Hydrocephalus presentation

1. Hamba Allah

2. Term derived from two Greek
words-

“hydro” means water and
“cephalus” means head.
This condition is sometimes known as “water
in the brain”.

3. 

Hydrocephalus is a condition caused
by an imbalance in the production
and absorption of CSF in the
ventricular system.
When production exceeds
absorption, CSF accumulates,
usually under pressure, producing
dilation of the ventricles.
 Hydrocephalus is a build up of fluid inside
the skull, leading to brain swelling.

5.  Incidence of primary hydrocephalus without
spina bifida is approximately 1 in 2500 live
births, making it one of the most common
developmental disabilities, more common
than Down syndrome or deafness. It is the
leading cause of brain surgery for children.
 In the past 25 years, death rates associated
with hydrocephalus have decreased from 54%
to 5% and the occurrence of intellectual
disability has decreased from 62% to 30%.

8. 1) CONGENITAL HYDROCEPHALUS
I. Intrauterine infections: Rubella,
Cytomegalovirus, Toxoplasmosis.
II. Trauma: Subarachnoid, Intracranial,
Intraventricular haemorrhages.
III.Congenital malformations:
 Dandy-walker syndrome: here posterior fossa
cyst continuous with 4th ventricle.

9.  Aqueduct stenosis: it accounts for 33% of
hydrocephalus cases. Stenosis of aqueduct of
sylvius causes dilation of lateral and 3rd
ventricles. In 2% of cases this could be
familial with X linked recessive inheritance.
 Arnold-Chiari syndrome- Portions of
cerebellum & brainstem herniating into
cervical spinal canal, blocking the flow of
CSF to the posterior fossa.

10. 2) ACQUIRED HYDROCEPHALUS: -
 Tuberculosis, chronic & pyogenic meningitis.
 Post-intraventricular hemorrhage.
 Posterior fossa tumors: medulloblastoma,
astrocytoma, ependymoma.
 Arteriovenous malformation, intracranial
hemorrhage, ruptured aneurysm.

11.  CSF is secreted at the choroid plexus within the ventricles by ultra
filtration & active secretion.
Lateral ventricles
FORAMEN OF MONRO
3rd ventricle
AQUEDUCT OF SYLVIUS
4th ventricle
CONTD…

12. Via lateral foramen of luschka & foramen
of magendie
Cistern magna
Cerebral & cerebellar subarachnoid
spaces

15. 16

16. 17

17. 

A large portion is absorbed through the
arachnoid villi, but the sinuses, veins, brain
substance & dura also participate in
absorption.
About 20ml of CSF is secreted in an hour.
• The total of CSF approximates 50ml in
an infant and 150ml in adults.

18. There are two types of hydrocephalus: -
1) Noncommunicating(intraventricular or
obstructive) hydrocephalus-In this there is
blockage between the ventricular &
subarachnoid systems, resulting in an
interference with circulation of CSF & lack of
access to the subaracnoid spaces. In this
fluid distends the ventricles. There is a
gradual thinning of the brain substance,
which is compressed between the distended
ventricles & the expanding skull.

19. 

Noncommunicating hydrocephalus
may be due to stenosis of the
aqueduct of sylivus, either a
congenital defect or acquired.
Obstructive hydrocephalus may result
postnatally from brain tumors that put
pressure on or extend into the
ventricles or circulation pathways.

21. 2) Communicating
(extraventricular)hydrocephalus- In this
there is normal communication between the
ventricles & the spinal subarachnoid space.
There is an interference with the absorption
of CSF caused by an occlusion of the
subarachnoid cisterns around the brain stem.
The fluid that is not absorbed in the
subarachnoid space accumulates,
compressing the brain & distending the
cranial cavity.

22.  Communicating hydrocephalus may be due to
subarachnoid hemorrhage or meningitis,
toxoplasmosis or cytomegalovirus infection,
in which there is an obliteration of the
subarachnoid spaces by fibrous tissue
reaction, or to diseases of connective tissue.

23. IN INFANTS-






Head grows at abnormal rate.
Anterior fontanel is tense, often bulging, & non
pulsatile.
Scalp veins are dilated & markedly so when
infant cries.
Macewen’s sign- with increase in intracranial
volume, the bones of the skull become thin &
the sutures become palpably separated to
produce the cracked pot sound on the percussion
of the skull.
Frontal bossing with depressed eyes.
Setting-sun sign- eyes rotated downward, in
which sclera may be visible above iris.

25. Feeds poorly
•Pupils are sluggish, with unequal response to light
• Changes in level of consciousness.
• Opisthotonus position & lower extremity spasticity.
• Cries when picked up & quiets when allowed to lie still.
• If hydrocephalus is allowed to progress- there
• will be disruption in the lower brainstem
• function as manifested by difficulty in feeding &
• a shrill, brief, high-pitched cry. Eventually the
• skull becomes enlarged, & the cortex is destroyed.







26. 
If the condition progress rapidly, the
infant may display emesis,
somnolence, seizures &
cardiopulmonary distress.
IN CHILDHOOD-




Headache on awakening with improvement
following emesis or upright posture.
Papilledema, strabismus.
Irritable & lethargic.
Apathetic, confused & often incoherent.
Bulging occiput, nystagmus, ataxia & cranial
nerve palsies.

27.  Routine daily head (occipitofrontal)
circumference measurements.
Echoencephalography.






A head CT scan is one of the best tests for
identifying hydrocephalus.
Arteriography.
Brain scan using radioisotopes
Cranial ultrasound (an ultrasound of the brain)
Lumbar puncture and examination of the
cerebrospinal fluid (rarely done).
Skull x-rays.

28. The treatment of hydrocephalus is
directed toward –
Relief of the
hydrocephalus,
Treatment of
complications,


 Management of problems related to the
effect of the disorder on psychomotor
development. The treatment is, with few
exceptions, surgical.

29. 1) MEDICAL MANAGEMENT,
2) SURGICAL MANAGEMENT &
3) NURSING MANAGEMENT.

30. 
This can be tried in mild
cases of hydrocephalus.
Acetozolamide: dose of
50mg/kg/day dimnishes CSF
production.
 Oral glycerol has also been used for the
similar purpose.

31. It may consist of




The removal of the obstruction (tumor,
hemorrhage or cyst) to the flow of CSF.
Reduction in the amount of CSF produced
through destruction of a portion of the choroid
plexus or a third or fourth ventriculostomy.
Shunting of CSF from the ventricle to another
site in the normal circulatory passageway of this
fluid.
Shunting of CSF from the ventricle to an area
outside the CNS, an extracranial body
compartment.

32. Shunting is the most common procedure to be
done in the surgical management of
hydrocephalus.
Most shunt systems consist of a ventricular
catheter, a flush pump, a unidirectional flow
valve & a distal catheter. All are radiopaque
for easy visualization after placement & all
are tested before insertion.

33. Types of shunts-
1. Ventriculoperitonial(VP) shunt.
2. Ventriculoatrial(VA) shunt.
3. Ventriculopleural shunt.

34.  Ventriculoperitonial(VP) shunt- This is the
preferred procedure especially in neonates &
young infants. There is greater allowance for
excess tubing, which minimizes the number
of revisions needed as the child grows. In this
ventricular catheter is inserted into the
anterior portion of a lateral ventricle through
a burr hole in the skull.

35.  An incision is made in abdomen & through
the rectus muscle into the peritoneum. The
proximal end of the catheter is slipped
beneath the skin of anterior abdominal &
chest wall to the neck. The ventricular
catheter with attached valve is then sutured
to the peritoneal catheter. The CSF is
absorbed by tissues in the abdominal cavity.

36. Ventriculoperitonial(VP) shunt-

38.  Ventriculoatrial(VA) shunt- It is reserved for
older children who have attained most of
their somatic growth & children with
abdominal pathology. It requires repeated
lengthening as child grows. A silicon catheter
is inserted in lateral ventricle & down
through the internal jugular vein into left
atrium of the heart.

39. 
The CSF drains into circulating blood.
This type of shunt may become easily
obstructed or infected. If an infection
occurs, bacterial endocarditis,
ventriculitis & bacteremia may result.

40. 
Ventriculopleural shunts- these shunts are
sometimes used in children over 5 years of
age. This type of shunt drains fluid from the
lateral ventricle to the pleural cavity.
• Drainage of the CSF may cause hydrothorax, necessitating either
removal of the shunt or a thoracentesis. The nurse must observe these
children carefully for respiratory difficulties.

41.  Endoscopic third ventriculostomy- It is a
procedure that has potential for greater
independence from VP or VA shunting in
children with noncommunicating
hydrocephalus. In this procedure a small
opening is made in the floor of the 3rd
ventricle, allowing CSF to flow freely through
previously blocked ventricle, thus bypassing
the aqueduct of sylvius.

42.  Reports of the success of endoscopic third
ventriculostomy in children; however, as
surgical techniques & advances continue, it
is expected that neonates & small children
will be successfully treated with this
procedure rather than conventional shunting.

44. 
The major complications of
shunts are
infection & malfunction.
 All shunts are subjected to mechanical
difficulties, such as kinking, plugging, or
separation & migration of tubing.

45. 1) Malfunction is most often caused by
mechanical obstruction either within the
ventricles from articulate matter (tissue or
exudates) or at the distal end from
thrombosis or displacement as a result of
growth. The child with a shunt obstruction
often presents as an emergency with clinical
manifestations of increased ICP, frequently
accompanied by worsening neurologic status.

46. 2) Shunt infection is also a serious
complication of shunts. It can occur at any
time, but the period of greatest risk is 1 to 2
months following placement. The infection
may be a result of intercurrent infections at
the time of shunt replacement. Infections
include sepsis, bacterial endocarditis, wound
infection, shunt nephritis, meningitis.

47. 3)Another serious shunt-related complication
is subdural hematoma caused by rapid
reduction of ICP & size.
4)Other complications that may include
peritonitis, abdominal abscesses, perforation
of abdominal organs by catheter or trochar
(at the time of insertion), fistulas, hernias.

48. NURSING MANAGEMENT
A)Teach the family about the management required
for the disorder.
a)Treatment is surgical by direct removal of an
obstruction and insertion of shunt to provide primary
drainage of the CSF to an extracranial compartment,
usually peritoneum (ventriculoperitoneal shunt).
1.The major complications of shunts are infections and
malfunction.
2.Other complications include subdural hematoma
caused by a too rapid reduction of CSF, peritonitis,
abdominal abscess, perforation of organs, fistulas,
hernias and ileus.
b. A third ventriculostomy is a new nonshunting
procedure used to treat children with hydrocephalus.

49. NURSING MANAGEMENT contd…
B) Provide preoperative nursing care
a.Assess head circumference, fontanelles,
cranial sutures, and LOC; check also for
irritability, altered feeding habits and a high-
pitched cry.
b.Firmly support the head and neck when
holding the child.
c.Provide skin care for the head to prevent
breakdown.
d.Give small, frequent feedings to decrease
the risk of vomiting.
e. Encourage parental-newborn bonding.

50. NURSING MANAGEMENT contd…
C) Provide Postoperative nursing care
a.Assess for signs of increased ICP and check the
following; head circumference (daily), anterior
fontanels for size and fullness and behaviour.
b.Administer prescribed medications which may
include antibiotics to prevent infection and
analgesics for pain.
c.If there is increased ICP elevate the head of the bed
or allow the child to sit up to enhance gravity flow
through shunt.
d. Observe the child for abdominal distension.
e. Maintain intake-output chart.

51. NURSING MANAGEMENT contd…
f. Provide shunt care
1.Monitor for shunt infection and malfunction which
may be characterized by rapid onset of vomiting,
severe headache, irritability, lethargy, fever, redness
along the shunt tract, and fluid around the shunt
valve.
2.Prevent infection (usually from Staphylococcus
epidermis or Staphylococcus aureus)
3.Monitor for shunt overdrainage (headache, dizziness
and nausea). Overdrainage may lead to slit ventricle
syndrome whereby the ventricle become accustomed
to a very small or slitlike configuration, limiting the
buffering ability to increased ICP variations

52. NURSING MANAGEMENT contd…
D) Teach home care
a.Encourage the child to participate in age-
appropriate activities as tolerated.
Encourage the parents to provide as normal
lifestyle as possible.
b.Explain how to recognize signs and
symptoms of increased ICP. Subtle signs
include changes in school performance,
intermittent headache, and mild behavior
changes
c.Frequent developmental screenings & follow
ups.

53. 1) NURSING DIAGNOSIS- Ineffective
cerebral tissue perfusion related to
increased ICP.
 Expected outcome- There will be effective
cerebral tissue perfusion.
 Interventions:


Give proper positioning to the baby. Keep
the head of the baby in neutral (midline)
position to promote venous drainage.
Avoid extreme rotation & flexion of the neck
as these can cause compression & distortion
of jugular veins which will further increase
the ICP.

54. 

Elevate the head at 30 to 45 degree to
aid in venous drainage.
Extreme hip flexion is also avoided as
this position causes increase in intra-
abdominal & intra-thoracic pressures,
which can produce a rise in ICP.


While turning hold the head of baby to avoid
any stimuli.
Check for abdominal distension it also results
in the rise of ICP.

55. 2) NURSING DIAGNOSIS- Imbalanced
nutrition, less than body requirement
related to reduced oral intake &
vomiting. Expected outcome- Nutritional status of the
baby will be maintained.
 Interventions:


Assess the nutritional status of the baby.
Weigh the baby daily & record.

56. 

Maintain intake-output chart of the
baby. Provide exclusive breast
feeding to the neonates & infants up
to 6 months of age. For older children, offer small frequent
feedings of light food.

57. 3) NURSING DIAGNOSIS- Risk for
impaired skin integrity related to
enlarged head.
 Expected outcome- Skin integrity will be
maintained.
 Interventions:





Assess the skin integrity of the baby.
Prevent the pressure on the enlarged head.
Provide firm-soft pillow under child’s head.
Keep the area clean & dry.
Good skin care & range of motion exercise
are also essential to prevent skin breakdown.

58. 4) NURSING DIAGNOSIS- Risk for infection related
to introduction of infecting organism through
shunt.
 Expected outcome- There will be no sign &
symptom of infection.
 Interventions:





Check & record the vital signs of the baby.
Use aseptic technique while doing any procedure
on the baby.
Wash the hands properly before touching the
baby.
Maintain the general cleanliness of the area &
baby.
Administer the antibiotics as prescribed.

59. 5) NURSING DIAGNOSIS- Ineffective family coping
related to life threatening problem of infant.
 Expected outcome- Family will be able to cope
up with the problem.
 Interventions:


Tell the family about the disease condition
(causes, treatment, prognosis).
Educate them about the care of baby like
maintaining the cleanliness, proper diet, skin
care, positioning of the baby (initially flat to
prevent the excessive CSF drainage then gradual
elevation of head of child’s bed to 30 to 45
degree).

60. 

Educate the family about the shunt
& its purpose.
Tell them about the assessment for
excessive drainage of CSF (sunken
fontanel, agitation, decrease level of
consciousness). Encourage them for treatment compliance &
regular follow up

61.  Marlow R. Dorothy, Redding A. Barbara; Textbook
of Pediatric Nursing; sixth edition; Saunders
Elsevier; 522-527.



Hockenberry, Wilson; Wong’s Nursing care of
infants and children; 7thedition; Mosby; 436-443.
Ghai OP, Paul K Vinod, Bagga Arvind; Ghai
essential paediatrics; 7thedition; CBS
Publications, 548-549.
Datta Parul; Pediatric Nursing; 2ndedition;Jaypee;
406-409.

62. 

Singh Meharban; Care of the Newborn; 5th
edition; Sagar Publications; 338.
Arvind R; Applied Neonatology; Jaypee; 332-
333.


www.ncbi.nlm.nih.gov/hydrocphalus.
www.medicinenet.com/hydrocephalus.