Reference range of cerebrospinal fluid opening pressure in children: historical overview and current data

Abstract

The lumbar puncture and cerebrospinal fluid (CSF) opening pressure (OP) in children remains an essential diagnostic test for children with suspected elevated intracranial pressure. Recent prospective data have revised the normative CSF OP values and described how clinical variables such as age, depth of sedation, and obesity may influence the measurements. In addition, the new normative data are now reflected in revised diagnostic criteria for idiopathic intracranial hypertension/pseudotumor cerebri syndrome. This review highlights the recently published data and provides guidance on how it may impact clinical management.

Fig. 1

Color fundus photographs demonstrating elevated optic nerves in both eyes.

Fig. 2

Humphrey visual field results demonstrating a mildly enlarged blind spot. (A) Left eye and (B) right eye.

Fig. 3

Color fundus photographs demonstrating elevated optic nerves in both eyes.

Fig. 4

Distribution of cerebrospinal fluid (CSF) opening pressure and effects of sedation, body mass index, and age. (A) The distribution of the CSF opening pressure for 197 study subjects who met the inclusion criteria for the reference group. The mean (± SD) CSF opening pressure was 19.8 ± 6.8 cm of water. The values ranged from6 to 47 cm of water and were similar in subjects 10 years of age or older and those younger than 10 years. The threshold for an abnormally elevated opening pressure, which was based on subjects with opening pressures in the 90th percentile or higher, was 28 cm of water. The threshold for an abnormally low opening pressure, based on subjects in the 10th percentile, was 11.5 cm of water. (B) The results of an unadjusted linear regression analysis of the relationship between opening pressure and sedation (β = 3.459, p = 0.005). (C) The relationship between opening pressure and body mass index (BMI, the weight in kilograms divided by the square of the height in meters) (β = 0.138, p = 0.12) and (D) that between opening pressure and age (β = 0.328, p < 0.001). Statistically significant associations between opening pressure and moderate-to-deep sedation (β = 4.990, p = 0.002) and opening pressure and BMI (β = 0.313, p = 0.002) remained in multivariable analysis adjusted for age. In a multivariable linear regression model, no significant association was found between age (β = 0.097, p = 0.42) and opening pressure, even when age was categorized as 10 years or older or as younger than 10 years (β = 1.141, p = 0.30). No significant association was found between opening pressure and sedation with ketamine (β = 3.080; 95% confidence interval, −0.551 to 6.712; p = 0.10). Reprinted with permission from Avery et al.

Fig. 5

B-scan ultrasonography demonstrated optic nerve drusen of the right eye (arrow) from Case 1.