HYDROCEPHALUS
MOHD ROSLEE BIN ABD GHANI
LEARNING OBJECTIVES
• Define hydrocephalus
• Explain the causes of hydrocephalus
• State the signs and symptoms of hydrocephalus
• Describe the treatment of hydrocephalus
• State the complications of hydrocephalus
DEFINITION
• The term hydrocephalus is derived from the Greek words "hydro" meaning water and
"cephalus" meaning the head.
• Hydrocephalus is a condition in which an accumulation of cerebrospinal fluid (CSF)
occurs within the brain.
• This typically causes increased pressure inside the skull.
• Cerebrospinal fluid normally flows through the ventricles and bathes the brain and
spinal column. But the pressure of too much cerebrospinal fluid associated with
hydrocephalus can damage brain tissues and cause a range of impairments in brain
function.
CSF
CSF Production
• The CSF is produced by the choroid plexus which can be found in the two lateral
ventricles, and in the roof of the third and fourth ventricles. Around 500 ml is
produced each day, with around 150-250 ml being present in the body at any one
time.
• CSF is produced continuously which keeps the fluid in circulation around the
central nervous system. The fluid will move from the lateral ventricle to the third
and then to the fourth ventricle. From the fourth ventricle, the fluid moves out into
the subarachnoid space and/or the central canal of the spinal cord
CSF-functions
• Buoyancy – the brain weighs ~1400g, but due to the presence of CSF creating a bath, it only has
a net weight of 50g. The brain otherwise is only supported within the arachnoid space by blood
vessels and nerve roots which are fragile structures.
• Protection – CSF acts as a shock absorber preventing damage from occurring to the brain when
the cranium is jolted/hit.
• Homeostasis – regulates the distribution of metabolites surrounding the brain keeping the
environment ideal to prevent any damage to the nervous system.
• Clearing waste – waste products produced by the brain move into the CSF which then clears out
through the arachnoid granulations into the venous sinus so it can be absorbed into the
bloodstream.
INCIDENCE
• Hydrocephalus can happen at any age, but it occurs more frequently
among infants and adults 60 and over.
CAUSES
• Hydrocephalus is caused by an imbalance between how much
cerebrospinal fluid is produced and how much is absorbed into the
bloodstream.
CAUSES….
• Obstruction. The most common problem is a partial obstruction of the
normal flow of cerebrospinal fluid, either from one ventricle to another or
from the ventricles to other spaces around the brain.
• Poor absorption. Less common is a problem with the mechanisms that
enable the blood vessels to absorb 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.
RISK FACTORS
Newborns
• Hydrocephalus present at birth (congenital) or shortly after birth may
occur because of any of the following:
1. Abnormal development of the central nervous system that can obstruct the flow of
cerebrospinal fluid
2. Bleeding within the ventricles, a possible complication of premature birth
3. Infection in the uterus during a pregnancy, such as rubella or syphilis, that can
cause inflammation in fetal brain tissues
RISK FACTORS….
• Other factors that can contribute to hydrocephalus among any age
group include:
1. Lesions or tumors of the brain or spinal cord
2. Central nervous system infections, such as bacterial meningitis or
mumps
3. Bleeding in the brain from a stroke or head injury
4. Other traumatic injury to the brain
SIGNS AND SYMPTOMS -infants
• Changes in the head • Vomiting
• Sleepiness
• An unusually large head • Irritability
• A rapid increase in the size of the • Poor feeding
head • Seizures
• A bulging or tense soft spot • Eyes fixed downward (sunsetting of the eyes)
(fontanel) on the top of the head • Deficits in muscle tone and strength
• Poor responsiveness to touch
• Poor growth
SIGNS AND SYMPTOMS-toddler &children
• Headache • Poor appetite
• Blurred or double vision • Seizures
• Eyes fixed downward (sunsetting of eyes) • Urinary incontinence
• Abnormal enlargement of a toddler's head • Irritability
• Sleepiness or lethargy • Change in personality
• Nausea or vomiting • Decline in school performance
• Unstable balance • Delays or problems with previously
• Poor coordination acquired skills, such as walking or
talking
SIGNS AND SYMPTOMS-young & middle-
aged adults
• Headache
• Lethargy
• Loss of coordination or balance
• Loss of bladder control or a frequent urge to urinate
• Impaired vision
• Decline in memory, concentration and other thinking skills that may affect
job performance
SIGNS AND SYMPTOMS-older adults
• Loss of bladder control or a frequent urge to urinate
• Memory loss
• Progressive loss of other thinking or reasoning skills
• Difficulty walking, often described as a shuffling gait or the feeling of the
feet being stuck
• Poor coordination or balance
DIAGNOSIS
• History taking
• Physical examination
• Routine daily head (occipitofrontal) circumference measurements.
• Investigations
Investigations
1. Echoencephalography.
2. A head CT scan is one of the best tests for identifying hydrocephalus.
3. Arteriography.
4. Brain scan using radioisotopes
5. Cranial ultrasound (an ultrasound of the brain)
6. Lumbar puncture and examination of the cerebrospinal fluid (rarely done).
7. Skull x-rays.
TREATMENT
1. A shunt system
• A catheter is placed in the brain to drain away excess fluid from the
brain into another part of the body, such as the abdomen, the chest
cavity, or a chamber of the heart.
• Usually, this is all that is needed, and no further treatment is
required.
Most common shunt systems
Shunt Pathway Shunt Type CSF Inflow Location CSF Drainage Location
Ventriculo-peritoneal VP Ventricle Peritoneal cavity
Right atrium of the
Ventriculo-atrial VA Ventricle
heart
Ventriculo-pleural VPL Ventricle Pleural cavity
Lumbo-peritoneal LP Lumbar spine Peritoneal cavity
VP shunt
• To help drain the extra CSF from the brain, a VP shunt will be placed into the
head. The VP shunt works by taking the fluid out of the brain and moving it
into the abdomen, where it’s absorbed by the body. This lowers the pressure
and swelling in the brain.
• A VP shunt has 3 parts
1. A one-way valve with a reservoir.
2. A short catheter (thin, flexible tube)
3. A long catheter
• The valve controls the flow of CSF fluid. It’s attached on one end to the short
catheter so it can drain the fluid away from the brain. The short catheter can be
placed in the front, back, or side of the head.
VP shunt…
• The reservoir collects a small amount of CSF which can use to sample CSF
for tests if needed.
• The long catheter is attached to the other end of the valve. The long
catheter is placed under the skin, behind the ear, down the neck, and into
the abdomen.
• As the VP shunt drains extra CSF and lessens the pressure in the brain, it
may ease some of the symptoms. Some symptoms will stop right after the
VP shunt is inserted. Others will go away more slowly, sometimes over a
few weeks.
• The amount of fluid that’s drained by the VP shunt depends on the settings
on the shunt.
Ventriculo-peritoneal shunt
Ventriculo-atrial shunt
TREATMENT….
2. Ventriculostomy
• A procedure to make a hole in the bottom of a ventricle so that the excess
fluid flows towards the base of the brain.
• Normal absorption occurs at the base of the brain.
• This procedure is sometimes performed when the flow of fluids between
ventricles is obstructed.
TREATMENT….
Treatment for normal pressure hydrocephalus
1. Lumbar puncture – some of the cerebrospinal fluid is removed from the
base of the spine. If this improves the patient’s gait or mental abilities, fitting
a shunt will probably help.
2. Lumbar infusion test – a needle is inserted through the skin of the lower
back into the spine. Measurements are taken of CSF pressure as fluid is
injected into the spine. Patients usually benefit from having a shunt fitted if
their CSF pressure is over a certain limit.
DIAGNOSIS
1. Computed tomography scan (CT or CAT scan)
2. Magnetic resonance imaging (MRI)
3. Lumbar puncture (spinal tap)
4. Intracranial pressure monitoring
5. Isotope cisternography
Radionuclide/isotope cisternography
• A radionuclide cisternogram is a nuclear scan test. It is used to diagnose problems
with the flow of spinal fluid.
• A lumbar puncture is done first. Small amounts of radioactive material, called a
radioisotope, are injected into the fluid within the spine. The needle is removed
immediately after the injection.
• The patient will then be scanned 1 to 6 hours after getting the injection. A special
camera takes images that show how the radioactive materials travel with the
cerebrospinal fluid (CSF) through the spine. The images also show if the fluid
leaks outside the spine or brain.
COMPLICATIONS
1. Permanent brain damage
2. Autism
3. Learning difficulties
4. Physical coordination problems
5. Problems with memory
6. Speech problems
7. Vision problems
PREVENTION
1. Pregnancy
2. Infectious diseases – vaccinations
3. Meningitis vaccine – meningitis used to be a common cause of
hydrocephalus.
4. Preventing head injuries
SUMMARY
• Definition
• Causes
• Signs and symptoms
• Diagnosis
• Treatment
• Complication
