Treatment Response in Pediatric Patients With Pseudotumor Cerebri Syndrome

Pseudotumor cerebri syndrome (PTCS) is a disorder defined by increased intracranial pressure in the absence of an intracranial space-occupying lesion. This retrospective study aimed to examine the outcomes in children with PTCS. Data was collected retrospectively from the charts of consecutive pediatric patients treated for PTCS at our hospital between 2000 and 2007 (60 patients; 36 females, 24 males). Forty-six patients (76.6%) responded well to acetazolamide therapy, with full resolution of symptoms, including papilledema (average treatment duration 1 year; range: 1 month-5 years). Of the 14 patients with no response to treatment, 9 (23.4%) required surgical intervention. Nonresponders tended to be younger at presentation (8.7 vs 11.5 years, P = 0.04). Twelve patients (26%) experienced relapse after acetazolamide was discontinued. The group that experienced relapse was significantly younger than the nonrelapsers (8.9 vs 12.1 years, P < 0.05). Younger age at presentation with PTCS was found to be a risk factor for treatment failure or relapse.

Original Contribution Treatment Response in Pediatric Patients With Pseudotumor Cerebri Syndrome Eliel Tovia, MD, Shimon Reif, MD, Asaf Oren, MD, Alexis Mitelpunkt, MD, Aviva Fattal-Valevski, MD, MHA Background: Pseudotumor cerebri syndrome (PTCS) is a disorder defined by increased intracranial pressure in the absence of an intracranial space-occupying lesion. This retrospective study aimed to examine the outcomes in children with PTCS. Methods: Data was collected retrospectively from the charts of consecutive pediatric patients treated for PTCS at our hospital between 2000 and 2007 (60 patients; 36 females, 24 males). Results: Forty-six patients (76.6%) responded well to acetazolamide therapy, with full resolution of symptoms, including papilledema (average treatment duration 1 year; range: 1 month-5 years). Of the 14 patients with no response to treatment, 9 (23.4%) required surgical intervention. Nonresponders tended to be younger at presentation (8.7 vs 11.5 years, P = 0.04). Twelve patients (26%) experienced relapse after acetazolamide was discontinued. The group that experienced relapse was significantly younger than the nonrelapsers (8.9 vs 12.1 years, P , 0.05). Conclusions: Younger age at presentation with PTCS was found to be a risk factor for treatment failure or relapse. Journal of Neuro-Ophthalmology 2017;37:393-397 doi: 10.1097/WNO.0000000000000516 © 2017 by North American Neuro-Ophthalmology Society P seudotumor cerebri syndrome (PTCS) is a disorder associated with increased intracranial pressure in the absence of clinical, laboratory, or radiologic evidence of an intracranial space-occupying lesion (1-4). The diagnosis is established according to the modified Dandy criteria (1). The annual incidence among adults in the United States seems to be 0.9 per 100,000; 3.5 per 100,000 females; and Pediatrics Department (ET, SR, AO) and Pediatric Neurology Unit (AM, AFV), Tel Aviv Sourasky Medical Center, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel. The authors report no conflicts of interest. Address correspondence to Aviva Fattal-Valevski, MD, MHA, Pediatric Neurology Unit, Dana-Dwek Children's Hospital, Tel Aviv Medical Center, 6 Weizmann Street, Tel Aviv 64239, Israel; E-mail: [e-mail] Tovia et al: J Neuro-Ophthalmol 2017; 37: 393-397 13-19 per 100,000 obese females (5). In a Canadian study, the prevalence in the pediatric population was found to be 1/100,000 with equal sex distribution (6). The precise terminology for PTCS remains unsettled (7). If the disorder occurs without any identifiable risk factors, the terms primary PTCS or idiopathic intracranial hypertension (IIH) are applied. In contrast, if a predisposing factor is present (e.g. minocycline use, cerebral venous sinus thrombosis), it is designated secondary PTCS. Previous studies have reported that the clinical profile of pediatric PTCS differs from that of adults, suggesting that the precipitating factors and the outcome may be different in children (8-10). In addition to appropriate management of any risk factors, acetazolamide is the mainstay of the medical treatment of PTCS (11). Disease relapse during and after discontinuation of treatment was reported to be 20% in one study (7). Indications for surgical intervention in the treatment of PTCS include deterioration in vision and incapacitating headaches or relapse of headaches despite aggressive medical management. Two surgical procedures, optic nerve sheath fenestration and cerebrospinal fluid shunting (lumboperitoneal and ventriculoperitoneal shunt), have a place in the treatment of PTCS. Unlike adult patients with PTCS, in whom the procedure choice is generally dictated by the predominant complaint (visual deterioration or headache), in pediatric patients, the guidelines for surgical intervention are less clear (11). The natural history of PTCS in childhood is poorly understood. Of the few studies on treatment, most were focused on visual acuity, visual fields, and papilledema (5,7,8). Our aim was to investigate the response to treatment and relapse in pediatric patients with PTCS 2 years after diagnosis. We included those with both the primary and secondary forms. METHODS This study was a retrospective follow-up of pediatric patients, who were treated for PTCS between 2000 and 393 Copyright © North American Neuro-Ophthalmology Society. Unauthorized reproduction of this article is prohibited. Original Contribution 2007 in the pediatric and the pediatric neurology departments at our institution. Their medical charts were reviewed for demographic and clinical data. In addition, a phone survey was conducted to complete the missing data. The study population included children diagnosed with PTCS, according to the modified Dandy criteria. All children were under 18 years of age at the time of diagnosis. As the purpose of the investigation was to shed light on patient outcomes, we included only children with at least 2 years of follow-up in the pediatric neurology clinic. Demographic and clinical data collected included: age at onset of symptoms; symptom/complaint (headache, vomiting, blurred vision etc); presence of papilledema; amount overweight (defined as BMI [body mass index] .25 kg/m2) at presentation; medical history of recent drug therapies; abnormal findings on neurological examination; neuroimaging studies; cerebrospinal fluid opening pressure measured during lumbar puncture; response to drug treatment (defined as relief of symptoms and improvement in the neuro-ophthalmological findings); duration of drug therapy; duration of follow-up; duration of symptoms before the diagnosis and after beginning drug therapy; disease relapse after cessation of drug therapy; and surgical intervention. The study was conducted with the approval of the hospital institutional review board. Statistical Analysis Data analysis was performed using SPSS version 13 for Windows (SPSS for Windows; SPSS Inc, Chicago, IL). The student t test and x2 test were used to compare the variables, including age of disease onset, sex, overweight, and cerebrospinal fluid opening pressure between the responders and nonresponders groups, as well as between the relapse and nonrelapse groups. For sex and for the presence of being overweight, contingency tables were used to compare between the prepubertal and pubertal groups. Puberty was defined by age at presentation (pubertal group . 11 years) (12). Fisher exact test was used when appropriate. Logistic regression was used by backward conditional removal of variables to estimate the predictors of response to therapy and the risk factors for relapse in the cohort. RESULTS Demographics The study group included 60 children with PTCS (36 females; 24 males). Onset of symptoms was at a mean age of 10.8 years (range: 2-18 years) and the mean duration of follow-up was 3.47 years (range: 2-13.5 years). Twentyfour patients were prepubertal (2-11 years), and 36 patients were pubertal (11-18 years). There was a distinct female predominance in the pubertal group (n = 26, 72.2%), whereas in the prepubertal group 41.7% were females, with a female male ratio of 10:14 (x2 = 5.6, P , 0.05). 394 Clinical Features The mean duration of complaints during the acute phase was 1.7 ± 2.2 months (range: few days-12 months). Eight patients (13%) were asymptomatic and they were diagnosed because of the incidental discovery of papilledema. Of the patients with recorded symptoms, 50 had headaches (83.3%), 21 complained of blurred vision (35%), 12 suffered from vomiting (20%), 6 had diplopia due to sixth cranial nerve palsy (10%), and 3 complained of paresthesias (5%). All patients had normal neuroimaging, either brain MRI (48.3%) or computed tomography (52.7%). The mean opening pressure on lumbar puncture was 38.4 ± 10.8 cm H2O (range: 20-60 cm H2O). Four patients (6.7%) had conditions previously associated with increased intracranial pressure: 2 patients (3.3%) had polycystic ovary syndrome and 2 (3.3%) were treated with minocycline. In addition, 1 patient was treated for hypothyroidism and 1 patient was given a homeopathic drug before admission. Fifty-six (93.3%) patients had no relevant medical history, but 29 patients had a BMI .25 kg/m2. The prevalence of being overweight was higher in the pubertal group (2-11 years: 29.2%, 11-18 years: 61.1%; x2 = 5.8, P , 0.05). Patients with PTCS but BMI #25 kg/m2 were significantly younger (8.4 ± 4.7 vs 12.6 ± 3.1 years, P , 0.001). Treatment All the patients received acetazolamide as first line therapy. Fourteen patients (23.3%) were treated with second line therapy because of acetazolamide treatment failure. Among them, 7 patients (11.6%) received topiramate, 4 (6.6%) were treated with acetazolamide and corticosteroids, 2 (3.3%) received acetazolamide, corticosteroids, and topiramate and 1 patient (1.6%) was treated with acetazolamide, corticosteroids, and furosemide. Treatment Course and Outcome Forty-six patients (76.6%) responded to acetazolamide with complete resolution of headache within an average of 3.8 weeks (range: 1 week-4 months) from initiation of therapy and with resolution of papilledema. The duration of drug therapy among the 46 patients who responded to acetazolamide ranged from 1 month to 5 years. In 27 patients (59%) treatment lasted less than 6 months, in 7 (15%) between 6 months and 1 year, in 5 (11%) 1-2 years and 7 (15%) were treated for more than 2 years. Thus, most responders (74%) received treatment for less than a year. One patient had their medication switched to topiramate because of side effects of acetazolamide. Among the 14 (23.4%) nonresponders to acetazolamide, 9 patients (15%) required surgical intervention: 6 (10%) Tovia et al: J Neuro-Ophthalmol 2017; 37: 393-397 Copyright © North American Neuro-Ophthalmology Society. Unauthorized reproduction of this article is prohibited. Original Contribution TABLE 1. Comparison between responders and nonresponders to acetazolamide in pediatric patients with PTCS Age at onset, y LP pressure (cm H2O) Sex (female) Overweight Headaches Responders (N = 46) Mean (SD) Nonresponders (N = 14) Mean (SD) OR (95% CI) P value 11.5 (4.1) 38.6 (10.2) 8.7 (4.8) 38.0 (12.9) 22.73 (25.34 to 20.11) 20.57 (28.48 to 7.35) 0.04 0.88 Responders (N = 46) N (%) Nonresponders (N = 14) N (%) OR (95% CI) P value 26 (72) 20 (69) 37 (74) 10 (33) 9 (31) 13 (26) 1.92 (0.53 to 7.04) 0.43 (0.12 to 1.48) 0.32 (0.04 to 2.74) 0.37 0.23 0.43 CI, confidence interval; LP, lumbar puncture; OR, odds ratio; PTCS, pseudotumor cerebri syndrome. underwent lumboperitoneal shunt; 2 (3.3%) underwent foramen magnum decompression; 1 (1.7%) required 3 spinal taps. The indications for surgical intervention included intractable headaches despite pharmacological therapy, or headache relapse. No patient in our study underwent optic nerve sheath fenestration. Table 1 summarizes the clinical data of the acetazolamide-responders vs the nonresponders. The only statistically significant difference between the 2 groups was age at onset. The nonresponders tended to present with PTCS at a younger age than the acetazolamide responders (8.7 ± 4.8 vs 11.5 ± 4.1 years, P = 0.04). To identify the risk factors for nonresponse to drug therapy, we applied a logistic regression model that included the following variables: sex, age of onset, presence of etiology (vs idiopathic), BMI, duration of complaints, headache, blurred vision, vomiting, diplopia, paresthesia, tinnitus, opening pressure on LP (lumbar puncture), papilledema, and puberty. Using backward stepwise variable selection, we found that (with 95% CI [confidence interval]) male sex (odds ratio = 5.59 [0.67, 46.57], P = 0.112), older age of onset (odds ratio = 1.64 [1.19, 2.25], P = 0.02), idiopathic (odds ratio = 0.83 [0.008, 0.83], P = 0.034) and no headaches (odds ratio = 0.64 [0.003, 1.21], P = 0.67) were predictors of good response to medical treatment. Of the responders, 3 patients were still under treatment during our study. Thirty-one out of the 43 responders (72%) remained asymptomatic after discontinuation of drug therapy, but 12 patients (26%) had a relapse of symptoms. We found that overall, 51.6% of patients with PTCS responded to the initial acetazolamide therapy with no relapse of symptoms (n = 31) and another 20% (n = 12) who had relapse of symptoms after discontinuation of acetazolamide, required longer periods of therapy to achieve a good response. Table 2 summarizes the differences between the relapse vs the nonrelapse subgroups among the responders group. On comparing these 2 subgroups, we found that the only statistically significant difference was younger age at onset in the relapse group than in nonrelapse group (8.9 ± 4.5 vs 12.1 ± 3.7 years, P , 0.05). The presence of BMI .25 kg/m2 or headaches did not significantly predict the rate of relapse (Table 2). It is important to note that all the patients with a relapse after acetazolamide discontinuation responded well to renewal of treatment and none required surgical intervention. A logistic regression model was applied to identify risk factors that could predict relapse. The variables entered TABLE 2. Comparison between pediatric PTCS patients with and without relapse after discontinuation of drug therapy Age at onset, y LP pressure (cm H2O) Sex (female) Overweight Headaches No Relapse (N = 31) Mean (SD) Relapse (N = 12) Mean (SD) OR (95% CI) P value 12.1 (3.7) 38.3 (9.0) 8.9 (4.5) 39.9 (12.2) 3.3 (0.56 to 5.94) 21.6 (29.89 to 6.62) 0.02 0.68 No Relapse (N = 31) N (%) Relapse (N = 12) N (%) OR (95% CI) P value 19 (61) 14 (77) 25 (60) 12 (39) 4 (23) 17 (40) 0.85 (0.26 to 2.74) 0.60 (0.15 to 2.45) 2.38 (0.44 to 12.87) 1.00 0.73 0.45 CI, confidence interval; LP, lumbar puncture; OR, odds ratio; PTCS, pseudotumor cerebri syndrome. Tovia et al: J Neuro-Ophthalmol 2017; 37: 393-397 395 Copyright © North American Neuro-Ophthalmology Society. Unauthorized reproduction of this article is prohibited. Original Contribution were: sex, age of onset, presence or absence of risk factors, BMI, duration of complaints, headache, blurred vision, vomiting, diplopia, paresthesia, tinnitus, opening pressure in LP, papilledema, and puberty. The only selected variable for the model (with 95% CI) in backward stepwise was puberty (odds ratio = 0.182 [0.04, 0.77], P = 0.021), meaning that prepubertal children had higher risk of relapse. DISCUSSION The aim of our study was to investigate the response to treatment in pediatric patients with PTCS. For this purpose, we examined duration of treatment required to achieve complete symptoms remission, response rate for initial drug therapy, relapse rate after discontinuation of drug treatment, the need for neurosurgical intervention, and potential predictors for worse outcome. All patients were treated with acetazolamide as first line therapy with a response rate characterized by resolution of symptoms and papilledema as high as 76.6%. Only 1 patient reported side effects related to acetazolamide treatment. We found that the nonresponders in our series were significantly younger than acetazolamide responders. The relationship between younger age at presentation and treatment-resistant PTCS has been reported previously (13). The response to second line therapy was poor among the 14 nonresponders, 9 patients requiring surgical intervention. Of the 46 patients with good response to acetazolamide, 12 patients (26%) experienced relapse after discontinuation of drug therapy, but all responded after resuming treatment, with no need for neurosurgical intervention. Comparison between the relapse and nonrelapse subgroups also found that patients with relapse presented with PTCS at a younger age. Our study revealed that 51.6% of patients with PTCS responded to initial acetazolamide therapy with no relapse of symptoms after an average of 1 year of treatment. Patients with initial response to treatment and relapse after drug discontinuation (20% of patients) required longer periods of therapy after resuming the medication, but all eventually responded to therapy. Compared with our results, the Idiopathic Intracranial Hypertension Treatment Trial (IIHTT) of adult patients found no significant change in headache disability score compared with baseline after 6 months of acetazolamide treatment and low-sodium diet, whereas the improvement in visual field with treatment was modest compared with controls (14). We assume that a possible reason, besides different age groups and ocular vs nonocular prominent symptomatology, may be the dissimilarity in the profile of the studied population (15). Although in the IIHTT the typical patient profile was a young overweight female, in the present study 40% of the children were males, 40% prepubertal and 53% of the prepubertal group were not 396 overweight. This confirms earlier reported observations in pediatric patients with PTCS (16). The demographic pattern in our series demonstrating female predominance in the postpubertal subgroup is similar to that seen in PTCS study on adult population (15) and in other pediatric series (9,17). Moreover, we found an increased prevalence of overweight individuals in the pubertal subgroup in accordance with previous reports (18-20). Only 9 patients (15%) in our series were asymptomatic, much less when compared with other studies that reported approximately 25%-33% of patients with PTCS being asymptomatic (21,22). A possible explanation for this difference may be the fact that in previous series, which were mainly reported by neuro-ophthalmologic teams, the presenting symptom was the incidental finding of papilledema. In conclusion, the treatment outcome in most patients (76.6%) in our PTCS series was favorable, with complete remission of symptoms with acetazolamide therapy and a low rate of side effects. However, for the subgroup of nonresponders the outcome was poor. A younger age at presentation was found to be associated with a poorer prognosis as it was a predictor of drug treatment failure, need for surgical intervention, and relapse after discontinuation of medical therapy. STATEMENT OF AUTHORSHIP Category 1: a. Conception and design: E. Tovia, S. Reif, and A. FattalValeski; b. Acquisition of data: E. Tovia, A. Oren, and A. Mitelpunkt; c. Analysis and interpretation of data: A. Fattal-Valevski, A. Mitelpunkt, and S. Reif; Category 2: a. Drafting the manuscript: E. Tovia, A. Oren, and A. Fattal-Valevski; b. Revising it for intellectual content: A. Oren, S. Reif, A. Mitelpunkt, and A. Fattal-Valevski; Category 3: a. Final approval of the completed manuscript: E. Tovia, S. Reif, A. Oren, A. Mitelpunkt, and A. Fattal-Valevski. REFERENCES 1. Digre KB. Idiopathic intracranial hypertension (pseudotumor cerebri): a reappraisal. Neurologist. 2001;21:15-17. 2. Radhakrishnan K. Idiopathic intracranial hypertension (pseudotumor cerebri). Descriptive epidemiology in Rochester, Minn. 1776 to 1990. Arch Neurol. 1993;50:78-80. 3. Ahlskog JE. Pseudotumor cerebri. Ann Intern Med. 1982;97:249-256. 4. Radhakrishnan K. Idiopathic intracranial hypertension. Mayo Clinic Proc. 1994;69:169-180. 5. Kesler A, Fattal-Valevski A. Idiopathic intracranial hypertension in the pediatric population. J Child Neurol. 2002;17:745-748. 6. Couch R, Camfield PR, Tibbles JA. The changing picture of pseudotumor cerebri in children. Can J Neurol Sci. 1985;12:48-50. 7. Tibussek D, Schneider DT, Vandemeulebroecke N, Turowski B, Messing-Juenger M, Willems PH, Mayatepek E, Distelmaier F. Clinical spectrum of the pseudotumor cerebri complex in children. Childs Nerv Syst. 2010;26:313-321. 8. Cincripini GS. Idiopathic intracranial hypertension in prepubertal pediatric patients: characteristics, treatment, and outcome. Am J Ophthalmol. 1999;127:178-182. 9. Babikian P, Corbett J, Bell W. Idiopathic intracranial hypertension in children: the Iowa experience. J Child Neurol. 1994;9:144-149. Tovia et al: J Neuro-Ophthalmol 2017; 37: 393-397 Copyright © North American Neuro-Ophthalmology Society. Unauthorized reproduction of this article is prohibited. Original Contribution 10. Baker RS, Baumann RJ, Buncic JR. Idiopathic intracranial hypertension (pseudotumor cerebri) in pediatric patients. Pediatr Neurol. 1989;5:5-11. 11. Wolf A, Hutcheson KA. Advances in evaluation and management of pediatric idiopathic intracranial hypertension. Curr Opin Ophthalmol. 2008;19:391-397. 12. Fuqua JS. Treatment and outcomes of precocious puberty: an update. J Clin Endocrinol Metab. 2013;98:2198-2207. 13. Distelmaier F, Sengler U, Messing-Juenger M, Assmann B, Mayatepek E, Rosenbaum T. Pseudotumor cerebri as an important differential diagnosis of papilledema in children. Brain Dev. 2006;28:190-195. 14. The NORDIC Idiopathic Intracranial Hypertension Study Group Writing Committee. Effect of acetazolamide on visual function in patients with idiopathic intracranial hypertension and mild visual loss. The idiopathic intracranial hypertension treatment trial. JAMA. 2014;311:1641-1651. 15. Wall M, Kupersmith MJ, Kieburtz KD, Corbett JJ, Feldon SE, Friedman DI, Katz DM, Keltner JL, Schron EB, McDermott MP; the NORDIC Idiopathic Intracranial Hypertension Study Group. The Idiopathic Intracranial Hypertension trial: clinical profile at baseline. JAMA Neurol. 2014;71:693-701. Tovia et al: J Neuro-Ophthalmol 2017; 37: 393-397 16. Lessell S. Pediatric pseudotumor cerebri (idiopathic intracranial hypertension). Surv Ophthalmol. 1992;37:155- 166. 17. Phillips PH, Repka MX, Lambert SR. Idiopathic intracranial pressure in children. J AAPOS. 1998;2:33-38. 18. Keltner JL, Miller NR, Gittinger JW, Burde RM. Pseudotumor cerebri. Surv Ophthalmol. 1979;23:315-322. 19. Balcer LJ, Liu GT, Forman S, Pun K, Volpe NJ, Galetta SL, Maguire MG. Idiopathic intracranial hypertension: relation of age and obesity in children. Neurology 1999;52:870-872. 20. Sheldon CA, Paley GL, Xiao R, Kesler A, Eyal O, Ko MW, Boisvert CJ, Avery RA, Salpietro V, Phillips PH, Heidary G, McCormack SE, Liu GT. Pediatric idiopathic intracranial hypertension: age, gender, and anthropometric features at diagnosis in a large, retrospective, multisite cohort. Ophthalmology 2016;123:2424-2431. 21. Bassan H, Berkner L, Stolovich C, Kesler A. Asymptomatic intracranial hypertention in children. Acta Neurol Scand. 2008;118:251-255. 22. Galvin JA, Van Stavern GP. Clinical characterization of idiopathic intracranial hypertention at the Detroit Medical Center. J Neurol Sci. 2004;223:157-160. 397 Copyright © North American Neuro-Ophthalmology Society. 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