Archives of Pediatric Neurosurgery

The presence of craniofacial alterations such as craniosynostosis and midface hypoplasia are some features of Apert syndrome. Those characteristics may lead to intracranial hypertension. For clinical evaluation, a non-invasive intracranial pressure measurement can be performed both as a preoperative examination and to evaluate surgical treatment.

Several methods have been used to measure intracranial pressure non-invasively, such as optic nerve sheath ultrasound, optical coherence tomography, and intracranial pressure waveform (ICPw) monitoring with the sensor Brain4Care®. Some methods like ICPw, require that the patient remains standstill. Because the patient wasn’t cooperative, it was decided to register the ICPw under hypnosis. A specific anesthetic planning was done to minimize the impact on the ICPw.

The proper antiviral therapy, initiated empirically with endovenous acyclovir (and later oral), following suspicion raised by the ophthalmological assessment (which identified signs of retinal necrosis in the Right Eye (RE) and opacification in the Left Eye (LE)), and confirmed by positive serum IgM antibodies to HSV-1 and HSV-2, resulted in an improvement in the patient's condition (regression of corneal edema and no progression of retinal necrosis). Although the patient developed necrotizing enterocolitis requiring surgical resection of 15 cm of the ileum, the treatment made it possible to preserve the integrity of the posterior pole of the RE and prevent the spread of infection to the LE. At the 8-month follow-up, the child showed interest in objects > 10 cm in diameter. The report concludes that the ocular assessment was crucial in the correct diagnosis and timely initiation of antiviral therapy, leading to an improved prognosis.

Likely, an appropriate way to obtain a reliable non-invasive ICPw measurement under hypnosis includes positioning the patient at neutral decubitus, choosing hypnotics with minimal impact on ICP, and maintaining spontaneous ventilation during the exam.