INTRODUCTION

A syndrome, or sign, resulting from disturbances in the dynamics of

cerebrospinal fluid (CSF), which may be caused by several diseases.

Occurs in 3-4 of every 1000 births.Cause may be congenital or acquired.Congenital- may be due to maldevelopment or

intrauterine infectionAcquired- may be due to infection, neoplasm

or hemorrhage.

The CSF volume of an average adult ranges from 80 to 160 ml

The ventricular system holds approximately 20 to 50 ml of CSF

CSF is produced in the choroid plexuses at a daily rate of 14-36 ml/hr

The choroid plexuses are the source of approximately 80% of the CSF

The blood vessels in the subependymal regions, and pia also contribute to the formation of CSF

The majority of CSF is produced from within the two lateral ventricles. From here, the CSF passes through the interventricular foramina of monro to the third ventricle, then the cerebral aqueduct (of Sylvius) to the fourth ventricle. The fourth ventricle is an outpouching on the posterior part of the brainstem. From the fourth ventricle, the fluid passes through three foramen to enter the subarachnoid space. It passes through the Foramen of Magendie on the midline, and twoForamen of Luschka laterally. The subarachnoid space covers the brain and spinal cord.

Imbalance of csf formation and absorption resulting in excess of CSF with subsequent increase in intracranial pressure

Hydrocephalus results from:1. Impaired absorption of CSF within the

subarachnoid space (communicating hydrocephalus), or

2. Obstruction to the flow of CSF through the ventricular system (non-communicating hydrocephalus)

CLASSIFICATION

CONGENITAL ACQUIRED - COMMUNICATING - NON- COMMUNICATING

Most common category in children

Usually present in infancy

-Hydrocephalus presenting after age of 6 months is less likely to be congenital and neoplasms must be excluded

Aqueduct stenosis -due to arnold chiari 1 and 2 malformation

-post infectious (toxoplasmosis, cytomegalic inclusion disease

rubella, syphilis). Obstruction of foreman of Luschka and Magendie

-dandy walker malformation

Myelomeningocele

Noncommunicating hydrocephalus : Intra venticular obstruction Tumor (posterior fossa tumor ,brain stem glioma , tumor of pinael body,choroid plexus) papilloma,ependymoma,colloid cystinfection (cerebral abcess , ventriculitis ) Hemorrhage

Communicating hydrocephalus extra-ventricular obstruction by - infection (T.b) -Subarachnoid hemorrhage - head injury

It is characterized by dilatation of ventricular system by intermittent

rise in csf pressureIt is most commonly seen

in older adults and is accompanied by

following symptomgait disturbance

dementiaurinary incontinence

CLINICAL FEATURES

Clinical features of hydrocephalus are influenced by the patient's age, the cause of the hydrocephalus, the location of the obstruction, its duration, and its rapidity of onset.

Symptoms in infants include poor feeding, irritability, reduced activity, and vomiting.

Symptoms in children and adults include the following:

•Slowing of mental capacity, cognitive deterioration•Headaches (initially in the morning)•Neck pain•Vomiting, more significant in the morning•Blurred vision: A consequence of papilledema and, later, of optic atrophy•Double vision: Related to unilateral or bilateral sixth nerve palsy•Difficulty in walking•Drowsiness

Examination in infants may reveal the following findings:

Head enlargement Dysjunction of suturesDilated scalp veinsTense fontanelleSetting-sun sign: Characteristic of increased

intracranial pressure (ICP); downward deviation of ocular globes, retracted upper lids, visible white sclera above iris

Increased limb tone (spasticity preferentially affects the lower limbs)

Children and adults may demonstrate the following findings on physical examination:

Papilledema Failure of upward gaze Unsteady gait Large head Unilateral or bilateral sixth nerve palsy (secondary to

increased ICP) Children may also exhibit the Macewen sign, in which a

"cracked pot" sound is noted on percussion of the head.

INVESTIGATIONS

Ultrasound scan Plain skull X-Ray CT scan MRI

IS USUALLY DONE TO DIAGNOSE CONGENITAL HYDROCEPHALUS.

SEPARATION OF SUTURES

EROSION OF SUTURES

INCREASED CONVOLUTIONAL MARKINGS (SILVER BEATEN APPERANCE)

WHAT IS IT?

THESE ARE ROUNDED ZONES OF BONY ATTENTUATION OF THE CRANIAL BONES CAUSED BY PRESSURE FROM THE CEREBRAL CORTICAL GYRI, RESULTING FROM PREMATURE CLOSURE OF CRANIAL SUTURES IN INFANTS AND BY EXTENSION, INCREASED INTRACRANIAL PRESSURE.

BOTH TEMPORAL HORNS ARE >2MM.

CT SCAN FINDINGS

COMPLICATIONS

The severity of hydrocephalus depends on the time of onset and whether the disease is progressive. If the condition is well advanced at birth, major brain damage and physical disabilities are likely. In less severe cases, with proper treatment, it's possible to have a nearly normal life span and intelligence.

Other complications of hydrocephalus include:Intellectual impairment Neurological damage, such as decreased function,

movement or sensation

MANAGEMENT

Hydrocephalus (fluid on the brain) is treated with surgery.

Babies born with hydrocephalus (congenital) and adults or children who develop hydrocephalus (acquired) usually need prompt treatment to reduce the pressure on their brain. If hydrocephalus isn't treated, the increase in pressure will cause brain damage.

Both congenital and acquired hydrocephalus will be treated with either shunt surgery or neuroendoscopy

• Shunt surgery• Shunt surgery involves implanting a thin

tube, called a shunt, in the brain. The excess cerebrospinal fluid (CSF) in the brain runs through the shunt to another part of the body, usually the abdomen. From here, the fluid is absorbed into your blood stream. The shunt has a valve inside to control the flow of CSF and ensure it doesn't drain too quickly. You can feel the valve as a lump under the skin of your scalp.

• A ventriculoperitoneal (VP) shunt is used most commonly. The lateral ventricle is the usual proximal location. The advantage of this shunt is that the need to lengthen the catheter with growth may be obviated by using a long peritoneal catheter.

• A ventriculoatrial (VA) shunt also is called a "vascular shunt." It shunts the cerebral ventricles through the jugular vein and superior vena cava into the right cardiac atrium. It is used when the patient has abdominal abnormalities (eg, peritonitis, morbid obesity, or after extensive abdominal surgery). This shunt requires repeated lengthening in a growing child.

• A lumboperitoneal shunt is used only for communicating hydrocephalus, CSF fistula, or pseudotumor cerebri.

• A Torkildsen shunt is used rarely. It shunts the ventricle to cisternal space and is effective only in acquired obstructive hydrocephalus.

• A ventriculopleural shunt is considered second line. It is used if other shunt types are contraindicated.

Normal pressure hydrocephalus

Normal pressure hydrocephalus (NPH) can sometimes be treated with a shunt, although experience has shown that not everyone with the condition will benefit from shunt surgery. Due to the risk of complications, you'll need tests to assess whether the potential benefits of surgery outweigh the risks. A lumbar drainage or lumbar infusion test, or both, can be used to determine whether shunt surgery will benefit you.

Shunt infection is most serious complication!Period of greatest risk is 1 to 2 months

following placement.Staph and strep most common organisms

Mechanical difficultieskinking, plugging, migration of tubing.

Malfunction is most often by mechanical obstruction!

Look for signs of increased ICP; fever, inflammation and abdominal pain.

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