Hydrocephalus is a condition characterized by the excessive accumulation of cerebral spinal fluid in the ventricles of the brain, causing their enlargement. It occurs due to an imbalance between CSF production and absorption. CSF is produced by the choroid plexus within the ventricles and circulates through the ventricular system before being absorbed into the venous system. Hydrocephalus can be obstructive, caused by a blockage in CSF flow within the ventricles, or communicating, caused by impaired absorption of CSF out of the ventricles. It is diagnosed through imaging like CT scans and MRIs showing ventricle dilation and treated through surgical implantation of shunts to drain CSF or endoscopic procedures to open blockages.

1. Hydrocephalus
Dr. Akshita (PT)
M.P.T (Cardiopulmonary)
D.C.P.T
Certified BLS & ACLS, AHA

2. Definition
Hydrocephalus is excessive accumulation of cerebral spinal fluid (CSF)
within the cranial cavity which results in ventricular enlargement due
to disturbance of production, flow or reabsorption of CSF.
It results due to imbalance of production and absorption of CSF.

3. CSF- Cerebral Spinal Fluid
CSF is secreted by the choroid plexus within the
ventricles.
CSF fills the subarachnoid spaces, protecting and
cushioning the brain.
CSF volumes – forms at a rate of 500 ml/day.

4. CSF in ventricles

5. Course of CSF
CSF
Secreted from lateral ventricles, third and fourth ventricles.
Flows in cadual direction through ventricular system.
Exists from foramen of Lushka and Magendie.
Reaches to cerebral and spinal subarachnoid space.
There gets absorbed via arachnoid villi into venous system.

7. Classification
1. Obstructive Hydrocephalus: Obstruction of CSF flow within the
ventricular system.
2. Communicating Hydrocephalus: Obstruction of CSF flow out with
the ventricular system, i.e. ventricular CSF communicates with the
subarachnoid space

8. Causes
Obstructive Communicating
Congenital Acquired

9. Causes
Congenital
Intracranial bleeds
Intraventricular hemorrhage
Intrauterine infections- Rubella, Cytomegalovirus
Midline tumors obstructing CSF flow
Congenital malformation:
• Aqueduct stenosis or forking (Aqueduct stenosis is a narrowing of the aqueduct of Sylvius which
blocks the flow of cerebrospinal fluid (CSF) in the ventricular system).
• Dandy walker syndrome: Atresia (closed/absent) of foramina of Magendie and Lushka.
• Arnold-Chiari syndrome (malformation of medulary spinal junction).

10. Acquired hydrocephalus
Acquired aqueduct stenosis: Adhesions following infection or hemorrhage.
Supratentorial masses causing tentorial herniation.
Chronic and pyogenic meningitis.
Abscesses/ granuloma.
Post intraventricular hemorrhage- haematoma.
Tumors – Ventricular (colloid cyst), tumors of pineal region, posterior fossa.
Arachnoid cysts
Causes

11. Communicating
Thickening of leptomeninges or involvement of arachnoid granulation.
Infections- Pyogenic, TB, Fungal.
Subarachnoid hemorrhage- traumatic or post operative.
Carcinomatous meningitis.
Increased CSF viscosity- due to high protein content.
Excessive CSF production- choroid plexus papilloma
Causes

12. Etiology
1. Excessive CSF production (rare)
Choroid plexus papilloma/carcinoma
2. Obstructive hydrocephalus
Hydrocephalus—when there is an obstruction to the flow of CSF through the
ventricular system
 Lesions within the ventricle.
 Lesions in the ventricular wall.
 Lesions distant from the ventricle but with a mass effect.

13. 3. Communicating hydrocephalus (impaired absorption)
 Post- haemorrhagic
 CSF infection (especially bacterial and tuberculous)
 Raised CSF protein
Etiology

14. Pathophysiology

15. Results in :
1) Raised ICP
2) White matter damage
3) Gliotic scarring
4) Some CSF absorption occurs from periventricular region
Pathophysiology
CSF flow obstruction/ CSF impaired absorption
Ventricular dilation
CSF permeates through the ependymal lining into periventricular white matter.

16. Clinical features

17. Infants & young children
Acute onset: irritability, impaired conscious levels, vomiting.
Gradual onset: Mental retardation, failure to thrive (undergrowth or inability to growth)
Enlargement of Head (Ventricular dilation)
Increased ICP (Intra cranial pressure)
Tense anterior fontanel, delayed closure.
Headache, nausea, fever.
Seizures.
Sunset sign.
Papilloedema.
Clinical features

18. On observation and examination
Cracked pot sound on skull percussion.
Increased head circumference.
Thin scalp with dilated veins.
Lid retraction
Impaired upwards gaze
Clinical features
Sunset Sign

19. Sunset sign
Seen in up to 40% of children with obstructive hydrocephalus and 13% of children with shunt
dysfunction

20. Juvenile & Adults
Acute sign:
• Impaired upwards gaze
• Increased ICP (Intra cranial pressure)
Signs of increased ICP-
1) Headache
2) Vomiting
3) Papilloedema
4) Deterioration of conscious level
5) Irritability
6) Swelling
7) Fever
Clinical features

21. Gradual sign: Dementia, gait ataxia, incontinence.
Ventricular dilation
Personality and behavioral changes
Visual disturbances
Confusion
Sleepiness
Clinical features

22. Ventricle Dilation

23. Hydrocephalus ex vacuo
Hydrocephalus ex vacuo, also known as compensatory enlargement of the CSF
spaces, is a term used to describe the increase in the volume of CSF,
characterized on images as an enlargement of cerebral ventricles and
subarachnoid spaces, caused by encephalic volume loss.
It occurs when there is damage to the brain caused by stroke or injury, and there
may be an actual shrinkage of brain substance. Although there is more CSF than
usual, the CSF pressure itself is normal in hydrocephalus ex vacuo.

24. Normal Pressure Hydrocephalus
Normal pressure hydrocephalus (NPH) is a condition that is caused by an
abnormal build up of cerebrospinal fluid (CSF) in the ventricles (cavities or
spaces) of the brain. Cerebrospinal fluid is a clear liquid that circulates around
the brain and spinal cord, cushioning and protecting them from damage.
The differences between NPH and other forms of hydrocephalus is that even
though there is a larger than normal amount of CSF, the pressure inside the
ventricles remains the same.

25. Diagnosis
Diagnosis/Investigation
X-RAY
CT-SCAN
Ultra
Sonography
MRI
ICP
Monitoring
Development
and
Psychometric
Analysis

26. X-ray shows
Enlarged size of head
Suture width
Copper beating (evidence of chronic
raised pressure)
Diagnosis

27. CT Scan shows
Ventricular enlargement
Lateral and 3rd ventricular
dilation suggests aqueduct
stenosis or posterior fossa
mass.
Generalized dilation
suggests a communicating
hydrocephalus or 4th ventricle
obstruction.
Dilated ventricles.
Diagnosis

28. Ultrasonography
Through anterior fontenalle shows ventricular enlargements in infants.
MRI
ICP Monitoring
Developmental assessment and psychometric analysis
Detects impaired cerebral function and provides base line for future comparison
Diagnosis

29. Management
Medical Management
Surgical Management
Physiotherapy Management

30. Management
Medical Management
Acetazolamide: decrease CSF production.
Isossorbide: increases CSF absorption.
Surgical Management
If there is obstructive or non-communicating hydrocephalus removal the obstruction is
preferred.

31. Surgical Management
Ventriculoperitoneal shunting-
Shunts cause cerebrospinal fluid to flow
unidirectional under a valve system to
peritoneal cavity in abdomen.
Common causes for failure are infection,
obstruction, over-drainage, disconnection
and loculated cerebrospinal fluid collection.

32. Ventriculoatrial shunting-
First choice for those who are unable to have
abdominal distal catheters.
It runs from ventricles via jugular vein into
the right atrium of the heart.
High risk procedure.
Complications such as renal failure or
thrombosis of great vein.
Surgical Management

34. Endoscopic Third Ventriculostomy (ETV)
An alternative therapy to cerebrospinal fluid shunting.
Minimally invasive procedure.
Ventriculostomy is to create an opening in the floor of the third ventricle to subarachnoid
space, usually the trapped fluid begin to absorb right after the opening.
Surgical Management

35. Physiotherapy management
Regardless of medical & surgical management, children with hydrocephalus still have some
disabilities. Therefore, early intervention and rehabilitation is essential.
Goals
Improve functional skills
Improve developmental skills
Reducing secondary impairment
Maximize independency
Perform activities of daily living
Improve mobility

36. Gait training
Muscle Tone management
Strength and endurance training
Bowel and bladder training
Postural training
Balance and coordination training
bed mobility and transfer training such as sitting to standing
Functional mobility training
Use of assistive devices and mobility equipment if necessary
Physiotherapy Intervention

37. Motor control
Achieving delayed developmental milestone
Behavioral training
Physiotherapy Intervention

38. Thank You