title: Evaluation of Optical Coherence Tomography to Detect Elevated Intracranial Pressure in Children.
abstract: OBJECTIVE
  Detecting elevated intracranial pressure in children with subacute conditions, such as craniosynostosis or tumor, may enable timely intervention and prevent neurocognitive impairment, but conventional techniques are invasive and often equivocal. Elevated intracranial pressure leads to structural changes in the peripapillary retina. Spectral-domain (SD) optical coherence tomography (OCT) can noninvasively quantify retinal layers to a micron-level resolution.
  
  
  OBJECTIVE
  To evaluate whether retinal measurements from OCT can serve as an effective surrogate for invasive intracranial pressure measurement.
  
  
  METHODS
  This cross-sectional study included patients undergoing procedures at the Children's Hospital of Philadelphia from September 2014 to June 2015. Three groups of patients (n = 79) were prospectively enrolled from the Craniofacial Surgery clinic including patients with craniosynostosis (n = 40). The positive control cohort consisted of patients with hydrocephalus and suspected intracranial hypertension (n = 5), and the negative control cohort consisted of otherwise healthy patients undergoing a minor procedure (n = 34).
  
  
  METHODS
  Spectral-domain OCT was performed preoperatively in all cohorts. Children with cranial pathology, but not negative control patients, underwent direct intraoperative intracranial pressure measurement. The primary outcome was the association between peripapillary retinal OCT parameters and directly measured elevated intracranial pressure.
  
  
  RESULTS
  The mean (SD) age was 34.6 (45.2) months in the craniosynostosis cohort (33% female), 48.9 (83.8) months in the hydrocephalus and suspected intracranial hypertension cohort (60% female), and 59.7 (64.4) months in the healthy cohort (47% female). Intracranial pressure correlated with maximal retinal nerve fiber layer thickness (r = 0.60, P ≤ .001), maximal retinal thickness (r = 0.53, P ≤ .001), and maximal anterior retinal projection (r = 0.53, P = .003). Using cut points derived from the negative control patients, OCT parameters yielded 89% sensitivity (95% CI, 69%-97%) and 62% specificity (95% CI, 41%-79%) for detecting elevated intracranial pressure. The SD-OCT measures had high intereye agreement (intraclass correlation, 0.83-0.93) and high intragrader and intergrader agreement (intraclass correlation ≥0.94). Conventional clinical signs had low sensitivity (11%-42%) for detecting intracranial hypertension.
  
  
  CONCLUSIONS
  Noninvasive quantitative measures of the peripapillary retinal structure by SD-OCT were correlated with invasively measured intracranial pressure. Optical coherence tomographic parameters showed promise as surrogate, noninvasive measures of intracranial pressure, outperforming other conventional clinical measures. Spectral-domain OCT of the peripapillary region has the potential to advance current treatment paradigms for elevated intracranial pressure in children.
authors.affiliation: Craniofacial Surgery Center and Division of Plastic Surgery, The Children's Hospital of Philadelphia and the University of Pennsylvania, Philadelphia.
authors.forename: Jordan W
authors.initials: JW
authors.lastname: Swanson
authors.affiliation: Scheie Eye Institute and the Department of Ophthalmology, Perelman Center for Advanced Medicine and the University of Pennsylvania, Philadelphia3Division of Ophthalmology, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania.
authors.forename: Tomas S
authors.initials: TS
authors.lastname: Aleman
authors.affiliation: Craniofacial Surgery Center and Division of Plastic Surgery, The Children's Hospital of Philadelphia and the University of Pennsylvania, Philadelphia.
authors.forename: Wen
authors.initials: W
authors.lastname: Xu
authors.affiliation: Scheie Eye Institute and the Department of Ophthalmology, Perelman Center for Advanced Medicine and the University of Pennsylvania, Philadelphia.
authors.forename: Gui-Shuang
authors.initials: GS
authors.lastname: Ying
authors.affiliation: Scheie Eye Institute and the Department of Ophthalmology, Perelman Center for Advanced Medicine and the University of Pennsylvania, Philadelphia.
authors.forename: Wei
authors.initials: W
authors.lastname: Pan
authors.affiliation: Scheie Eye Institute and the Department of Ophthalmology, Perelman Center for Advanced Medicine and the University of Pennsylvania, Philadelphia3Division of Ophthalmology, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania.
authors.forename: Grant T
authors.initials: GT
authors.lastname: Liu
authors.affiliation: Division of Neurosurgery, The Children's Hospital of Philadelphia and the University of Pennsylvania, Philadelphia.
authors.forename: Shih-Shan
authors.initials: SS
authors.lastname: Lang
authors.affiliation: Division of Neurosurgery, The Children's Hospital of Philadelphia and the University of Pennsylvania, Philadelphia.
authors.forename: Gregory G
authors.initials: GG
authors.lastname: Heuer
authors.affiliation: Division of Neurosurgery, The Children's Hospital of Philadelphia and the University of Pennsylvania, Philadelphia.
authors.forename: Phillip B
authors.initials: PB
authors.lastname: Storm
authors.affiliation: Craniofacial Surgery Center and Division of Plastic Surgery, The Children's Hospital of Philadelphia and the University of Pennsylvania, Philadelphia.
authors.forename: Scott P
authors.initials: SP
authors.lastname: Bartlett
authors.affiliation: Division of Ophthalmology, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania.
authors.forename: William R
authors.initials: WR
authors.lastname: Katowitz
authors.affiliation: Craniofacial Surgery Center and Division of Plastic Surgery, The Children's Hospital of Philadelphia and the University of Pennsylvania, Philadelphia.
authors.forename: Jesse A
authors.initials: JA
authors.lastname: Taylor
mesh_terms: D002675:Child, Preschool; D003398:Craniosynostoses / Q000000981:diagnostic imaging; D003430:Cross-Sectional Studies; D005260:Female; D006801:Humans; D006849:Hydrocephalus / Q000000981:diagnostic imaging; D007223:Infant; D019586:Intracranial Hypertension / Q000000981:diagnostic imaging*; D007427:Intracranial Pressure; D008297:Male; D015588:Observer Variation; D011446:Prospective Studies; D012160:Retina / Q000000981:diagnostic imaging; D012680:Sensitivity and Specificity; D041623:Tomography, Optical Coherence / Q000379:methods*