1
38
the diagnostic criteria except that she had impaired con-
sciousness at presentation. Although, she was conscious
and alert when she was first seen at the referring hospi-
tal, the subsequent alteration of consciousness makes
this case somewhat atypical. It is important to note that
specific paediatric diagnostic criteria have not been es-
tablished. Interestingly, children with IIH may display a
greater spectrum of clinical presentation than adults.
These may include irritability, apathy, somnol4ence,
and magnetic resonance venography (MRV) are recom-
2
0
mended, cranial tomography scan can be used espe-
cially in places where MRI is not available. It can ex-
clude hydrocephalus and most mass lesions as well as
venous sinus thro13m, 1b4osis, meningeal infiltrations and
isodense tumours.
Neuroimaging are mandatory not
only to exclude potential secondary causes of elevated
ICP but the possibility of herniation prior to a lumbar
puncture.. The result of neuroimaging should be normal
in IIH, however, signs of increased intracranial pressure
may be found such as flattening of the posterior globe
where the optic nerve inserts in 80% of patients, empty
sella 1i3n 70% and distension of perioptic nerve sheath in
45%. In addition, a lumbar puncture in a patient who
has IIH should display an increased opening pressure as
well as normal cell count, normal glucose concentration,
normal or low protein content and the absence of infec-
tion. In our patient neuroimaging studies as well as CSF
biochemical and microbiological studies were all normal
fulfilling a major diagnostic criterion. Although ma-
nometry could not done to determine the exact CSF
pressure because of non availability, the flow rate was
suggestive of a CSF pressure that was very high. Robert
et al showed in a study that CSF drops counts per given
time can be used to estimate CSF pressure with a rea-
1
ataxia, dizziness neck pain, stiff neck and seizure Im-
pairment of consciousness in our patient was preceded
by a series of collapsing episodes. This, we thought
could have been due to a pla5teau wave; a phenomenon
1
first described by Lundberg. It is characterized by an
acute elevation of ICP in a situation where baseline ICP
is already moderately elevated. A plateau wave develops
as a result of a rapid increase in intracerebral blood vol-
ume. These acute elevations of ICP have been observed
in patients with brain tumour, subarachnoid haemor-
rhage, acute h6ydrocephalus and idiopathic intracranial
1
hypertension. and may be triggered in ambulatory pa-
tient by postural changes. It follows a reduction in in-
tracranial compliance. The normal process of cerebral
autoregulation is the result of a slow rise in cerebral
blood volume as a result of vasodilatation which occurs
because of a reduction in cerebral perfusion pressure
2
2
sonable degree of accuracy.
(
CPP). However, when CPP drops below a critical level,
the rate of vasodilatation also increases dramatically,
resulting in a rapid increase in cerebral blood volume
and a sudden sustained increase in ICP. This may pro-
duce paroxysmal symptoms in patient with IIH and
these include among others7]alteration in consciousness,
The key to a good outcome in IIH is early recognition
and prompt treatment. This is to forestall permanent
optic nerve death and subsequent visual loss. Weight
reducing measu3res should form part of the initial treat-
2
ment regimen. Drugs that have been used with success
1
postural and motor control
include acetazolamide,, a sulfa-derived diuretic and car-
bonic anhydrase inhibitor that reduces CSF production.
The starting dose in children is 25mg/kg/day which may
Multiple cranial neuropathies was another unusual find-
ing in our patient. M2 ost cases of IIH presents with ab-
2
4
be increased to 100mg/kg/day (maximum, 2g/day).
1
ducent nerve palsy. In this case, both abducent nerves
Furosemide, a loop diuretic, can be used in combination
with or as an alternative to acetazolamide at a dose of
1mg/kg/dose. Corticosteroids have also been use25d espe-
cially in patient with rapid visual deterioration. Other
interventions found useful in selected cases include se-
rial lumbar puncture, although this is technically diffi-
cult in children and their pressure lowering effect is only
temporary. Surgery may be indicated such as Bariatric
surgery, CSF26diversion procedures and optic nerve de-
compression.
and the right facial nerve were affected. Facial nerve
palsy in IIH has b8 een described in the literature in about
1
2
-6% of cases. Some reports suggest that increase
pressure at the posterior fossa and9enlargement of the
1
fallopian canal may be responsible. Other atypical fea-
tures of IIH that have been reported include hypoglossal
nerve palsy, hyperreflexia with positi2v0e Babinski sign,
choreiform movement and nystagmus.
The prior use of an antibiotics in this patient could have
been a limitation because of the possibility of a partially
treated meningitis; given the atypical features seen this
patient. However, this was less likely because there is no
significant effect of previous antimicrobial therapy on
CSF cell count or glucose and protein a1 mong patients
Idiopathic Intracranial Hypertention is a rare disease
especially in children and may be easily confused with
more common central nervous system morbidities. A
high index of suspicion and appropriate investigations
are therefore needed to reduce the attendant sequelae of
a misdiagnosis.
2
with positive or negative CSF culture. This was the
finding of Shohet et al in a review of 115 children with
clinical diagnoses of meningitis, of which 47 had re-
ceived antimicrobial therapy before hospitalization. Our
patient had normal microbiological and biochemical
CSF results .
Conflict of interest : None
Funding : None
The choice of neuroimaging studies for suspected cases
of IIH3 is still the biggest controversy among physi-
1
cians. Although, magnetic resonance imaging (MRI)