Idiopathic Intracranial Hypertension in a Young Child Without Visual Symptoms or Signs

Abstract

A 7-year-old boy presented with a 4-week history of daily headache. His parents reported that he was unable to attend school the week prior to presentation. Intermittent nausea without vomiting was reported, but no blurred vision, photophobia, or diplopia were described. There was no history of trauma or recent systemic illness. The physical examination showed mild neck discomfort, no papilledema, and normal cranial nerve, motor and sensory functioning. Both a CT scan of the sinuses and an MRI of the brain were normal. Although the opening pressure was elevated, the cerebrospinal fluid was also normal. In previous accounts idiopathic intracranial hypertension in children, concomitant papilledema, visual symptoms and/or palsy of the sixth cranial nerve are described. This case demonstrates that idiopathic intracranial hypertension in a young child can present as a daily headache without any visual symptoms or signs. Key words: idiopathic intracranial hypertensionAbbreviations: IIH idiopathic intracranial hypertension (Headache 1996;36:574-576) Idiopathic intracranial hypertension (pseudotumor cerebri) (IIH) is traditionally defined as a syndrome that satisfies the following criteria: (1) clinical manifestations of raised intracranial pressure, (2) normal cerebrospinal fluid (CSF) analysis, and (3) the absence of space-occupying lesions with normal or small ventricles on neuroimaging studies of the brain. Either unilateral or bilateral papilledema is assumed to be present. Double vision caused by abducens palsy may be present, but the remainder of the neurological examination should be unremarkable. In a study of children with IIH, Dhiravibulya et al reported papilledema in 96%, blurred vision in 57%, abducens palsy in 48%, and visual impairment in 45%. 1 Here we describe a young child with IIH without any visual symptoms or signs, and the outcome of medical management. CASE HISTORYA 7-year-old boy presented with a 4-week history of daily, bifrontal, progressive headaches. During the first 3 weeks, the headaches had fluctuated from mild to moderate. In the week prior to presentation, the headaches had been severe, and he had been unable to attend school. No reports of blurred vision, photophobia, phonophobia, or diplopia could be elicited either from the parents or child by interview. There was no history of recent trauma or systemic illness. Intermittent nausea without vomiting was reported, however, and the headache had not responded to acetaminophen or ibuprofen.The parents reported that the child began to have headaches at 5 years of age. The headaches were bifrontal, lasting 1 to 2 hours and occurring at 1-to 2-month intervals. There was no associated photophobia or phonophobia, although there was nausea without vomiting. The headaches responded to acetaminophen and/or sleep.The patient's prenatal and natal histories were unremarkable. No exposure to environmental toxins was reported. The patient had a postnatal pyloric stenosis, which was repaired at 6 weeks of age. Otherwise, the past medical history was...

Long-term evolution of papilledema in idiopathic intracranial hypertension: observations concerning two cases

“…However, its absence does not exclude IIH 2,13,[18][19][20][21][22] . Paralysis of the abducent nerve, trochlear and facial paralysis 23 are also common findings.…”

MR Imaging of Papilledema and Visual Pathways: Effects of Increased Intracranial Pressure and Pathophysiologic Mechanisms

“…27 The ophthalmoscopic appearance of IIH is most often characterized by bilateral ON head swelling, but this can be subtle and variable. [28][29][30][31][32][33] Furthermore, papilledema may be asymmetric or unilateral, 33,34 and the degree of ON head swelling is poorly correlated with ICP.…”

“…22 On the other hand, intracranial hypertension can occur without the presence of papilledema. [28][29][30][31][32]35 Possibly, MR imaging could assess the presence of intracranial hypertension before the development of papilledema. According to Hansen and Helmke, 4 there is a correlation between the width of the ONS and increased ICP.…”

Pediatric Idiopathic Intracranial Hypertension (Pseudotumor Cerebri)

“…Asymptomatic IIH, diagnosed when papilledema is incidentally noted during a routine physical exam, has become a recognized entity in younger children [9,22,23,24,25,26]. These children are asymptomatic and apart from headache management, they receive the same treatment as those with symptoms.…”