RAISED INTRACRANIAL PRESSURE (ICP) IN CHILDREN- ETIOLOGY AND MANAGEMENT.
Introduction:
Increased intracranial pressure (ICP) is a potentially life-threatening emergency. In children, it is most often a complication of traumatic brain injury, hydrocephalus, brain tumors, intracranial infections, idiopathic intracranial hypertension, metabolic and structural causes. Successful management of children with elevated ICP requires prompt recognition and therapy directed at both reducing ICP and reversing its underlying cause
Purpose:
To discuss the etiologies and management of raised intracranial pressure in a series of children who visited a tertiary eye care centre
Methods:
This was a retrospective, hospital-based, observational study conducted at a tertiary care centre in Southern India between the period of January 2013- July 2015. All children, less than 18 years of age that presented to our centre with the diagnosis of raised ICP were included in the study. All patients underwent detailed evaluation by a pediatric ophthalmologist and a pediatric neurologist and/or neurosurgeon (depending on the condition).
The ophthalmologic work-up included visual assessment, dilated fundoscopy, Humphrey visual field perimetry (when age and condition of the patient permitted) and ultrasound B scan of the optic nerve head to assess the size of optic nerve head and to confirm the presence of sub-arachnoid fluid around the optic nerve head. They underwent Magnetic Resonance Imaging (MRI) and Magnetic Resonance Venography (MRV) scan of brain. Lumbar puncture (LP) was performed to measuring opening pressure and to collect sample of the cerebrospinal fluid (CSF) for cellular, chemical and microbiological examination.
17 children, under 18 years, diagnosed with raised ICP based on the Modified Dandy Criteria for benign intracranial hypertension (BIH)were retrospectively reviewed. They underwent a thorough neurological and ophthalmologic examination including MRI of brain and LP for CSF opening pressure. They were divided into 2 groups- Idiopathic intracranial hypertension (IIH) (8 children) and secondary to other causes (9 children).
Results:
There were 17 children who fulfilled the inclusion criteria with 8 children in the IIH group and 9 in the other group. The mean age in IIH group was 10.8 years (1 month-17 years) and 9.4 years (2-17 years) in others group. There was a female predominance seen in either group (87.5% in IIH group and 66.7% in others group). Headache was the presenting complaint in 75% in IIH group and 44.45% in the others group. Some had horizontal diplopia, visual loss, nausea, vomiting and vertigo.(Table 1)
Table 1
Sixth nerve paresis was seen in four children from the IIH group while in three from the other group. Amongst the children in group 1, 2 children had normal optic discs and 1 child was diagnosed with sub-arachnoid fluid on the B-Scan, while all children from the second group showed papilledema of which 2 children had chronic papilledema with disc pallor.
Visual fields could be tested reliably in 6 children from group 1 and 4 children from group 2, showing enlargement of the blind spot, constriction of visual field and bitemporal hemianopia.
All children with IIH were initially managed medically using acetazolamide and steroids. 1 child underwent optic nerve sheath decompression (ONSD) for failing optic disc. In group 2, two children underwent ventriculo-peritoneal shunt and two underwent ONSD or were treated with tumor and cyst excision depending on the cause.
Discussion:
IIH amongst children is mostly seen in post-pubertal children, however we had one infant in our series (1,2). Also, typically there is a male preponderance in the pre pubertal age group while we found female predominance in our series. Pediatric IIH is not commonly associated with obesity versus that seen in adults, which was also seen in our series, wherein only one child was obese. Headache was the most common symptom seen in 75% of our patients, similar to that seen by Distelmaier et al (3). Similarly it is important to note that 25% of our children with IIH did not present with headache. Detection of papilledema is necessary for the diagnosis of IIH amongst adults, however that is not the case in pediatric IIH. We had two children with IIH with normal discs. This was seen in other series as well (4). And this is an important difference between the presentation in adults and children. The disc findings showed improvement from day 3 to 1 month. These findings were similar to previous studies, where majority of children had complete resolution of disc swelling and visual abnormalities after treatment, however 25% still can have visual field deficit and visual acuity(5). None of our patient progressed to optic atrophy.
Conclusion:
Raised ICP in children needs detailed evaluation for the cause and it’sappropriate management toprevent visual loss secondary to optic atrophy.
References:
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