Sick Children, Glasgow, UK
| | - Manish Prasad
- Department of Paediatrics, Pinderfield General Hospital, Wakefield, UK
| | - Stewart MacLeod
- Fraser of Allander Neurosciences Unit, Royal Hospital of Sick Children, Glasgow, UK
| | - Gabriel Chow
- Department of Paediatric Neurology, Nottingham Children's Hospital, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - William P Whitehouse
- Department of Paediatric Neurology, Nottingham Children's Hospital, Nottingham University Hospitals NHS Trust, Nottingham, UK School of Medicine, University of Nottingham, Nottingham, UK
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25
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Endoscopic optic nerve fenestration amongst pediatric idiopathic intracranial hypertension: a new surgical option. Int J Pediatr Otorhinolaryngol 2014; 78:1686-91. [PMID: 25103775 DOI: 10.1016/j.ijporl.2014.07.019] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/23/2014] [Revised: 07/13/2014] [Accepted: 07/14/2014] [Indexed: 11/22/2022]
Abstract
OBJECTIVE To assess the effectiveness of transnasal trans-sphenoid endoscopic optic nerve fenestration for the reversal of vision loss in pediatric idiopathic intracranial hypertension (IIH). MATERIAL AND METHODS This is a single center observational retrospective case series. Fifteen diagnosed pediatric patients of IIH satisfying the modified Dandy criteria and reported to the out-patient services of otolaryngology, Post Graduate Institute of Medical Education and Research (PGIMER), Chandigarh, India were included in this study. All children underwent thorough clinical examination, complete neuro-ophthalmological work up including visual acuity (V/A), visual field charting(V/F), fundus venogram and radiological work up with MRI for special optic nerve sections in sagittal reconstruction. cerebro-spinal fluid pressure (CSF) measured pre operatively for all children. Standard endoscopic optic nerve sheath fenestration was performed on all children. Visual improvement was assessed by comparing pre-operative ophthalmological findings. RESULTS Improvement in vision was taken as a positive outcome. Vision improved in all except two children, who had pre-existing optic nerve atrophy. CONCLUSION Endoscopic optic nerve fenestration is an effective minimally invasive procedure to revert visual loss in pediatric Idiopathic Intracranial Hypertension.
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26
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Krishnakumar D, Pickard JD, Czosnyka Z, Allen L, Parker A. Idiopathic intracranial hypertension in childhood: pitfalls in diagnosis. Dev Med Child Neurol 2014; 56:749-55. [PMID: 24854011 DOI: 10.1111/dmcn.12475] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/03/2014] [Indexed: 12/29/2022]
Abstract
AIM Idiopathic intracranial hypertension (IIH) is prone to misdiagnosis. Our aim was to identify the reasons for this in children in our region referred for suspected IIH. METHOD We reviewed the records of all children referred with symptoms and/or signs consistent with raised intracranial pressure (ICP) and normal magnetic resonance imaging of the brain to our tertiary neurology unit over 4 years. IIH was confirmed after expert ophthalmology including ultrasound/tomography and advanced cerebrospinal fluid (CSF) pressure studies. RESULTS Of 15 children (six males, nine females; median age 12y, range 3-15y), six (five females, one male) were confirmed to have IIH. All weighed above the 91st centile and were over 10 years old. Four of the six had raised ICP secondary to other causes. Four had been misdiagnosed locally with papilloedema, three had drusen, and one had 'crowded discs'. Two had raised CSF pressures on standard lumbar puncture, but 20-minute steady state and infusion studies were normal, with symptoms settling after therapy was withdrawn. INTERPRETATION Misdiagnosis of IIH was frequent, but could be reduced by (1) expert ophthalmological fundoscopy, orbital ultrasound, and optical coherence tomography; (2) expert neuroradiology; and (3) assessment of steady state CSF pressure rather than standard opening pressure in centimetres of water.
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Affiliation(s)
- Deepa Krishnakumar
- Department of Paediatric Neurology, Addenbrooke's Hospital, Cambridge, UK
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27
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Singh RR, Lim M. Idiopathic intracranial hypertension: new insights, new definitions but the same old problems. Dev Med Child Neurol 2014; 56:707-8. [PMID: 24894578 DOI: 10.1111/dmcn.12499] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/07/2014] [Indexed: 11/29/2022]
Affiliation(s)
- Rahul R Singh
- Children's Neurosciences, Evelina London Children's Hospital at Guy's & St Thomas' NHS Trust, Kings Health Partners Academic Health Science Centre, London, UK
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28
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Higgins N, Pickard J, Lever A. Lumbar puncture, chronic fatigue syndrome and idiopathic intracranial hypertension: a cross-sectional study. JRSM SHORT REPORTS 2013; 4:2042533313507920. [PMID: 24475346 PMCID: PMC3899735 DOI: 10.1177/2042533313507920] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 12/02/2022]
Abstract
OBJECTIVE Unsuspected idiopathic intracranial hypertension (IIH) is found in a significant minority of patients attending clinics with named headache syndromes, if it is specifically sought out. Chronic fatigue syndrome is frequently associated with headache. Could the same be true of chronic fatigue? Moreover, there are striking similarities between the two conditions. Could they be related? Attempting to answer these questions, we describe the results of a change in clinical practice aimed at capturing patients with chronic fatigue who might have IIH. DESIGN Cross-sectional. SETTING Hospital outpatient and radiology departments. PARTICIPANTS Patients attending a specialist clinic with chronic fatigue syndrome and headache who had lumbar puncture to exclude raised intracranial pressure. MAIN OUTCOME MEASURES Intracranial pressure measured at lumbar puncture and the effect on headache of cerebrospinal fluid drainage. RESULTS Mean cerebrospinal fluid pressure was 19 cm H2O (range 12-41 cm H2O). Four patients fulfilled the criteria for IIH. Thirteen others did not have pressures high enough to diagnose IIH but still reported an improvement in headache after drainage of cerebrospinal fluid. Some patients also volunteered an improvement in other symptoms, including fatigue. No patient had any clinical signs of raised intracranial pressure. CONCLUSIONS An unknown, but possibly substantial, minority of patients with chronic fatigue syndrome may actually have IIH. An unknown, but much larger, proportion of patients with chronic fatigue syndrome do not have IIH by current criteria but respond to lumbar puncture in the same way as patients who do. This suggests that the two conditions may be related.
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Affiliation(s)
- Nicholas Higgins
- Department of Radiology, Addenbrooke’s
Hospital, Cambridge CB2 0QQ, UK
| | - John Pickard
- Academic Department of Neurosurgery,
Addenbrooke’s Hospital, Cambridge CB2 0QQ, UK
| | - Andrew Lever
- Department of Infectious diseases,
Addenbrooke’s Hospital, Cambridge CB2 0QQ, UK
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29
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Barnett M, Sinha MD, Morrison D, Lim M. Intracranial hypertension presenting with severe visual failure, without concurrent headache, in a child with nephrotic syndrome. BMC Pediatr 2013; 13:167. [PMID: 24112785 PMCID: PMC3851983 DOI: 10.1186/1471-2431-13-167] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/21/2013] [Accepted: 10/10/2013] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Idiopathic intracranial hypertension is a condition typically characterised by headache, normal level of consciousness, papilloedema and raised cerebrospinal fluid pressure. Children often present with visual loss and atypical features of raised pressure, posing a diagnostic and management challenge. A range of renal disorders can predispose to developing this raised intracranial pressure syndrome. We present a case of severe visual failure in a child with nephrotic syndrome, with no headache when elevated pressure was proven. In nephrotic syndrome, visual failure related to elevated intracranial pressures without concurrent headache symptoms has not been reported previously. CASE PRESENTATION We discuss a 5-year-old Caucasian girl with steroid sensitive nephrotic syndrome who went on to become a late non-responder and presented with intracranial hypertension. Following initial response to steroids, she had a relapse of her nephrotic syndrome; her proteinuria did not resolve on steroid treatment, requiring addition of cyclosporine therapy to manage her nephrotic syndrome. Three months following this, she presented with visual failure in the right eye with bilateral central scotoma and papilloedema. At the time of presentation of visual impairment, she was otherwise well, with no symptoms of a raised intracranial pressure syndrome or associated systemic illness. Medical management was initiated following confirmation of a raised intracranial pressure. Her intracranial pressure remained elevated requiring serial therapeutic lumbar punctures before some improvement in visual acuity was observed. Later in the clinical course, she presented with worsening of her visual impairment with further deterioration of the vision in the left eye, again associated with elevated intracranial pressure. An urgent surgical cerebrospinal fluid diversion procedure was performed. At review, three years after presentation our patient has severe visual impairment with no perception of light in her right eye and 6/36 Snellen acuity in the left secondary to optic atrophy. CONCLUSION Our case demonstrates the occurrence of intracranial hypertension in nephrotic syndrome, highlighting the atypical presentation of severe visual failure without concurrent headache at presentation. This demonstrates the management complexities and the need for clear guidelines for ophthalmological surveillance to aim to reduce permanent visual impairment.
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Affiliation(s)
- Madeleine Barnett
- Children's Neurosciences, Evelina Children's Hospital at Guy's and St Thomas' NHS Foundation Trust, King's Health Partners Academic Health Science Centre, Westminster Bridge Road, London, SE1 7EH, England.
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30
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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: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
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31
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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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32
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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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Abstract
Idiopathic intracranial hypertension (IIH) is a disease of unknown etiology associated with increased intracranial pressure, predominantly affecting obese females of childbearing age. The history of IIH is quite unique, featuring only limited advancements in evidenced-based treatments, but boasting literally countless changes in nomenclature, proposed etiology, and conceptual approach. Despite its elusive pathogenesis, an evolution of our approach to IIH can be traced sequentially through identifiable periods. Contemporary research suggests that we are approaching a new phase in IIH, redefining it as a global neurologic syndrome with more far-reaching effects than previously realized.
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Affiliation(s)
- Kapil G Kapoor
- Department of Ophthalmology and Visual Sciences, University of Texas Medical Branch at Galveston, 301 University Boulevard, Galveston, TX 77550, USA.
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Outcome bei Papillenschwellung im Kindesalter. SPEKTRUM DER AUGENHEILKUNDE 2010. [DOI: 10.1007/s00717-010-0443-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Tibussek D, Schneider DT, Vandemeulebroecke N, Turowski B, Messing-Juenger M, Willems PHGM, Mayatepek E, Distelmaier F. Clinical spectrum of the pseudotumor cerebri complex in children. Childs Nerv Syst 2010; 26:313-21. [PMID: 19902218 DOI: 10.1007/s00381-009-1018-0] [Citation(s) in RCA: 47] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/09/2009] [Indexed: 11/24/2022]
Abstract
PURPOSE Our aim was to improve diagnosis and management of pseudotumor cerebri (PTC; also known as idiopathic intracranial hypertension) in children. METHODS We performed a comprehensive analysis of epidemiology, diagnostic work-up, therapy, and clinical follow-up in 53 consecutive patients. RESULTS We identified several important aspects to be considered in the management of these children. First, patients may present without obvious symptoms at diagnosis. Second, bilateral papilledema might not or not yet be present in symptomatic patients. Third, measurement of cerebrospinal fluid (CSF) opening pressure may not always be reliable due to drugs used for sedation, which may alter intracranial pressure. Fourth, normal CSF pressure values in childhood are not well established and diagnosis might even be justified if pressure is <20 cm H(2)O. Fifth, associated conditions are frequent (at least in our cohort); however, in most cases, a causative link cannot be proven. Finally, disease relapse is a serious problem (20% in our group), which stresses the importance of standardized follow-up programs. CONCLUSIONS PTC constitutes an important and possibly underrecognized disorder in children and adolescents. Considering the high percentage of possibly associated conditions in our study, a detailed diagnostic work-up is crucial to identify treatable underlying conditions.
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Affiliation(s)
- Daniel Tibussek
- Department of General Pediatrics, University Children's Hospital, Heinrich-Heine-University Düsseldorf, Moorenstr. 5, 40225, Düsseldorf, Germany
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Lim MJ, Pushparajah K, Jan W, Calver D, Lin JP. Magnetic resonance imaging changes in idiopathic intracranial hypertension in children. J Child Neurol 2010; 25:294-9. [PMID: 19638638 DOI: 10.1177/0883073809338874] [Citation(s) in RCA: 53] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
To evaluate the usefulness of neuroimaging in children with idiopathic intracranial hypertension, brain magnetic resonance imaging (MRI) scans of children with idiopathic intracranial hypertension and age-matched controls were reviewed. Compared with controls, patients with idiopathic intracranial hypertension had flattening of the posterior sclera in 61% versus 40% of cases, distension of perioptic subarachnoid space in 65% versus 35%, intraocular protrusion of pre-laminar optic nerve in 17% versus 0%, tortuosity of optic nerve in 30% versus 5%, and an empty sella in 26% versus 5% of cases. The presence of 3 or more of the MRI features is 95% specific in predicting idiopathic intracranial hypertension. The observed general anesthetic effect on these neuroimaging features are also minimized when multiple features are taken into account. Magnetic resonance imaging features can assist in suspecting the diagnosis of idiopathic intracranial hypertension in children, provided caution is applied when interpreting imaging performed under a general anesthesia.
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Affiliation(s)
- Ming Jin Lim
- Evelina Children's Hospital, Guys and St Thomas Hospital NHS Foundation Trust, London, United Kingdom.
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Lim MJ, Lin JP. The effects of carbon dioxide on measuring cerebral spinal fluid pressure. Childs Nerv Syst 2009; 25:783-4. [PMID: 19452156 DOI: 10.1007/s00381-009-0902-y] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/25/2009] [Indexed: 11/28/2022]
Abstract
PURPOSE The effects of pCO2 on cerebral spinal fluid (CSF) pressure measurement were observed in four patients. METHODS Children presenting with either a diagnosis or suspected diagnosis of IIH, who were undergoing lumbar puncture under a general anaesthetic for pressure measurement, were recruited to study the relationship between pCO2 and CSF pressure measurements. RESULTS A rise of end-tidal pCO2 by 1 kPa causes a rise of CSF pressure by 3.5-12 cm H20. CONCLUSION Controlling of pCO2 is important when measuring CSF pressure to prevent misdiagnosis and over treatment of patients with idiopathic intracranial hypertension (IIH).
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Affiliation(s)
- Ming Jin Lim
- Paediatric Neurology Department, Evelina Children's Hospital, Guy's and St Thomas' Hospitals NHS Foundation Trust, Lambeth Palace Road, London, SE1 7EH, UK.
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Dhellemmes P, Defoort S, Vinchon M. Hypertension intracrânienne bénigne : place du traitement médical. Neurochirurgie 2008; 54:717-20. [DOI: 10.1016/j.neuchi.2008.10.004] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2007] [Accepted: 12/05/2007] [Indexed: 11/26/2022]
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Ghosh S, Sarkar K, Mukhopadhyay S, Bhaduri G. Idiopathic intracranial hypertension in a child after hemodialysis. Pediatr Neurol 2008; 39:272-5. [PMID: 18805366 DOI: 10.1016/j.pediatrneurol.2008.07.007] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/10/2007] [Revised: 07/14/2008] [Accepted: 07/16/2008] [Indexed: 11/28/2022]
Abstract
Idiopathic intracranial hypertension remains a disease of unknown etiology. Epidemiology, associations, features, and prognosis in children have changed over the years. The main clinical complaint of pediatric idiopathic intracranial hypertension is headache with visual disturbance. We report on a patient with childhood idiopathic intracranial hypertension, who presented without headache after hemodialysis for acute renal failure. Idiopathic intracranial hypertension without headache is believed to have a poor prognosis. However, this child demonstrated a favorable outcome with medical therapy. The child was followed with serial optical coherence tomography of retinal nerve fiber layer thickness around the optic nerve head. In the absence of a reliable procedure to evaluate the therapeutic efficacy in the follow-up of patients with idiopathic intracranial hypertension, the importance of optical coherence tomography, a noninvasive, objective, and reproducible procedure, is highlighted as a useful adjunct in the management of idiopathic intracranial hypertension.
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Abstract
Our understanding of pediatric idiopathic intracranial hypertension has been refined since Dr. Simmons Lessell's review in 1992. The use of rigorous methodologies and standard definitions in recent studies has demonstrated distinct demographic trends. Specifically, the incidence of idiopathic intracranial hypertension seems to be increasing among adolescent children, and among older children its clinical picture is similar to that of adult idiopathic intracranial hypertension (female and obese). Within younger age groups there are more boys and nonobese children who may develop idiopathic intracranial hypertension. The pathogenesis of the disease has yet to be elucidated. Idiopathic intracranial hypertension among young children has been associated with several new etiologies, including recombinant growth hormone and all-trans-retinoic acid. More modern neuroimaging techniques such as MRI and MRI-venograms are being used to exclude intracranial processes. Although most cases of pediatric idiopathic intracranial hypertension improve with medical treatment, those who have had visual progression despite medical treatment have undergone optic nerve sheath fenestration and lumboperitoneal shunting. Because idiopathic intracranial hypertension in young children appears to be a different disorder than in adolescents and adults, separate diagnostic criteria for younger children are warranted. We propose new criteria for pediatric idiopathic intracranial hypertension in which children should have signs or symptoms consistent with elevated intracranial pressure, be prepubertal, have normal sensorium, can have reversible cranial nerve palsies, and have an opening cerebrospinal fluid pressure greater than 180 mm H(2)O if less than age 8 and papilledema is present, but greater than 250 mm H(2)0 if age 8 or above or less than 8 without papilledema.
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Affiliation(s)
- Lubaina M Rangwala
- Neuro-ophthalmology Services of the Children's Hospital of Philadelphia, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania 19104, USA
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Abstract
Idiopathic intracranial hypertension is common in obese women and can lead to significant visual impairment. First described more than 100 years ago, the cause of the disorder remains unknown. Despite a multitude of proposed links, the aetiology has never been established. Impairment of cerebrospinal-fluid reabsorption is the most likely underlying pathophysiological cause of the raised pressure, but this notion has yet to be proven. Cerebral venous sinus abnormalities associated with the disorder need further exploration. Although the major symptoms of headache and visual disturbance are well documented, most data for disease outcome have been from small retrospective case series. No randomised controlled trials of treatment have been done and the management is controversial. The importance of weight loss needs clarification, the role of diuretics is uncertain, and which surgical intervention is the most effective and safe is unknown. Prospective trials to examine these issues are urgently needed.
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Affiliation(s)
- Alex K Ball
- University of Birmingham, Department of Neurology, City Hospital, Birmingham B18 7QH, UK
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Gordon NS. Idiopathic intracranial hypertension. Eur J Paediatr Neurol 2006; 10:1-4. [PMID: 16500124 DOI: 10.1016/j.ejpn.2005.10.005] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/14/2005] [Revised: 10/25/2005] [Accepted: 10/25/2005] [Indexed: 11/21/2022]
Abstract
Idiopathic intracranial hypertension results from cerebral oedema. The symptoms and signs of the condition are reviewed, especially the risks of visual failure if the condition is prolonged without adequate treatment. The most significant symptom in childhood is headache, and the most important sign is papilloedema. The difficulties of diagnosis are discussed, especially the cerebral oedema that can occur on the withdrawal of steroid therapy, and the increased intracranial pressure that may develop with minimal forms of craniostenosis. The causes of intracranial hypertension are many, and include ear infections, venous sinus thrombosis, the use of certain drugs, and as a complication of acute disseminated encephalomyelitis and Cushing's disease, and impaired renal function. The condition may remit spontaneously, but even so a careful watch must be kept on visual acuity. If treatment is needed various drugs can be tried, and if the response is unsatisfactory repeated lumbar punctures will be indicated. It is rarely necessary to consider surgical intervention such as cerebral decompression.
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