Benjamin was rushed to the emergency department with possible increased intracranial pressure (ICP); which of the following is an early clinical manifestation of increased ICP in older children?
A. Macewen’s sign
B. Setting sun sign
C. Papilledema
D. Diplopia
Correct Answer: D. Diplopia
Diplopia is an early sign of increased ICP in an older child. Visual changes can range from blurred vision, double vision from cranial nerve defects, photophobia to optic disc edema and eventually optic atrophy. Clinical suspicion for intracranial hypertension should be raised if a patient presents with the following signs and symptoms: headaches, vomiting, and altered mental status varying from drowsiness to coma.
Option A: Macewen sign refers to a “cracked pot” sound that is noted on percussion of the head. “The cracked pot sound,” Macewen’s sign, was originally described by Macewen in his book, Pyogenic infectious diseases of the brain and spinal cord in 1893. The method of elicitation of differential cranial percussion as an aid to cerebral diagnosis was practiced by him for years, particularly in children.
Option B: The setting sun appearance of the eyes is noted in infants with increased ICP. The sunset eye sign (also known as the setting sun phenomenon) is a clinical phenomenon encountered in infants and young children with raised intracranial pressure (seen in up to 40% of children with obstructive hydrocephalus and 13% of children with shunt dysfunction).
Option C: Papilledema is a late sign of increased ICP. If the raised ICP is not treated, this can lead to optic atrophy and vision loss. The absence of papilledema does not rule out increased intracranial pressure, since it does not develop acutely.