Sensitivity of papilledema as a sign of shunt failure in children

Nazir, Sayeda A.; O'Brien, Mark S.; Qureshi, Nazer H.; Slape, Lamonda; Green, T.J.; Phillips, Paul H.

doi:10.1016/j.jaapos.2008.08.003

Cited by 53 publications

(55 citation statements)

References 12 publications

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“…These findings are consistent with the anecdotal but extensive experience ofophthalmologists who have examined children with increased ICP over decades. [17][18][19] The RHs observed in association with raised ICP were not consistent with the severe hemorrhagic retinopathy seen in many victims of AHT (Fig 2). Even when children had severe papilledema and markedly elevated OP, the RHs were neither widespread nor numerous, were not present in the peripheral retina, and did not even extend throughout the posterior pole of the fundus.…”

Section: Discussionmentioning

confidence: 82%

Patterns of Retinal Hemorrhage Associated With Increased Intracranial Pressure in Children

Binenbaum¹,

Rogers

Forbes³

et al. 2013

Pediatrics

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WHAT'S KNOWN ON THIS SUBJECT: Retinal hemorrhage (RH) is an important sign of pediatric abusive head trauma. Raised intracranial pressure (ICP) is sometimes proposed as an alternate cause of RH in children being evaluated for possible child abuse.WHAT THIS STUDY ADDS: Nontraumatic, markedly elevated ICP rarely causes RH in children. When it does, RH are superficial intraretinal and located adjacent to a swollen optic nerve head. This pattern does not match the widespread pattern seen in abusive head trauma. abstract OBJECTIVE: Raised intracranial pressure (ICP) has been proposed as an isolated cause of retinal hemorrhages (RHs) in children with suspected traumatic head injury. We examined the incidence and patterns of RHs associated with increased ICP in children without trauma, measured by lumbar puncture (LP). METHODS:Children undergoing LP as part of their routine clinical care were studied prospectively at the Children' s Hospital of Philadelphia and retrospectively at Nationwide Children' s Hospital. Inclusion criteria were absence of trauma, LP opening pressure (OP) $20 cm of water (cm H 2 O), and a dilated fundus examination by an ophthalmologist or neuro-ophthalmologist. RESULTS:One hundred children were studied (mean age: 12 years; range: 3-17 years). Mean OP was 35 cm H 2 O (range: 20-56 cm H 2 O); 68 (68%) children had OP .28 cm H 2 O. The most frequent etiology was idiopathic intracranial hypertension (70%). Seventy-four children had papilledema. Sixteen children had RH: 8 had superficial intraretinal peripapillary RH adjacent to a swollen optic disc, and 8 had only splinter hemorrhages directly on a swollen disc. All had significantly elevated OP (mean: 42 cm H 2 O). CONCLUSIONS:Only a small proportion of children with nontraumatic elevated ICP have RHs. When present, RHs are associated with markedly elevated OP, intraretinal, and invariably located adjacent to a swollen optic disc. This peripapillary pattern is distinct from the multilayered, widespread pattern of RH in abusive head trauma. When RHs are numerous, multilayered, or not near a swollen optic disc (eg, elsewhere in the posterior pole or in the retinal periphery), increased ICP alone is unlikely to be the cause. Pediatrics 2013;132:e430-e434 AUTHORS:

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Section: Discussionmentioning

confidence: 82%

Patterns of Retinal Hemorrhage Associated With Increased Intracranial Pressure in Children

Binenbaum¹,

Rogers

Forbes³

et al. 2013

Pediatrics

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“…Studies have confirmed the absence of extensive RHs caused by increased ICP. 55,56 In 1 study there was no correlation between signs of increased ICP and RHs in SBS. 10 If hemorrhages were caused by CRV compression, one would expect to see RH patterns of CRV obstruction (CRVO), a well-known and easily recognized ophthalmic entity in which severe intraretinal and preretinal RHs radiate out centripetally from the optic nerve, with dilated and tortuous retinal veins.…”

Section: Increased Icpmentioning

confidence: 84%

Retinal Hemorrhage in Abusive Head Trauma

2010

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Retinal hemorrhage is a cardinal manifestation of abusive head trauma. Over the 30 years since the recognition of this association, multiple streams of research, including clinical, postmortem, animal, mechanical, and finite element studies, have created a robust understanding of the clinical features, diagnostic importance, differential diagnosis, and pathophysiology of this finding. The importance of describing the hemorrhages adequately is paramount in ensuring accurate and complete differential diagnosis. Challenges remain in developing models that adequately replicate the forces required to cause retinal hemorrhage in children. Although questions, such as the effect of increased intracranial pressure, hypoxia, and impact, are still raised (particularly in court), clinicians can confidently rely on a large and solid evidence base when assessing the implications of retinal hemorrhage in children with concern of possible child abuse.

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“…3). In the literature, the sensitivity of papilledema for increased ICP ranges from 14 to 40 % [11,12]. Steffen et al showed that in 37 patients with acute elevated ICP due to hemorrhage or trauma, papilledema was an uncommon occurrence [45]; this, however, may be related to the pathophysiology of papilledema, and perhaps the duration of elevated ICP was insufficient to cause clinically apparent papilledema.…”

Section: Fundoscopymentioning

confidence: 99%

“…The eye as an extension of the central nervous system (CNS) has been traditionally used as a monitor of ICP through the exam of the optic nerve head during dilated fundus examinations. The subjective nature of this assessment leads to variable or low reliability as a predictor of ICP [11][12][13]. These noninvasive modalities assess either the three-dimensional structure of the brain, skull, ventricles, optic disk, or optic nerve, or the function of cerebral blood flow or nerve conduction, each of which can be related to the ICP.…”

Section: Introductionmentioning

confidence: 99%

Noninvasive methods of detecting increased intracranial pressure

Gerety

Alemán

et al. 2016

Childs Nerv Syst

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The detection of elevated intracranial pressure (ICP) is of paramount importance in the diagnosis and management of a number of neurologic pathologies. The current gold standard is the use of intraventricular or intraparenchymal catheters; however, this is invasive, expensive, and requires anesthesia. On the other hand, diagnosing intracranial hypertension based on clinical symptoms such as headaches, vomiting, and visual changes lacks sensitivity. As such, there exists a need for a noninvasive yet accurate and reliable method for detecting elevated ICP. In this review, we aim to cover both structural modalities such as computed tomography (CT), magnetic resonance imaging (MRI), ocular ultrasound, fundoscopy, and optical coherence tomography (OCT) as well as functional modalities such as transcranial Doppler ultrasound (TCD), visual evoked potentials (VEPs), and near-infrared spectroscopy (NIRS).

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Sensitivity of papilledema as a sign of shunt failure in children

Cited by 53 publications

References 12 publications

Patterns of Retinal Hemorrhage Associated With Increased Intracranial Pressure in Children

Patterns of Retinal Hemorrhage Associated With Increased Intracranial Pressure in Children

Retinal Hemorrhage in Abusive Head Trauma

Noninvasive methods of detecting increased intracranial pressure

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