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.

Comparision between 3% Hypertonic Saline and 20% Mannitol in the Management of Raised Intracranial Pressure in Children

Background Osmotic agents like mannitol and hypertonic saline are the mainstay of management of raised intracranial pressure (ICP) along with non-pharmacological measures like head elevation, hyperventilation, and hypothermia and CSF drainage. Several recent studies have shown hypertonic saline relatively superior to mannitol however, both are being used commonly. So, this study was done to compare the efficacy of mannitol and hypertonic saline in management of raised ICP in children. Methods This was a prospective randomized comparative study done among 40 children aged 1-5 years admitted in department of Pediatrics and Adolescent Medicine, BPKIHS, Dharan with clinical signs and symptoms of raised ICP They were divided into two groups based on consecutive sampling with group 1 receiving 20% mannitol and group 2 receiving 3% hypertonic saline. Results Both the groups were comparable for age distribution, gender and baseline characteristics. Pretreatment mean MAP was higher in group 2 as compared to group 1 while decrease in MAP was present in both groups at 24, 36-, 48-, 56- and 60-hours post-treatment; however, this was not statistically significant. 78.9% cases improved with mannitol while 90.5% improved with 3% hypertonic saline but this was not statistically significant. Conclusion Hypertonic saline can be an equally effective agent for management of raised ICP in children but larger and multi-centric study may help in determining which one is better.

Enhancing Diagnostic Accuracy Through Neuroimaging Revisions in Pediatric Pseudotumor Cerebri Syndrome: A Cross-Sectional Study

BackgroundThis cross-sectional study aimed to report all neuroimaging findings suggestive of raised intracranial pressure in children with pseudotumor cerebri syndrome (PTCS), before and after re-review by two neuroradiologists. MethodsWe included 48 children aged <18 years diagnosed with PTCS between 2016 and 2021. Clinical and radiological data were obtained from their medical files. Two neuroradiologists independently re-reviewed all neuroimages, and the average of their assessments was compared with the initial neuroimaging reports; an additional review was done to analyze inter- and intraclass correlation. ResultsThe initial neuroimaging reports showed under-reporting of findings, with only 26 of 48 (54.1%) patients identified with abnormal reports. After revision, the proportion of the reported findings increased to 44 of 48 (91.6%). Distention of the perioptic space was the most commonly reported finding after revision (36.5 of 48; 76%). Flattening of the posterior globe and empty sella were initially under-reported but improved after revision. Moreover, several findings suggestive of increased intracranial pressure not mandated by Friedman criteria were identified, such as narrowing of the Meckel cave, posterior displacement of the pituitary stalk, and narrowing of the cavernous sinus. Analysis of associations between neuroimaging findings and demographic and clinical characteristics yielded no statistically significant results. The inter- and intraclass correlation results demonstrated a significant agreement between raters and within each rater's assessment (P < 0.05). ConclusionsThis study highlights the impact of image revision in enhancing PTCS diagnosis. Intra- and interclass correlations underscore the reliability of the review process, emphasizing the importance of meticulous image analysis in clinical practice.

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.

Effects of osmotic diuretics at the water-electrolyte metabolism in the management of children with traumatic intracranial hypertension

Introduction. A comparative study on the effects of osmotic diuretics (OD) at parameters of water-electrolyte metabolism in children with brain injury was conducted. The researchers analyzed these effects depending on the treatment algorithm whether it was done by the Protocol or by generally accepted indications. Material and methods. 51 case-histories of children with severe, combined TBI were taken for the analysis. The patients were treated with osmotic diuretics (OD) to relieve intracranial hypertension (ICH). All patients were divided into two groups: Group 1 ( studied group) – 25 children enrolled prospectively. In this group, OD were administered according to the Protocol. Group 2 (control group) – 26 children (retrospective group). In this group, OD was administered according to the accepted clinical recommendations. Results. As it has been revealed, OD in the control group (Group 2) were used 8.7 % more often than in patients from Group 1 at Step 3 of the Protocol. In patients from Group 2, hypernatremia and hyperosmolarity had more persistent and pronounced type; such tendency persisted for the next 5–7 days of the study. However, there were no statistically significant differences between the groups in average values of sodium levels and osmolarity of blood plasma under ICH therapy. The conducted statistical analysis has shown that the lack of reliable differences is associated with a significant variance of analyzed indicators in Group 2. At the same time, we registered a statistically significant increase (p 0.05) of unfavorable outcomes in Group 2 by 24.9 %. Conclusion. Regular and rationally frequent administration of osmotic diuretics leads to less persistent violations of water-electrolyte metabolism. A prerequisite for the effective management of traumatic ICP in children is monitoring the intracranial pressure (ICP) and cerebral perfusion pressure (CPP).

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.

Sensitivity of Papilledema as a Sign of Increased Intracranial Pressure

Our study evaluates the sensitivity of papilledema as a sign of high intracranial pressure in children. Patients younger than 18 years old, diagnosed with increased ICP, and who had received dilated fundus examination between 2019 and 2021 were retrospectively reviewed. Factors including the patient's age, sex, aetiology, duration of signs or symptoms, intracranial pressure (ICP), and presence of papilledema were evaluated. We included 39 patients in this study, whose mean age was 6.7 years. The 31 patients without papilledema had a mean age of 5.7 years, and 8 patients (20%) with papilledema had a mean age of 10.4 (p < 0.037). The mean duration of signs or symptoms was nine weeks in patients without papilledema and seven weeks in those with papilledema (p = 0.410). The leading causes of increased ICP with papilledema were supratentorial tumor (12.5%), infratentorial tumor (33.3%), and hydrocephalus (20%) (p = 0.479). Papilledema was statistically significantly more common in older patients. We found no statistical significance between sex, diagnosis, and symptoms. The relatively low incidence of papilledema (20%) in our study shows that papilledema's absence does not ensure the absence of increased ICP, especially in younger patients.

Optic Nerve Ultrasound Evaluation in Children: A Review.

Managing patients with neurocritical illness requires monitoring and treating elevated intracranial pressure (ICP), especially in cases in children. In terms of precise and real-time measurements, invasive ICP measurements are presently the gold standard for the initial diagnosis and follow-up ICP assessments. As a rapid and non-invasive way to detect elevated ICP, point-of-care ultrasonography (POCUS) of optic nerve sheath diameter (ONSD) has been proposed. The utility of bedside POCUS of ONSD to detect elevated ICP with excellent diagnostic test accuracy in adults has already been demonstrated. Nonetheless, data on the relationship between POCUS of ONSD and ICP in children are scarce. Therefore, the purpose of this review is to point out the most recent findings from the pediatric published literature and briefly discuss what was assessed with ONSD ultrasound examination, and also to describe and discuss the diagnostic procedures available for optic nerve ultrasound appraisal. A search of the medical databases PubMed and Scopus was carried out. The terms such as "ocular ultrasonography", "ICP assessment", "children", "point-of-care ultrasound", and "POCUS" were searched. In conclusion, the use of the standardized A-scan technique coupled with the B-scan technique should be suggested to provide data that are as accurate, precise, repeatable, and objective as possible.

Comparison of 3% Hypertonic Saline and Mannitol in the Management of Children with Raised Intracranial Tension: A Research Protocol

Introduction: Raised Intracranial Tension (ICT) is a common medical emergency with varied aetiology. Immediate medical or surgical intervention is mandated in most cases. Conservatively, osmotherapy with 3% Hypertonic Saline (HTS) or Mannitol is the mainstay to reduce raised ICT. Additionally, the patient may also need surgical intervention along with osmotherapy. The need for the study: Cerebral oedema and raised ICT in children and its treatment protocol are under-estimated and need further research and study in terms of identification of the condition and the choice of osmotherapy, which is the cornerstone in treating raised ICT among others. Aim: To analyse the role of 3% HTS and mannitol and their individual efficacy in reducing intracranial pressure in children. Materials and Methods: An open-labeled, prospective study, where alternately patients between the age group of one month to 16 years admitted to the Pediatric Intensive Care Unit (PICU) of a designated tertiary care hospital situated in the state of Maharashtra, in India from November 2020 to October 2022, diagnosed to have or showing signs and symptoms of raised ICT will be given 3% HTS or Mannitol after considering the exclusion criteria for each if any will be conducted. The patient will be treated with a fixed dose of either drug as pre-decided by the principal investigator and the secondary investigator and the patient will be monitored within the next hour for immediate effects and improvement in the clinical state of the patient as well as the immediate general outcome in terms of vitals and sensorium and final outcome in terms of discharge rate with neuromorbidity, if any, or resulting death in patients treated with either drug will be noted. The chi-square test, Fischer’sexact test for categorical data, and independent t-test for continuous data with normal distribution will be used to assess the relationship between various demographic, clinical, and aetiological characteristics and outcomes. The parameters that will be compared are sensorium, heart rate, respiratory rate and pattern, and Blood Pressure (BP) at admission. The above parameters will be monitored immediately after infusion of osmotherapy and the final outcome, as mentioned above, of patients on either of the drugs will be noted. The p-value of less than 0.05 will be considered significant.

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.

Cerebrospinal Fluid Shunting in Children with Hydrocephalus and Increased Intracranial Pressure Secondary to Human Immunodeficiency Virus–Related Cryptococcal Meningitis

Hydrocephalus and increased intracranial pressure secondary to human immunodeficiency virus-related cryptococcal meningitis are rare in children. The role and outcomes of cerebrospinal fluid (CSF) shunting in children are not well reported. We report our experience with CSF shunting in the management of this condition in children over a 14-year period. This was a retrospective review of data collected from a single neurosurgery unit. Data collected included demographics, clinical characteristics, Glasgow Coma Scale score, lumbar puncture opening pressure, antiretroviral therapy, laboratory results, neuroimaging findings, shunting procedures, complications, and mortality. Seventeen children underwent CSF shunting. Median age was 10 years (range, 6-13), most being male (76%). All children were on antiretroviral therapy. Median Glasgow Coma Scale score was 15 (interquartile range [IQR], 14-15). Clinical characteristics included headaches (100%), visual impairment (82%), and seizures (47%). Lumbar puncture opening pressure was >30 cm H2O in 88% of children. Median CD4 count was 45 cells/μL (IQR, 17-56). Computed tomography brain scans showed hydrocephalus in 14 children (82%). Surgical procedures included ventriculoperitoneal shunts (82%) and lumboperitoneal shunts (18%). Shunt complications included infection (18%) and obstruction (18%). Staphylococcus aureus was cultured in all infections. Median follow-up was 45 months (IQR, 7.5-74). Three children (18%) died during the admission period. Ten children (59%) were alive at 1 year follow-up. This study is the largest series reporting on CSF shunting of hydrocephalus and increased intracranial pressure in children with human immunodeficiency virus-related cryptococcal meningitis. Treatment with ventriculoperitoneal shunt and lumboperitoneal shunt regardless of the CD4 count is an important option in suitable children to reduce mortality.

Posterior Calvarial Distraction in older paediatric population: single centre paediatric neurosurgery craniofacial unit outcomes.

Posterior calvarial distraction (PCD) is a safe and effective technique used to increase cranial vault volume and therefore reduce intracranial pressure in children with complex craniosynostosis. Optimal timing and method used for PCD is controversial. This procedure is usually performed in children younger than 2years. Literature regarding calvarial distraction in older children is sparse and limited. We report our single-centre experience with PCD in children aged 6 and above to outline the applications, benefits and challenges of employing this technique in an older paediatric population. A retrospective analysis of a database on craniofacial cases from 2006 to 2021 was performed. Patients undergoing PCD were identified and children aged 6 and above at the time of operation were included. Data on demographics and clinical outcomes were obtained from electronic records and relevant imaging was reviewed. All cases were reviewed prior to a decision for surgery by the multidisciplinary craniofacial team (composed of neurosurgery, maxillofacial and plastics teams) and underwent surgery in our paediatric craniofacial centre. Overall, 98 PCD cases were identified during the study period, of which 20 cases were identified as having undergone PCD at age 6 or above with mean age of 8.8years (range 6-18). The most common indication was pansynostosis associated with raised intracranial pressure. Four cases had calvarial remodelling previously and represented with symptoms of raised intracranial pressure sometime after their initial surgery requiring PCD as rescue procedure. Average duration of inpatient stay was 5.85days. The average duration of follow-up was 3.5years (0.3 to 11years). Mean distraction distance achieved was 22.5mm (18-29mm). Five patients experienced complications related to wound infection or distractor. Follow-up assessment in all patients demonstrated evidence of vault expansion and symptomatic improvement and resolution of intracranial pressure signs. Comparison with younger cohort did not reveal any difference in any parameters except lower rate of transfusion in the older cohort compared to young cohort (5% vs 38%). Posterior calvarial distraction in older children is safe and effective for vault expansion and treatment of raised intracranial pressure in selected cases. A multidisciplinary craniofacial team approach is crucial for appropriate case selection and management in order to optimise outcomes.

The role of sonographic optic nerve sheath diameter measurements in pediatric head trauma.

To determine the accuracy of bedside sonographic measurements of optic nerve sheath diameter (ONSD) and ONSD/eyeball transverse (ETD) diameter ratios to predict space-occupying lesions (SOLs) or elevated intracranial pressure (ICP) in pediatric head trauma. Children who presented to the emergency department with head trauma and underwent cranial computed tomography (CT) were enrolled and examined by ocular ultrasonography (US), and the ONSD was measured at 3mm posterior to the globe and ETD were measured. Ratios of ONSD at 3mm/ETD were calculated. All ONSD measurements and ratios were calculated from cranial CT images. Subjects with elevated ICP had increased ONSD measurements and ratios. To predict elevated ICP, the AUC for ONSD at 3mm was 0.956 (95% CI 0.896-1). At a cut-off level of 5.1mm, the sensitivity and specificity of ONSD 3mm values for elevated ICP were 92.9% and 94.0%. For the ONSD 3mm/ETD ratio, it was 0.980 (95% CI 0.959-1). At a cut-off level of 0.22, the sensitivity and specificity were 100% sensitivity and 88.0%. All sonographic ONSD measurements and ratios were significantly correlated with readings calculated from cranial CT images. Sonographic ONSD measurements and ratios were found to be quite sensitive to detect elevated ICP on cranial CT images. Additionally, there was a significant correlation between measurements calculated by ocular US and cranial CT scans. Bedside ocular US seems to be a promising and useful tool to determine ICP in children with head trauma.

Educational Nursing Strategies for the Management of Increased Intracranial Pressure in Children with Neurological Injury at Pediatric Intensive Care Units

Educational Nursing Strategies for the Management of Increased Intracranial Pressure in Children with Neurological Injury at Pediatric Intensive Care Units

A RARE PRESENTATION OF BILATERAL PAPILLEDEMA WITHOUT HYDROCEPHALUS: A CASE REPORT

Generally intracranial tumors causing bilateral papilledema present with hydrocephalus. The lack of hydrocephalus despite extensive and aggressive tumor spread make this case unique to report. We report a case of 11-year-old girl who presented with left sided headache with visual deterioration and bilateral fundoscopy on fundus examination. Magnetic resonance imaging (MRI) revealed an extra axial intracranial mass in the middle cranial fossa compressing the ventricles and the orbit. Even though there was ventricular compression and midline shift, the patient had bilateral papilledema without hydrocephalus. It is thought that the papilledema developed by some other mechanism and is not connected with hydrocephalus. Raised intracranial pressure in children can be due to Idiopathic intracranial hypertension (pseudotumor cerebri) or due to a secondary cause like meningitis, structural defects, tumors as seen in this case. Therefore, fundus examination is important in pediatric patients presenting with headache as papilledema may be the rst sign of an intracranial tumor with or without hydrocephalus.

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.

A Comparative Study of Hypertonic Saline V/S Mannitol in Raised Intracranial Pressure in Children Aged Between 02 to 12 Years

Raised intracranial pressure, the most common problem encountered in critical care unit, is often end result of various neurological disorders1. It is an important independent prognostic factor1 Most of the available therapies in the management of raised intracranial pressure in children are like double edged sword. Hence this study was undertaken, to know the efficacy, safety, complications and outcome of Osmotherapies (hypertonic saline v/s Mannitol). This study was carried out in children aged between 02-12 years, admitted to paediatric critical care Unit in the Department of paediatric, at Vijayanagar institute of medical sciences Ballari, from January-16 to December-16 with features of raised ICP. 50 children were randomly given. Hypertonic saline (HTS) and 50 were given mannitol. Following parameters compared n results drawn: symptomatology, GCS, papilledema, pupillary reactions after 72 hrs of administration and effects on serum electrolytes, urea n creatinine, and osmolarity. We found that out of 50 children who were onmannitol therapy, 12 children needed HTS for sustained reduction of ICP beyond 72 hours (p=0.056). Improvement in GCS was better with use of mannitol (p=0.024) during first 72 hours compared to HTS. Increase in serum sodium levels were seen with use of HTS which was statistically significant (p=0.064). But mortality in both groups was similar. Hence, we concluded that mannitol was a better drug to be used in first 72 hrs but for sustained reduction of ICP beyond 72 hrs hts was better option.

Possible additional MRI markers for critical brain swelling with increased intracranial pressure in children?

A retrospective study was performed evaluating the volume and T2/T1 signal intensity of orbital fat in five children diagnosed with severe global brain swelling and confirmed cessation of cerebral perfusion. Imaging showed a volume increase (five of five) and a heterogeneous T2-hypointensity of orbital fat (four of five). This preliminary study suggests that swelling and T2-hypointensity of orbital fat may be a marker of global brain swelling and/or increased intracranial pressure.