title: Patterns of retinal hemorrhage associated with increased intracranial pressure in children.
abstract: OBJECTIVE
  Raised intracranial pressure (ICP) has been proposed as an isolated cause of retinal hemorrhages (RHs) in children with suspected traumatic head injury. We examined the incidence and patterns of RHs associated with increased ICP in children without trauma, measured by lumbar puncture (LP).
  
  
  METHODS
  Children undergoing LP as part of their routine clinical care were studied prospectively at the Children's Hospital of Philadelphia and retrospectively at Nationwide Children's Hospital. Inclusion criteria were absence of trauma, LP opening pressure (OP) ≥ 20 cm of water (cm H2O), and a dilated fundus examination by an ophthalmologist or neuro-ophthalmologist.
  
  
  RESULTS
  One hundred children were studied (mean age: 12 years; range: 3-17 years). Mean OP was 35 cm H2O (range: 20-56 cm H2O); 68 (68%) children had OP >28 cm H2O. The most frequent etiology was idiopathic intracranial hypertension (70%). Seventy-four children had papilledema. Sixteen children had RH: 8 had superficial intraretinal peripapillary RH adjacent to a swollen optic disc, and 8 had only splinter hemorrhages directly on a swollen disc. All had significantly elevated OP (mean: 42 cm H2O).
  
  
  CONCLUSIONS
  Only a small proportion of children with nontraumatic elevated ICP have RHs. When present, RHs are associated with markedly elevated OP, intraretinal, and invariably located adjacent to a swollen optic disc. This peripapillary pattern is distinct from the multilayered, widespread pattern of RH in abusive head trauma. When RHs are numerous, multilayered, or not near a swollen optic disc (eg, elsewhere in the posterior pole or in the retinal periphery), increased ICP alone is unlikely to be the cause.
authors.affiliation: Division of Ophthalmology, The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania 19104, USA. binenbaum@email.chop.edu
authors.forename: Gil
authors.initials: G
authors.lastname: Binenbaum
authors.forename: David L
authors.initials: DL
authors.lastname: Rogers
authors.forename: Brian J
authors.initials: BJ
authors.lastname: Forbes
authors.forename: Alex V
authors.initials: AV
authors.lastname: Levin
authors.forename: Sireesha A
authors.initials: SA
authors.lastname: Clark
authors.forename: Cindy W
authors.initials: CW
authors.lastname: Christian
authors.forename: Grant T
authors.initials: GT
authors.lastname: Liu
authors.forename: Robert
authors.initials: R
authors.lastname: Avery
mesh_terms: D000293:Adolescent; D002648:Child; D002675:Child, Preschool; D003430:Cross-Sectional Studies; D005260:Female; D006776:Hospitals, Pediatric; D006801:Humans; D015994:Incidence; D019586:Intracranial Hypertension / Q000150:complications / Q000453:epidemiology* / Q000209:etiology; D008297:Male; D010211:Papilledema / Q000453:epidemiology / Q000209:etiology; D011446:Prospective Studies; D012166:Retinal Hemorrhage / Q000453:epidemiology* / Q000209:etiology; D013129:Spinal Puncture
keywords: intracranial pressure; papilledema; retinal hemorrhage