HYDROCEPHALUS

INDEX
S.No Topic Page No.
1.0 Introduction of hydrocephalus
1.1 Defination of hydrocephalus
1.2 Relevant History
1.3 Epidemiology
1.4 Scope and significance
2.0 Relevant Anatomy and physiological
3.0 Cause
4.0 Clinical manifestations
4.1 Symptoms
4.2 Prognosis
5.0 Relevant investigation
6.0 Differntail diagnosis
7.0 Medical management and surgerical
treatment
8.0 Physiotherapy examination
8.1 Subjective
8.2 Objective
8.3 Examination
9 Physiotherapy management
9.1 Non operative rehabilitation
a) short goals and mangement
b) long gaols and
mangement
9.2 Operative rehabilitation
a) short goals and mangement
b) long gaols and
mangement

10 Secondary prevention
11 Relevant complications
12 Case study
13 Conclusion
14 Bibliography
 FIGURE INDEX
S.No Name Of Figure Page No.
1 Child with
hydrocephalus
2 Epidemiology
( Prevalance of
pediatric
hydrocephalus
3 CSF in brain
4 Ventricle of the brain
5 Fourth ventrical
6 Third ventricle
7 Structure of lateral
ventricle
8 CSF flow
9 Congenital
hydrocephalus
10 Acquired
hydrocephalus
11 Sunset sign
12 Ultrasound of
HYDROCEPHALUS
13 CT scan of
HYDROCEPHALUS
14 Lumbar puncture
15 Ventriculoatrial shunt
16
Lumboperitoneal shunt
17 ENDOSCOPIC THIRD
VENTRICULOSTOMY
FIGURE No.1
Hydrocephalus child with increased head circumference
1) INTRODUCTION
Hydrocephalus is the an abnormal build up of cerebrospinal fluid (CSF)
within and around the brain which can be due to excess of fluid flow in the
ventricle.
Hydrocephalus is the buildup of fluid in cavities called ventricles deep within
the brain. The excess fluid increases the size of the ventricles and puts
pressure on the brain.
Cerebrospinal fluid usually flows through the ventricles and bathes the brain
and spinal column. But the pressure of too much cerebrospinal fluid can
damage brain tissues and cause a range of symptoms related to brain
function.
ABSTRACT
Hydrocephalus is a common clinical neurological problem seen in pediatric
neuro surgical practice.
Hydrocephalus involves dilated of cerebral ventricular system with
corresponding , compressive effect on the parenchyma .
It can be communicative or obstructive types.
Congenital, acquire, infective and secondarily hydrocephalus have different
cliniclinical features with different mode of treatment.
Ventriculoperitoneal shunt is the gold standard of treatment .
DEFINITION
1) Hydrocephalus is a condition in which excess cerebrospinal fluid (CSF)
builds up within the fluid-containing cavities or ventricles of the brain.

"The term hydrocephalus is derived from the Greek words "hydro" meaning
water and "cephalus" meaning the head. "
2) Hydrocephalus is a neurological disorder caused by an abnormal buildup
of cerebrospinal fluid in the ventricles (cavities) deep within the brain. This
excess fluid causes the ventricles to widen, putting harmful pressure on the
brain's tissues. Hydrocephalus may be present at or shortly after birth, or
may result over time from damage or injury.

Too much cerebrospinal fluid in the ventricles can occur for one of the
following reasons:
OBSTRUCTION :-Partial blockage of the flow of cerebrospinal fluid is the
most common cause of too much cerebrospinal fluid in the ventricles. A
blockage may happen from one ventricle to another or from the ventricles
to other spaces around the brain.
POOR ABSORPTION :-Less common is a problem with absorbing
cerebrospinal fluid. This is often related to inflammation of brain tissues from
disease or injury.
OVERPRODUCTION:- Rarely, cerebrospinal fluid is created more quickly than
it can be absorbed.
RELEVANT HISTORY
Hydrocephalus cases were regularly described by Hippocrates, Galen, and
early and medieval Arabian physicians, who believed that this disease was
caused by an extracerebral accumulation of water. Operative procedures
used in ancient times are neither proven by skull findings today nor clearly
reported in the literature.

Hydrocephalus was known to the ancients with Hippocrates describing it as

early as the fifth century BC; some even claim that he made the first
attempt to drain this excess fluid. Hundreds of years later, Galen (130–200
AD) made some of the early contributions to the then-mysterious condition.
In the tenth century, Abul-Qasim Al-Zahrawi, who is also known as Abulcasis,
wrote a 30-volume treatise considered by many as a medical encyclopedia;
he was the first to give details about the instruments used in decompression
-trepanation as a treatment for hydrocephalus.
Figure No. 2
Infant with hydrocephalus engraved by Cornelis Huyberts for Frederik
Ruysch’s Thesaurus Anatomicus, 1701.
EPIDEMIOLOGY
Hydrocephalus is most common in infancy secondary to congenital
malformations and from intraventricular hemorrhage in premature babies.
Late in life, it presents another peak due to NPH cases. The overall global
prevalence of hydrocephalus is approximately 85 per 100,000 individuals
with a significant difference between different age groups; 88 per 100,000
for the pediatric population and 11 per 100,000 in adults.
The prevalence in the elderly population is much higher, somewhere around
175 per 100,000, and more than 400 per 100,000 for those more than 80
years old due to the high incidence of NPH later in life. Africa and South
America have higher hydrocephalus prevalence.Infantile hydrocephalus
prevalence is between 1 and 32 per 10,000 births. Both genders are
generally equally affected.
SCOPE /SIGNIFICANCE
Here's what I found on the scope and significance of hydrocephalus ¹ ² ³:
*Scope:*
- Hydrocephalus is a condition where there is an accumulation of fluid in the
ventricles deep within the brain.
- The excess fluid increases the size of the ventricles and puts pressure on
the brain.
- Hydrocephalus can occur at any age, but it is more common among
infants and adults 60 and older.
*Significance:*
- If left untreated, hydrocephalus can lead to complications such as learning
disabilities, developmental and physical disabilities, and even death.
- Mild cases of hydrocephalus may have few, if any, serious complications.
- Treatment for hydrocephalus depends on the severity and progression of
symptoms and may include observation, serial lumbar punctures, or a
ventricular shunt procedure.
- Hydrocephalus can cause permanent brain damage, so it is important to
recognize the symptoms and seek medical attention promptly.
2) RELEVANT ANATOMY AND PHYSIOLOGY
CSF
It is a modified tissue fuild.
The cerebrospinal fluid (CSF) is contained in the brain ventricles and the
cranial and spinal subarachnoid spaces.
CSF is replace by lymph in CNS.
The mean CSF volume is 150 ml, with 25 ml in the ventricles and 125 ml in
subarachnoid spaces. CSF is predominantly, but not exclusively, secreted by
the choroid plexuses. Brain interstitial fluid, ependyma and capillaries may
also play a poorly defined role in CSF secretion. CSF circulation from sites of
secretion to sites of absorption largely depends on the arterial pulse wave.
Additional factors such as respiratory waves, the subject's posture, jugular
venous pressure and physical effort also modulate CSF flow dynamics and
pressure. Cranial and spinal arachnoid villi have been considered for a long
time to be the predominant sites of CSF absorption into the venous outflow
system. Experimental data suggest that cranial and spinal nerve sheaths, the
cribriform plate and the adventitia of cerebral arteries constitute substantial
pathways of CSF drainage into the lymphatic outflow system. CSF is
renewed about four times every 24 hours. Reduction of the CSF turnover
rate during ageing leads to accumulation of catabolites in the brain and CSF
that are also observed in certain neurodegenerative diseases. The CSF
space is a dynamic pressure system. CSF pressure determines intracranial
pressure with physiological values ranging between 3 and 4 mmHg before
the age of one year, and between 10 and 15 mmHg in adults. Apart from its
function of hydromechanical protection of the central nervous system, CSF
also plays a prominent role in brain development and regulation of brain
interstitial fluid homeostasis, which influences neural functions.
Figure No.03
Image showing the location of CSF highlighting the brain's ventricular
system
Structure of the brain

Figure No.04
Ventricle of the brain
Gross Anatomy Of Ventricles

The ventricle of the brain is a communicating network of cavities filled with

CSF and located within the brain parenchyma.
The ventricular system composed of
:- 2 lateral ventricle
:- third ventricle
:- forth ventricle
The choroid plexus are located in the ventricle produce CSF , which fills the
ventricles and subarachnoid space following a cycle of constant
productin6and absorption.
FORTH VENTRICLE
Introduction
The cavity of hindbrain is called the fourth ventricle. It is a tent-shaped space
situated between the pons and upper part of medulla oblongata in front and
cerebellum behind. So it lies dorsal to pons and upper part of medulla
oblongata and ventral to cerebellum.
It has lateral boundaries, floor, roof and a cavity
Figure No. 05
Fourth ventricle
BOUNDARIES
Lateral
On each side, fourth ventricle is bounded :
1 Inferolaterally by gracile, cuneate tubercles and inferior cerebellar
peduncles.
2 Superolaterally by the superior cerebellar peduncles.
FLOOR
It is also called 'Rhomboid fossa’ because of its rhomboidal shape. The floor
is formed by:
1 Posterior (dorsal) surface of lower or closed part of pons.
2 Posterior (dorsal) surface of open or upper part of medulla oblongata.
Roof
Diamond shaped structure presents at the ventricle and can divided into
superior and inferior parts.
Angle
Superior angle : - Continous with cerebral aqueduct .
Inferior angle: continuous below with central canal of spinal cord.
Lateral angle: - one on each side toward the inferior cerebellar peduncles.
THIRD VENTRICLE
Introduction
The third ventricle is the median cleft of two thalami . Developmentally , it
represents the cavity of the diencephalon m except for the area in the front
of the interventricular foreman which is derived from the median part of the
telencephalon .
Figure No.06
Third ventricle
The cavity is lined by ependyma.
Posteroinferiorly, in the median plane, it communicates with the fourth
ventricle through the cerebral aqueduct .
RECESSES
Recesses are extensions of the cavity. These are:
1 Suprapineal.
2 Pineal.
3 Infundibular (Latin funnel).
4. Optic .
BOUNDARIES
Anterior Wall
1 Lamina terminalis.
2 Anterior commissure.
3 Anterior columns of fornix. The two columns of the fornix diverge, pass
downwards and backwards, and sink into the lateral wall of the third
ventricle to reach the mammillary body.
Posterior Wall
1 Pineal body.
2 Posterior commissure (in the lower lamina of the pineal stalk).
3 Cerebral aqueduct.
Roof
It is formed by the ependyma lining the under surface of the tela choroidea
of the third ventricle. The choroid plexus of the third ventricle projects
downwards from the roof. At the junction of the roof with the anterior and
lateral walls, there are the interventricular foramina.
Floor
It is formed by hypothalamic structures:
Optic chiasma.
Tubercinerium.
Infundibulum (pituitary stalk).
Mammillary bodies.
Posterior perforated substance.
Tegmentum of the midbrain.
At the junction of the floor with the anterior wall, there is the optic recess .
Lateral Wall
It is formed by the following:
1 Medial surface of thalamus (in its posterosuperior part).
2 Hypothalamus (in its anteroinferior part).
3 The hypothalamic sulcus which separates the thalamus from the
hypothalamus. The sulcus extends from the interventricular foramen to the
cerebral aqueduct.
LATERAL VENTRICLE
Introduction
The lateral ventricles are two irregular cavities situated one in each cerebral
hemisphere. Each lateral ventricle communicates with the third ventricle
through an interventricular foramen (foramen of Monro).
Figure no. 07
Structure of lateral ventricle
lateral ventricle consists of:
A) central part
B) Three horns :- Anterior, posterior and inferior
CENTRAL PART
This part of the lateral ventricle extends from the interventricular foreman in
front to the selenium of the corpus calcium behind.
BOUNDARIES
Roof
Formed by the under surface of the corpus callosum .
Floor
It is formed (from lateral to medial side) by:
1 Body of caudate nucleus.
2 Stria terminalis.
3 Thalamostriate vein.
4 Lateral portion of the upper surface of the thalamus.
Medial wall
It is formed by:
1 Septum pellucidum.
2 Body of fornix .
Choroid fissure
The line along which the choroid plexus invaginates into the lateral ventricle
is called the choroid fissure. It is a C-shaped slit in the medial wall of the
cerebral hemisphere. It starts at the interventricular foramen (above and in
front) and passes around the thalamus and cerebral peduncle to the uncus
(in the temporal lobe). Thus it is present only in relation to the central part
and inferior horn of the lateral ventricle.
In the central part of lateral ventricle, the choroid fissure is a narrow gap
between the edge of the fornix and the upper surface of the thalamus. The
gap is invaginated by the choroid plexus.
ANTERIOR HORN
This is the part of the lateral ventricle which lies in front of the
interventricular foramen and extends into the frontal lobe. It is directed
forwards, laterally and downwards, and is triangular on cross-section
Boundaries
Anterior:-
Posterior surface of genu and rostrum of the corpus callosum.
Roof:-
Anterior part of the trunk of the corpus callosum.
Floor
1 Head of the caudate nucleus.
2 Upper surface of the rostrum of the corpus callosum.
Medial
1 Septum pellucidum.
2 Column of fornix.
POSTERIOR HORN
This is the part of the lateral ventricle which lies behind the splenium of the
corpus callosum and extends into the occipital lobe. It is directed backwards
and medially
Boundaries
Floor and medial wall:-
1 Bulb of the posterior horn raised by the forceps major.
2 Calcar avis raised by the anterior part of the calcarine sulcus.
Roof and lateral wall :- Tapetum.
INFERIOR HORN
This is the largest horn of the lateral ventricle. It begins at the junction of the
central part with the posterior horn of the lateral ventricle; and extends into
the temporal lobe
BOUNDARIES
Roof and lateral wall:-
1 Chiefly the tapetum.
2 Tail of caudate nucleus.
3 Stria terminalis.
4 Amygdaloid body.
Floor:-
1 Collateral eminence raised by the collateral sulcus.
2 Hippocampus, medially.
In the inferior horn, the line of ependymal invagination by the choroid plexus
(i.e. the choroid fissure) lies between the stria terminalis and the fimbria.
PHYSIOLOGICAL
The total CSF volume, on average, is 140 mL and this is divided between the
ventricular system (25% or 35 mL), spinal canal (30—70 mL) and the cranial
subarachnoid space . In young children the total amount of CSF is smaller,
around 70 ml, divided between the various compartments in a way similar
to adults. The three components influencing CSF dynamics are production,
circulation and drainage. Most CSF is produced by a highly vascular
ingrowth through the ependymal lining of the ventricles known as the
choroid plexus . CSF is derived by adenosine triphosphate (ATP) dependant
active secretion from cerebral arterial blood across epithelial walls. Mean
CSF production in humans is 0.36 mL/min (approximately 20 mL/h, or 500
mL/day) although in young children the total daily production is smaller than
in adults, possibly half . The choroid plexus has a blood supply ten times that
of the cortex, and can produce CSF at a rate up to 0.21 mL/min/g tissue, a
rate higher than any other secretory epithelium.
The current widely accepted view is that CSF circulation is via bulk flow .
CSF is produced mainly within the lateral, third and fourth ventricles. Net
bulk flow occurs from the lateral to the third ventricle via the foramen of
Monro, on into the fourth ventricle via the aqueduct of Sylvius,
and then out of the fourth ventricle via the midline foramen of Magendie,
and the lateral foramina of Lushka into the subarachnoid space . Once
produced, CSF circulation is limited by the cells, membranes, and junctional
barriers lining the ventricular and subarachnoid spaces. The dynamics of
CSF flow are in part governed by these anatomical configurations, and
hence abnormalities within the system can affect CSF flow.
The subarachnoid space comprises of an interconnecting network of basal
CSF cisterns. CSF rapidly moves around the basal cisterns, and then moves
more slowly into the subarachnoid space on the cortical convexity and to a
Figure no.08
Flow of csf
lesser extent the spinal subarachnoid space, until reabsorption into the
systemic circulation granulations in the superior sagittal sinus, the
lymphatics across the cribiform plate, and the nerve root subarachnoid
angleoccurs via the venous system at the arcnoid space.
3) CAUSE
Hydrocephalus is a typically a symptom of some other problems and a
pediatric neurologist and neurosurgeon can to determine the cause.
Sometimes hydrocephalus develop during and in other case after birth.
Normally CSF flows through brain and spinal cord, but in some abnormal
conditions CSF amount is increase in brain such condition like :-
1 Blockage in CSF flow.
2 Problem in absorption.
3 Brain produce excessive CSF.
A :- CONGENITAL HYDROCEPHALUS
It can be caused by inherited genetic abnormalities or developmental
disorders affecting the brain's CSF flows.
They include :-
A) Intrauterine infection
They are CMV ( cytomegalvirus ), rubella , mumps , syphilis or toxoplasma ...
Rubella :- Hydrocephalus is a very rare presentation in Congenital Rubella
Syndrome with very few cases been reported in literature . The
development of hydrocephalus in this child may be attributed to be the
sequalae of some form of leptomeningitis and also to the Intraventricular
haemorrhage seen in CT Brain.
Mumps :- The presence of cytoplasmatic inclusions of viral nucleocapsid-like
material in the CSF of patients with mumps meningitis supports the
hypothesis that mumps may cause granular ependymitis and subsequent
aqueduct occlusion .
Figure no.09
Congenital hydrocephalus
B) Stenosis of the aqueduct of sylvia malformation
Aqueductal stenosis is one of the known causes of hydrocephalus and the
most common cause of congenital (present at birth) hydrocephalus. It can
also be acquired during childhood or adulthood.
In some cases, this is due to a brain tumor compression (such as a pineal
tumor) surrounding the aqueduct of Sylvius
Aqueductal stenosis is a narrowing of the aqueduct of Sylvius which blocks
the flow of cerebrospinal fluid (CSF) in the ventricular system. Blockage of
the aqueduct can lead to hydrocephalus, specifically as a common cause of
congenital and/or obstructive hydrocephalus.
It mainly causes non communicating hydrocephalus.
10% of all cases of hydrocephalus in newborns.
C) Dandy Walker malformation
Dandy-Walker deformity is an uncommon posterior fossa anomaly marked
by vermis agenesis or hypoplasia, as well as cystic expansion of the fourth
ventricle . During the embryonic development of the cerebellum and fourth
ventricle, this causes the tentorium to be displaced upwards and the
posterior fossa gets enlarged. The association of hydrocephalus with Dandy-
Walker malformation is due to blockage of normal cerebrospinal flow leading
to an excessive amount of fluid accumulating in and around the brain and
causing an increase in intracranial pressure and head circumference, which
ultimately causes neurological impairment.
D ) Arnold - chiari malformation
Type 1 :- The most common type that affects both children and adults,
because the back of the skull is too small or deformed a crowding of the
brainstem, cerebellum and tonsils occur.
As the tonsils push out of the skull , they block CSF flow Chairi 1 may causes
a fuild filled cyst in the spinal cord and may result hydrocephalus.
Type 2 :- When the spinal cord does not close before birth some of the
spinal cord protrudes like a sac form on the baby's back.
Both the brainstem and tonsils are pulled down into the spinal cord to block
CSF flow in brain and causing hydrocephalus.
E) Agenesis of the foramen of monroe
F) Bickers Adam syndrome
G) Congenital brain tumor
H ) Intrauterine hemorrhage

B:- ACQUIRED HYDROCEPHALUS

A) Head injury
A head injury or repeated head trauma can damage the brain's tissue,
nerves or blood vessels.
Blood from ruptured vessels may enter the CSF pathway causing
inflammation. Sites of CSF absorption might then be blocked by scarred
membranes: - meanings or by blood cells.
The CSF flows if restricted and hydrocephalus develops . Severe head
injuries can cause structural changes to the brain , resulting in the inability
for fuild to pass freely through the system and causing hydrocephalus.
B) Brain tumors
In children, brain most commonly occurs in back of the brain which is
referred to as the posterior fossa . As a tumour grows it may fill or compress
the fourth ventricle blocking the flow of CSF and causing hydrocephalus.
A tumour somewhere else in the brain might also block or compress the
ventricular system.
Finger No. 10
Acquired hydrocephalus
C) Intraventricular Hemorrhage
An Intraventricular Hemorrhage, which most frequently affects premature
newborn may also cause an acquired form of hydrocephalus.
When small blood vessels along side the ventricular lining may rupture,
blood may block or scar the ventricles or plug the arachnoid vali, which
allows CSF to be absorbed and results hydrocephalus.
D) Meningitis
It is a inflammation of the members of the brain and spinal cord.
It is caused by bacterial or viral infection, in meanings can scar the delicate
membranes called meanings that line the CSF pathway.
An acquired form of hydrocephalus may develop if this scarring obstructs
the flow of CSF as if passes through the narrow ventricles or over the
surface of the brain in the subarachnoid space.
4) CLINICAL MANIFESTATIONS
SYMPTOM
The symptoms of hydrocephalus can vary by age.
INFANTS
Common symptoms of hydrocephalus in infants include:
Changes in the head
A head that is larger than usual.
A rapid increase in the size of an infant's head.
A bulge or tense soft spot on the top of the head.
Physical symptoms
Nausea and vomiting.
Sleepiness or sluggishness, known as lethargy.
Irritability.
Poor eating.
Seizures.
Eyes fixed downward, known as sunsetting of the eyes.
Problems with muscle tone and strength.
TODDLERS AND OLDER CHILDREN
Among toddlers and older children, symptoms might include:
Physical symptoms
Headache.
Figure no.11
Sunset sign
Blurred or double vision.
Eye movements that are not usual.
Enlargement of a toddler's head.
Sleepiness or sluggishness.
Nausea or vomiting.
Trouble with balance.
Poor coordination.
Poor appetite.
Loss of bladder control or urinating often.
Behavioral and cognitive changes
Irritability.
Change in personality.
Decline in school performance.
Delays or problems with earlier gained skills, such as walking or talking.
YOUNG AND MIDDLE AGED ADULTS
Common symptoms in this age group include:
Headache.
Sluggishness.
Loss of coordination or balance.
Loss of bladder control or needing to urinate often.
Vision problems.
Decline in memory, concentration and other thinking skills that may affect
job performance.
OLDER ADULTS
Among adults 60 and older, the more common symptoms of hydrocephalus
are:
Loss of bladder control or needing to urinate often.
Memory loss.
Progressive loss of other thinking or reasoning skills.
Trouble walking, often described as shuffling or the feeling of the feet being
stuck.
Poor coordination or balance.
PROGNOSIS
The prognosis for hydrocephalus depends on the cause, the extent of
symptoms and the timeliness of diagnosis and treatment. Some patients
show a dramatic improvement with treatment, while others do not. In some
instances of normal pressure hydrocephalus, dementia can be reversed by
shunt placement. Other symptoms, such as headaches, may disappear
almost immediately if the symptoms are related to elevated pressure.

In general, the earlier hydrocephalus is diagnosed, the better the chance for
successful treatment. The longer the symptoms have been present, the less
likely it is that treatment will be successful. Unfortunately, there is no way to
accurately predict how successful surgery will be for each individual. Some
patients will improve dramatically, while others will reach a plateau or
decline after a few months.
5) RELEVANT INVESTIGATIONS

LABORATORY STUDIES
No specific blood tests are recommended in the workup for hydrocephalus.
Genetic testing and counseling might be recommended when X-linked
hydrocephalus is suspected.
Evaluate cerebrospinal fluid (CSF) in posthemorrhagic and postmeningitic
hydrocephalus for protein concentration and to exclude residual infection.
Radiology investigation
There are humorous tests that can help diagnose hydrocephalus.

The first and simplest test is measuring a baby’s head circumference at birth
and during routine visits with your pediatrician. If your baby’s head is larger
than normal or if there is a rapid increase in the head size, your doctor will
refer you to a specialist (neurosurgeon).

For toddlers and older children,

it may be a neurological evaluation that warrants a referral to a specialist
and further diagnostic testing, which typically includes brain imaging
techniques such as
ultrasonography (US),
computed tomography (CT), and
magnetic resonance imaging (MRI).
Figure 12
Ultrasound of brain
BRAIN IMAGING TECHNIQUES

ULTRASOUND
ULTRASOUND is used in infants with open soft spots or fontanels. The
ultrasound has no ill effects on the brain, it is painless, and it requires no
sedation. It provides adequate visualization of the lateral ventricles, but
other parts of the brain are not so well seen
CT SCAN is a reliable procedure for diagnosing and assisting in the
management of hydrocephalus. A CT Scan is a sophisticated technique in
which X-ray beams are passed through a patient’s body and pictures of the
internal structures, in this case, the brain, are made by the computer. CT
scans can usually be performed without sedation.
Figure no.13
CT SCAN
Note:
CT scans use higher doses of radiation compared to simpler imaging tests.
Improvements in CT equipment, however, have allowed for better images at
lower doses for children. These are referred to as low-dose CT scans.
MRI (MAGNETIC RESONANCE IMAGING)
It is uses radio signals, a large magnet, and a computer to scan your child’s
body. The signals are then developed into images by the computer.
NOTE:
Like the CT scan, it is a diagnostic technique that produces images of the
brain-but unlike CT scanning, MRI does not use x-rays/radiation. Instead, MRI
uses radio signals and a very powerful magnet to scan your child’s body,
and the signals are then formed into pictures by a computer. MRI is a
painless procedure and has no known side effects.
There are two types of MRI scans:
The Single Shot Fast Spin Echo (also called a ‘quick brain MRI), which takes
about three minutes and rarely requires sedation, is used to assess
ventricular size.
The full MRI, which takes 30 to 60 minutes and may require sedation, shows
more minute details. Before the longer scans are performed, your child may
be given a sedative to minimize movement that would cause blurring of the
images.
At this point in the diagnostic process, it is important that a neurosurgeon
become part of your medical team, along with your primary care physician.
Their involvement from the diagnostic stage onward is helpful not only in
interpreting test results but also in selecting candidates for shunt surgery.

They should also discuss the actual surgery and follow-up care, as well as
outcomes and possible complications of surgery.
OTHER TESTS
After shunt insertion, confirm correct positioning of installed hardware with
a plain radiograph.
EEG can be used if seizure occurs.
LUMBAR PUNCTURE
Procedure
(LP) is a valuable test in evaluating NPH, but should be performed only after
CT or MRI of the head. Normal LP opening pressure (OP) should be less than
180 mm H2 O (ie, 18 cm H2 O). Patients with initial OP greater than 100 mm
H2 O have a higher rate of response to CSF shunting than those with OPs
less than 100 mm H2 O. Improvement of symptoms after a single LP in
which 40-50 mL of CSF is withdrawn appears to have some predictive value
for success of CSF shunting.

Continuous CSF drainage through external lumbar drainage (ELD) is a highly

accurate test for predicting the outcome after ventricular shunting in NPH,
although false negative results are not uncommon.

Continuous CSF pressure monitoring can help in predicting a patient's

Finger no . 14
Lumbar puncture.
response to CSF shunting in NPH. Some patients with normal OP on LP
demonstrate pressure peaks of greater than 270 mm H2 O or recurrent B
waves. These patients tend to have higher rates of response to shunting
than those who do not have these findings. This procedure also could
differentiate NPH from atrophy.

Additionally, ICP monitoring can be helpful in patients with labile intracranial

pressure, where an LP may miss the elevation, in determine when shunting
may be indicated (for example, pseudotumor patients with persistent
headaches despite medical treatment but normalized LP opening pressures).
HISTOLOGICAL FINDINGS
Histologic findings include the following:
Thinning and stretching of the cortical mantle may be seen as a result of
ventricular dilation.
In the acute phase, edema of the periventricular white matter is observed.
Relatively few neuronal lesions are present. Ventricular ependyma shows
cellular flattening and loss of cilia.

At a later stage, the edema disappears and is replaced by fibrosis, axonal

degeneration, demyelination, focal loss of cerebral cortical neurons, cellular
flattening, and further loss of cilia.
6) DIFFERENTIAL DIAGNOSIS
Hydrocephalus presentation mimics many other diseases; the following
differential diagnosis should be considered when evaluating a patient with
hydrocephalus.
1) IDIOPATHIC INTRACRANIAL HYPERTENSION (IIH) (pseudotumor cerebri):
Intracranial pressure is elevated, but there is no identifiable pathology.
Aged-related changes.
2) SECONDARY ATROPHY:
Autoimmune diseases,
HIV infection,
Chemotherapy
Brainstem gliomas
Frontal lobe epilepsy
Frontal lobe syndromes
Intracranial hemorrhage
Migraine headache
Primary CNS lymphoma
Pituitary tumors
Acute subdural hematoma
Subdural empyema
Acute Subdural Hematoma Management in the ED
Childhood Migraine Variants
Frontotemporal Dementia and Frontotemporal Lobar Degeneration
Glioblastoma
Oligodendroglioma Imaging
Intracranial Epidermal
Marrow Failure Syndromes
Meningioma
Migraine Variants
Pediatric Craniopharyngioma
Pediatric Headache
Pediatric Idiopathic Intracranial
Sudden Visual Loss
7) MEDICAL AND SURGICAL TREATMENTS
Hydrocephalus, if left untreated, can cause permanent brain damage,
physical and mental impairment, and death. Initial treatment is directed to
the etiology. In cases of intraparenchymal hemorrhage or tumors, surgical
evacuation may resolve the hydrocephalus. When hydrocephalus persists,
treatment is surgical with the insertion of a ventricular shunt.[20] The shunt
moves CSF to another part of the body where it can be absorbed. With
treatment, many patients have healthy lives with few limitations.
MEDICAL TREATMENT

Medical Care
Medical treatment in hydrocephalus is used to delay surgical intervention. It
may be tried in premature infants with posthemorrhagic hydrocephalus (in
the absence of acute hydrocephalus). Normal CSF absorption may resume
spontaneously during this interim period.
Medical treatment is not effective in long-term treatment of chronic
hydrocephalus. It may induce metabolic consequences and thus should be
used only as a temporizing measure.
Medications affect CSF dynamics by the following mechanisms:
Decreasing CSF secretion by the choroid plexus - Acetazolamide and
furosemide
Acetazolamide, a carbonic anhydrase inhibitor, decreases CSF secretion by
thAe choroid plexus and hence used in the treatment of hydrocephalus. It is
mostly used in pseudotumor cerebri.

Increasing CSF reabsorption - Isosorbide (effectiveness is questionable)

Patients on acetazolamide (ACZ) or furosemide (FUR) should be followed for
possible electrolyte imbalance and metabolic acidosis.
Clinical signs that should prompt attention are lethargy, tachypnea, or
diarrhea
.BEFORE SURGERY
Patients with shunts
should be reevaluated periodically, including assessment of distal shunt
length in growing children. The first follow-up examination usually is
scheduled 3 months after surgery, and CT scan or MRI of the head should be
done at that time. Follow-up is performed every 6-12 months in the first 2
years of life. In children aged 2 years and older, follow-up is performed every
2 years.

SURGICAL TREATMENTS
Surgical treatment is the preferred therapeutic option.
Repeat lumbar punctures (LPs) can be performed for cases of
hydrocephalus after intraventricular hemorrhage, since this condition can
resolve spontaneously. If reabsorption does not resume when the protein
content of cerebrospinal fluid (CSF) is less than 100 mg/dL, spontaneous
resorption is unlikely to occur. LPs can be performed only in cases of
communicating hydrocephalus.
Alternatives to shunting include the following:
1) Choroid plexectomy or choroid plexus coagulation may be effective in
cases of CSF over-production.
2)Opening of a stenosed aqueduct has a higher morbidity rate and a lower
success rate than shunting, except in the case of tumors. However, lately
cerebral aqueductoplasty has gained popularity as an effective treatment
for membranous and short-segment stenoses of the sylvian aqueduct. It can
be performed through a coronal approach or endoscopically through
suboccipital foramen magnum trans-fourth ventricle approach.
3)In cases where a tumor is the cause, removal cures the hydrocephalus in
80%.
4)Endoscopic fenestration of the floor of the third ventricle establishes an
alternative route for CSF toward the subarachnoid space. It is
contraindicated in communicating hydrocephalus, but can be used
especially with aqueductal stenosis.

SHUNTS
Shunts eventually are performed in most patients. Only about 25% of
patients with hydrocephalus are treated successfully without shunt
placement. The principle of shunting is to establish a communication
between the CSF (ventricular or lumbar) and a drainage cavity (peritoneum,
right atrium, pleura). Remember that shunts are not perfect and that all
alternatives to shunting should be considered first.

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.
Finger no.15
Ventriculoatrial shunt
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 the 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.

Rapid-onset hydrocephalus with increased intracranial pressure (ICP) is an emergency. The

following can be done, depending on each specific case:
Ventricular tap in infants
Open ventricular drainage in children and adults
LP in posthemorrhagic and postmeningitic hydrocephalus
VP or VA shunt
Patients with shunt-dependent hydrocephalus should be admitted for consideration of shunt
revision if shunt malfunction or infection is suspected.
In children, shunt revisions are scheduled according to growth rate
Figure no.16
Lumboperitoneal shunt
Ventriculoperitoneal
VPshunt is the most common type of shunt. It usually drains CSF from the
lateral ventricle to the peritoneal cavity; in children, it has the advantage
that the distal peritoneal part may be left long and will not require changing
during the growth of the child. The other common type is a ventriculoatrial
shunt (VA) shunt. It shunts CSF through the jugular vein and superior vena
cava into the right atrium. It’s mostly used in patients with abdominal
abnormalities like peritonitis, after extensive abdominal surgery, or morbid
obesity. Ventriculo-pleural shunt is a second line option only if the
treatments mentioned above fail. A lumboperitoneal shunt is considered in
cases of pseudotumor cerebri. Historically, in cases of acquired obstructive
hydrocephalus, a shunt of choice was a Torkildsen shunt. It shunts the
ventricles to the basal posterior cisternal space.

There are alternatives to shunting that may be considered. Endoscopic third

ventriculostomy
ENDOSCOPIC THIRD VENTRICULOSTOMY
ETV opens the floor of the third ventricle to permit the CSF in the third
ventricle to enter the prepontine basal cistern. ETV is commonly used in
cases of aqueductal stenosis to prevent a permanent shunt; however, the
result in very young infants is not good. Also, results are not good in patients
with long-standing shunted obstructed hydrocephalus as the arachnoid
granulations had lost the absorptive capacity. Choroid plexus coagulation
can be used for cases over-production of CSF. Repeat lumbar punctures can
be done in cases of communicating hydrocephalus if it’s considered that
spontaneous resorption is likely to occur.

Premature infants with posthemorrhagic hydrocephalus may improve with

serial fontanelle taps. The majority of patients with a posterior fossa tumor .
Figure no.17

ENDOSCOPIC THIRD VENTRICULOSTOMY

who present with hydrocephalus do not require a permanent shunt. A
ventriculostomy may be placed temporarily preoperative or intraoperative
to help for the tumor resection and removed when not needed.
CONSULTATIONS
Consultation with the following may prove helpful:
Neurosurgeon
Neurologist
Neurorehabilitation specialist
Ophthalmologist
8) PHYSIOTHERAPY EVALUATION
DEMOGRAPHIC DATA
Name
Age
Gender
Address
Height
Weight
Referred by
Date
Mother age
CHIEF COMPLAIN
Bulging of skull
Increased head size
Headache
Projectile vomiting
Sleepiness
Poor feeding
Irritability
High pitched cry
Loss of vision
Seizures
Neck stiffness
Unsteady gait

HISTORY
History of presenting illness
History of headache
History of vomiting
History of epsisode of fever
History of epsisode of seizures
History of loss of vision or poor or blurred vision
History of difficulty of feeding
 History of lateral gaze palsy
History of hearing deficits, drooling of saliva, neural regurgitation.
History of difficulty in wearing napkins

Present medical History :-

In take of any medicine like acetazolamide or furosemide
Or in take any medicine of fever , vomiting, etc

Birth history
(History of mother)
ANTENATAL HISTORY
Mother may be :-
Primigravida or multigravida or primipara
First trimester :- conceived spontaneously...
History of fever with rash, burning micturiton
History of exposure to radiation or intake of drugs
Ultrasound scan done or not
Second trimester: - quickening felt at 6th month
History of fever with rash.
History of gestational diabetes mellitus
History of pregnancy induced hypertension
Ultrasound scan can done or not
Third trimester: -
History of gestational diabetes mellitus
History of pregnancy induced hypertension
Ultrasound scan normal or abnormal
Delivery: - Early term: 37 0/7 weeks through 38 6/7 weeks
Full term: 39 0/7 weeks through 40 6/7 weeks
Late term: 41 0/7 weeks through 41 6/7 weeks
Postterm: 42 0/7 weeks and beyond
Type of delivery
Vaginal Birth
Scheduled Induction
Natural Birth
Scheduled Cesarean
Unplanned Cesarean
Vaginal Birth after C-Section (VBAC)
Scheduled Induction
Baby birth weight
Baby cried immediately after birth or not
Meconium and urine passed within 24hrs or not
Any post operative complications

Developmental history
 Gross motor skills:-
In case of hydrocephalus mainly two disturb gross motors
skills present they are :-
1) head control not achieved
2) baby cannot sit with support
Following are the gross motors skill that may or may not be disturb: -
These larger movements include moving legs and arms,
rolling over, sitting up, crawling, balancing while standing, walking, running,
jumping, and riding a bike.

Fine motor skills.

Following are various fine motor skills that may be disturb .
These smaller, more precise movements include grasping and
holding onto something, picking up objects with the palmar grasp and
pincer grasp, scribbling or drawing, stacking blocks or toys, cutting with
safety scissors, folding clothing, self-feeding with utensils, and using a zipper.
Language and communication
Abnormal language
Inferences: - global developmental delay
Immunization history
Immunized agr
Last date of vaccine
Dietary history
Exclusive brest feeding till the age.....
Weaning months
Family history
Genetic history
Any case of hydrocephalus in family
Child born out with consanguinous marriage
Socioeconomic history
Members in family
Financial status
:- classes - upper
- middle
- lower
OBSERVATION
Posture
Headsize
Deformity
External devices
Facial apprehension
Especial observation for hydrocephalus
PALPATION
Palpation for hydrocephalus involves assessing specific areas of the head
and neck for signs of increased intracranial pressure (ICP) or abnormalities
related to the condition. Here's a detailed outline of palpation techniques:
1) Fontanelles (Infants):
Palpate the anterior fontanelle (soft spot) for bulging or fullness, which can
indicate increased ICP.
Note any tension or bulging of the fontanelle, as well as its size and shape.
2) Scalp:
Gently palpate the scalp for tenderness, swelling, or abnormalities.
Note any areas of localized tenderness, which may indicate trauma or
inflammation.
3)Skull:
Palpate the skull bones for abnormalities, such as asymmetry or irregularities.
Note any areas of localized swelling, depressions, or bony prominences.
4) Shunt Site (If applicable):
If the patient has a ventriculoperitoneal (VP) shunt or other shunt system,
palpate the shunt tubing and valve components.
Inspect the shunt site for signs of infection, such as redness, swelling,
warmth, or drainage.
Palpate along the shunt tract to assess for tenderness, induration, or
firmness, which may indicateshunt malfunction or infection.
5) Temporal Arteries:
Palpate the temporal arteries for pulsations and tenderness, particularly in
patients with suspected elevated ICP.
Note any asymmetry, prominence, or discomfort along the course of the
arteries.
6) Cervical Lymph Nodes:
Palpate the cervical lymph nodes for enlargement, tenderness, or firmness,
which may suggest underlying infection or inflammation.
7) Mastoid Process:
Palpate the mastoid process behind the ears for tenderness, swelling, or
signs of mastoiditis, which can sometimes be associated with
hydrocephalus.
8) Cranial Sutures:
Assess the integrity and alignment of the cranial sutures, noting any
abnormalities such as separation or overriding.
# During palpation, it's essential to communicate with the patient and assess
their comfort level. Gentle pressure should be applied, especially in sensitive
areas, to avoid causing discomfort or exacerbating symptoms. Any
abnormal findings should be documented and reported to the healthcare
provider for further evaluation and management.
EXAMINATION
A detailed physical examination for hydrocephalus typically involves several
components:

1) Neurological Examination:
Assessing motor function
Reflexes :- Testing deep tendon reflexes, such as the knee-jerk
reflex, can provide further information about neurological function and
potential signs of hydrocephalus
Muscle tone and strength:- Assessment of muscle strength and
tone can help detect any weakness or spasticity that may be associated
with hydrocephalus.
 Sensory Examination :- Evaluating sensory function, including touch,
proprioception, and vibration sense, can help assess the extent of
neurological involvement in hydrocephalus.
coordination( can help identify any neurological abnormalities
associated with hydrocephalus).
Cranial Nerve Assessment :
Examining the function of the cranial nerves can reveal any
deficits that might indicate hydrocephalus-related pressure on the
brainstem or cranial nerves.
Head Circumference Measurement:
In infants and young children, measuring head circumference
over time can help identify abnormal head growth patterns, which could be
indicative of hydrocephalus.
Fontanelle Examination:
Palpating the fontanelles (soft spots) on an infant's head can
provide information about intracranial pressure. Bulging fontanelles may
suggest increased pressure due to hydrocephalus.
Papilledema Assessment:
Fundoscopic examination of the optic nerve head can reveal signs
of increased intracranial pressure, such as papilledema.
Gait and balance evaluation :
Observing the patient's gait and balance can help detect any
abnormalities that may be caused by hydrocephalus-related pressure on the
brain.
Mental Status Examination:
Evaluating cognitive function, memory, attention, and behavior
can provide insights into the impact of hydrocephalus on brain function.
Review of Symptoms:
In addition to specific neurological signs, inquiring about
symptoms such as headaches, nausea, vomiting, vision changes, and
urinary incontinence can help identify potential hydrocephalus-related
symptoms.
INVESTIGATION
1 MRI
2 CT SCAN
3 Ultrasound
4 Cerebral angiography
PHYSIOTHERAPY MANAGEMENT
Non operative rehabilitation
Short Term
Physical rehabilitation for children with hydrocephalus focuses on
improving their mobility, strength, balance, and coordination. Here
are some detailed short-term goals:
Improving Motor Skills:
Goal: Enhance gross motor skills such as crawling, walking, and running.
Objective: Perform specific exercises targeting muscle groups involved in
these activities.
Enhancing Balance and Coordination:
Goal: Improve balance and coordination to prevent falls and improve overall
mobility.
Objective: Practice activities that challenge balance, such as standing on
one leg or walking on uneven surfaces.
Strengthening Weak Muscles:
Goal: Strengthen muscles weakened due to hydrocephalus or lack of
mobility.
Objective: Use resistance training exercises to target specific muscle groups,
gradually increasing resistance as strength improves.
Improving Range of Motion:
Goal: Increase flexibility and range of motion in affected joints.
Objective: Perform stretching exercises for tight muscles and joints, holding
stretches for a specific duration to improve flexibility.
Promoting Independence in Activities of Daily Living (ADLs):
Goal: Help the child gain independence in performing daily activities such as
dressing, feeding, and grooming.
Objective: Practice ADLs with appropriate modifications and adaptive
equipment as needed to encourage independence.
Enhancing Functional Mobility:
Goal: Improve the child's ability to move efficiently and safely in various
environments.
Objective: Work on tasks such as negotiating obstacles, transitioning
between different surfaces, and navigating stairs with supervision and
guidance.
Improving Posture:
Goal: Correct poor posture and promote proper alignment of the spine and
extremities.
Objective: Perform exercises to strengthen core muscles and improve body
awareness to maintain a correct posture during daily activities.
Increasing Endurance:
Goal: Improve cardiovascular fitness and endurance to support increased
physical activity levels.
Objective: Engage in aerobic exercises such as swimming, biking, or walking,
gradually increasing duration and intensity over time.
Monitoring Progress and Adjusting Interventions:
Goal: Regularly assess the child's progress and adjust rehabilitation
interventions accordingly.
Objective: Periodically review goals, measure outcomes, and modify the
treatment plan as needed to address evolving needs and capabilities.
Promoting Participation and Enjoyment:
Goal: Foster a positive attitude towards physical activity and rehabilitation,
encouraging active participation and enjoyment.
Objective: Incorporate fun and engaging activities that the child enjoys into
the rehabilitation program, promoting motivation and compliance.
LONG TERM
Long-term goals for physical rehabilitation in children with hydrocephalus
aim to promote maximal functional independence, mobility, and quality of
life. Here are detailed long-term goals:
1)Maximizing Functional Independence:
Goal: Enable the child to independently perform activities of daily living
(ADLs) to the best of their ability.
Objective: Continuously work on improving strength, balance, coordination,
and mobility to support independent participation in daily tasks.
2)Optimizing Mobility:
Goal: Facilitate the child's ability to move efficiently and safely in various
environments and situations.
Objective: Focus on refining walking, running, climbing stairs, and navigating
obstacles with minimal assistance, ensuring adaptability to different
surfaces and environments.
3)Preventing the secondary complications
Goal: Minimize the risk of secondary complications such as muscle
contractures, joint deformities, and pressure sores.
Objective: Implement preventative strategies including regular stretching,
positioning, and pressure relief techniques to maintain joint mobility and skin
integrity.
4)Improving Physical Fitness:
Goal: Enhance cardiovascular fitness, muscular strength, endurance, and
flexibility.
Objective: Incorporate a variety of aerobic, strength training, and flexibility
exercises into the rehabilitation program, tailored to the child's abilities and
interests.
5)Promoting Participation in Recreational Activities:
Goal: Encourage engagement in recreational and leisure activities that
promote physical fitness, social interaction, and enjoyment.
Objective: Explore and support participation in sports, games, and hobbies
adapted to the child's abilities and preferences, fostering social inclusion and
confidence.
6)Facilitating School and Community Integration:
Goal: Support successful integration into school and community settings,
including participation in physical education, extracurricular activities, and
community events.
Objective: Collaborate with educators, therapists, and community resources
to address barriers and provide necessary accommodations and support
services.
7)Enhancing Safety and Fall Prevention:
Goal: Reduce the risk of falls and injuries by improving balance, coordination,
and environmental awareness.
Objective: Implement strategies such as home modifications, assistive
devices, and education on fall prevention techniques to enhance safety
both at home and in other environments.
8)Encouraging Self-Advocacy and Self-Management:
Goal: Empower the child to advocate for their own needs and actively
participate in decision-making regarding their rehabilitation and healthcare.
Objective: Foster self-awareness, problem-solving skills, and self-
management strategies to promote independence and autonomy in
managing their condition.
9)Monitoring and Managing Progression of Hydrocephalus:
Goal: Continuously monitor and manage the progression of hydrocephalus
and its impact on physical function and rehabilitation outcomes.
Objective: Collaborate with healthcare providers to optimize shunt function,
manage associated medical conditions, and adjust rehabilitation
interventions as needed based on changes in the child's condition.
10)Promoting Lifelong Health and Well-Being:
Goal: Cultivate habits and behaviors that support lifelong physical health,
well-being, and participation in meaningful activities.
Objective: Provide education and resources on healthy lifestyle choices,
injury prevention, and self-care practices to promote long-term health and
independence.
POST OPERATIVE REHABILITATION
SHORT TERM

LONG TERM
Post-operative long-term physical rehabilitation for hydrocephalus aims to
promote sustained recovery, functional independence, and quality of life
over an extended period. Here are detailed long-term goals for post-
operative rehabilitation:

1)Maintaining Optimal Shunt Function:

Goal: Ensure ongoing monitoring and management of the shunt system to
maintain optimal function and prevent complications.
Objective: Regularly assess shunt parameters, monitor for signs of
malfunction or infection, and collaborate with healthcare providers to
address any issues promptly to minimize the risk of shunt-related
complications.
2)Continued Neurological Monitoring:
Goal: Monitor neurological status and response to treatment to detect any
changes or complications over time.
Objective: Conduct periodic neurological assessments to evaluate cognitive
function, motor skills, sensory function, and other neurological parameters,
adapting interventions as needed based on the child's evolving needs and
progress.
3)Promoting Functional Independence:
Goal: Support the child's ongoing development of functional independence
in daily activities and mobility.
Objective: Continue to provide rehabilitation interventions focused on
improving mobility, strength, balance, coordination, and activities of daily
living (ADLs), gradually increasing challenges and independence as the child
progresses.
4)Preventing Secondary Impairments:
Goal: Minimize the risk of secondary impairments such as muscle weakness,
joint contractures, and orthopedic complications.
Objective: Implement preventative measures such as regular stretching,
strengthening exercises, orthotic management, and assistive devices to
maintain joint mobility, muscle strength, and alignment, reducing the risk of
secondary complications.
5)Optimizing Physical Fitness and Wellness:
Goal: Promote lifelong physical fitness, health, and wellness to support
overall well-being.
Objective: Encourage regular participation in physical activity, sports,
recreational activities, and healthy lifestyle behaviors tailored to the child's
abilities and preferences, fostering cardiovascular fitness, muscular strength,
flexibility, and mental well-being.
6)Facilitating Social Participation and Integration:
Goal: Support the child's participation in social, educational, and community
activities to enhance social integration and quality of life.
Objective: Collaborate with educators, therapists, and community resources
to address barriers and provide support for participation in school,
extracurricular activities, social events, and recreational programs,
promoting social inclusion and peer relationships.
7)Addressing Long-Term Rehabilitation Needs:
Goal: Address ongoing rehabilitation needs and challenges that may arise as
the child grows and develops.
Objective: Continuously reassess functional status, monitor for changes in
mobility, cognition, and psychosocial well-being, and adjust rehabilitation
interventions and goals as needed to accommodate evolving needs and
optimize long-term outcomes.
8)Educating and Empowering Caregivers
Goal: Equip caregivers with the knowledge, skills, and resources to support
the child's ongoing rehabilitation and well-being.
Objective: Provide education on home exercise programs, adaptive
strategies, safety precautions, and community resources, empowering
caregivers to actively participate in the child's care and advocate for their
needs.
9)Promoting Independence and Self-Advocacy:
Goal: Foster the child's independence, self-confidence, and self-advocacy
skills to navigate life with hydrocephalus.
Objective: Encourage the child to take ownership of their health,
communicate their needs effectively, and develop problem-solving skills to
overcome challenges and advocate for themselves as they transition to
adolescence and adulthood.
10)Monitoring Long-Term Outcomes and Quality of Life:
Goal: Evaluate long-term functional outcomes, quality of life, and overall well
-being following hydrocephalus surgery and rehabilitation.
Objective: Conduct periodic assessments of functional status, health-related
quality of life, and psychosocial functioning, seeking feedback from the child
and family to inform ongoing care and support holistic well-being.
SECONDARY PREVENTION
Primary prevention:-
Preventing hydrocephalus involves addressing the underlying causes and
risk factors that contribute to its development. Here are some preventive
measures:
Early Detection and Treatment of Infections:
Prompt identification and treatment of infections such as meningitis or
encephalitis can help prevent complications that may lead to hydrocephalus.
Vaccinations:
Immunizations against infectious diseases such as measles, mumps, rubella,
and Haemophilus influenzae type b (Hib) can prevent certain infections that
may cause hydrocephalus.
Prenatal Care:
Adequate prenatal care, including regular check-ups and screenings during
pregnancy, can help identify and manage conditions such as congenital
infections or neural tube defects that may increase the risk of
hydrocephalus in newborns.
Preventing Traumatic Brain Injury (TBI):
Taking precautions to prevent accidents and injuries, such as using seat
belts, helmets, and child safety seats, can reduce the risk of traumatic brain
injury, a common cause of acquired hydrocephalus.
Genetic Counseling:
Genetic counseling and testing can help identify genetic disorders or
syndromes associated with hydrocephalus, allowing families to make
informed decisions about family planning and reproductive options.
Monitoring and Managing Intracranial Pressure (ICP):
Timely recognition and management of conditions that increase intracranial
pressure, such as brain tumors or bleeding in the brain, can help prevent
secondary hydrocephalus.
Prompt Treatment of Congenital Conditions:
Early diagnosis and intervention for congenital conditions that may cause
hydrocephalus, such as spina bifida or congenital aqueductal stenosis, can
help prevent complications and minimize the risk of hydrocephalus
progression.
Shunt Complications Prevention:
Regular follow-up care and monitoring of individuals with shunts are
essential to detect and manage complications such as infections, blockages,
or malfunctions promptly, minimizing the risk of shunt-related
hydrocephalus.
Maintaining Optimal Brain Health:
Adopting a healthy lifestyle, including regular exercise, a balanced diet,
adequate hydration, and proper management of chronic medical conditions,
can support overall brain health and reduce the risk of conditions that may
lead to hydrocephalus.
Environmental Factors:
Minimizing exposure to environmental toxins, pollutants, and substances
known to increase the risk of brain injury or developmental abnormalities
can help prevent hydrocephalus.
Secondary prevention
Secondary prevention for hydrocephalus focuses on early detection, prompt
intervention, and management of risk factors and conditions that may lead
to hydrocephalus or exacerbate existing cases. Here are detailed strategies
for secondary prevention:
Regular Monitoring and Surveillance:
Conduct regular monitoring and surveillance of individuals at risk for
hydrocephalus due to conditions such as intraventricular hemorrhage (IVH),
meningitis, or traumatic brain injury (TBI). This includes routine neuroimaging
studies (e.g., MRI, CT scans) and clinical assessments to detect signs of
hydrocephalus early.
Neurological Assessments:
Perform regular neurological assessments to evaluate cognitive function,
motor skills, sensory function, and other neurological parameters in
individuals with conditions predisposing them to hydrocephalus. This helps
detect any changes or deterioration in neurological status that may indicate
the development of hydrocephalus.
Infection Prevention and Treatment:
Implement measures to prevent and treat infections known to increase the
risk of hydrocephalus, such as meningitis or ventriculitis. This includes
appropriate antibiotic therapy, infection control practices, and vaccination
strategies to reduce the incidence of infectious causes of hydrocephalus.
Management of Intracranial Pressure (ICP):
Monitor and manage intracranial pressure (ICP) in individuals at risk for
increased ICP, such as those with brain tumors, intracranial hemorrhage, or
cerebral edema. This may involve pharmacological interventions, mechanical
ventilation, or surgical procedures to relieve pressure on the brain and
prevent secondary hydrocephalus.

Treatment of Underlying Conditions:

Provide timely and appropriate treatment for underlying conditions that
may lead to hydrocephalus, such as brain tumors, congenital malformations,
or aqueductal stenosis. This may include surgical intervention, radiation
therapy, chemotherapy, or other medical treatments to address the root
cause of hydrocephalus.
Shunt Surveillance and Maintenance:
Monitor individuals with ventriculoperitoneal (VP) shunts or other
cerebrospinal fluid (CSF) diversion devices for signs of shunt malfunction,
infection, or other complications. Regular clinical evaluations, imaging
studies, and shunt function tests help detect and address issues early to
prevent shunt-related hydrocephalus.
Educational and Supportive Interventions:
Provide education and support to individuals and families affected by
hydrocephalus to help them recognize signs and symptoms of worsening
condition or shunt malfunction. This empowers them to seek prompt
medical attention and advocate for appropriate care to prevent
complications.
Optimizing Brain Health and Development:
Promote factors that support optimal brain health and development, such as
proper nutrition, stimulation, and early intervention services for infants and
children at risk for developmental delays associated with hydrocephalus or
its underlying causes.
Regular Follow-Up Care:
Ensure regular follow-up care and monitoring by healthcare providers
specializing in neurology, neurosurgery, or rehabilitation for individuals with
hydrocephalus or conditions predisposing them to hydrocephalus. This
facilitates early detection of complications and adjustments to treatment
plans as needed to optimize outcomes.

Research and Innovation:

Support research efforts aimed at understanding the pathophysiology of
hydrocephalus, improving diagnostic methods, developing novel treatment
modalities, and enhancing long-term outcomes for individuals affected by
hydrocephalus. This contributes to the advancement of secondary
prevention strategies and overall care for hydrocephalus.
RELEVANT COMPLICATIONS AND ITS MANAGEMENT
List of complications associated with hydrocephalus and their management:
Increased Intracranial Pressure (ICP):
Complications: Elevated ICP can lead to headaches, nausea, vomiting, visual
disturbances, altered consciousness, and seizures. If left untreated, it can
result in brain herniation and death.
Management: Management of increased ICP involves measures to reduce
CSF production (e.g., acetazolamide), promote CSF drainage (e.g., shunt
placement), and control symptoms (e.g., analgesics, antiemetics).
Shunt Malfunction or Failure:
Complications: Shunt malfunction or failure can occur due to mechanical
issues (e.g., blockage, disconnection), infection (e.g., shunt-associated
meningitis), or overdrainage. This can lead to recurrence of hydrocephalus
symptoms.
Management: Management may involve surgical revision or replacement of
the shunt system, administration of antibiotics in cases of infection, and
monitoring for complications such as shunt overdrainage or underdrainage.
Infection:
Complications: Shunt-related infections, such as shunt-associated meningitis
or ventriculitis, can lead to serious complications, including neurological
deficits and death.
Management: Treatment typically involves antibiotics tailored to the specific
pathogens identified through culture and sensitivity testing. Surgical
intervention may be necessary to remove infected hardware or drain
infected fluid collections.
Cognitive and Neurological Impairment:
Complications: Hydrocephalus can result in cognitive impairment,
developmental delays (in pediatric cases), memory deficits, gait
disturbances, and other neurological deficits.
Management: Management strategies may include cognitive rehabilitation,
physical therapy, occupational therapy, speech therapy, and educational
interventions tailored to the individual's needs.
Hydrocephalus-Related Morbidity:
Complications: Long-term complications of hydrocephalus may include
intellectual disability, learning difficulties, behavioral problems, and
diminished quality of life.
Management: Comprehensive management involves ongoing monitoring,
timely intervention for complications, multidisciplinary care, and support
services to optimize functional outcomes and quality of life.
Obstructive Hydrocephalus:
Complications: Obstructive hydrocephalus, caused by blockage of CSF flow
within the ventricular system, can lead to rapid neurological deterioration if
not promptly treated.
Management: Management typically involves surgical interventions such as
endoscopic third ventriculostomy (ETV) to create a new CSF pathway or
shunt placement to bypass the obstruction.
Psychosocial Impact:
Complications: Hydrocephalus and its management can have significant
psychosocial impacts on patients and their families, including stress, anxiety,
depression, social isolation, and financial burdens.
Management: Supportive services, counseling, support groups, and
resources for coping with the psychosocial aspects of hydrocephalus can be
beneficial for patients and families.
Overall, the management of hydrocephalus requires a multidisciplinary
approach tailored to the individual's specific needs, with a focus on
preventing complications, optimizing functional outcomes, and improving
quality of life. Regular monitoring and timely intervention are essential for
minimizing complications and maximizing long-term outcomes.
CASE STUDY
case study of hydrocephalus in a pediatric patient:
Patient Profile
Name: Matthew Thompson
Age: 3 years old
Background: Matthew was born full-term without any complications. His
parents noticed that his head size seemed larger than normal during infancy
but didn't think much of it until it became more noticeable as he grew older.
Presenting Symptoms:
Macrocephaly: Matthew's parents report that his head circumference has
been consistently above the 97th percentile for his age. They observe that
his head appears disproportionately large compared to his body.
Developmental Delays: Matthew has been slow to reach developmental
milestones. He started walking later than expected, and he struggles with
balance and coordination.
Vision Problems: Matthew's parents have noticed that he squints and has
difficulty focusing on objects. They suspect that he might have vision
problems.
Behavioral Changes: Recently, Matthew has become more irritable and
easily frustrated. He has difficulty sleeping through the night and often
wakes up crying.
Clinical Examination:
Head Circumference: Measurement confirms macrocephaly, with Matthew's
head circumference tracking significantly above the 97th percentile for his
age.
Fontanelle Examination: Matthew's anterior fontanelle is tense and bulging,
indicating increased intracranial pressure.
Neurological Assessment: Matthew demonstrates poor muscle tone and
coordination. He has difficulty maintaining balance while standing and tends
to sway from side to side.
Diagnostic Workup:
MRI Scan: Imaging reveals marked enlargement of the lateral and third
ventricles, consistent with obstructive hydrocephalus. There is also evidence
of periventricular white matter compression.
CSF Analysis: Lumbar puncture is performed to assess CSF composition and
rule out infections or hemorrhage. CSF analysis reveals elevated protein
levels and normal cell counts, suggestive of non-inflammatory
hydrocephalus.
Treatment Plan:
Ventriculoperitoneal (VP) Shunt Surgery: Given the severity of Matthew's
hydrocephalus and associated symptoms, he undergoes VP shunt surgery
to divert excess CSF from his brain's ventricles to his abdominal cavity.
Ophthalmology Evaluation: Matthew is referred to an ophthalmologist for a
comprehensive eye examination to assess for any vision abnormalities or
optic nerve damage related to increased intracranial pressure.
Pediatric Neurology Consultation: Matthew is followed closely by a pediatric
neurologist for ongoing management of his hydrocephalus, monitoring of
shunt function, and assessment of developmental progress.
Outcomes:
Postoperative Recovery: Following VP shunt surgery, Matthew experiences
gradual improvement in his symptoms. His head circumference stabilizes
within the normal range, and his irritability and sleep disturbances diminish.
Developmental Progress: With the support of physical therapy and
developmental interventions, Matthew begins to make strides in his motor
skills and coordination. He gains better balance and confidence in walking
and starts to explore his environment more actively.
Long-Term Management: Matthew requires regular follow-up appointments
with his pediatric neurologist and ophthalmologist to monitor shunt function,
assess vision development, and address any emerging issues. He may
require shunt revisions or adjustments as he grows and his anatomy
changes.
This case underscores the importance of early recognition, diagnosis, and
intervention in pediatric hydrocephalus to prevent neurological sequelae
and optimize long-term outcomes. A multidisciplinary approach involving
neurosurgery, neurology, ophthalmology, and developmental specialists is
essential for comprehensive management and support of affected children
and their families.

CONCLUSION