• Neuro-Ophthalmology/Orbit

    This case study and literature review found pediatric cerebrospinal fluid opening pressure (CSFOP) should be interpreted with other clinical findings to help the physician make a well-informed assessment of whether a child has elevated intracranial pressure.

    Understanding the reference range of CSFOP in children is essential to the diagnosis of elevated intracranial pressure. However, recent studies have highlighted several clinical elements that need to be considered when interpreting CSFOP measures.

    The authors reviewed peer-reviewed literature, primarily from the past decade, and their own clinical and research experience to come up with recommendations on interpreting CSFOP measures.

    Their literature review covered how the current “normal” pediatric CSFOP range was established, and the factors affecting CSFOP, including age, body mass index, sedation and patient positioning.

    They also looked at one of their own cases in which a 12-year-old boy presented with three months of unremitting holocephalic headache and an unremarkable comprehensive neuro-ophthalmologic examination without papilledema. After sedated lumbar puncture, his CSFOP was 28 cm H2O and, on awakening, the child stated he had relief of headache. But his headache returned the next day, so he was placed on topiramate.

    One month later, he underwent a second lumbar puncture with a CSFOP of 27 cm H2O, resulting in one day of headache relief. Neuro-ophthalmologic examination and MRI remained normal with no objective findings suggestive of elevated intracranial pressure (ICP).

    Despite continued therapy, the child’s headache persisted, although repeated neuro-ophthalmologic examinations and MRI remained normal. A third lumbar puncture demonstrated a CSFOP of 28 cm H2O. Given the lack of therapeutic benefit from medications, an ICP monitor was placed and revealed consistently normal readings (12 cm H2O) over a 48-hour period. Because the child did not meet all of the necessary criteria for idiopathic intracranial hypertension, he was diagnosed as having chronic daily headache.

    The authors write that this case highlights both the inaccuracy of CSFOP measures by lumbar puncture and inherent variability of intracranial pressure. It further reinforces that a single CSFOP value should not be considered in isolation and as the sole determinant of elevated intracranial pressure. When the CSFOP is below 28 cm H2O, the clinician should be reassured that the subject likely does not have elevated intracranial pressure, especially in the absence of other objective findings. If clinical suspicion of elevated intracranial pressure persists, a follow-up examination is recommended.

    They conclude that in children whose CSFOP is greater than 28 cm H2O, it is not recommended that the value be classified as “abnormal,” but instead the clinician should assess both the clinical findings and the circumstances of the lumbar puncture (i.e., sedation, sedation medications, body mass index, and patient agitation during the puncture).  Although a strict cutoff above or below 28 cm H2O can be useful for research purposes, it certainly will not apply to all children.