HYDROCEPHALUS

Congenital or acquired increased enlargement of the head due to excessive

accumulation of cerebrospinal fluid (CSF) within the ventricles of the brain.

TYPES OF HYDROCEPHALUS
Congenital: is a buildup of excess cerebrospinal fluid (CSF) in the brain at birth.
● inherited genetic abnormalities that block the flow of CSF
● developmental disorders such as those associated with birth defects in the brain, spine,
or spinal cord
● complications of premature birth such as bleeding within the ventricles
● infection during pregnancy such as rubella that can cause inflammation in the fetal brain
tissue.

Acquired: occurs after birth when a tumor, injury or disease blocks the absorption of
cerebrospinal fluid in the brain
● brain or spinal cord tumors
● infections of the central nervous system such as bacterial meningitis
● injury or stroke that causes bleeding in the brain.

PREDISPOSING/PRECIPITATING FACTORS
1. Congenital malformation
2. Infection: meningitis, encephalitis
3. Tumor
4. Trauma: accidental head injury (intranatal or postnatal)

Medication Management

The following medications are used to treat hydrocephalus.

● Diuretics. Acetazolamide (ACZ) and furosemide (FUR) treat posthemorrhagic
hydrocephalus in neonates; both are diuretics that also appear to decrease secretion of
CSF at the level of the choroid plexus.
● Anticonvulsants. Helps to interfere impulse transmission of cerebral cortex and prevent
seizures.
● Antibiotics. Culture and sensitivity dependent for shunt infections such as septicemia,
ventriculitis, meningitis, or given as a prophylactic treatment.

Hydrocephalus can be either communicating or non communicating;

1. Communicating hydrocephalus: occurs when the flow of CSF is blocked after it exits
the ventricles. Reduced flow and absorption of CSF into specialized blood vessels called
arachnoid villi can also result in a buildup of CSF in the ventricles and communicating
hydrocephalus.
 2. Non-communicating hydrocephalus: obstruction in the system between the source of
CSF production (ventricles) and the area of its reabsorption (the subarachnoid space).

Surgical Management
A. Shunt: most common treatment for hydrocephalus a surgical insertion of a drainage system
- It consists of a long, flexible tube with a valve that keeps fluid from the brain flowing in
the right direction and at the proper rate.
- One end of the tubing is usually placed in one of the brain's ventricles. The tubing is
then tunneled under the skin to another part of the body where the excess cerebrospinal
fluid can be more easily absorbed — such as the abdomen or a chamber in the heart.

1. Ventriculoperitoneal (V-P) shunt connects the lateral ventricle of the brain to the peritoneal
cavity;does not require frequent revisions and is easier to revise.
a. most commonly used shunt in children
2. Atrioventricular (A-V) shunt connects the lateral ventricle to right atrium of the heart.
3. Ventriculoureteral (V-U) shunt connects the lateral ventricle of the brain to the ureter; requires
unilateral nephrectomy which, may cause recurrent fluid and electrolyte imbalance.

B. Endoscopic Third Ventriculostomy:

- A surgery may be an option for older children with hydrocephalus, especially for those
who have a blocked connection between the third and fourth ventricles of the brain. This
is a minimally-invasive procedure that creates an opening in the floor of the third
ventricle in the brain, allowing trapped fluid to escape into its normal pathway.

POSTSURGERY COMPLICATIONS
1. Shunt blockage
2. Infections
3. Seizures

IF TREATED
NOTE:

The long-term effects of hydrocephalus vary widely and depend on the cause and the
extent of symptoms. Without treatment, hydrocephalus will get worse over time, but with
surgery, therapy, and education, many people live relatively active lives. The earlier it's
diagnosed, the better the chances for successful treatment and recovery.

● Choroid plexus produces most of the cerebrospinal fluid (CSF) foramen of Monro lies
at the junction between the paired lateral ventricles and the third ventricle of the brain.
● Aqueduct of Sylvius) is a conduit for cerebrospinal fluid (CSF) that connects the third
ventricle to the fourth ventricle of the ventricular system of the brain.
● Myelin gives the white matter and its color. It is found in the deeper tissues of the brain
(subcortical). It contains nerve fibers (axons), which are extensions of nerve cells
(neurons). Many of these nerve fibers are surrounded by a type of sheath or covering
called myelin.
 ● ISCHEMIA: Ischemia or ischaemia is a restriction in blood supply to tissues, causing a
shortage of oxygen that is needed for cellular metabolism (to keep tissue alive).
Ischemia is generally caused by problems with blood vessels, with resultant damage to
or dysfunction of tissue.

DIAGNOSTIC PROCEDURE
1. Level II Ultrasonography: also known as a fetal anatomical survey, is recommended
for almost all pregnant women. It is similar to a standard ultrasound, except it provides
more detailed information. During the level II ultrasound, they will examine the baby's
organs, brain, umbilical cord, gender and more.
2. MRI: utilizes radio waves and a magnetic field to produce multi-faceted images of the
brain and its ventricles to detect presence of excessive CSF and its presumptive causes.
Sedation may be given for young children to allow for proper imaging results.
3. CT Scan: like the MRI, can produce cross-sectional images of the brain, involving the
use of specialized xray technology, but with less detailed images. Oftentimes, a cranial
CT scan for hydrocephalus is done only in emergency situations.

NURSING DX, GOAL and INTERVENTION

Ineffective Tissue Perfusion (Cerebral) related to increased intracranial pressure (ICP)
The patient will be able to re-establish cerebral tissue perfusion as evidenced by increased level
of consciousness (i.e. awake and alert) and will have an oriented with persons, places, and
things.

Interventions Rationales

Assess the patient’s vital signs and To assist in creating an accurate

neurological status at least every 4 diagnosis and monitor effectiveness
hours, or more frequently if there is of medical and surgical treatment for
a change in them. hydrocephalus.

Observe the patient for any signs and To facilitate early detection and
symptoms of increased ICP, such as management of increased ICP.
sudden headache, vomiting, and
decreased alertness. Increased ICP can be life-threatening
as it may lead to brain damage,
stroke, or coma.

Prepare the patient for the surgery as To treat the hydrocephalus, which is
instructed by the surgeon. the underlying cause of the patient’s
 increased ICP.

Administer osmotic diuretics (e.g. To promote blood flow to the brain

Mannitol) as prescribed. and to reduce cerebral edema.

Elevate the head of the bed at 15-45 To promote venous drainage from
degrees. the patient’s head to the rest of the
body in order to decrease ICP.

Risk for Infection post shunt insertion

The patient will be able to avoid the development of an infection after surgery.
Interventions Rationales

Assess vital signs and observe for any signs Infection may be evidenced by fever and can
of infection. be accompanied by respiratory distress.

Obtain daily blood samples as ordered. To monitor neutrophil and white blood cell
counts.

Teach the patient and carer how to perform To maintain patient safety and reduce the
proper hand hygiene. risk of infection.

Orient the patient (or child’s carer) on how to To ensure that the principles of asepsis are
perform proper wound care. carefully followed when changing wound
dressings.

Risk for delayed Growth and Development related to impaired ability to achieve
developmental tasks

Client will not experience injury by (date and time to evaluate).

Nursing Interventions Rationale

Perform neurologic and vital assessment every 4 hours Provides date

or as needed. indicating an
increasing ICP
causing decreased
respirations,
increased blood
 pressure and pulse.

Assess for a rapidly increased circumference of head, Indicates increasing

tense, bulging fontanels, widening suture lines, ICP in infant/small
irritability, lethargy, “cracked pot” sound percussion, child.
sunset sign, opisthotonus, spasticity of lower
extremities, seizures, high-pitched cry, distended scalp
veins, changes in normal feeding patterns.

Assess for early signs including headache, nausea, Indicates increasing

vomiting, diplopia, blurred vision, seizures, irritability, ICP in children with
restlessness, decrease in school performance, symptoms related
decreased motor performance, sleep loss, weight loss, to cause of
memory loss progressing to lethargy and drowsiness. hydrocephalus.

Late signs: decreased level of consciousness,

decreased motor response to commands, decreased
response to pain, change in pupils, posturing,
papilledema.

Position with head elevated 30 degrees and support Promotes drainage

head when handling or changing position; monitor skin of CSF and reduces
integrity with position changes. accumulation of
CSF; infant may not
be able to lift and
move the head.

Support an enlarged head by cradling it in an arm when Protect’s infant’s

holding, place the infant on a pillow when moving, move head from trauma
head and body of the infant at the same time. and neck from the
strain.
http://imet2000-pal.org/files/file/Nursing%20Material/HYDROCEPHALUS.pdf