hydrocephalus pranay dr.pranaya

1. HYDROCEPHALUS

2. INTRODUCTION
 COMMON PEDIATRIC DISORDER
 INCIDENCE- 0.9 – 1.8 /1000 BIRTH
 MORTALITY- APPROX 1% PER YEAR
 DUE TO INCREASE IN CSF VOLUME CAUSING ENLARGED VENTRICLE, THINNING
OF CORTICAL MANTLE AND ELEVATION OF ICP(INTRA CRANIAL PRESSURE)
 DISPARITY BETWEEN CSF PRODUCTION AND ABSORPTION
 MOST ARE DUE TO IMPAIRED ABSORPTION

3. CLINICAL ANATOMY- VENTRICLES OF
BRAIN

6. CSF DYNAMICS

7.  HYDROCEPHALUS CAN BE DIVIDED –
 OBSTRUCTIVE OR NON-COMMUNICATING
 NON-OBSTRUCTIVE OR COMMUNICATING
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OBSTRUCTIVE – OBSTRUCTION PROXIMAL TO ARACHNOID VILLI, RESULTING IN
SELECTIVE ENLARGEMENT OF VENTRICLES PROXIMAL TO OBSTRUCTION.
COMMUNICATING- BLOCK AT LEVEL OF ARACHNOID VILLI WITH IMPAIRED CSF
ABSORPTION

8. OBSTRUCTIVE HYDROCEPHALUS
 CAUSES-
 AT THE LEVEL OF FORAMEN OF MONRO
 CONG. ATRESIA OR STENOSIS
 INTRACRANIAL CYST
 PORENCEPHALIC CYST
 HYPOTHALAMIC GLIOMA
 CRANIOPHARYNGIOMA
 ASTROCYTOMA
 CAVERNOUS MALFORMATION

9. PORENCEPHALIC CYST

10.  OBSTRUCTION OF AQUEDUCT-
 UPWARD HERNIATION OF CEREBELLUM THROUGH TENTORIAL INCISURA.
(SEEN WITH MENINGOMYELOCELE AND CHIARI II MALFORMATION)
 VEIN OF GALEN MALFORMATION
 GLIOSIS OF AQUEDUCT DUE TO INFECTION OR HEMORRHAGE
 TUMOR AT PINEAL REGION
 TECTAL PLATE GLIOMA

11. TECTAL PLATE GLIOMA

14. ARNOLD CHIARI TYPE II
 The brain herniation results in external compression of the IV ventricle, which in turn disrupts normal
CSF circulation resulting in obstructive hydrocephalus.
 Present in almost every case of thoracolumbar, lumbar and lumbosacral myelomeningocele.
 Inferior displacement of the medulla and fourth ventricle into the upper cervical canal.
 Elongation and thinning of the upper medulla and lower pons and persistence of the embryonic flexures
of these structures.
 Hydrocephalus.

15.  AT LEVEL OF FOURTH VENTRICLE OUTFLOW OBSTRUCTION
 MEDULLOBLASTOMA
 EPENDYMOMA
 PILOCYTIC ASTROCYTOMA
 DANDYWALKER MALFORMATION- LARGE POSTERIOR FOSSA CYST
COMMUNICATING WITH 4TH VENTRICLE WITH FORAMEN OF LUSCHKA AND
MAGENDIE ATRESIA
 CHIARI II MALFORMATION

18. COMMUNICATING HYDROCEPHALUS
BLOCKADE AT LEVEL BASAL CISTERN
 CSF IS BLOCKED BETWEEN SPINAL AND CORTICAL SUBARACHNOID SPACE
 LATERAL , 3RD AND 4TH VENTRICLE ARE DILATED
CAUSES-
 CONG. INFECTION
 MENINGITIS
 TB
 FUNGAL INF.
 SUB ARAHNOID HEMORRHAGE
 TRAUMA
 TUMOR PRODUCING HIGH PROTEIN

19. BLOCKADE AT ARACHNOID VILLI
 DILATATION OF SUBARACHNOID SPACE AND VENTRICLES
 CAUSE- OCCLUSION OR ATRESIA OF ARACHNOID VILLI
DURAL SINUS BLOCKADE-
 CAUSES- ACHONDROPLASIA
 MULTIPLE CRANIOSYNOSTOSIS WITH JUGULAR FORAMEN STENOSIS
 HIGH RIGHT ATRIAL PRESSURE IN CHD
 THROMBOSIS OF DURAL VENOUS SINUSES

20. CLINICAL FEATURES
IN INFANTS-
 IRRITABILTY
 LETHARGY
 FAILURE TO THRIVE WITH OR WITHOUT VOMITING
 DELAYED DEVELOPMENT
 APNEA
 BRADY
 HYPERREFLEXIA
 HYPERTONIA
 INCREASED HEAD CIRCUMF
 BULGING FONTANELLE
 SPLAYING OF CRANIAL SUTURES
 THIN SCALP WITH DISTENDED VEINS
 FRONTAL BOSSING

21.  UPWARD GAZE IMPAIRED WITH EYELID RETRACTION- “SETTING SUN SIGN”- DUE TO
PRESSURE ON TECTAL PLATE
 DECREASE LEVEL OF CONSCIOUSNESS
 PAPILLOEDEMA
 3RD 4TH 6TH NERVE PALSY
IN OLDER CHILDREN(suture closed)
 HEADACHE IN MORNING
 NAUSEA VOMITING LETHARGY
 PAPILLOEDEMA
 VISION LOSS
 MEMORY LOSS, ATTENTION DEFICIT, WORSEN SCHOOL PERFORMANCE, GAIT CHANGE ,
DIPLOPIA FROM 6TH NERVE PALSY
 SEIZURES

23. INVESTIGATIONS
PLAIN SKULL XRAY-
BEATEN COPPER APPERANCES
SPLITTING OF CORONAL SUTURES
CT AND MRI REVEALS DILATED TEMPORAL HORN AND OBLITERATION OF SYLVIAN AND
INTERHEMISPHERIC FISSURE, SULCI AND BASILAR CISTERN
BALLONING OF FRONTAL HORN AND THIRD VENTRICLE
UPWARD BOWING OR ATROPHY OF CORPUS CALLOSUM
PERIVENTRICULAR EDEMA

24. COPPER BEATEN SKULL

27.  Suture closure by-
 Posterior Fontanel- 1.5mnths
 Anterior fontanelle- 1.5 years
 Other fontanelle- 6mnths
 Head circumference-
 At birth- 33-35cm
 1st 3 months- 2cm/mnth
 2nd 3mnth-1cm/month
 Next 6mnths- 0.5cm/mnth
 At end of 1 year- 45-47cm
 Attains adult size by 5-6years of age.
 Normal ICP- 7CM OF H20 OR 5MM OF HG
 PRODUCTION- 450ML/DAY – ENERGY DEPENDENT- ICP INDEPENDENT- CARBONIC
ANYHDRASE DEPENDENT

28. TREATMENT
 Treat the cause
 If not, shunt the CSF
 most commonly used distal sites for systemic absorption-
 peritoneal cavity (ventriculoperitoneal shunt)
 basilar cisterns (i.e., third ventriculostomy )
Others- right atrium, pleural cavity, gallbladder, bladder/ureter
 CSF shunt systems - three components: a ventricular catheter, which is usually placed in the occipital
or frontal horn of the lateral ventricle
 Distal shunt tubing to drain CSF into a distal site for reabsorption
 Valve. As per pressure gradient

33. ENDOSCOPIC THIRD VENTRICULOSTOMY

34. THANK YOU

35. DR PRANAYA-
pkpsurg@bhu.ac.in