Elevated Intracranial Pressure In Children Research Articles

P.106 Using optic nerve sheath diameter over ventricular size to assess elevated intracranial pressure in pediatric patients with pineal region tumors

Background: Pineal region tumors are a heterogenous group of pathologies often symptomatic due to occlusive hydrocephalus leading to elevated intracranial pressure (ICP). High ICP may not always be associated with clinical signs. A non-invasive technique for assessment of ICP is measuring the optic nerve sheath diameter (ONSD). The goal of this study was to determine the utility of preoperative and postoperative ONSD measurements for assessment of elevated ICP in children with pineal region tumors. Methods: Retrospective data analysis was performed in patients operated for pineal region tumors at our tertiary care center between 2003 and 2022. Preoperative and postoperative MRI scans were reviewed. Clinical data and ONSD at multiple time points were analyzed and correlated. Results: Thirty-four patients with forty operative cases met the inclusion criteria. Hydrocephalus was seen in 80% of patients preoperatively (n=32/40). Presence of hydrocephalus was associated with significantly elevated ONSD preoperatively (p=0.006) and postoperatively (p=0.017). There was significant decrease in ONSD immediately postoperatively (p<0.001), at 3 months (p<0.001) and 12 months (p<0.001). In patients without hydrocephalus, no significant changes in ONSD were observed (p=0.369). Conclusions: ONSD is a useful adjunct for the identification of high ICP preoperatively and evaluation of treatment response postoperatively in patients presenting with pineal region tumors.

Transorbital point-of-care ultrasound versus fundoscopic papilledema to support treatment indication for potentially elevated intracranial pressure in children

PurposeTo compare transorbital point-of-care ultrasound techniques —optic nerve sheath diameter (US-ONSD) and optic disc elevation (US-ODE)— with fundoscopic papilledema to detect potentially raised intracranial pressure (ICP) with treatment indication in children.MethodsIn a prospective study, 72 symptomatic children were included, 50 with later proven disease associated with raised ICP (e.g. pseudotumour cerebri, brain tumour, hydrocephalus) and 22 with pathology excluded. Bilateral US-ONSD and US-ODE were quantified by US using a 12-MHz-linear-array transducer. This was compared to fundoscopic optic disc findings (existence of papilledema) and, in 28 cases, invasively measured ICP values.ResultsThe sensitivity and specificity of a cut-off value of US-ONSD (5.73 mm) to detect treatment indication for diseases associated with increased ICP was 92% and 86.4%, respectively, compared to US-ODE (0.43 mm) with sensitivity: 72%, specificity: 77.3%. Fundoscopic papilledema had a sensitivity of 46% and a specificity of 100% in this context. Repeatability and observer-reliability of US-ODE examination was eminent (Cronbach’s α = 0.978–0.989). Papilledema was detected fundoscopically only when US-ODE was > 0.67 mm; a US-ODE > 0.43 mm had a positive predictive value of 90% for potentially increased ICP.ConclusionIn our cohort, transorbital point-of-care US-ONSD and US-ODE detected potentially elevated ICP requiring treatment in children more reliably than fundoscopy. US-ONSD and US-ODE indicated the decrease in ICP after treatment earlier and more reliably than fundoscopy. The established cut-off values for US-ONSD and US-ODE and a newly developed US-based grading of ODE can be used as an ideal first-line screening tool to detect or exclude conditions with potentially elevated ICP in children.

Venous 3D Phase Contrast Magnetic Resonance Angiography Increases Diagnostic Certainty in Children with Ventriculoperitoneal Shunt and Suspected Shunt Failure

BackgroundClinical symptoms in children with suspected malfunction of ventriculoperitoneal shunt may not be specific and difficult to interpret. The presence or absence of ventricular enlargement on magnetic resonance imaging (MRI) does not reliably predict raised intracranial pressure (ICP) in these patients. Therefore, the aim was to investigate the diagnostic utility of 3D venous phase-contrast MR angiography (vPCA) in these patients.MaterialsThe MR studies of two groups of patients at two different examination dates were retrospectively analyzed; one group without clinical symptoms on both examinations and one with symptoms of shunt dysfunction on one examination receiving surgery. Both MRI examinations had to have been performed including axial T2 weighted (T2-w) images and 3D vPCA. Two (neuro)radiologists evaluated T2-w images alone and in combination with 3D vPCA in terms of suspected elevated ICP. Interrater reliability, sensitivity and specificity were assessed.ResultsCompression of venous sinuses was seen significantly more often in patients with shunt failure (p = 0.00003). Consequently, evaluation of 3D vPCA and T2-w images increases sensitivity to 0.92/1.0 compared to T2-w images alone with 0.69/0.77, the interrater agreement for the diagnosis of shunt failure rises from κ = 0.71 to κ = 0.837. Concerning imaging markers, three groups could be identified in children with shunt failure.ConclusionIn accordance with the literature, the results show that ventricular morphology alone is an unreliable marker for elevated ICP in children with shunt malfunction. The findings confirmed 3D vPCA as a valuable supplemental diagnostic tool improving diagnostic certainty for children with unchanged ventricular size in cases of shunt failure.

Hypertonic Saline vs. Mannitol in Management of Elevated Intracranial Pressure in Children: A Meta-Analysis.

To compare the efficacy and safety of two hyperosmolar agents (hypertonic saline vs. mannitol) used for the reduction of elevated intracranial pressure (ICP) in children. A meta-analysis of randomized controlled trials (RCTs) was conducted and GRADE system (Grading of Recommendations, Assessment, Development and Evaluation) of evidence was applied. Relevant databases were searched till 31st May 2022. Primary outcome was mortality rate. Of 720 citations retrieved, 4 RCTs were included in the meta-analysis (n = 365, male = 61%). Traumatic and non-traumatic cases of elevated ICP were included. There was no significant difference in the mortality rate between the two groups [relative risk (RR), 1.09; (95% confidence interval (CI), 0.74 to 1.6)]. No significant difference was found for any of the secondary outcomes, except serum osmolality (being significantly higher in mannitol group). Adverse events like shock and dehydration were significantly higher in the mannitol group, and hypernatremia in the hypertonic saline group. The evidence generated for primary outcome was of "low certainty", and for secondary outcomes, it varied from "very-low to moderate certainty". There is no significant difference between hypertonic saline and mannitol used for the reduction of elevated ICP in children. The evidence generated for primary outcome (mortality rate) was of "low certainty", and for secondary outcomes, it varied from "very-low to moderate certainty". More data from high-quality RCTs are needed to guide any recommendation.

Hypertonic Saline Solution Compared to Mannitol for the Management of Elevated Intracranial Pressure in Children: A Systematic Review

Objective: To explore the effectiveness of commonly used dosing for mannitol (MN) compared with hypertonic saline solution (HSS) in children with elevated intracranial pressure (ICP) due to diabetic ketoacidosis (DKA), head trauma, or acute central nervous system (CNS) infections. Methods: We followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. A structured literature review was carried out using the component of the PICO framework. The literature search was conducted in Medline, Ovid, Embase, Google Scholar, and PubMed. A combination of relevant search terms was used. Electronic searches were supplemented by manual searches of references of included studies and review articles. The duplicate citations were identified and removed. Results: A total of 169 articles were identified through the searches, while 8 articles met the inclusion criteria. The characteristics and results of included studies were discussed, regarding the study design, sample size, and outcome. Conclusions: Osmotic agents, such as HSS and MN are commonly used in the management of high ICP. HSS (3% or 7.5%) has superior therapeutic effects over MN (20%) in lowering increased ICP in children with cerebral edema. Key Words: Cerebral edema, Increased intracranial pressure, Children, Osmotic agents, Mannitol, hypertonic saline solution, systematic review, PRISMA.

The management of elevated intracranial pressure and sinus vein thrombosis associated with mastoiditis: the experience of eighteen patients.

Cerebral sinus vein thrombosis (CSVT) associated with acute mastoiditis is a rare complication of acute otitis media. Elevated intracranial pressure (ICP) frequently occurs secondary to CSVT. The study aims to review the 5years of experience of four medical centres to treat sigmoid sinus thrombosis and elevated intracranial pressure in children. Patients with CSVT that developed secondary mastoiditis from 2016 through 2021 were evaluated in four centres from Turkey. Patients diagnosed with a preceding or synchronous mastoiditis and intracranial sinus thrombosis were included in the study. Magnetic resonance imaging (MRI), magnetic resonance venography (MRV), ICP measurements, ophthalmological examinations, thrombophilia studies and treatments for increased ICP have also been recorded. The study group comprises 18 children. Twelve patients were diagnosed with right-sided, six patients with left-sided sinus vein thrombosis. All of the patients had ipsilateral mastoiditis. The most common presenting symptoms were fever, ear pain, headache, visual disorders and vomiting. The most encountered neurologic findings were papilledema, strabismus and sixth cranial nerve palsy. ICP was over 20cm H2O in eleven patients. Anticoagulant treatment, antibiotics, pressure-lowering lumbar puncture and lumboperitoneal shunt were among the treatment modalities. Elevated ICP can damage the brain and optic nerve irreversibly, without treatment. For treating elevation of ICP associated with cerebral sinus thrombosis, pressure-lowering lumbar puncture (LP), acetazolamide therapy, optic nerve sheath fenestration (ONSF) and cerebrospinal fluid (CSF)-shunting procedures are suggested in case of deteriorated vision.

Optical Coherence Tomography for Assessment of Elevated Intracranial Pressure in Sagittal Craniosynostosis

INTRODUCTION: Children with early diagnosis of isolated sagittal craniosynostosis are candidates for spring-mediated cranioplasty or endoscopic-assisted strip craniectomy. Neurocognitive developmental differences are seen in some children with craniosynostosis, and elevated intracranial pressure (ICP) has been correlated to a lower intelligence. However, no studies have evaluated ICP in children with craniosynostosis younger than 6 months of age. Optical coherence tomography (OCT) of the peripapillary retina is a recently validated noninvasive quantitative modality to predict ICP elevations in pediatric patients with craniosynostosis. The purpose of this study was to utilize OCT data to better understand the incidence of elevated ICP in infants undergoing early surgical correction for sagittal craniosynostosis. METHODS: OCT measurements were obtained in patients undergoing spring-mediated cranioplasty for sagittal craniosynostosis. OCT parameters analyzed included the maximal retinal nerve fiber layer thickness and maximal anterior projection using the OCT cross-section that corresponded most closely to the center of the optic disc.1,2 Previous investigation demonstrated that OCT parameters for predicting ICP elevation above 15 mm Hg required maximal retinal nerve fiber layer thickness thickness of 159.8 µm and maximal anterior projection of 129.1 µm.2 This combination yielded a sensitivity of 77.3% and specificity of 95.0%. Previous investigation demonstrated that OCT parameters for predicting ICP elevation above 20 mmHg required maximal retinal nerve fiber layer thickness thickness of 170.6 µm and maximal anterior projection of 138.3 µm.2 This combination yielded a sensitivity of 90.0% and specificity of 81.3%. RESULTS: Seventy-two patients underwent corrective surgery for sagittal craniosynostosis with OCT scans available. In total, 48.6% (n = 35) patients were younger than 6 months, 15.3% (n = 11) patients were aged between 6 and 12 months, and 36.1% (n = 26) patients were 12 months or older. Retinal parameter measurements demonstrated ICP < 15 mm Hg in 88.6% (n = 31 of 35) patients <6 months of age. Compared with these children, significantly fewer patients were in the age of 6–12 months (54.5%, n = 6 of 11, P = 0.025) and in the age of ≥12 months (46.2%, n = 12 of 26, P < 0.001) had ICP < 15 mm Hg. Retinal parameter measurements demonstrated ICP < 20 mm Hg in 91.4% (n = 32 of 35) patients aged <6 months. Compared with these children, significantly fewer patients were in the age of 6–12 months (54.5%, n = 6 of 11, P = 0.013), and those aged ≥12 months (53.8%, n = 14 of 26, P = 0.001) had ICP < 20 mm Hg. Directly measured intracranial pressure was inversely correlated to the cephalic index (P = 0.009) such that patients with more severe scaphocephaly had a higher intracranial pressure. CONCLUSIONS: The vast majority of patients undergoing early intervention for sagittal craniosynostosis do not have elevated intracranial pressure by OCT measurement, whereas those older than 6 months of age have a significantly higher incidence of elevated intracranial pressure. REFERENCES: 1. Swanson JW, et al. Evaluation of optical coherence tomography to detect elevated intracranial pressure in children. JAMA Ophthalmol. 2017;135(4):320–328. 2. Kalmar CL, et al. Elevated intracranial pressure in patients with craniosynostosis by optical coherence tomography. Plast Reconstr Surg. In press.

Effect of hypertonic saline in the management of elevated intracranial pressure in children with cerebral edema: A systematic review and meta-analysis

Objective:To determine the hypertonic saline efficacy in children with cerebral edema and raised intracranial pressure.Method:Studies assessing the efficacy and safety of hypertonic saline in children with cerebral edema and elevated intracranial pressure were identified using Medline, Web of Science, Scopus, and Google Scholar databases. Two reviewers independently assessed papers for inclusion. The primary outcome was a reduction of elevated intracranial pressure by the administration of hypertonic saline.Results:We initially evaluated 1595 potentially relevant articles, and only 7 studies met the eligibility criteria for the final analysis. Out of the seven studies, three of them were randomized controlled trials. Three of the studies found that hypertonic saline significantly reduced elevated intracranial pressure compared to control. One study reported a resolution of the comatose state as a measure of reduced intracranial pressure. It also found a significantly higher resolution of coma in the hypertonic saline group rather than the control. Three studies reported that the reduction of intracranial pressure was comparable between the groups. The random-effects model using pooled estimates from four studies showed no difference in hypertonic saline and conventional therapy mortality outcomes. Hypertonic saline was administered as bolus-only therapy at a rate of 1–10 mL/kg/dose over 5 min to 2 h and or bolus followed by infusion therapy (0.5–2 mL/kg/h). One study reported a twofold faster resolution of high intracranial pressure following hypertonic saline administration compared to controls. The re-dosing schedule varied greatly in all included studies. However, three studies reported adverse events but not methodically, and there were no reports on neurological sequelae.Conclusion:Hypertonic saline appears to reduce intracranial pressure in children with cerebral edema. However, we cannot draw a firm conclusion regarding the safest dose regimens of hypertonic saline, including the safe and effective therapeutic hypernatremia threshold in the management of raised intracranial pressure with cerebral edema. Future clinical trials should focus on the appropriate concentration, dose, duration, mode of administration, and adverse effects of hypertonic saline to standardize the treatment.

Is Ocular Sonography a Reliable Method for the Assessment of Elevated Intracranial Pressure in Children?

Point-of-care ultrasound has been widely used by clinicians at the bedside in recent years. Various types of point-of-care ultrasound practices are employed, especially in pediatric emergency rooms and intensive care units. Pediatric intensive care specialists perform point-of-care ultrasound virtually as a part of physical examination since it provides just-in-time vital clinical information, which could assist in acute management strategies in critically ill patients. Measurement of optic nerve sheath diameter using point-of-care ultrasound is a noninvasive and radiation-free technique to determine raised intracranial pressure. Ophthalmic artery and central retinal artery Doppler indices can be used as transcranial Doppler to assess raised intracranial pressure. The aim of this review was to provide detailed information on ultrasonographic measurements of optic nerve sheath diameter and central retinal artery Doppler indices as techniques of interest for predicting increased intracranial pressure in pediatric patients in view of the literature.

23.4% Hypertonic Saline and Intracranial Pressure in Severe Traumatic Brain Injury Among Children: A 10-Year Retrospective Analysis.

To explore the effect of 23.4% hypertonic saline for management of elevated intracranial pressure in children admitted to our institution for severe traumatic brain injury. Single-center, retrospective medical chart analysis. A PICU at a level 1 pediatric trauma center in the United States. Children admitted for severe traumatic brain injury from 2006 to 2016 who received 23.4% hypertonic saline and whose intracranial pressures were measured within 5 hours of receiving 23.4% hypertonic saline. None. Over the 10-year period, 1,587 children were admitted for traumatic brain injury, 155 of whom were deemed severe per this study's criteria. Forty of these children received at least one dose of hypertonic saline, but 14 were excluded for insufficient intracranial pressure data. Among the remaining 26 children, one hundred one 23.4% hypertonic saline boluses were used in the analysis. Use of 23.4% hypertonic saline was associated with a decrease in intracranial pressure of approximately 7 mm Hg at both within 1 hour after the bolus (p < 0.01) and 4 hours after the bolus (p < 0.01) when compared with the intracranial pressure measured within 1 hour before the hypertonic saline bolus. These effects remained significant after adjusting for Functional Status Scale score and CT Marshall scores. There was no statistically significant association between adjunctive therapies, such as antiepileptics and analgesics, and changes in intracranial pressure. There was no laboratory evidence of hyperkalemia or renal injury after use of 23.4% hypertonic saline. Across all hospitalizations, 65% of the study population demonstrated an abnormally elevated creatinine at least once, but only three episodes of acute kidney injury occurred in total, all before hypertonic saline administration. Eight of the 26 children in this analysis died during their hospitalization. The Functional Status Scale scores ranged from 6 to 26 with a mean of 12.2 and SD of 5.7. Use of 23.4% hypertonic saline with children admitted for severe traumatic brain injury is associated with a statistically significant decrease in intracranial pressure within 1 hour of use.

Thresholds for identifying pathological intracranial pressure in paediatric traumatic brain injury

Intracranial pressure (ICP) monitoring forms an integral part of the management of severe traumatic brain injury (TBI) in children. The prediction of elevated ICP from imaging is important when deciding on whether to implement invasive ICP monitoring for a patient. However, the radiological markers of pathologically elevated ICP have not been specifically validated in paediatric studies. Here in, we describe an objective, non-invasive, quantitative method of stratifying which patients are likely to require invasive monitoring. A retrospective review of patients admitted to Cambridge University Hospital’s Paediatric Intensive Care Unit between January 2009 and December 2016 with a TBI requiring invasive neurosurgical monitoring was performed. Radiological biomarkers of TBI (basal cistern volume, ventricular volume, volume of extra-axial haematomas) from CT scans were measured and correlated with epochs of continuous high frequency variables of pressure monitoring around the time of imaging. 38 patients were identified. Basal cistern volume was found to correlate significantly with opening ICP (r = −0.53, p < 0.001). The optimal threshold of basal cistern volume for predicting high ICP (ge 20 mmHg) was a relative volume of 0.0055 (sensitivity 79%, specificity 80%). Ventricular volume and extra-axial haematoma volume did not correlate significantly with opening ICP. Our results show that the features of pathologically elevated ICP in children may differ considerably from those validated in adults. The development of quantitative parameters can help to predict which patients would most benefit from invasive neurosurgical monitoring and we present a novel radiological threshold for this.

Early Detection of Central Nervous System Relapse of Pediatric Leukemia with Measurement of Optic Nerve Sheath Diameter on MRI

Leukemia is the most common pediatric malignancy. Central Nervous System (CNS) is the most frequently involved extramedullary location at diagnosis and at relapse. To determine if Magnetic Resonance Imaging (MRI) findings of optic nerves should contribute to early detection of CNS relapse in pediatric leukemia. Twenty patients (10 boys, 10 girls; mean age 8,3 years, range 4-16 years) with proven CNS relapse of leukemia followed up between 2009 and 2017 in our institution were included. Orbital MRI exams performed before and during CNS relapse were reviewed retrospectively. Forty optic nerves with Optic Nerve Sheaths (ONS) and Optic Nerve Heads (ONH) were evaluated on fat-suppressed T2-weighted TSE axial MR images. ONS diameter was measured from the point 10 mm posterior to the globe. ONS distension and ONH configuration were graded as 0, 1 and 2. Before CNS relapse, right mean ONS diameter was 4.52 mm and left was 4.61 mm which were 5.68 mm and 5.66 mm respectively during CNS relapse showing a mean increase of 25% on right and 22% on left. During CNS relapse, ONS showed grade 0 distension in 15%, grade 1 in 60%, grade 2 in 25% and ONH demonstrated grade 0 configuration in 70%, grade 1 in 25% and grade 2 in 5% of the patients. MRI findings of optic nerves may contribute to diagnose CNS relapse by demonstrating elevated intracranial pressure in children with leukemia.

Pediatric Pseudotumor Cerebri Syndrome.

Idiopathic intracranial hypertension, otherwise known as primary pseudotumor cerebri syndrome (PTCS), most frequently occurs in obese women of childbearing age. However, children may be affected as well. This review will address recent findings regarding demographics, diagnosis, and treatment of pediatric PTCS. Prepubertal children with primary PTCS have an equal sex distribution and less frequent obesity compared with adult patients. However, female gender and obesity are risk factors for primary PTCS in postpubertal children. Compared with adults, children with PTCS more frequently present with ocular motility deficits and more often have associated medical conditions that increase the risk of developing PTCS. Visual field testing may be unreliable, and the optimal modality to monitor visual function is unknown. MRI shows signs of elevated intracranial pressure (ICP) in children with PTCS similar to that of adults. It has now been established that elevated ICP in children ≤18 years old is greater than 25 cm H20 in nonobese, nonsedated children, and greater than 28 cm H2O in the remainder. Optical coherence tomography (OCT) may be used to distinguish pseudopapilledema from papilledema, monitor response to treatment in preverbal children, and identify patients with PTCS at risk for permanent visual loss. However, the precise role of OCT in the management of pediatric PTCS remains to be determined.

Evaluation of Optical Coherence Tomography to Detect Elevated Intracranial Pressure in Children

Detecting elevated intracranial pressure in children with subacute conditions, such as craniosynostosis or tumor, may enable timely intervention and prevent neurocognitive impairment, but conventional techniques are invasive and often equivocal. Elevated intracranial pressure leads to structural changes in the peripapillary retina. Spectral-domain (SD) optical coherence tomography (OCT) can noninvasively quantify retinal layers to a micron-level resolution. To evaluate whether retinal measurements from OCT can serve as an effective surrogate for invasive intracranial pressure measurement. This cross-sectional study included patients undergoing procedures at the Children's Hospital of Philadelphia from September 2014 to June 2015. Three groups of patients (n = 79) were prospectively enrolled from the Craniofacial Surgery clinic including patients with craniosynostosis (n = 40). The positive control cohort consisted of patients with hydrocephalus and suspected intracranial hypertension (n = 5), and the negative control cohort consisted of otherwise healthy patients undergoing a minor procedure (n = 34). Spectral-domain OCT was performed preoperatively in all cohorts. Children with cranial pathology, but not negative control patients, underwent direct intraoperative intracranial pressure measurement. The primary outcome was the association between peripapillary retinal OCT parameters and directly measured elevated intracranial pressure. The mean (SD) age was 34.6 (45.2) months in the craniosynostosis cohort (33% female), 48.9 (83.8) months in the hydrocephalus and suspected intracranial hypertension cohort (60% female), and 59.7 (64.4) months in the healthy cohort (47% female). Intracranial pressure correlated with maximal retinal nerve fiber layer thickness (r = 0.60, P ≤ .001), maximal retinal thickness (r = 0.53, P ≤ .001), and maximal anterior retinal projection (r = 0.53, P = .003). Using cut points derived from the negative control patients, OCT parameters yielded 89% sensitivity (95% CI, 69%-97%) and 62% specificity (95% CI, 41%-79%) for detecting elevated intracranial pressure. The SD-OCT measures had high intereye agreement (intraclass correlation, 0.83-0.93) and high intragrader and intergrader agreement (intraclass correlation ≥0.94). Conventional clinical signs had low sensitivity (11%-42%) for detecting intracranial hypertension. Noninvasive quantitative measures of the peripapillary retinal structure by SD-OCT were correlated with invasively measured intracranial pressure. Optical coherence tomographic parameters showed promise as surrogate, noninvasive measures of intracranial pressure, outperforming other conventional clinical measures. Spectral-domain OCT of the peripapillary region has the potential to advance current treatment paradigms for elevated intracranial pressure in children.

Hypertonic Saline: Safe therapy for Children with cute Brain Insult in Emergency Department of Low and Middle Income Country

Hypertonic saline (HTS) has been used for some years to treat elevated intracranial pressure in children in high income countries. There is limited safety data from low and middle income countries. Objective: The primary objective of this study was to assess the immediate response and safety of intravenous administration of hypertonic saline in children with acute brain injury presenting to the pediatric emergency department (PED) of Aga Khan University Hospital (AKUH). The secondary outcomes were changes in outcome- predictive physiological parameters. Methods: A retrospective, chart review of children who received intravenous HTS in the pediatric emergency department of AKU between January 2013 and December 2013 to treat acute brain injury (ABI). We studied both changes in physiological parameters and adverse effects related to HTS therapy. Results: In the period studied, 216 children received intravenous bolus of 3% HTS as part of their initial management in the PED. The median age of the patients was 6.1 years (1 month to 16 years) and a median dose of 5 mL/kg with 98% of doses given via peripheral line between 30 minutes to one hour. Diagnosis included traumatic brain injury in 110 patients (50.9%) and non-traumatic injury 106 (49.1%) including CNS infection (43.4%), intracranial bleeding (7.5%), acute hepatic failure (10.4%), diabetic ketoacidosis with altered mental status (4.7%). Clinical indications included: depressed consciousness (75.5%), seizures (24%) and shock (0.5%). Significant improvement was observed in both heart rate (p value < 0.05) and GCS (p value=0.001) after 3% HTS therapy No adverse events related to the HTS or its route of administration were noted in any child. Conclusion: We found 3% HTS was safe in children with acute brain injury traumatic or non–traumatic brain injury.

Intracranial Pressure Monitoring in Infants and Young Children With Traumatic Brain Injury.

To examine the use of intracranial pressure monitors and treatment for elevated intracranial pressure in children 24 months old or younger with traumatic brain injury in North Carolina between April 2009 and March 2012 and compare this with a similar cohort recruited 2000-2001. Prospective, observational cohort study. Twelve PICUs in North Carolina. All children 24 months old or younger with traumatic brain injury, admitted to an included PICU. None. The use of intracranial pressure monitors and treatments for elevated intracranial pressure were evaluated in 238 children with traumatic brain injury. Intracranial pressure monitoring (risk ratio, 3.7; 95% CI, 1.5-9.3) and intracranial pressure therapies were more common in children with Glasgow Coma Scale less than or equal to 8 compared with Glasgow Coma Scale greater than 8. However, only 17% of children with Glasgow Coma Scale less than or equal to 8 received a monitoring device. Treatments for elevated intracranial pressure were more common in children with monitors; yet, some children without monitors received therapies traditionally used to lower intracranial pressure. Unadjusted predictors of monitoring were Glasgow Coma Scale less than or equal to 8, receipt of cardiopulmonary resuscitation, nonwhite race. Logistic regression showed no strong predictors of intracranial pressure monitor use. Compared with the 2000 cohort, children in the 2010 cohort with Glasgow Coma Scale less than or equal to 8 were less likely to receive monitoring (risk ratio, 0.5; 95% CI, 0.3-1.0), although the estimate was not precise, or intracranial pressure management therapies. Children in the 2010 cohort with a Glasgow Coma Scale less than or equal to 8 were less likely to receive an intracranial pressure monitor or hyperosmolar therapy than children in the 2000 cohort; however, about 10% of children without monitors received therapies to decrease intracranial pressure. This suggests treatment heterogeneity in children 24 months old or younger with traumatic brain injury and a need for better evidence to support treatment recommendations for this group of children.

Pediatric pseudotumor cerebri.

Recent findings in the literature regarding the epidemiology, diagnosis, and treatment of pediatric pseudotumor cerebri (PTC) are described. In the past, children with PTC have been treated like adult cases; however, the literature highlights important differences between children and adults with PTC. Revised diagnostic criteria define an opening cerebrospinal fluid pressure greater than 28 cm water as elevated in the pediatric population. Obesity is an important risk factor for primary and secondary PTC in post-pubertal children. Magnetic resonance imaging shows findings suggestive of elevated intracranial pressure in children with PTC, similar to those of adults with PTC. Diamox and weight loss are effective treatments for PTC patients with mild visual field loss. Severe papilledema, decreased vision, and optical coherence tomography measures at presentation identify patients at increased risk for subsequent visual loss. Findings summarized in the recent literature may change practice patterns in the diagnosis and treatment of pediatric PTC. Although there are many similarities between the adult and pediatric populations, the differences should be considered when managing children with PTC.

PS-148a Does Obstructive Sleep Apnea Contribute To Elevated Intracranial Pressure In Children With Syndromic Craniosynostosis? A Prospective Cohort Study

Background and aims Children with syndromic or complex craniosynostosis have a prevalence of 68% of obstructive sleep apnea (OSA), which has been associated with an increased risk for developing elevated intracranial pressure (ICP). The objective of this study was to evaluate how often and to what extend OSA increases the risk of elevated ICP in patients with syndromic and complex craniosynostosis and to prospectively evaluate our current clinical treatment protocol. Methods A prospective observational cohort study of patients with syndromic or complex craniosynostosis treated at the Sophia Children’s Hospital, started in January 1st 2007. All patients received repeated sleep studies and fundoscopy (to evaluate papilledema as proxy for elevated ICP), according to a standardised protocol. Results Sixty-two patients underwent full analysis, with a mean age at time of latest follow-up of 6.0 years. Mean age at first presentation of papilledema was 1.9 years (range 0.4–6.0). Twenty-three of 62 patients (37.1%) had papilledema, of whom 13 (21.0%) pre-operative. Thirty-nine of 62 (62.9%) patients had OSA. Compared to patients without OSA, papilledema was not more frequently present in patients with mild or moderate OSA. However, patients with severe OSA had pre-operatively significantly more often papilledema (p = 0.015). Conclusions Children with syndromic craniosynostosis are at risk of elevated ICP due to a complex interaction of risk factors. The relationship between mild and moderate OSA and elevated ICP is weak, however in individual patients OSA may be the decisive factor. Severe OSA significantly increases the risk of elevated ICP.

Optimal timing of autologous cranioplasty after decompressive craniectomy in children

The object of this study was to determine if early cranioplasty after decompressive craniectomy for elevated intracranial pressure in children reduces complications. Sixty-one consecutive cases involving pediatric patients who underwent autologous cranioplasty after decompressive craniectomy for raised intracranial pressure at a single academic children's hospital over 15 years were studied retrospectively. Sixty-one patients were divided into early (< 6 weeks; 28 patients) and late (≥ 6 weeks; 33 patients) cranioplasty cohorts. The cohorts were similar except for slightly lower age in the early (8.03 years) than the late (10.8 years) cranioplasty cohort (p < 0.05). Bone resorption after cranioplasty was significantly more common in the late (42%) than the early (14%) cranioplasty cohort (p < 0.05; OR 5.4). No other complication differed in incidence between the cohorts. After decompressive craniectomy for raised intracranial pressure in children, early (< 6 weeks) cranioplasty reduces the occurrence of reoperation for bone resorption, without altering the incidence of other complications.

Chapter 11. Barbiturates

Chapter 11. Barbiturates