© Med Sci Monit, 2004; 10(4): MT53-63
WWW.MEDSCIMONIT.COM
PMID: 15039654
Diagnostics and Medical Technology
Received: 2003.09.22
Prolonged intracranial pressure (ICP) monitoring
Accepted: 2003.12.03
Published: 2004.04.01
in non-traumatic pediatric neurosurgical diseases
Authors Contribution:
Gianpiero Tamburrinibcdef, Concezio Di Roccoa, Francesco Velardia,
A
Study Design
Pietro Santinia
B
Data Collection
C
Statistical Analysis
MT
D Pediatric Neurosurgical Unit, Catholic University Medical School, Rome, Italy
Data Interpretation
E
Manuscript Preparation
F
Literature Search
Source of support: Department sources.
G
Funds Collection
Summary
Background: A limited number of studies have addressed the methods, indications and particular problems
that may occur when programming prolonged intracranial pressure (ICP) monitoring in
pediatric patients. Parenchymal fiberoptic transducers have been shown to give reliable ICP
readings; moreover, they present a relatively low rate of complications, are easily placed and,
as they are solid state, they are not subject to obstruction.
Material/Methods: A recently developed fiberoptic ICP transducer (Codman® intraparenchymal sensor) was used
to continuously monitor intracranial pressure in seventy children with non-traumatic neuro-
surgical diseases. The admitting diagnoses were hydrocephalus or shunt-related problems in
33 cases, single-suture (5 cases) or complex (16 cases) craniosynostosis in 21 patients, and syl-
vian scissure arachnoid cyst (SAC) in 16 cases. A software (ICP monitoring release®) designed
in our department was used for ICP recording storage and analysis.
Results: Raised ICP values were found in six of the seventeen patients with a suspected active hydro-
cephalus, 24% of children with non-syndromic craniosynostosis, 52.8% of syndromic cranio-
synostosis patients, 50% of the children with a Type II SAC and two of the three patients with
Type III SAC.
Conclusions: Overall, prolonged ICP monitoring proved to be extremely useful in guiding surgical indica-
tions. The fiberoptic device used in our unit was shown to be reliable and associated with a
relatively low rate of complications. Finally, the software allowed easy review and analysis of
the obtained data.
key words: intracranial pressure " monitoring " children " non-traumatic diseases
Full-text PDF: http://www.MedSciMonit.com/pub/vol_10/no_4/4188.pdf
Word count: 4631
Tables: 3
Figures: 1
References: 31
Author s address: Gianpiero Tamburrini, Pediatric Neurosurgical Unit, Catholic University Medical School, Largo  A. Gemelli ,8,
00168 Rome, Italy, e-mail: [e-mail]
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Diagnostics and Medical Technology Med Sci Monit, 2004; 10(4): MT53-63
BACKGROUND MATERIAL AND METHODS
Intracranial pressure (ICP) monitoring is now a widely All children with non-traumatic neurosurgical diseases
accepted tool in the management of various neurosurgi- who underwent ICP monitoring in our Unit between
cal diseases. The results and complications of monitoring 1998 and January 2003 were reviewed. Seventy patients
adult patients have been extensively reported; in con- were selected and subdivided into three groups accord-
trast, a limited number of studies have been addressed to ing to admission diagnoses: the first group was com-
the indications and particular problems that may occur posed of 33 children admitted with a diagnosis of ven-
in pediatric patients. The main indications in children triculomegaly, hydrocephalus or shunt-related prob-
have been head trauma, ventriculomegaly and shunt lems; the second was composed of 21 children affected
complications (i.e. shunt malfunction, slit ventricles syn- by single suture (5 cases) or complex (16 cases) cranio-
drome), craniosynostosis, intracranial tumors, and hem- synostoses and the third of 16 children who were affect-
orrhage [1 11]. ed by arachnoid cysts (sylvian arachnoid cysts: 15 cases,
intraventricular arachnoid cysts: 1 case). The children
One problem is that there is no universally accepted with sylvian arachnoid cysts (SAC) were further subdi-
scale of normal and abnormal ICP values in children. vided into three groups based on CT scan and MRI
The lack of accurate measurements in normal babies imaging, according to the morphological classification
and modifications of the intracranial compliance during propounded by Galassi et al. in 1980 [23]. Group I was
the first year of life specifically contribute to this point made up of four children with Type I cysts: i.e. small
[5,9,12,13]. Most papers refer to Minns conclusions; semicircular arachnoid cysts confined to the anterior
according to this author, who reviewed all studies part of the temporal fossa. Group II comprised eight
before 1990 in which ICP had been objectively mea- children with quadrangular, medium-sized temporal
sured, the upper limits of normal are: 3.5 mmHg in cysts (Type II). Finally, group III consisted of three
neonates, 5.8 mmHg in infants, 6.4 mmHg in children, children with Type III cysts: i.e. large, oval, fluid collec-
and 15.3 mmHg in adolescents and adults [13]. tions which occupied the temporal fossa entirely,
However, some authors disagree with this assessment, opened the Sylvian fissure and partially extended over
stating that all the children above one year of life with the cerebral convexity.
closed sutures should be evaluated with adult parame-
ters (normal range: 0 15 mmHg) [8,9,11]. Prolonged intracranial pressure (ICP) recording (min:
12 h; max: 92 h; mean recording time: 47 h) was per-
One of the other main difficulties encountered when formed in all cases. For this we utilized a system com-
programming ICP measurement in children is the lack posed of an extensible silicone microprocessor (Cod-
of cooperation of younger patients, which influences the man®) connected to a Codman ICP Express® display
reliability of the recordings. A number of devices and developed for ICP check. ICP Express® is programmed
techniques have been proposed which can be divided in to give an electrical signal which is proportional to the
three major groups: 1) extracranial devices (anterior ICP values. The collected information was uploaded by
fontanelle transducers, tympanic membrane displace- cable to a personal computer (PC) provided with a digi-
ment sensors) [10,14], 2) superficial ICP monitoring tal/analog converter card. A software devised in our
transducers (extradural subdural and subarachnoid department (ICP Monitoring Release®) was used to
bolts) [5,6,12,15,16], and 3) deep devices (intraparenchy- store ICP recordings (256 values/sec) on the PC s hard
mal fiberoptic transducers and ventricular catheters) disk. This program allows continuous tracking during
[8,9,11]. Whatever the chosen monitoring apparatus, the recording or at a later time, with the possibility of
continuous and prolonged ICP recording is needed in choosing the date, hour and minutes of the recording to
most cases. Currently, paper waveforms have been review. It also enables the automatic analysis of the col-
replaced by digital recorders which, however, if taken lected ICP values in bar or star graphics once a time
alone, require periodic nurse control and value registra- interval (1 24 h) is selected.
tion. In addition, most of them do not allow wave analy-
sis, which can be particularly useful in sleep recordings. The microprocessor was implanted intraparenchimally
For this reason a number of software has been created to in the posterior right frontal brain tissue in the children
store registrations on a personal computer s (PC) hard of the first two groups (hydrocephalus, shunt-related
disk, with the possibility to analyze the data obtained ret- diseases, and craniosynostosis) and adjacent to the
rospectively [1 4, 17 22). major extension of the arachnoid cyst in the last group
(arachnoid cysts).
The present study had two objectives: the first was to
evaluate the reliability of a recently developed fiberoptic Nurses and parents were asked to register the child s
ICP transducer (Codman® intraparenchymal sensor) in activity during the recording period; artifacts due to
a population of pediatric patients with different non- crying, feeding, or playing were noted and excluded
traumatic neurosurgical diseases; the second was to from the final assessment. For all the patients we evalu-
review our experience with a software (ICP Monitoring ated the tracks of the continuous recording and changes
Release®) that was designed in 1998 in our department in ICP during physiological sleep and those following
for this kind of transducer and the connected digital artificial maneuvers, such as jugular vein compression
analyzer system (Codman® ICP Express). and release. The presence or absence of plateau A-
waves was also accounted and was chosen as a decision
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Med Sci Monit, 2004; 10(4): MT53-63 Gianpiero T et al  Prolonged intracranial pressure (ICP) monitoring&
MT
Figure 1. An example of the images offered by the software used in our Unit for ICP monitoring; (A) Trace of ICP recording; (B) Automatic bar graphic
of the ICP percentages distribution during the entire recording; (C) Automatic star graphic showing day and night distribution of ICP values.
parameter in children with doubtful results of the ICP the incidental discovery of shunt migration was asymp-
recordings. Ten mmHg was chosen as the upper nor- tomatic. Neuroradiologic examinations (CT and/or
mal ICP limit in resting conditions in children under MRI) did not allow definite conclusions in all cases.
one year of age and/or with opened sutures and 15
mmHg in patients with closed sutures. Bar graphs were The length of ICP monitoring varied between 12 and
utilized in each case to illustrate the percentage distribu- 92 hours (mean: 46.1 h). Six of the 17 patients with ven-
tion of the ICP values during the recording period, gen- triculomegaly or suspected active hydrocephalus (four
erally in steps of 2, 5 or 10 mmHg. A  star-like graphic children with congenital hydrocephalus and one each
representation of the ICP pattern was also utilized to with hydrocephalus in myelomeningocele and post-
compare visually ICP behavior immediately during the hemorrhagic hydrocephalus) showed abnormal ICP val-
day and night (Figure 1). ues for 65 % or more of the recording time period.
Plateau A-waves were documented in three of these
RESULTS cases. Normal ICP values (62% or more in the normal
range) were recorded in the remaining eleven patients
Hydrocephalus and shunt-related diseases of this group (five patients with benign hydrocephalus;
three with congenital hydrocephalus, 2 with arrested
This group was composed of 33 children (M/F=22/11) hydrocephalus, and 1 with post-hemorrhagic hydro-
with ages at diagnosis varying between 3 months and 17 cephalus), excluding the need to surgical treatment.
years (mean: 5.27 years). The indication to ICP moni- Four of the ten patients referred to us with a diagnosis
toring was ventriculomegaly or suspected active hydro- of shunt malfunction had normal ICP values (68 93.8%
cephalus in 17 cases, suspected shunt malfunction in 10 of the recordings in the normal range), in spite of symp-
patients, slit ventricles syndrome in 4 cases, and an inci- toms simulating intracranial hypertension (H/A, vomit-
dentally discovered shunt migration and a post-shunt ing) had been exhibited by three of them. Slight clinical
craniosynostosis with secondary Chiari I in the last two symptoms indicated ICP monitoring in the other six
cases. Symptoms at the time of admission to our unit patients of this group that showed pathological ICP val-
included macrocrania in 16 cases, symptoms of intracra- ues for 43.2% to 79.4% of the recording time. Plateau A-
nial hypertension (headache, vomiting, tense anterior waves were also found in 5/6 of these children. The
fontanelle) in 17 patients, seizures in four patients, and presence or absence of nocturnal A-waves was particu-
a psychomotor retardation in one case. The patient with larly important in the evaluation of children with sus-
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Diagnostics and Medical Technology Med Sci Monit, 2004; 10(4): MT53-63
pected slit ventricles syndrome; indeed, although all of Arachnoyd cysts
them had normal ICP values for more than 50% of the
recordings, plateau A-waves were found in three cases, Of our sixteen children with arachnoid cysts, fifteen
indicating the need for a surgical treatment (Table 1). were affected by sylvian fissure arachnoid cysts (SAC)
and one by a left lateral ventricle cyst. Eight patients
Craniosynostosis were symptomatic: three presented with a history of
recurrent headache (one had a Type I SAC and two had
Twenty-one children (13 M/8 F) affected by simple (five a Type II SAC) and one with epileptic seizures (Type I
cases) or complex (sixteen cases) craniosynostosis under- SAC). The other four children of this subgroup of
went ICP monitoring in our unit between 1998 and patients (one with a Type II SAC and three with Type
January 2003. Mean age was 1.6 years (min: 3 months, III SAC) showed signs of increased ICP (tense and
max: 5 years). Diagnoses at admission were Apert syn- bulging anterior fontanelle in one case, headache and
drome in five children, Crouzon syndrome in four vomiting in the remaining three cases). The diagnosis
cases, Pfeiffer syndrome in three cases (two children was incidental in six of the remaining eight children
with Pfeiffer III and one child with Pfeiffer II syn- after a CT or MR imaging carried out because of head
drome), scaphocephaly in three cases, brachicephaly in injury in three cases (two with a Type I and the third
two cases, turricephaly in two children, and osteopetro- with a Type II SAC), macrocrania in one case (left ven-
sis in the last two cases. A clinical geneticist confirmed tricular cyst), or to investigate the possible cause of
the diagnosis in all cases. hypertonia (1 case: Type II SAC) or generalized dyston-
ic movements (1 case: Type II SAC). In two instances a
Fourteen out of the sixteen children with complex cran- temporal cyst was recognized in utero at  routine echo-
iosynostosis (five with Apert syndrome, four with graphic examination during pregnancy. Both of the
Crouzon syndrome, two with Pfeiffer syndrome, two infants had a Type II SAC and did not show any appar-
with turricephaly, and one with osteopetrosis) presented ent sign of increased ICP at birth. Neurological exami-
abnormal ICP values with evidence of nocturnal A- nation at admission was negative in ten patients and
waves in all cases (mean length of ICP monitoring: 43.5 presumably unrelated to the presence of the arachnoid
h). A case-based surgical treatment was performed in cyst in three (psychomotor delay and increased muscle
these patients: eleven children underwent an occipital tone due to perinatal hypoxia in two cases and bilateral
expansive cranioplasty as a first step, followed by a anacusia in one case). Bilateral papilledema was discov-
bifronto-orbital advancement in four cases (two patients ered in one patient, while cranial asymmetry was the
with Crouzon syndrome, one with Pfeiffer II syndrome, only sign in the last two cases (Table 3).
and one with Apert syndrome), or by a ventriculo-peri-
toneal shunt for an associated hydrocephalus in two The EEG examination was normal or characterized only
patients (one child with Pfeiffer III syndrome and the by unspecific abnormalities in 13 cases. In particular,
second with Apert syndrome), or by a bifronto-orbital the only child who presented with seizures had bilateral,
advancement and subsequent ventriculoperitoneal unspecific EEG abnormalities. Three children, one har-
shunt in two cases (one child with Apert syndrome and boring a Type I, the second a Type II, and the third a
one with turricephaly). The last three children of this Type III cyst, showed focal EEG anomalies on the tem-
subgroup (one with Crouzon syndrome, one with Apert poral region homolaterally to the lesion.
syndrome, and one with osteopetrosis), all showing rela-
tively lower ICP values (53.2%, 45.4%, 45.7% of the Mean length of ICP monitoring was 46.9 hours. ICP
recordings in the normal range), underwent exclusively recordings were in the normal range in the four chil-
a bifronto-orbital advancement. dren with type I SAC, in spite of the fact that two of
them were symptomatic (one complaining of recurrent
Post-operative ICP monitoring was effected in seven headaches, the second of epileptic seizures). When the
patients (mean postoperative length of ICP monitoring: ICP values were distributed in steps of 5 mmHg, they
42.1 h) and a significant reduction of ICP values, a re- remained below the limit of 15 mmHg for more than
duction or disappearance of plateau A-waves was docu- 80% of the recording time in all cases (83.9%, 87.9%,
mented in all cases. Only two children affected by com- 89.6%, 92%, respectively). Four of the eight children
plex craniosynostosis (one with Pfeiffer III syndrome with a Type II SAC had repeated episodes of abnormal-
and one with osteopetrosis) who underwent preopera- ly elevated ICP (55%, 57%, 76%, 84.4% of the record-
tive ICP monitoring had normal ICP values for the ings >15 mmHg), even though three of them had inci-
majority of the recording time (86.5% 97.9% of the ICP dental (1 case) or prenatal (2 cases) diagnosis. The
values within the normal range). remaining four patients with Type II SAC had normal
ICP values for more than 80% of the recording time
The five patients affected by single-suture craniosynos- period. Two of the three patients with Type III SAC
tosis (three children with scaphocephaly and two chil- had almost constantly abnormal ICP values (92.9%,
dren with brachicephaly) had all ICP values in the nor- 98.7% >15 mmHg), while ICP values were in the nor-
mal range (mean recording time: 39.6 h, 65.1 82.4% of mal range in the third patient of this subgroup, which
the recordings <15mmHg); plateau A-waves were was apparently symptomatic at admission (headache,
absent in all cases (Table 2). vomiting). The patient with an intraventricular arach-
noid cyst had normal ICP values for more than 70% of
the recording time.
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Med Sci Monit, 2004; 10(4): MT53-63 Gianpiero T et al  Prolonged intracranial pressure (ICP) monitoring&
Table 1. Clinical features and ICP findings in patients affected by hydrocephalus or shunt- related problems.
ICP <10 ICP >10 ICP <15 ICP >15 Plateau Complica-
Patient Sex Age Diagnosis* *Sy/Si CT/MRI *TR
MmHg MmHg MmHg MmHg A-waves tions
**Sh. Malf.
1 .A.A. M 15 Y **H/A, Vo. No VD 42 h   93.8% 6.2% No No
(PE Hy)
2. A.C. F 11 M **Hy/MMC Ma. Tetra-VD 39 h 20.6% 79.4%   No No
**Se. Ps. Extreme 78.6%
3. A.F. F 6 M Pe Hy 36 h 21.4%   Yes CSF leak
Ret., Ma. Tetra-VD
Sh. Malf. Moderate
4. A.I. F 3 Y H/A 42 h   68.6% 31.4% No No
(**Co. Hy) Tetra-VD
Sh. Malf. Moderate
5. A.M. F 4 Y H/A 24 h   20.6% 79.4% No No
(Co. Hy) Tri-VD
Sh. Malf. Moderate
6. B.A. M 7 Y H/A 36 h   74.3% 25.7% No No
MT
(Pe Hy) Tetra-VD
7. B.R. F 11 Y Co. Hy H/A, Vo. Tetra-vd 46 h   98.1% 1.9% No No
Sh. Malf.
8. B.Re. F 11 M Ma. Tri-VD 40 h 56.8% 43.2%   Yes CSF leak
(Co. Hy)
Ma., H/A
9. C.G. M 4 Y Co. Hy Tetra-VD 48 h   21.4% 78.6% Yes No
10. C.M. F 3 Y **Arr. Hy Ma. Tetra-VD 48 h   81.5% 18.5% No No
Moderate
11. E.G. M 13 M **Be. Hy Ma. 62 h   66.8% 33.2% No No
Tetra-VD
12. G.V. F 4 Y **SVS H/A, Vo. SV 74 h   96.4% 3.6% Yes No
13. L.C. M 3 Y SVS H/A, Vo. SV 92 h   75.7% 24.3% No No
14. L.A. F 3 M Co. Hy **Taf, Vo. Tetra-VD 38 h 34.7% 65.3%   Yes CSF leak
Sh. Malf.
15. L.G. M 11 Y H/A Tri-VD 87 h   29.5% 70.5% Yes No
(Pe Hy)
Moderate
16. L. Gi. M 15 M Be. Hy Ma. 27 h 92.5% 7.5%   No No
Tetra-VD
Sh. Malf. Se., H/A,
17. L.P. M 15 Y No VD 36 h   22.9% 77.1% Yes No
(Pe Hy) Vo.
Moderate
18. M.A. M 9 M Co. Hy. Ma. 36 h 12.6% 87.4%   Yes No
Tetra-VD
Sh. Malf.
19. M.D. M 4 M Ma. Tetra-VD 48 h 87.5% 12.5%   No CSF leak
(Co. Hy)
Sh. Malf.
20. M.V. F 17 Y H/A, Vo. No VD 36 h   47.5% 52.5% Yes No
(Co. Hy)
Sh. Malf.
21. M.F. M 9 Y H/A No VD 70 h   28.6% 71.4% Yes No
(Co. Hy)
Moderate
22. M.J. M 4 Y Be. Hy Ma. 72 h   69.1% 30.9% No No
Tri-VD
23. M.A. M 5 Y SVS H/A, Vo. SV 48 h   57.6% 42.4% Yes No
Asympto- Moderate
24. P.F. M 2 Y **Sh. Migr. 50 h   89.0% 11.0% No No
matic Tri-VD
Moderate
25. P.G. F 3 Y Be. Hy Ma. 12 h   93.6% 6.4% No No
Tetra-VD
Hemorrha-
Post-shunt
ge + me-
26. P.V. M 14 Y **CRS and H/A Chiari I 24 h   72.7% 27.3% Yes
chanical
Chiari I
malfunction
27. R.F. M 8 Y SVS H/A SV 46 h   64.3% 35.7% Yes No
28. S.N. M 4 Y Co. Hy Ma. Tetra-VD 60 h   73.5% 26.5% No No
29. T.M M 3 Y Co. Hy Ma. Tetra-VD 36 h   19.8% 80.2% Yes No
30. T.R. M 4 Y Arr. Hy Ma., Vo. Tri-VD 62 h   63.6% 36.4% No No
31. T.F. M 2 Y Pe Hy Ma., Se. Tri-VD 46 h   62.7% 37.3% No No
32. V.E. M 11 Y Co. Hy Ma., Se. Tri-VD 24 h   96.9% 3.1% No No
Moderate
33. V.N. M 2 Y Be. Hy Ma. 36 h   89.6%
10.4% No No
Tetra-VD
* diagnosis  at admission; sy/si  symptoms/signs; tr  length of icp monitoring;
** h/a  headache; vo.  vomiting; hy  hydrocephalus; be.  benign; co.  congenital; arr.  arrested; pe  posthemorrhagic; mmc  mielomeningocele;
ext hy  external hydrocephalus; sh. migr. shunt migration; sh. malf.  shunt malfunction; svs  slit ventricle sindrome; vd  ventricular dilatation; sv  slit ventricles ;
se  seizures; ps. ret.  psychomotor retardation; ma.  macrocrania; taf  tense anterior fontanel; crs  craniosynostosis
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Diagnostics and Medical Technology Med Sci Monit, 2004; 10(4): MT53-63
Table 2. Clinical features and ICP findings in patients affected by Craniosynostosis.
Preop Postop Postop Postop
Preop ICP Preop ICP Type Complica-
Patient Sex Age Diagnosis* Tr/Preop* plateau (TR) ICP ICP plateau
<10 MmHg >10 MmHg of surgery tions
A-waves <10 MmHg >10 MmHg A-waves
**Occipital (46 h) Yes
1. C.G. M 5 M Apert 39 h 45.9% 54.1% Yes 32.5% CSF leak
EC **VPS 67.5% (Reduced)
2. C.Ma. M 8 M Pfeiffer III 48 h 86.5% 13.5% No     No
Biparietal
3. C.M. M 8 M Scaphocephaly 48 h 82.4% 17.6% No   
CP No
1.Occipital
EC (36 h)
4. C.S. F 6 M Apert 30 h 14.1% 85.9% Yes 30.7% No CSF leak
2. Bifronto 69.3%
A.
1.Occipital
ec (68 h)
5. D.S. F 6 M Crouzon 40 h 17% 83.0% Yes 37.3% No CSF leak
2. Bifronto 62.7%
A.
67.9% 32.1%
Scaphocephaly
6. F.G. F 2 Y 49 h (<15 (>15 No     No
(moderate)
MmHg) MmHg)
(68h)
3.4% 96.6%
Occipital 37.6% 62.4%
(<15 (>15 No No
7. F.A. F 3 Y Turricephaly 48 h Yes EC (<15 >15
MmHg) MmHg)
MmHg) MmHg)
Occipital (32 h) Yes
8. K.R. M 6 M Apert 30 h 6.1% 93.9% Yes 49.8% No
EC 50.2% (reduced)
Occipital
9. L.P. M 2 M Crouzon 48 h 67.3% 32.7% Yes    No
EC
1. Occipital
EC
36.1% 63.9%
2. ** Bi-
10. M.A. M 5 Y Turricephaly 63 h (<15 (>15 Yes    No
fronto. A
MmHg) MmHg)
3.VPS
Biparietal
11. M.V. M 11 M Scaphocephaly 45 h 65.1% 34.9% No    No
CP
12. M.F. F 8 M Crouzon 65 h 53.2% 46.8% Yes Bifronto. A    No
13. N.D. M 5 M Brachicephaly 36 h 68.5% 31.5% Yes Bifronto. A    No
45.7% 54.3%
14. P.M. M 2 Y Apert 45 h (<15 (>15 Yes Bifronto. A    No
MmHg) MmHg)
15. P.F M 4 M Osteopetrosis 36 h 97.9% 2.1% No Bifronto. A    No
1. Occipi-
16. P.Fr. F 5 M Pfeiffer II 67 h 20.1% 79.9% Yes tal EC 2.    No
Bifronto. A
17. P.G. M 7 M Brachicephaly 24 h 73.7% 26.3% No Bifronto. A    No
1. Occipital
18. S.F. F 3 M Pfeiffer III 36 h 1.8% 98.2% Yes    No
EC 2. VPS
(46h)
45.4% 54.6% 26.7%
73.3%
19. T. A. M 8 Y Osteopetrosis 44 h (<15 (>15 Yes Bifronto. A (>15 No No
(<15
MmHg) MmHg) MmHg)
MmHg)
1. Occipital
20. T.F. F 3 M Crouzon 50 h 57.1% 42.9% Yes EC 2. Bi-    No
fronto. A
1. Occipital
EC 2. VPS (46 h)
21. T.A M 4 M Apert 48 h 5.0% 95.0% Yes 32.7% No No
3. Bifronto. 67.3%
A
* diagnosis  at admission; tr  length of icp monitoring;
** ec  expansive cranioplasty; hy  hidrocephalus; vps  ventriculo-peritoneal shunt; bifronto. a  bifrontoorbital advancement; cp  cranioplasty
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Med Sci Monit, 2004; 10(4): MT53-63 Gianpiero T et al  Prolonged intracranial pressure (ICP) monitoring&
Table 3. Synopsis of clinical and ICP findings in children with arachnoid cysts.
Clinical Neuroilogical (TR) ICP
Symptoms that ICP >15 Complica-
Patient Sex Age Location symptoms examination EEG <15
lead to diagnosis MmHg tions
at admission at admission MmHg %
*L. Sylvian Incidental (46 h)
1. B.S. M 8 Y Asymptomatic Negative Focal 8.0% No
(*type I) posttraumatic 92%
R. Sylvian Incidental (43 h)
2. C.M. M 2 Y Asymptomatic Negative Aspecific 16.1% No
(*type I) posttraumatic 83.9%
L. Sylvian Incidental Cranial (40 h)
3. S.G.M. M 3 Y Headache Aspecific 12.1% No
(*type I) posttraumatic asymmetry 87.9%
*R. Sylvian Psychomotor (36 h)
4.S. M. M 2 Y Epilepsy Epilepsy Aspecific 10.4% No
(*type I) delay 89.6%
MT
L. Sylvian (46 h)
5. A.R. M 12 Y Headache Headache Negative Aspecific 15.0% No
(*type ii) 85%
Psycomothor Psychomotor
L. sylvian (42 h) 25.0%
delay due to Headache delay; spastic Aspecific No
6. S. V. F 12 Y (*type II) 85%
perinatal hypoxia tetraparesis
L. Sylvian Increased bilateral (51 h)
7. D. F. M 1 Y Asymptomatic Negative Aspecific 3.3% CSF leak
(*type II) muscle tone 96.7%
Functional dysto-
L. Sylvian nic movement (48 h)
8. R. M. M 12 Y Asymptomatic Negative Aspecific 19.0% No
(*type II) of the neck and 81%
the four arms
L. Sylvian Headache, Headache, (46 h)
9. N.S. M 11 Y Negative Aspecific 76.30% No
(*type II) vomiting vomiting 24%
R. Sylvian Incidental: prena- Bilateral anacusia (48 h)
10. B. E. M 2 Y Asymptomatic Aspecific 55.0% No
(*type II) tal ecographic (not related) 45%
R. Sylvian Incidental: (60 h)
11. S. E. M 15 Y Asymptomatic Negative Focal 57.0% No
(*type II) posttraumatic 43%
mechani-
R. sylvian Incidental: prena- (48 h)
12. V.G. M 13 M Asymptomatic Negative Aspecific 84.4% cal mal-
(*type II) tal ecographic 15.6%
function
L Sylvian Headache, Headache, Bilateral (65 h)
13. B.M. M 5 Y Aspecific 92.2% No
(*type III) vomiting vomiting papilledema 7.8%
Incidental: Intracranial (52 h) 1.3 % 98.7%
R. Sylvian Cranial
14. M.M. M 15 Days prenatal hypertension Aspecific (<10 (>10 CSF leak
(*type III) asymmetry
ecographic (tense a.f.) MmHg) mmhg)
L Sylvian Headache, Headache, (50 h)
15. M.S. M 10 Y Negative Focal 0.9% No
(*type III) vomiting vomiting 99.1%
Intraventricular (30 h)
16. O.W. M 4 Y Macrocrania Asymptomatic Negative Negative 25.4% No
(*LLV) 74.6%
* L  left; R  right; TYPE  according to Galassi classification; LLV  left lateral ventricle; ECM  endoscopic cyst marsupialization
Complications major indication that can be found in the literature
involves children with severe craniocerebral trauma
The overall complication rate was 17.1%, including 9 cases [8,11,15,16,21,22]. Less information is available on
of CSF leak (12.8%), which resolved with medication of patients with non-traumatic conditions. However, dif-
the surgical wound, two cases of mechanical failure (2.8%) ferent authors have stressed the importance of pro-
which required the reimplantation of the transducer, and longed ICP recording in the diagnosis and preoperative
one case of hemorrhage (1.4%) surrounding the tip of the management of children with hydrocephalus, shunt-
fiberoptic device. The hemorrhage was documented on a related problems, and craniosynostosis [1 7,9,15]. Many
control CT performed because of a malfunction of the techniques have been proposed; extracranial as well as
ICP transducer (ICP values >100 mmHg, in an asympto- epidural, subdural, and deep devices have been alterna-
matic child); no specific medical or surgical treatment was tively used. Extracranial devices have the advantage of
required. No case of infection was recorded. being mini-invasive, not requiring a surgical procedure
to be implanted. A comparison with deep ICP measure-
DISCUSSION ments (intraparenchymal and ventricular) has also
demonstrated their good reliability. They do, however,
There is increasing experience in the use of continuous present serious problems of fixation; indeed, exact
ICP monitoring in pediatric neurosurgical diseases. The coplanimetry is needed. Furthermore, results are influ-
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Diagnostics and Medical Technology Med Sci Monit, 2004; 10(4): MT53-63
enced by the external pressure applied and by the ten- perfusion pressure, transcranial Doppler blood flow
sion of the contact surface (for example, anterior velocity, and jugular bulb oxygen saturation) with the
fontanelle and tympanic membrane) [10,13,14]. objective of multimodal studies [10]. Eide et al. recently
Epidural screws avoid opening of the dura, theoretically proposed a software which allows not only the evalua-
lessening the risk of surgical complications. However, tion of mean ICP and pulse waves, but also the relation-
they have not proven to be reliable because of signal ship between mean ICP and the number of ICP eleva-
dampening and recording artifacts [13]. In this respect, tions within 10 24-hour periods [1 4]. The software
modern subdural and subarachnoid bolts give more used in our unit (ICP monitoring release®), apart from
predictable results, although some authors have report- on-line and off-line evaluation of pulse waves, allows the
ed disparate recordings (compared with ventricular analysis of the mean ICP percentage distribution for
catheters) at pressures greater than 20 mmHg any chosen time period as well as for the whole record-
[11,13,15]. Historically, the most accurate ICP record- ing. Bar and star graphics can be automatically
ings are obtained from the ventricles; however, ven- obtained, enabling a general view. Furthermore, a cur-
triculostomy is related to a higher though limited risk of sor can be moved over the desired part of the record-
complications compared with the other techniques ing; in this way not only the number and duration of
(seizures, hematoma, catheter obstruction and CSF ICP elevations can be calculated, but artifacts can be
infections) [11,13]. excluded from the final evaluation.
Intraparenchymal fiberoptic devices were introduced at Hydrocephalus and shunt-related problems
the beginning of 1990s in order to reduce these risks
and obtain results comparable to ventricular ICP mea- Clinical symptoms and radiological data ensure the diag-
surements. After more than ten years of practice, the nosis of active hydrocephalus or shunt dysfunction
advantages and disadvantages of the technique have (mechanical obstruction, SVS) in most cases. However,
become clearer. The advantages are that transducers there is a significant minority of patients in whom the
give reliable ICP readings, can be easily placed, and clinical and radiological pictures are not so clear.
they are solid state, not subject to obstruction. Further- Symptoms, which may include headache and vomiting,
more, they allow direct measurement of brain tissue may not be related to the shunt or to the presence of
pressure in patients with small, compressed, or dislocat- hydrocephalus. Viral infections or migraine may indeed
ed ventricles in which placement of a ventricular present with a picture suggesting an increase in intracra-
catheter would be difficult. The main disadvantages are nial pressure, and children with chronic or episodic low
a relatively high rate of mechanical failures and the ICP after shunting may present with symptoms which
inability to recalibrate devices in situ [11 13,15,16]. simulate a mechanical obstruction of the shunt. As the
Concerning mechanical failures, most authors report an long-term risks of a shunt implantation or revision may
incidence of 2 7%. In a series of 98 children, Jensen et be far from benign, it is important to make the right
al. referred to a rate as high as 13%. However, these diagnosis. Fouyas et al. continuously monitored intra-
authors probably overstated this kind of complication; parenchymal intracranial pressure in 18 patients with
indeed, in twelve patients there was only a suspicion of ventriculomegaly and 23 patients with presumed shunt
 drifting of the system, and only in one case (1%) was malfunction. In 9 of the 18 children with ventricu-
there a real malfunction of the fiberoptic device [12]. lomegaly, the ICP was within normal limits and the
Other complications that have been described using insertion of a shunt could be avoided; in 13 of the 23
parenchymal fiberoptic devices are hemorrhages sur- children assessed for shunt malfunction, the change in
rounding the tip of the transducer (0.5 1.5%), CSF the ICP profile indicated a siphoning or over-drainage
leaks (1.9 3%), and infections (0.3 7%) [11 13,15,16]. process [9]. Massager studied intracranial pressure in 20
In our experience, nine children presented a CSF leak asymptomatic infants with increased head growth rates:
(12.8%), a rate higher than in previous reports. Six only eight of these children showed pathological ICP
patients were under one year of age: it is possible that recordings and needed surgical treatment [10].
the presence of more slack subcutaneous tissues in
infants may have favored the occurrence of this compli- Our experience confirms previous reports. Only six of
cation in our series. Mechanical failure (2.8%) and hem- the seventeen patients with suspected active hydro-
orrhage (1.4%) rates were in line with literature data. cephalus showed abnormal ICP values and needed sur-
No infection was observed. gical treatment. Four of the ten patients referred to us
with a diagnosis of shunt malfunction had normal ICP
Another important point to consider when performing values in spite of symptoms simulating intracranial
prolonged monitoring of the ICP is how to store and hypertension (H/A, vomiting) present in three of them.
analyze the results. In the past this kind of assessment
was carried out on paper tracings. Since the early 1980s, The usefulness of ICP monitoring has also been demon-
a number of software systems have been proposed for strated in children with suspected slit ventricles syn-
PC storage of the obtained data. Single pulse analysis of drome (SVS). Using a parenchymal fiberoptic transduc-
the ICP waves, pulse-amplitude, and mean pressure er, Rekate was able to identify five separate groups of
diagrams have been the main parameters included in patients among those initially referred for a SVS. He
the evaluation programs [18 20]. For intensive care use, concluded that there are several different syndromes
the analysis of intracranial pressure has also been inte- associated with headaches and small ventricles in shunt-
grated within the cerebrovascular parameters (cerebral ed children, and that ICP monitoring can help to select
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Med Sci Monit, 2004; 10(4): MT53-63 Gianpiero T et al  Prolonged intracranial pressure (ICP) monitoring&
the proper management procedure [7]. The presence Crouzon syndrome, in both the children with cloverleaf
or absence of plateau A-waves, in our experience was a craniosynostosis, in two of the three children with
particularly important parameter for the evaluation of Pfeiffer syndrome, and in one of the two patients with
these patients. Indeed, although all of them had normal osteopetrosis. Post-operative ICP monitoring was effect-
ICP values for more than 50% of the recordings, ed in seven of these patients (four of the five children
plateau A-waves were found in three cases, indicating a with Apert syndrome and one each with a Crouzon syn-
periodic pathological increase in the ICP and the need drome, a cloverleaf craniosynostosis and osteopetrosis)
for surgical treatment. and documented a reduction of ICP values in all cases.
However, in no case was there a return of ICP to nor-
Craniosynostosis mal; nevertheless, plateau sleep waves disappeared in
only four of these children, while they were only
Different factors may contribute to an elevation of the reduced in the remaining three cases. This finding con-
ICP in children with craniosynostosis. Apart from the firms previous reports. Upper airways obstruction,
restricted skull volume, herniation of the hindbrain, which is an almost constant association in syndromic
MT
intracranial venous congestion, hydrocephalus, and craniosynostosis, contributes to the persistence of patho-
upper airways obstruction are well-documented associa- logical ICP parameters in this kind of patient. This may
tions particularly with the syndromic forms, and all can be particularly true for plateau waves which are related
be responsible of this process. Clinical and radiological with REM sleep. The restricted number of children with
features often give little information. For this reason, non-syndromic craniosynostosis of our series does not
ICP monitoring can be a particularly important diag- allow definite conclusions; however, it should be noticed
nostic tool. Indeed, the separation of children with an that, including the two children with brachicephaly, in
increase in ICP from those with an exclusively cosmetic no case could we find a pathological increase in ICP.
problem is an important parameter in the definition of
the surgical indication and may help to establish the Arachnoid cysts
times of single- or multiple-staged operative treatment.
The relatively frequent detection of arachnoid cysts in
A limited number of studies can be found on this issue; apparently otherwise asymptomatic patients has empha-
moreover, differing techniques of patient selection and sized the current lack of reliable surgical indicators in a
the measurement and interpretation of ICP values do significant proportion of cases [24 31]. Consequently, a
not allow meaningful comparisons between them. conservative approach in patients, followed by means of
Thompson et al. measured ICP in a consecutive series seriated neuroimaging and neuropsychological exami-
of 136 patients. Eighty-three of them were affected by nations, has been advocated by several authors [26,30].
non-syndromic craniosynostosis and fifty-three by syn- In 1980 Galassi and co-workers proposed a classification
dromic craniosynostosis. A Camino fiberoptic subdural based on the cysts size and the effectiveness of their
device was selected for continuous ICP monitoring anatomofunctional communication with the normal sub-
(mean time of ICP monitoring: 21 h). There was a sig- arachnoid spaces, evaluated by means of metrizamide-
nificant difference in the prevalence of raised ICP enhanced CT cysternography. This classification identi-
between the non-syndromic and syndromic groups. In fies three main types. Type I cysts usually are biconvex
non-syndromic craniosynostosis, raised ICP was present or semicircular, small in size, and confined to the anteri-
in 24% of the cases, compared with 52.8% in the syn- or part of the temporal fossa. These cysts exert only a
dromic group. Among the non-syndromic children, negligible mass effect because of free and rapid commu-
cases of single-suture synostosis showed a significantly nication with the basal cisterns. Type II cysts tend to be
lower prevalence of raised ICP (12.9%) than cases where roughly triangular or quadrangular in shape and medi-
more than one suture was fused (brachicephaly, multi- um-sized. They often have a moderate mass effect,
ple sutures) (57.1%). Of the syndromic craniosynostoses, mostly within the anterior and middle portions of the
Crouzon (65%) and Pfeiffer (60%) syndrome were the temporal fossa. Type II cysts fill with water-soluble con-
most commonly associated with increased ICP. Apart trast medium relatively late on CT cisternography.
from mean ICP, plateau sleep waves were recorded; a Finally, Type III cysts are large, roundish or oval
significant difference was found in the presence of these lesions that occupy the middle cranial fossa entirely,
waves between non-syndromic (28.2%) and syndromic obviously compressing the adjacent nervous and vascu-
(62.2%) patients. Postoperative assessment of the ICP lar structures, eventually causing deformation of the
was performed in 15 patients; five of them (two with homolateral cerebral ventricle and controlateral midline
Apert syndrome, two with cloverleaf craniosynostosis, shift. These cysts may appear to be not permeable to the
and one with Crouzon syndrome) had persistent post- contrast medium, or filled only very late because of
operative elevated ICP, confirming that increased ICP absent or functionally inadequate communication with
may have a multifactorial pathogenesis in children with the normal subarachnoid spaces [23].
syndromic craniosynostosis [5,6].
The results we obtained by prolonged ICP recording in
Fourteen of the sixteen children with complex cran- the series here examined appear to confirm the useful-
iosynostosis (87.5%) in our series presented abnormal ness of Galassi s classification, as the recorded ICP val-
ICP values with the evidence of nocturnal plateau waves ues tended to be within the normal range in Type I
in all cases. In particular, pathological ICP recordings lesions and consistently above the limit in two of the
were documented in all the patients with Apert and three children with Type III cysts. Unfortunately, the
MT61
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Diagnostics and Medical Technology Med Sci Monit, 2004; 10(4): MT53-63
5. Thompson DNP, Harkness W, Jones B et al: Subdural intracranial
examination proved less discriminating in Type II cysts,
pressure monitoring in craniosynostosis: its role in surgical man-
where normal and abnormally elevated ICP values agement. Child s Nerv Syst, 1995; 11: 269-75
could be observed with similar incidence. With the limit 6. Thompson DNP, Malcolm GP, Jones BM et al: Intracranial pres-
sure in single suture craniosynostosis. Pediatr Neurosurg, 1995; 22:
of the relatively small number of patients, prolonged
235-40
recording of ICP appears to be particularly important
7. Rekate HL. Classification of Slit-Ventricle-Syndromes using intracra-
in ruling out the need to relieve the pressure exerted by
nial pressure monitoring. Pediatr Neurosurg, 1993; 19: 15-20
the lesion in patients with Type I cysts, even in cases
8. Pople IK, Muhlbauer MS, Sanford RA, Kirk E: Results and compli-
presenting with unspecific clinical manifestations, such
cations of intracranial pressure monitoring in 303 children. Pediatr
Neurosurg, 1995; 23: 64-67
as transient headache or seizure disorders. Similarly,
this is confirmed by the results of this study. The detec- 9. Fouyas IP, Casey ATH, Thompson D et al: Use of intracranial pres-
sure monitoring in the management of childhood hydrocephalus
tion of one patient with a Type III cyst and normal ICP
and shunt-related problems. Neurosurgery, 1996; 38(4): 726-32
recordings confirms that an increase in ICP is not
10. Massager N, Wayenberg JL, Raftopoulos C et al: Anterior
always at the base of a severe distortion or compression
fontanelle pressure monitoring for the evaluation of asymptomatic
of neurological structures revealed by neuroimaging infants with increased head growth rate. Child s Nerv Syst, 1996;
12: 38-42
studies.
11. Gambardella G, Zaccone C, Cardia E, Tomasello F. Intracranial
pressure monitoring in children: comparison of external ventricu-
In cases of Type II temporal arachnoid cysts, prolonged
lar device with the fiberoptic system. Child s Nerv Syst, 1993; 9:
ICP recording may be particularly useful for the surgi-
470-73
cal indication, as it may allow to differentiate those
12. Jensen RL, Hahn YS, Ciro E: Risk factors of intracranial pressure
monitoring in children with fiberoptic devices: a critical review.
patients who may benefit from the surgical excision of
Surg Neurol, 1997; 47: 16-22
the cystic lesion or diversion of its content, because of
13. Minns RA: Intracranial pressure monitoring. Archives Dis Child,
evidence of increased intracranial pressure, from those
1984; 59: 486-88
cases where a wait-and-see policy could be adopted, in
14. Reid A, Marchbanks RJ, Bateman DE et al: Mean intracranial pres-
which the pressure of the cyst does not appear to impair
sure monitoring by a non-invasive audiological technique: a pilot
CSF dynamics. study. J Neurol Neurosurg Psych, 1989; 52: 610-12
15. Munch E, Weigel R, Schmiedek P, Schurer L: The Camino
intracranial pressure device in clinical practice: reliability, handling
Future developments of the present study may come
characteristics and complications. Acta Neurochir (Wien), 1998;
from a comparison between ICP findings and cerebral
140(11): 1113-20
perfusion examinations results. In 2001, in fact, Sgouros
16. Morgalla MH, Cuno M, Mettenleiter H et al: ICP monitoring wih
and Chapman demonstrated a reduction in cerebral
a re-usable transducer: experimental and clinical evaluation of the
Gaeltec ICT/b pressure probe. Acta Neurochir (Wien), 1997; 139:
blood flow not associated with signs or symptoms of
569-73
increased ICP in three children with Sylvian arachnoid
17. Penson RP, Allen R. Intracranial pressure monitoring by time
cysts who were investigated by means of SPECT scans.
domain analysis. J R Soc Health, 1998; 118(5): 289-94
In all cases, surgical excision of the cyst resulted in nor-
18. Morgalla MH, Stuum F, Hesse G: A computer-based method for
malization of cerebral blood flow following a partial re-
continuous single pulse analysis of intracranial pressure waves.
expansion of the temporal lobe [31]. J Neurol Sci, 1999; 168(2): 90-95
19. Lemarie JJ, Boire JY, Chazal J, Irthum B: A computer software
for frequential analysis of slow intracranial pressure waves. Comput
CONCLUSIONS
Methods Programs Biomed, 1994; 42(1): 1-14
20. Gaab MR, Ungersbock K, Hufenbeck B: Evaluation of ICP by com-
The present study confirms that prolonged ICP moni-
puterized bedside monitoring. Neurol Res, 1986; 8(1): 44-52
toring is an important diagnostic tool in non-traumatic
21. Allen R: Time series methods in the monitoring of intracranial
pediatric neurosurgical diseases. In our experience, it
pressure. Part 2: comparative study and initial assessment. J Bio-
med Engl, 1983; 5(2): 103-9
enabled a more correct surgical indication in children
22. Steinmeier R, Hoffman RP, Bauhuf C et al: Continuous cerebral
with hydrocephalus and arachnoid cysts. In children
autoregulation monitoring by cross-correlation analysis. J Neuro-
with craniosynostosis it was useful in defining the func-
trauma 2002; 19(10): 1127-38
tional role of the disease and to establish the times of
23. Galassi E, Tognetti F, Gaist G et al: CT scan and metrizamide CT
the operative treatment.
cisternography in arachnoid cysts of the middle cranial fossa: classi-
fication and pathophysiological aspects. Surg Neurol, 1982; 17(5):
363-69
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195-204
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Med Sci Monit, 2004; 10(4): MT53-63 Gianpiero T et al  Prolonged intracranial pressure (ICP) monitoring&
29. Sommer IEC, Smit LME: Congenital supratentorial arachnoidal 31. Sgouros S, Chapman S: Congenital middle fossa arachnoid cysts
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