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1. HYDROCEPHALO
US
PRESENTED BY
MR. ABHIJIT P.
BHOYAR
M SC. NURSING
CHILD HEALTH

2. INTRODUCTION
• Hydrocephalus is the abnormal accumulation of cerebrospinal
fluid (CSF) in the intracranial spaces.
• It occurs due to imbalance between production or absorption
of CSF or due to obstruction of the CSF pathways.
• It results in the dilatation of the cerebral ventricles and
enlargement of head.

3. DEFINITION
• A CONDITION IN WHICH FLUID
ACCUMULATES IN THE BRAIN,
TYPICALLY IN YOUNG
CHILDREN, ENLARGING THE
HEAD AND SOMETIMES
CAUSING BRAIN DAMAGE.

4. CSF CIRCULATION &
PATHWAYS
• Cerebrospinal fluid is secreted at the
choroid plexus within the cerebral
ventricles by ultrafiltration and active
secretion.
• From the lateral ventricles CSF passes
to the third ventricle through the
foramina of Monroe.
• From third ventricle, it passes
through cerebral aqueduct (aqueduct
of salvias) to the fourth ventricle.

5. • From fourth ventricle, CSF passes to the basal
cisterns and subarachnoid spaces through the
foramina luschka and foramina magendie.
• CSF is absorbed via the archnoid villi into the
venous channel and sinuses. About 20 ml of CSF
is secreted in an hour, and 500 ml/day.
• The total volume of CSF is about 100 to 150 ml.
In the child, the quantity is proportionately less
and gradually increasing with Increased to the
adult figure.

6. ETIOLOGY OF HYDROCEPHALUS
Hydrocephalus may occur due to congenital
or acquired causes.
CONGENITAL HYDROCEPHALUS
It occurs due to the followings conditions:
• Intrauterine infections—mainly in rubella,
toxoplasmosis, cytomegalovirus.
• Congenital brain tumour obstructing the
CSF flow.
• Intracranial haemorrhage.
• Congenital malformations like aqueduct
stenosis, arnold-Chiari malformation
(displacement of the brainstem and
cerebellum through foramen magnum),
dandy-walker anomaly (congenital septum
or membrane blocking the outlet of 4th
ventricle).
• Malformations of arachnoids villa.

7. Acquired hydrocephalus
It occurs usually following the
conditions like:
• Inflammation—meningitis,
encephalitis.
• Trauma—birth injury, head injury,
intracranial haemorrhage.
• Neoplasm—space occupying
lesions like tuberculoma, subdural
hematoma or abscess, gliomas,
• Chemical—hypervitaminosis 'a'
• Connective tissue disorder—hurler
syndrome, achondroplasia.
• Degenerative atrophy of brain—
hydrocephalus ex-vacuo.
• Arteriovenous malformations

8. TYPES
Hydrocephalus can be divided into two types.
1. COMMUNICATING HYDROCEPHALUS
• In this type, there is no blockage between ventricular system, the basal
cisterns and the spinal subarachnoid space.
• There may be failure in the absorption of CSF (cavernous sinus
thrombosis) or excessive production of CSF as in choroid plexus papilloma,
pseudotumor cerebri, etc.

9. 2. NONCOMMUNICATING HYDROCEPHALUS
• In this of hydrocephalus, there is obstruction at any level in the ventricular
system, commonly at the level of aqueduct or at foramina luschka and/or
magendie.
• The obstruction may be partial, intermittent or complete.
• It develops mainly due to inflammation and developmental obstructive
lesions.
• It occurs in majority of cases.

10. PATHOLOGY
Ventricular system becomes greatly distended and dilated
Increased intraventricular pressure
Thinning of cerebral cortex and cranial
bones
Ependymal lining of ventricles is disrupted
Periventricular ooze.

11. Sub ependymal edema occurs and white matter is compressed.
Outward bulging of third ventricle
Compresses the optic nerves and hypophysis cerebri with dilation of sella turcicle
Choroid plexus is usually atrophied to some degrees
&
Cortical atrophy may alsO OCCUR

12. CLINICAL MANIFESTATIONS
INFANTS
• Common signs and symptoms of
hydrocephalus in infants include:
• Changes in the head
• An unusually large head
• A rapid increase in the size of the head
• A bulging or tense soft spot (fontanel) on the
top of the head

13. • PHYSICAL SIGNS AND
SYMPTOMS
• Vomiting
• Sleepiness
• Irritability
• Poor feeding
• Seizures
• Eyes fixed downward
(sunsetting of the eyes)
• Deficits in muscle tone and
strength
• Poor responsiveness to
touch
• Poor growth

14. • Toddlers and older
children
• Among toddlers and older
children, signs and
symptoms may include:
• Physical signs and
symptoms
• Headache
• Blurred or double vision
• Eyes fixed downward
(sunsetting of eyes)

15. • Abnormal enlargement of a
toddler's head
• Sleepiness or lethargy
• Nausea or vomiting
• Unstable balance
• Poor coordination
• Poor appetite
• Seizures
• Urinary incontinence

16. • Behavioral and cognitive
changes
• Irritability
• Change in personality
• Decline in school performance
• Delays or problems with
previously acquired skills, such
as walking or talking
• Young and middle-aged adults
• Common signs and symptoms in
this age group include:
• 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

17. • Older adults
• Among adults 60 years of age and older, the more common signs
and symptoms of hydrocephalus are:
• 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

18. INVESTIGATIONS
HISTORY COLLECTION AND PHYSICAL
EXAMINATION
BLOOD INVESTIGATIPN
X RAY
MRI
CT SCAN
USG
CSF STUDIES

19. MANAGEMENT
Medical management
• Management of hydrocephalus depends upon specific cause,
associated malformations, clinical course and severity of the
condition.
• Surgery may not be indicated, if the hydrocephalus gets
spontaneous arrest. When the surgical management is not
necessary, then medical management is done to reduce increased
ICP by carbonic anhydrase inhibitor, acetazolamide (diamox) 50
mg/kg/day to reduce CSF production in slow progressiv
hydrocephälus.
• Oral glycerol and isosorbide can also be used for the same purpose

20. • SURGICAL MANAGEMENT
• Surgical management is indicated in obstructive hydrocephalus, in
rapid enlargement of head, visual disturbances in life-threatening
increase ICP.
• Ventriculostomy and choroid plexectomy have been performed with
variable results.
• Surgical shunts are the treatment of choice at the present time.
• Intracranial or extracranial shunt is done to bypass the obstruction
and system to other compartment
•

21. • The most commonly performed extracranial shunt is ventriculo
peritoneal shunt (V-P shunt)
• Other approaches are ventriculo atrial shunt, ventriculo pleural
shunt or ventriculo gallbladder shunt.

23. PROGNOSIS
• Prognosis depends on early diagnosis and prompt therapy.
• With improved diagnostic and management techniques, the prognosis is
becoming considerably better.
• Many children experience normal motor and intellectual development.
• The severity of neurologic deficits is directly proportional to the interval between
onset of hydrocephalus and the time of diagnosis.
• Hydrocephalus due to meningitis might spontaneously resolve due to gradual
disappearance of adhesions.
• Approximately two-thirds of patients will die at an early age if they do not receive
surgical treatment.

24. COMPLICATIONS
• SEIZURES.
• HERNIATION OF THE BRAIN.
• SPONTANEOUS ARREST DUE TO NATURAL
COMPENSATORY MECHANISMS, PERSISTENT
INCREASED ICP, AND BRAIN HERNIATION.
• DEVELOPMENTAL DELAYS.
• DEPRESSION IN ADOLESCENTS IS COMMON

25. NURSING MANAGEMENT
• NURSING ASSESSMENT
• Along with routine nursing assessment, the most important is the
measurement of head circumference. The measurement should be
done at the occipito-frontal circumference at largest point and
approximately at same time each day and in centimeter.
• Other important aspects of assessment are status of fontanel, level
of consciousness, pupillary response, vital signs, pattern of
respiration, signs of increased icp, condition of the scalp, presence
of pressure sore or any skin breakdown, incontinence of bladder
and bowel, neurological deficits, motor activity, change in feeding
behavior and signs of complications

26. NURSING DIAGNOSES
• INEFFECTIVE CEREBRAL TISSUE PERFUSION RELATED TO
INCREASED ICP BEFORE SURGERY
• IMBALANCED NUTRITION: LESS THAN BODY REQUIREMENTS
RELATED TO REDUCED ORAL INTAKE AND VOMITING
• RISK FOR IMPAIRED SKIN INTEGRITY RELATED TO
ALTERATIONS IN LOC AND ENLARGED HEAD
• ANXIETY OF PARENTS RELATED TO CHILD UNDERGOING
SURGER

27. NURSING INTERVENTIONS
MAINTAINING CEREBRAL PERFUSION
OBSERVE FOR EVIDENCE OF INCREASED ICP, AND REPORT
IMMEDIATELY.
ASSIST WITH DIAGNOSTIC PROCEDURES TO DETERMINE CAUSE OF
HYDROCEPHALUS AND INDICATION FOR SURGICAL INTERVENTION.
• EXPLAIN THE PROCEDURE TO THE CHILD AND PARENTS AT THEIR LEVELS OF
COMPREHENSION.
• ADMINISTER PRESCRIBED SEDATIVES 30 MINUTES BEFORE THE
PROCEDURE TO ENSURE THEIR EFFECTIVENESS.
• ORGANIZE ACTIVITIES SO THE CHILD IS PERMITTED TO REST AFTER
ADMINISTRATION OF THE SEDATIVE.

28. • OBSERVE CLOSELY AFTER VENTRICULOGRAPHY
FOR THE FOLLOWING:
• LEAKING OF CSF FROM THE SITES OF SUBDURAL OR
VENTRICULAR TAPS. THESE TAP HOLES SHOULD BE
COVERED WITH A SMALL PIECE OF GAUZE OR COTTON
SATURATED WITH COLLODION.
• REACTIONS TO THE SEDATIVE, ESPECIALLY
RESPIRATORY DEPRESSION.
• CHANGES IN VITAL SIGNS INDICATIVE OF SHOCK.
• SIGNS OF INCREASED ICP, WHICH MAY OCCUR IF AIR
HAS BEEN INJECTED INTO THE VENTRICLES

29. • BE AWARE THAT FEEDING IS FREQUENTLY DIFFICULT
BECAUSE THE CHILD MAY BE LISTLESS, ANORECTIC, AND
PRONE TO VOMITING.
• COMPLETE NURSING CARE AND TREATMENTS BEFORE
FEEDING SO THE CHILD WILL NOT BE DISTURBED AFTER
FEEDING.
• HOLD THE INFANT IN A SEMI-SITTING POSITION WITH HEAD
WELL SUPPORTED DURING FEEDING. ALLOW AMPLE TIME
FOR BUBBLING.
• OFFER SMALL, FREQUENT FEEDINGS.
• PLACE THE CHILD ON SIDE WITH HEAD ELEVATED AFTER

30. MAINTAINING SKIN INTEGRITY
• PREVENT PRESSURE SORES (PRESSURE SORES OF THE HEAD
ARE A FREQUENT PROBLEM) BY PLACING THE CHILD ON A
SPONGE RUBBER OR LAMB'S WOOL PAD OR AN ALTERNATING-
PRESSURE OR EGG-CRATE MATTRESS TO KEEP WEIGHT EVENLY
DISTRIBUTED.
• KEEP THE SCALP CLEAN AND DRY
• PROVIDE METICULOUS SKIN CARE TO ALL PARTS OF THE BODY,
AND OBSERVE SKIN FOR THE EFFECTS OF PRESSURE.
• GIVE PASSIVE ROM EXERCISES TO THE EXTREMITIES, ESPECIALLY
THE LEGS.
• KEEP THE EYES MOISTENED WITH ARTIFICIAL TEARS IF THE CHILD