Precipitating factors Predisposing factors

Age (more common in Infection (meningitis)

children and may occur
in addult) Tumors in central nervous
system including the brain
Heridiry (genitic defect) and spinal cord

Birth (conginital) Injury (before, during an after

child birth including
subarachnoid hemorrhage)

Increased cerebrospinal
fluid

Accomulation or build
up of fluid in the
brain

Increased Intracranial
fluid

Pushing the brain up

against the skull and
damaging or
destroying brain
tissue

HYDROCEPHALUS
NON-COMMUNICATING COMMUNIATING CONGENITAL

S/Sx: S/Sx: S/Sx:

-Symptoms may -Symptoms may -The infant skull can

include headache include headache expand to accommodate
followed by nausea, followed by nausea, the buildup of CSF
vommiting, vommiting, papilledema because the sutures (the
fibrous joints that connect
papilledema (swelling (swelling of the optic
the bones of the skull)
of the optic disk which disk which is part of the
have not yet closed.
is part of the optic optic nerve), blurred or
nerve), blurred or double vission, - Other symptoms may
double vission, sunsetting of the eyes, include vomiting,
sunsetting of the eyes, problems with balance, sleepiness, irritability,
problems with poor coordination, gait downward deviation of
balance, poor disturbance,urinary the eyes (also called
coordination, gait incontinence, slowing "sunsetting"),
disturbance,urinary or loss of and seizures.
incontinence, slowing developmental
or loss of progress, lethargy,
developmental drowsiness, irritability,
progress, lethargy, or other changes in
drowsiness, irritability, personality or cognition
or other changes in including memmory
personality or loss.
cognition
including memmory
loss.
Older children and adults may experience different symptoms because their skulls cannot
expand to accommodate the buildup of CSF. Symptoms may includeheadache followed
by vomiting, nausea, papilledema (swelling of the optic disk which is part of the optic nerve),
blurred or double vision, sunsetting of the eyes, problems with balance, poor coordination,
gait disturbance, urinary incontinence, slowing or loss of developmental progress, lethargy,
drowsiness, irritability, or other changes in personality or cognition including memory loss.

Symptoms of normal pressure hydrocephalus include, problems with walking, impaired

bladder control leading to urinary frequency and/or incontinence, and progressive mental
impairment and dementia. An individual with this type of hydrocephalus may have a general
slowing of movements or may complain that his or her feet feel "stuck." Because some of
these symptoms may also be experienced in other disorders such as Alzheimer's
disease, Parkinson's disease, and Creutzfeldt-Jakob disease, normal pressure
hydrocephalus is often incorrectly diagnosed and never properly treated. Doctors may use a
variety of tests, including brain scans (CT and/or MRI), a spinal tap or lumbar catheter,
intracranial pressure monitoring, and neuropsychological tests, to help them accurately
diagnose normal pressure hydrocephalus and rule out any other conditions.

The symptoms described in this section account for the most typical ways in which
progressive hydrocephalus manifests itself, but it is important to remember that symptoms
vary significantly from one person to the next.

What is hydrocephalus?
The term hydrocephalus is derived from the Greek words "hydro" meaning water and
"cephalus" meaning head. As the name implies, it is a condition in which the primary
characteristic is excessive accumulation of fluid in the brain. Although hydrocephalus was
once known as "water on the brain," the "water" is actually cerebrospinal fluid (CSF) — a
clear fluid that surrounds the brain and spinal cord. The excessive accumulation of CSF
results in an abnormal widening of spaces in the brain called ventricles. This widening
creates potentially harmful pressure on the tissues of the brain.

The ventricular system is made up of four ventricles connected by narrow passages..

Normally, CSF flows through the ventricles, exits into cisterns (closed spaces that serve as
reservoirs) at the base of the brain, bathes the surfaces of the brain and spinal cord, and
then reabsorbs into the bloodstream.

CSF has three important life-sustaining functions: 1) to keep the brain tissue buoyant, acting
as a cushion or "shock absorber"; 2) to act as the vehicle for delivering nutrients to the brain
and removing waste; and 3) to flow between the cranium and spine and compensate for
changes in intracranial blood volume (the amount of blood within the brain).

The balance between production and absorption of CSF is critically important. Because
CSF is made continuously, medical conditions that block its normal flow or absorption will
result in an over-accumulation of CSF. The resulting pressure of the fluid against brain
tissue is what causes hydrocephalus.

What are the different types of hydrocephalus?

Hydrocephalus may be congenital or acquired. Congenital hydrocephalus is present at

birth and may be caused by either events or influences that occur during fetal development,
or genetic abnormalities. Acquired hydrocephalus develops at the time of birth or at some
point afterward. This type of hydrocephalus can affect individuals of all ages and may be
caused by injury or disease.

Hydrocephalus may also be communicating or non-communicating. Communicating

hydrocephalus occurs when the flow of CSF is blocked after it exits the ventricles. This form
is called communicating because the CSF can still flow between the ventricles, which
remain open. Non-communicating hydrocephalus - also called "obstructive" hydrocephalus -
occurs when the flow of CSF is blocked along one or more of the narrow passages
connecting the ventricles. One of the most common causes of hydrocephalus is "aqueductal
stenosis." In this case, hydrocephalus results from a narrowing of the aqueduct of Sylvius, a
small passage between the third and fourth ventricles in the middle of the brain.
There are two other forms of hydrocephalus which do not fit exactly into the categories
mentioned above and primarily affect adults: hydrocephalus ex-vacuo and normal pressure
hydrocephalus.

Hydrocephalus ex-vacuo occurs when stroke or traumatic injury cause damage to the brain.
In these cases, brain tissue may actually shrink. Normal pressure hydrocephalus can
happen to people at any age, but it is most common among the elderly. It may result from
a subarachnoid hemorrhage, head trauma, infection,tumor, or complications of surgery.
However, many people develop normal pressure hydrocephalus even when none of these
factors are present for reasons that are unknown.

Who gets this hydrocephalus?

The number of people who develop hydrocephalus or who are currently living with it is
difficult to establish since there is no national registry or database of people with the
condition. However, experts estimate that hydrocephalus affects approximately 1 in every
500 children.

What causes hydrocephalus?

The causes of hydrocephalus are still not well understood. Hydrocephalus may result from
inherited genetic abnormalities (such as the genetic defect that causes aqueductal stenosis)
or developmental disorders (such as those associated withneural tube defects including
spina bifida and encephalocele). Other possible causes include complications of premature
birth such as intraventricular hemorrhage, diseases such as meningitis, tumors, traumatic
head injury, or subarachnoid hemorrhage, which block the exit of CSF from the ventricles to
the cisterns or eliminate the passageway for CSF into the cisterns.

What are the different types of spina bifida?

There are four types of spina bifida:

1. occulta, 

2. closed neural tube defects, 

3. meningocele, and 

4. myelomeningocele.
Occulta is the mildest and most common form in which one or more vertebrae are
malformed. The name "occulta," which means "hidden," indicates that themalformation, or
opening in the spine, is covered by a layer of skin. This form of spina bifida rarely causes
disability or symptoms.

Closed neural tube defects make up the second type of spina bifida. This form consists of
a diverse group of spinal defects in which the spinal cord is marked by a malformation of fat,
bone, or membranes. In some patients there are few or no symptoms; in others the
malformation causes incomplete paralysis with urinaryand bowel dysfunction.

In the third type, meningocele, the meninges protrude from the spinal opening, and the
malformation may or may not be covered by a layer of skin. Some patients with
meningocele may have few or no symptoms while others may experience symptoms similar
to closed neural tube defects.

Myelomeningocele, the fourth form, is the most severe and occurs when the spinal cord is
exposed through the opening in the spine, resulting in partial or complete paralysis of the
parts of the body below the spinal opening. The paralysis may be so severe that the
affected individual is unable to walk and may have urinary and bowel dysfunction.

What is meningitis?

Meningitis is an inflammation of the membranes (called meninges) that surround the brain
and spinal cord. Meningitis may be caused by many different viruses and bacteria. It can
also be caused by diseases that can trigger inflammation of tissues of the body without
infection (such as systemic lupus erythematosus and Behcet's disease).

What are the signs and symptoms of meningitis?

Symptoms of meningitis, which may appear suddenly, often include high fever, severe and
persistent headache, stiff neck, nausea, and vomiting. Changes in behavior, such as
confusion, sleepiness, and difficulty waking up, are important symptoms. In infants,
symptoms of meningitis are often much less specific and may include irritability or tiredness,
poor feeding, and fever.

Some types of meningitis can be deadly if not treated promptly. Anyone experiencing
symptoms of meningitis should see a doctor immediately.

What is encephalomyelitis?
Encephalomyelitis is the term used to refer to inflammation of both the brain and spinal
cord. Encephalomyelitis can be caused by a variety of conditions that lead to irritation of the
brain and spinal cord. Among the common causes of encephalomyelitis are viruses which
infect the nervous tissues (for example, herpes zoster virus). People with encephalomyelitis
can exhibit combinations of the various symptoms of either encephalitis or meningitis.

How are encephalitis and meningitis diagnosed?

Encephalitis or meningitis is suggested when the symptoms described above are present.
The doctor diagnoses encephalitis or meningitis after a completing a thorough history
(asking the patient questions) and examination. The examination includes special
maneuvers to detect signs of inflammation of the membranes that surround the brain and
spinal cord (meninges). Based on the history and examination, the doctor suggests specific
tests to further help in determining the diagnosis.

Tests that are used in the evaluation of individuals suspected of having encephalitis or
meningitis include evaluation of the blood for signs of infection and possible presence of
bacteria, brain scanning (such as CT scanning or MRI scan), and cerebrospinal fluid
analysis.

A lumbar puncture is the most common method of obtaining a sample of the fluid in the
spinal canal (the cerebrospinal fluid or CSF) for examination. A lumbar puncture (an LP) is
the insertion of a needle into the fluid within the spinal canal. It is termed a "lumbar
puncture" because the needle goes into the lumbar portion of the back (the lower portion of
the back). The needle passes between the bony parts of the spine until it reaches the
cerebral spinal fluid. A small amount of fluid is then collected and sent to the laboratory for
examination. The evaluation of the spinal fluid is usually necessary for the definite diagnosis
and to help make optimal treatment decisions (such as the appropriate choice of
antibiotics).

The diagnosis is confirmed by abnormal spinal fluid results and in the case of an infection
by identifying the organism causing the infection.