HYDROCEPHELUS

• NEUROLOGY
 DEFINTION
• Is a disturbance of formation , flow, and
absorption of CSF in the brain which leads to
increase C=volume of CSF in the brain
 ANATOMY OF VENTRICULAR SYSTEM ANS
FLOW OF CSF

CSF is mainly produced by the

1 choroid plexus of lateral and
fourth ventricular

2
CSF production is
about 0.2 to 0.35
ml/min

Normal circulation
3
volume of CSF is 120 ml
CSF production is greater than CSF
absorption

Accumulation of
CSF inside ventricles
and subarachnoid
space which
increase the ICP
 This Imbalance occur due to

Increase
resistance of
CSF flow

Overproduction Reduced
of CAF absorption of CSF

Increased pressure
in Dural sinuses
Absorption of CSF Dilatation of lateral
by optic nerve roots Ventricles

I. Elevation of corpus callosum

II. Stretching and perforation of the septum
pellucidum
III. Thining of cerebral cortex

Enlargement of optic nerve

sheath
( Papilledema)
Enlargement of the 3rd Compresion of
ventricle
mid brain

Increase ICP

Cerebral herniation
 Sign and Symptoms
I. S/S of hydrocephalus are influenced bye
II. Age
III. Cause
IV. Location of obstruction
V. Duration
 Signs & Symptoms

Premature Infants Older Adults

infants Drowsiness, irritability children
• Apnea Vomiting • Headache  headache
• Bradycardia Macrocephaly, tense • Vomiting
• Tense AF fontanel • Lethargy  vomiting
• Rapid head Frontal bossing • Diplopia,
growth
Distended scalp veins
blurred  dementia
• Globoid head vision
Poor head control • Papilledema
Lateral rectus palsy
 epileptic fits
,Lateral
rectus palsy  urinary
• Hyperreflexi
a, clonus
incontinence
 L. weakness
 papilloedema
 Types of hydrocephalus
I. Normal pressure hydrocephalus (NPH)
II. Communicating hydrocephalus
III. Non communicating hydrocephalus
IV. Congenital hydrocephalus
 NPH
• Is a rare condition which occur in elderly people
• Ventricle get enlarged with Normal ICP but
sometimes intracranial pressure increases at night
• No papilledema
• CLASSICAL TRAID OF NPH
Incontinence

Gait apraxia Dementia

 MO-NPH
Unknown but some
 Resistance of CSF
 Raised ICP at night
 Stretching of the ventricle walls
 Enlargement of ventricle
 C-H
Normal CSF flow between ventricles and subarachnoid space
this condition occur due to
1. defects absorption of csf in the venous blood
2. Overproduction of csf
Cause
 Intracranial hemorrhage
All these cause damage to
 Meningitis granulation
 Brain tumors

Venous thrombosis Venous drainage insufficient

 Non communicating Hydrocephalus

• CSF obstruction flow within ventricle system

or its outlet of like foramen of Lucia or
magendie
• Major cause mass occupied lesions within
brain which disrupts ventricular anatomy this
leads to accumulation of CSF which results
Enlargement of the ventricles
 Congenital Hydrocephalus
• Dilation of the ventricular during fetal life or
infancy period
• Cause
1. Obstruction of cerebral aqueduct
2. Chiari malformation
3. Premature brith- bleeding in the brains
4. Daily walker malformation
Investigations
 Head circumference
• 35 – 37 cms at birth

Increases at rate of
• 2cm/ mth for 1st 3 mths
• 1cm/mth for next 3 mths
• 0.5cm/mth for the next 6 mths
 CSF examination
• Lumbar puncture should be done with care as
coning can occur in non communicating
hydrocephalus

• Pyogenic meningitis, TBM, and intraventricular

bleed can be diagnosed
 Radiological investigations

X RAY SKULL
• Widening of sutures

• Silver beaten appearance

• Enlargement of pituitary fossa with erosion of dorsal

sella

• Shallow posterior fossa

 Ultrasonography

• Non invasive, no exposure to radiation

• Can show lateral & third ventricle but not 4th ventricle or
subarachnoid space

• Can measure resistive index which is a sensitive indicator

• atrial size most useful measurement of ventricular size

• Ventriculohemispheral ratio more than 35% indicates

ventriculomegaly
 CT scan

• Provide greater anatomical detail

• Can distinguish between communicating and non

communicating

• With IV contrast tumours / abscess/ bleed/ Ca

deposit can be seen

• Provides only axial image

• Inferior to MRI for visualization of brain

stem/posterior fossa
CT scan
 Magnetic resonance imaging

 Provide greatest amount of anatomic detail

 Differentiate between subdural effusion & enlarge sub

arachnoidal spaces

 Visualization of posterior fossa and brain stem

 Cine MRI is useful to identify site of obstruction

Magnetic resonance imaging
 Medical Management

• Mannitol decreases ICP

• Loop diuretics, Acetazolamide decrease CSF

production for a few days

• Doesn't resolve ventriculomegaly or affect

intellectual outcome
 Surgical treatment
• Shunt surgeries

• Third Ventriculostomy

• Choroid plexectomies/ coagulation

 Complications of Shunt surgery
• Three main groups
1. Mechanical failure – proximal, valve or distal

2. Infection – mainly by staph. Epidermidis & aureus

3. Overdrainage – causing headache

 Treatment of Hydrocephalus diagnosed in
utero
• Can cause cephalopelvic disproportion & inhibit labour

• USG used for diagnosis

• MRI after engagement of head used to visualise cerebral

morphology

• Severe brain malformation treated by cephalocentesis

• Results of ventriculoamniotic shunts discouraging

• Babies with normal cerebral morphology delivered by LSCS

when maturity documented & treated by shunt surgery
 Outcome & Prognosis

• Regular follow up essential

• Baseline scan post shunt for ventricular size

• Prognosis depends on brain morphology & factors like

perinatal ischemia, IVH, ventriculitis

• Number of shunt revisions / malfunctions not key factors in

outcome

• Cause of death in these pts is primary disease progression or

factors related neither to hydrocephalus nor its treatment