Hydrocephalus

Pembimbing : dr. Nick Tobing, Sp. BS

Michelle Husin (2013-061-118)
Ellysa Virgiana (2013-061-119)

Cereberos
pinal Fluid

The Function of the CSF

The CSF acts as a
water jacket for
the brain and
spinal cord

The 1300 g adult

brain weighs
approximately 45
g when suspended
in CSF

The Function of the CSF

The CSF acts like a
sink, effectively
flushing waste
products as new fluid is
secreted reabsorbed

A constant CSF
electrolyte composition
helps maintain a stable
medium for excitable
cells (neurons)

Hydrocephalus
Increase in cereberospinal fluid (CSF)
volume usually resulting from impaired
absorption, rarely from excessive
secretion.

This definition excludes ventricular

expansion secondary to brain shrinkage
from a diffuse atrophic process
(Hydrocephalus ex vacuo)

Classification
By
Pathophysiology

By Etiology

Obstructive
Hydrocephalus
Communicating
Hydrocephalus

Congenital
Hydrocephalus
Acquired
Hydrocephalus

Causes

Non-communicating
hydrocephalus
There is no communication
between the ventricular system
and the subarachnoid space.
The commonest is aqueduct
blockage or stenosis

Aqueductal stenosis
The normal
aqueduct
measures about 1
mm in diameter,
and is about 11
mm in length.

Aqueductal stenosis
Is the most common cause of congenital
hydrocephalus(43%)
Aqueduct develops about the 6th week
of gestation
M:F = 2:1
Other congenital anomalies (16%):
thumb deformities
Prognosis: 11-30% mortality

Etiology of aqueductal
stenosis
Extrinsic Pathology of the Aqueduct:
Infectious: Abscesses.
Neoplastic: Pineal tumors,
brainstem gliomas,
medulloblastoma, ependymoma.
Vascular: AVM, aneurysm, Galen
aneurysm.
Developmental: Arachnoid cysts.

Etiology of aqueductal
stenosis
Intrinsic Pathology of the Aqueduct
Septum or Membrane Formation: A thin
membrane of neuroglia may occlude the aqueduct
Forking of the Aqueduct: Typically, there are
two channels seen in midsagittal plane unable to
handle CSF volume. Most often seen with spina
bifida.
Gliosis of the Aqueduct: Usually of infectious
origin showing a marked gliofibrillary response.
Stenosis of the Aqueduct: Narrowed aqueduct
without evidence of gliosis. This may have
hereditary basis.

Imaging of Aqueductal
Stenosis
Ultrasonography
can detect
aqueductal
stenosis in utero

Sonogram

Imaging of Aqueductal
Stenosis
CT and MRI. MRI
is essential if third
ventriculostomy is
to be considered.

Aqueductal stenosis

T2-weighted MRI of tectal tumor: The

tumor (tectal glioma or hamartoma)

Dandy Walker Syndrome

A common cause of
obstructive
hydrocephalus is Dandy
Walker Syndrome where
there is blockage of
foramina of the 4th
ventricle (atresia of
foramina of Luschka
and Magendie)

Communicating
hydrocephalus
In communicating or non-obstructive
hydrocephalus there is communication
between the ventricular system and the
subarachnoid space. The commonest cause of
this group is post-infectious and posthemorrhagic hydrocephalus.

Causes of communicating
hydrocephalus

Overproduction of CSF
Blockage of CSF
circulation

Blockage of CSF
resorption

Hydrocephalus exvacuo

Normal pressure
hydrocephalus

Overproduction of CSF
Excessive
secretion of CSF
by the choroid
plexus as in cases
of choroid
plexus
papilloma or
carcinoma. This
is a rare cause.

Blockage of CSF
circulation
This could be at any level
of the CSF circulation
with either unilateral or
bilateral occlusion of the
foramen of Monroe.
Dilatation of one or both
lateral ventricles. This is
commonly seen in the
colloid cyst and
tumors of the third
ventricle.

Blockage of CSF
resorption
Poor resorption
of CSF into the
venous sinuses
caused by
scarring of the
arachnoid villi
and is commonly
seen after
meningitis or
hemorrhage

Hydrocephalus Ex Vacuo
Hydrocephalus exvacuo involves the
presence of too much
CSF, although the CSF
pressure itself is
normal. This condition
occurs when there is
damage to the brain
and there may be an
actual shrinkage of
brain.

Normal pressure
hydrocephalus
Normal pressure
hydrocephalus is
usually due to a gradual
blockage of the CSF
drainage pathways.
NPH is an unusual
cause of dementia,
which can occur as a
complication of brain
infection or bleeding
(hemorrhage).

Pathology of
Hydrocephalus

Clinical Manifestation
In infants & young children
In adult

Investigations
X-ray
!!: - skull size, suture width
- evidence of chronic raised pressure erosion of
the posterior clinoids)
- associated defects

 CT
Scan

Normal

3rd ventricle and anterior horns are dilated, 4th ventricle

are normal
Aqueduct stenosis

Dilated 3rd and lateral ventricle, deviated or absent 4th ventricle

Posterior fossa mass

Dilated lateral, 3rd, normal 4th ventricle

Communicating hydrocephalus

 Ultrasonography
Less good than CT Scan

 Magnetic Resonance Imaging

More clear vision of periventricular lucency,
neoplastic mass

Enlargement of the lateral, third, and fourth ventricles and

effacement of the subarachnoid space (Panels A and B). No gross
transependymal absorption of cerebrospinal fluid was noted. Several
small, nonenhancing periventricular areas of hyperintensity were
present. Communicating hydrocephalus, presumptively longstanding, was diagnosed.

 Intracranial pressure (ICP) monitoring

Useful for normal pressure hydrocephalus
To predict the likelihood of a beneficial response to
shunting

 Developmental assessment & psychometric

analysis
To detect impaired cerebral function and provide a
baseline for future comparison

Management

Complications of Shunting
Infections
Subdural haematoma
Shunt obstruction
Low pressure state