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CORRESPONDENCE
Year : 2015  |  Volume : 63  |  Issue : 2  |  Page : 292-294

Role of ocular ultrasound in idiopathic intra-cranial hypertension


Department of Pediatric Ophthalmology and Neuro-Ophthalmology, Narayana Nethralaya-2, Bengaluru, Karnataka, India

Date of Web Publication5-May-2015

Correspondence Address:
Jyoti Matalia
Department of Pediatric Ophthalmology and Neuro-Ophthalmology, Narayana Nethralaya-2, Bengaluru, Karnataka
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0028-3886.156330

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How to cite this article:
Matalia J, Shirke S, Kekatpure M. Role of ocular ultrasound in idiopathic intra-cranial hypertension. Neurol India 2015;63:292-4

How to cite this URL:
Matalia J, Shirke S, Kekatpure M. Role of ocular ultrasound in idiopathic intra-cranial hypertension. Neurol India [serial online] 2015 [cited 2019 Oct 18];63:292-4. Available from: http://www.neurologyindia.com/text.asp?2015/63/2/292/156330


Sir,

We came across the original article titled "Idiopathic intracranial hypertension in paediatric population: A case series from India" by Arun Roy and colleagues [1] while researching the literature for our pediatric patients with idiopathic intra-cranial hypertension (IIH). At the outset, we would like to congratulate the authors for this large series which is probably the first from India. The reason for writing this letter is to highlight the role of an ocular B-scan ultrasound from the neuro-ophthalmogy point of view in evaluating IIH in children. As we all know, IIH is characterized by increased intra-cranial pressure (ICP) with essentially normal brain magnetic resonance imaging (MRI) and magnetic resonance venography (MRV). [2] However, the presence of IIH in children offers some unique challenges. Small children may not complain of headache or diplopia. At times, it can be difficult to monitor the optic nerve function in children, especially in infants, as a formal visual acuity measurement and a visual field assessment cannot be carried out in them. The diagnosis of IIH mainly relies on the MRI study and cerebrospinal fluid opening pressure measurements, which is difficult to assess in the pediatric population. Also, these procedures need to be performed under anesthesia or sedation. MRI has a definitive diagnostic role as IIH is essentially a diagnosis of exclusion. Monitoring symptomatic improvement or ensuring resolution of papilledema by ophthalmoscopy can judge the response to therapy. Although papilledema is characteristically seen, its absence is increasingly reported in children, as was the case in the study being discussed.

Ocular B scan ultrasound is a simple yet effective tool in detecting an increased size of the optic nerve head and in the assessment of subarachnoid fluid around the optic nerve. It shows an intra-ocular elevation, specifically at the region of the optic nerve head, along with increased optic nerve sheath diameter [Figure 1]. The subarachnoid fluid can also be seen as a homogenous, echolucent crescent or as a ring-shaped area around the optic nerve [Figure 1]. The optic nerve is a part of the central nervous system with its sheath being in continuation with the dura mater. This sheath contains a potential space that communicates with the subarachnoid space. Any pressure changes in the intracranial cavity are transmitted to the optic nerve along this space, increasing the optic nerve sheath diameter. [3] Eventually, papilledema develops due to impedance of the axonal transport in the optic nerve as a result of the increased pressure. [4] Thus, increase in the optic nerve sheath diameter even prior to the development of papilledema can be picked up by the B-scan ultrasound. A review of the available literature regarding the use of ocular ultrasound and its value in the detection of increased ICP reveals a strong correlation between the optic nerve sheath and the level of ICP, with its greater diameter being strongly associated with an increased ICP. [5] It has widely been used in emergency medicine in the settings of acute brain injury, [3],[4],[5],[6],[7] and its usage has also occasionally been in the evaluation of IIH. [8],[9]
Figure 1: B scan ultrasound of the eye showing elevation of the optic nerve head (arrowhead) and increase in the size of the optic nerve head (5.40 mm) with presence of the echolucent arachnoidal fluid in a crescent shape around it (arrow)

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This simple tool offers various advantages. It is an outpatient procedure that does not need general anesthesia. It provides at bedside, a real-time, quantitative measurement, making it a more objective diagnostic tool. Also, ICP changes can easily be monitored over time. It can be an useful adjuvant in the diagnosis and management of patients with IIH, especially the children. An ultrasound may provide a useful alternative in determining the presence of papilledema in a patient in whom fundoscopy cannot be adequately performed or has been found to be non-diagnostic.

Therefore, in children with suspected increased ICP in whom there may be an absence of typical symptoms along with a non-diagnostic ocular examination, ultrasound can aid in the early detection of increased ICP. Moreover, in similar circumstances, when monitoring of response to therapy can be tricky due to the difficulties encountered in performing the necessary investigations to assess the visual function, ocular ultrasound can prove to be an important tool. [8] In summary, ocular ultrasound is a useful, easy, rapid, objective and sensitive tool to assess ICP in real time and may have an important role in diagnosing and monitoring the therapeutic response in children with IIH.

 
  References Top

1.
Roy AG, Vinayan KP, Kumar A. Idiopathic intracranial hypertension in pediatric population: Case series from India. Neurol India 2013;61:488-90.  Back to cited text no. 1
[PUBMED]  Medknow Journal  
2.
Wall M. Idiopathic intracranial hypertension. Neurol Clin 1991;9:73-95.  Back to cited text no. 2
    
3.
Soldatos T, Karakistos D, Chatzimichail K, Papathanasiou M, Gouliamos A, Karabinis A. Optic nerve sonography in diagnostic evaluation of adult brain injury. Crit Care 2008;12:R67.  Back to cited text no. 3
    
4.
Rajajee V, Vanaman M, Fletcher J, Jacobs T. Optic nerve ultrasonography for detection of increased raised intracranial pressure. Neurocrit Care 2011;15:506-15.  Back to cited text no. 4
    
5.
Hightower S, Chin EJ, Heiner JD. Detection of increased intracranial pressure by ultrasound. J Spec Oper Med 2012;12:19-22.  Back to cited text no. 5
[PUBMED]    
6.
Moretti R, Pizzi B. Ultrasonography of optic nerve in neurocritically ill patients. Acta Anaesthesiol Scand 2011;55:644-52.  Back to cited text no. 6
    
7.
Geeraerts T, Launey Y, Martin L, Pottecher J, Vigué B, Duranteau J, et al. Ultrasonography of optic nerve sheath may be useful for detecting raised intracranial pressure after severe brain injury. Intensive Care Med 2007;33:1704-11.  Back to cited text no. 7
    
8.
Singleton J, Dagan A, Edlow JA, Hoffmann B. Real-time optic nerve sheath diameter reduction measured with bedside ultrasound after therapeutic lumbar puncture in a patient with idiopathic intracranial hypertension. Am J Emerg Med. 2014 Dec 19. pii: S0735-6757 (14) 00932-2.  Back to cited text no. 8
    
9.
Stone MB. Ultrasound diagnosis of papilledema and increased intracranial pressure in pseudo-tumor cerebri. Am J Emerg Med 2009;27:376.e1-376.e2.  Back to cited text no. 9
    


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