AUTHOR AND EDITOR INFORMATION

Section 1 of 9  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• References

INTRODUCTION

Section 2 of 9  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• References

Background

Pseudotumor cerebri (PTC) or idiopathic intracranial hypertension is characterized by signs and symptoms of increased intracranial pressure (ICP) without identifiable cause. PTC typically occurs among obese women of childbearing age. Although prevalence among the pediatric population is not known, the condition is not uncommon among the young. In children younger than 6 years, a specific cause for intracranial hypertension can usually be identified. These patients would therefore not be classified as having PTC. Idiopathic cases are usually seen after age 11 years.

Children with PTC usually complain of headaches and may have vomiting, blurred vision, and horizontal diplopia. The headaches are diffuse, worse at night, and often aggravated by sudden movement. Less common complaints include irritability, transitory visual loss, dizziness, and tinnitus.

As in adults, treatment is designed to decrease intracranial pressure and preserve vision.

Pathophysiology

The precise mechanism of ICP in PTC is unknown. Factors probably important in the pathogenesis include CSF production, venous sinus pressure, and CSF absorption. The importance of venous sinus pressure is seen in young children who develop thrombosis of one or more of the dural sinuses usually as a complication of otitis or mastoiditis. Evidence exists to suggest that CSF formation in PTC is probably diminished. This may be related to increased resistance to absorption at the arachnoid villi. This would be consistent with studies showing the frequent finding of elevated sagittal sinus pressure.

Evidence for each mechanism has been documented in the literature. Radioisotope cisternography has demonstrated a 3- to 5-fold decrease in CSF absorption. Although controversial, histologic evidence of vasogenic brain edema has been observed in brain biopsy specimens from a small number of patients. Increased intracranial blood volume also has been shown in several studies. Malm et al provided a long-term study of CSF dynamics in 17 patients older than 15 years using a constant pressure infusion method. The authors concluded that these patients had evidence of reduced conductance to CSF flow; however, it was insufficient to explain the increase in CSF pressure. No significant difference in rate of CSF production was noted between patients with PTC and controls. They also found that sagittal sinus pressure was elevated in over half of their patients, which was attributed to increased brain water content causing compression of venous outflow.

Hormonal influences appear to play some role in the pathogenesis of PTC. In postpuberal patients, the condition is distinctly more common among females. Obesity is a well-recognized risk factor.

Studies have suggested a relationship with nonspecific infections, minor head injury, withdrawal from cortical steroid therapy, vitamin A, acne treatment, and certain antibiotics (tetracyclines). On rare occasion, severe iron deficiency anemia, endocrinopathies, and CO₂ retention have been implicated.

Frequency

United States

Epidemiologic studies in children are not available. The annual incidence among all adults in the United States appears to be 0.9 per 100,000; 3.5 per 100,000 females; and 13-19 per 100,000 obese females.

International

• 1.7 per 100,000 incidence in Libya
• 3.5 per 100,000 incidence in adult women

Mortality/Morbidity

• Mortality rate associated with PTC is no higher than in the general population.
• The only major morbidity is visual loss. The incidence of visual loss among children with PTC is unknown. Among all patients some degree a permanent visual loss can be seen in approximately 10% of all cases.

Sex

A strong predilection exists for women after puberty.

Age

PTC is most common among women of childbearing age. PTC has been reported in early infancy. Typically, a specific cause can be identified among young children.

CLINICAL

Section 3 of 9  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• References

History

Common signs and symptoms of PTC in the young include headache, vomiting, blurred vision, and diplopia.

• Headaches are intermittent, diffuse, worse at night, may awaken the child, and often aggravated by sudden movement.
• Visual disturbances include visual obscurations, blurred vision, double vision, and photophobia. Diplopia is almost always horizontal (side by side) and is secondary to paresis of the sixth cranial nerve. It has been estimated that up to 50% of children with PTC have sixth cranial nerve dysfunction.
• Other signs of increased intracranial pressure include lethargy, irritability, and vomiting.
• Nonspecific associated symptoms include neck stiffness, tinnitus, dizziness, clumsiness, and paresthesias.

Physical

• The neurologic examination is typically normal with the exception of papilledema and weakness of one or both of the abducens nerves.
• Other cranial nerve palsies have been reported on rare occasion.
• General medical examination may reveal signs of otitis media or mastoiditis and therefore raise the possibility of venous sinus thrombosis. The presence of acne vulgaris should prompt on inquiry about the possible use of retinoic acid or tetracyclines. Physical findings of adrenal or thyroid dysfunction may also be present.
• Papilledema: Funduscopic examination reveals optic disk nerve swelling (papilledema). Diagnosis should not be made in the absence of papilledema unless the patient has optic atrophy. Papilledema is typically bilateral but may be asymmetrical or unilateral. Visual acuity is usually preserved helping one to distinguish acute papilledema from optic neuritis.

Causes

Many conditions are associated with PTC in children, none of which are convincingly causative, with the exception of medications.

• Following medications may be associated with PTC:
• • Retinoic acid
  • Antibiotics - Tetracycline, nitrofurantoin, fluoroquinolones
  • Hormones - Steroid use or withdrawal (even topical use), oral contraceptives, L-thyroxine
  • Vitamin A
  • Lithium
  • Immunizations - In one case report, development of PTC in a 7-month-old following DTP immunization
• Refeeding and weight gain in nutritionally deprived children (eg, cystic fibrosis)
• Endocrine abnormalities: These include adrenal dysfunction and Addison disease, hypothyroidism or hyperthyroidism, hypocalcemia due to vitamin D deficiency or hypoparathyroidism, and panhypopituitarism.

DIFFERENTIALS

Section 4 of 9  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• References

Other Problems to be Considered

Abducens (CN VI) nerve palsy

WORKUP

Section 5 of 9  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• References

Lab Studies

• Diagnosis of PTC is made after exclusion of other causes of increased intracranial pressure such as mass lesions, particularly involving the midline (medulloblastoma), and causes of recurrent or chronic headache such as migraine and hydrocephalus.
• Laboratory studies should include a workup for underlying endocrine abnormalities, if indicated by a thorough history and physical examination.

Imaging Studies

• Brain imaging: MRI of the brain with MR venogram (MRV) is preferred. In children, CT scan of the head should be avoided when possible to minimize radiation exposure. The addition of MRV should enable one to exclude thrombosis of one of the major venous sinuses. Stenosis of the transverse sinus is a common finding in PTC but is probably the result of increased intracranial pressure. The MRI of the brain is normal but may show relatively small ventricles.
• Brain imaging should be obtained prior to performing a diagnostic lumbar puncture. Careful measurements of opening and closing pressures should be obtained.

Other Tests

• Assessment of the visual system
• • Visual field testing
  • Visual acuity assessment
• Serial photographs of the fundus may be taken for follow-up.

Procedures

• Lumbar puncture
• • Performing lumbar puncture (LP) in children can be challenging and difficult; sedation may be required. CSF pressure may be elevated falsely in the crying child. Also, no consensus exists on what constitutes the upper limit of normal for different age groups. In their review, Soler et al gave the following values:
    • 0-2 years - 75 mm H₂O
    • 2-5 years - 135 mm H₂O
  • Other sources cite the upper limit of normal in children as 200 mm H₂O.
  • Diurnal variations in CSF pressure are seen; therefore, the pressure measured at any given time may not reflect the peaks. CSF pressure may be normal in patients with florid papilledema. If the diagnosis of PTC is suspected, then repeat LP or prolonged pressure monitoring (ie, Camino catheter or lumbar pressure catheter) should be considered.
  • The diagnosis of PTC requires that the CSF be of normal composition (ie, cell count, protein, glucose).

TREATMENT

Section 6 of 9  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• References

Medical Care

Sometimes, the symptoms of PTC resolve with the initial "diagnostic" LP. If this occurs no further medical treatment is required. Acetazolamide and steroids are the mainstays of the medical treatment of PTC.

• Acetazolamide is administered in initial doses of 25 mg/kg/day and the dose titrated upward until clinical response is attained (maximum dose 100 mg/kg/day). Electrolytes must be monitored to evaluate for the development of hypokalemia and acidosis. If the patient remains on treatment for more than 6 months, renal ultrasound should be ordered to look for the presence of renal calculi.
• If acetazolamide is ineffective then prednisone can be given at a dose of 2 mg/kg/day for 2 weeks followed by a 2-week taper.
• A low-salt diet and weight reduction has been shown to be helpful in adult patients. If the child is obese, weight reduction may be beneficial.
• The authors have had some anecdotal experience of a dramatic response with topiramate in adults with PTC. Topiramate functions as a carbonic anhydrase (CA) inhibitor and has proven to be efficacious in the treatment of headache. This medication may prove to be useful is selected children with PTC.
• Repeat LP may help in some patients but its invasiveness and difficulty in children make it a less than ideal medical therapy. Reduction in pressures is transient.

Surgical Care

Indications for surgical intervention in the treatment of PTC are severe deterioration in vision and incapacitating headaches despite aggressive medical management. Two surgical procedures, lumboperitoneal shunting (LPS) and optic nerve sheath fenestration (ONSF), have a place in the treatment of PTC.

• Lumboperitoneal shunting
• • LPS may relieve headache and reduce ICP in patients with PTC.
  • The long-term visual outcome of patients treated with LPS is unknown.
  • Complications of LPS include infection and shunt obstruction. Low-pressure headaches have also been reported to develop as a result of LPS.
• Optic nerve sheath fenestration
• • ONSF has been shown to improve visual outcome.
  • ONSF has a better outcome in the patient with acutely decompensating vision and papilledema. The authors prefer optic nerve fenestration to a lumboperitoneal shunting.

Consultations

• Neuro-ophthalmology
• Pediatric neurology

Diet

Low-salt diet and weight loss may be beneficial. The authors' experience suggests that weight loss is difficult to achieve in the overweight adolescent.

MEDICATION

Section 7 of 9  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• References

Medications used in the treatment of PTC include acetazolamide and steroids.

Drug Category: Carbonic anhydrase inhibitors

CA is an enzyme found in many tissues of the body, including the eye. These agents catalyze a reversible reaction in which carbon dioxide becomes hydrated and CA dehydrated.

Drug Category: Corticosteroids

These agents have anti-inflammatory properties and cause profound and varied metabolic effects. Corticosteroids modify the body's immune response to diverse stimuli.

FOLLOW-UP

Section 8 of 9  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• References

Further Outpatient Care

• Neuro-ophthalmology follow-up with frequent assessment of visual fields is indicated.

In/Out Patient Meds

• See Medication section.

Complications

• As mentioned above, the most serious complication is permanent visual loss and blindness.

Prognosis

• The natural history of PTC in childhood is poorly understood.
• Some children respond to initial LP alone.
• Visual loss can occur at any point in the disease and no reliable predictive factors are associated with this complication.

Patient Education

• Patient and parental education as to the seriousness of permanent visual loss should be given. Early intervention in rapidly declining visual function is crucial to improve the long-term visual outcome.

REFERENCES

Section 9 of 9

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• References

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Article Last Updated: Jul 19, 2006