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The yield of ophthalmoscopy as a screening tool for intracranial pathology in pediatric headache

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Abstract

Headache is a common complaint in children who present at the pediatric emergency department (PED). Serious conditions such as intracranial tumors and idiopathic intracranial hypertension (IIH) should be rapidly ruled out. Ophthalmoscopy for the presence of papilledema has long been considered critical to the assessment of headaches in children; however, the yield of this procedure is poorly validated. This retrospective study implemented a computerized search of the medical records of a single tertiary center to identify all children aged 2–18 years who presented at the PED complaining of headache between 2007 and 2017. The clinical, demographic, radiographic, and laboratory data were analyzed. Of the 948 children aged 2–18 years who presented at the PED complaining of headache, 536 had an ophthalmoscopy examination carried out by an ophthalmologist. Forty-one had papilledema, of whom 7 had an intracranial tumor, 15 had IIH, and 9 had optic nerve head drusen. Of the 495 children without papilledema, 3 had intracranial tumor, and 11 had IIH. The sensitivity and specificity of papilledema for the diagnosis of intracranial tumor were 70% and 93.5%, respectively, with an NPV and PPV of 99.4% and 17.1%, respectively. The sensitivity and specificity of papilledema for the diagnosis of intracranial pathology in general were 61.1% and 96.2%, respectively, with an NPV and PPV of 97.2% and 53.7%, respectively.

  Conclusion: Assessment by ophthalmoscopy for papilledema in children presenting to the PED with headache had high sensitivity and high specificity, thus reinforcing the importance of ophthalmoscopy as a screening tool in these children.

What is Known:

• Headache is a common complaint in children. Serious intracranial pathologies need to be rapidly excluded.

• Ophthalmoscopy for the presence of papilledema is commonly used as a screening tool for intracranial pathology, but this procedure is poorly validated.

What is New:

• Ophthalmoscopy for the assessment of papilledema in children who present with headache to the pediatric emergency department is shown to exhibit sensitivity and specificity for the diagnosis of intracranial pathology.

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Abbreviations

PED:

Pediatric emergency department

ICP :

Intracranial pressure

IIH:

Idiopathic intracranial hypertension

OCT:

Optical coherence tomography

FA:

Fluorescein angiography

CT:

Computed tomography

MRI:

Magnetic resonance imaging

LP:

Lumbar puncture

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Author notes

  1. Rawan Azzam Kawar and Itai Gross contributed equally to this article.

Authors and Affiliations

  1. Department of Pediatrics, Hadassah and The Hebrew University Medical Center, Jerusalem, Israel

    Rawan Azzam Kawar

  2. Department of Pediatric Emergency Medicine, Hadassah and The Hebrew University Medical Center, Jerusalem, Israel

    Itai Gross, Yael Biro & Saar Hashavya

  3. Faculty of Medicine, Hadassah and The Hebrew University Medical Center, Jerusalem, Israel

    Noa Guzner, Moriah Peyser-Rosenberg & Shira Azulai

  4. Pediatric Ophthalmology Unit, Hadassah and The Hebrew University Medical Center, Jerusalem, Israel

    Hadas Mechulam

  5. Child Neurology Unit, Hadassah and The Hebrew University Medical Center, Jerusalem, Israel

    Tal Gilboa

  6. The Dyna and Fala Weinstock Department of Pediatric Hemato-Oncology, Hadassah and The Hebrew University Medical Center, Jerusalem, Israel

    Hodaya Cohen

Authors
  1. Rawan Azzam Kawar
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  2. Itai Gross
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  3. Yael Biro
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  7. Hadas Mechulam
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  10. Saar Hashavya
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Contributions

Drs. Hashavya, Mechulam, and Gilboa conceptualized and designed the study, drafted the initial manuscript, and reviewed and revised the manuscript. Drs. Biro, Cohen and Ms. Guzner, Ms. Peyser-Rosenberg, and Ms. Azulai designed the data collection instruments, collected data, carried out the initial analyses, and reviewed and revised the manuscript. Drs. Azzam Kawar and Gross conceptualized and designed the study, coordinated and supervised data collection, and critically reviewed the manuscript for important intellectual content. All authors approved the final manuscript as submitted and agree to be accountable for all aspects of the work.

Corresponding author

Correspondence to Itai Gross.

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This study was approved by the Institutional Review Board (approval number: 0274–17-HMO).

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Kawar, R.A., Gross, I., Biro, Y. et al. The yield of ophthalmoscopy as a screening tool for intracranial pathology in pediatric headache. Eur J Pediatr 182, 609–614 (2023). https://doi.org/10.1007/s00431-022-04708-0

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