This document discusses hydrocephalus, which is an excessive accumulation of cerebrospinal fluid in the brain resulting in abnormal widening of brain spaces. It defines hydrocephalus and describes the normal circulation of cerebrospinal fluid. It identifies the different types of hydrocephalus including congenital, acquired, communicating, and non-communicating hydrocephalus. The major causes and clinical features are outlined for each type. Finally, it discusses the typical treatment which is usually a CSF shunt procedure and highlights important considerations for anesthesia when performing a ventriculoperitoneal shunt.

1. HYDROCEPHALUS
Presented by : Dr. Vishal
kr. Kandhway
1

2. Introduction
 Derived from Greek word “Hydro” meaning
“Water”, and “Cephalus”, meaning “Head”.
 Excessive accumulation of cerebrospinal
fluid (CSF) resulting in abnormal widening
of the spaces in the brain.
 The normal volume of CSF is 140 ml. CSF is
produced by the choroid plexus in the
ventricles at a rate of about 500 ml in 24 hours.
2

3. 3

4. Ventricles of The Brain
 Lateral Ventricle
 Third Ventricle
 Fourth Ventricle
4

5. Circulation of CSF
 Normally, CSF flows continually from the
interior cavities in the brain (ventricles) to
the thin subarachnoid space that
surrounds the brain and spinal cord.
5

6. 6
Circulation of CSF

7.  Normally, CSF flows through the ventricles,
exits into cisterns (closed spaces that
serve as reservoirs) at the base of the
brain, bathes the surfaces of the brain and
spinal cord, and then reabsorbs into the
bloodstream.
7
Circulation of CSF

8. The major clinical features in infants are:
 failure to thrive
 increased skull circumference
 tense anterior fontanelle
 ‘cracked pot’ sound on skull percussion
 transillumination of cranial cavity with strong light
 when severe, impaired conscious level and
vomiting
 ‘setting sun’ appearance due to lid retraction and
impaired upward gaze from 3rd ventricular
pressure on the midbrain tectum
 thin scalp with dilated veins. 8

9.  The balance between production and
absorption of CSF is critically important.
Because CSF is made continuously,
medical conditions that block its normal
flow or absorption will result in an over-
accumulation of CSF. The resulting
pressure of the fluid against brain tissue is
what causes Hydrocephalus.
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Cause of Hydrocephalus

10. Causes of Hydrocephalus
10

11. Types of Hydrocephalus
 There are several different types of
Hydrocephalus:
 Congenital hydrocephalus
 Acquired hydrocephalus
 Communicating hydrocephalus
 Non-communicating hydrocephalus
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12. Congenital Hydrocephalus
 Congenital hydrocephalus is present at
birth and may be caused by environmental
influences during fetal development or by
genetic factors.
 Causes are:
 Aqueduct Stenosis
 Colloid Cyst
12

13. Acquired Hydrocephalus
 Develops at the time of birth or at some
point afterward. This type of hydrocephalus
can affect individuals of all ages and may
be caused by injury or disease.
13

14.  Acquired Hydrocephalus is due to:
 Tumors
 Hemorrhage
 Ventriculitis
Acquired Hydrocephalus
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15. Communicating Hydrocephalus
 Communicating hydrocephalus occurs
when the flow of cerebrospinal fluid (CSF)
is blocked after it exits the ventricles. This
form is called communicating, because the
CSF can still flow between the ventricles,
which remain open.
15

16.  Causes are due to:
 Post-hemorrhage
 Bacterial Meningitis
 Malignant Meningitis
 Increased Venous Pressure
Communicating Hydrocephalus
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17. Non-Communicating Hydrocephalus
 Non-communicating hydrocephalus, also
called "obstructive" hydrocephalus, occurs
when the flow of CSF is blocked along one
or more of the narrow pathways connecting
the ventricles.
 Causes include:
 Congenital
 Acquired
17

18. Treatment
 In general, the treatment of hydrocephalus is a CSF
shunt or a 3rd ventriculostomy. If there has been
rapid neurological deterioration this will need to be
performed as an emergency.
 If the hydrocephalus is due to an obstructing tumour
that is surgically accessible, resection of the mass may
lead to resolution of the hydrocephalus and a shunt
might not be necessary.

19. CSF shunt
 The usual method of CSF diversion is a
ventriculoperitoneal shunt, in which a catheter is
placed into the lateral ventricle and is connected
to a subcutaneous unidirectional pressure-
regulated valve which is attached to a catheter
threaded subcutaneously down to the abdomen
and inserted into the peritoneal cavity.
 Modern valves can have their draining pressures
adjusted percutaneously and shunts are being
developed allowing intracranial pressure to be
monitored percutaneously.

20. Complications of ventriculoperitoneal shunt
The major possible complications are:
• infection of the shunt
• obstruction of the shunt
• intracranial haemorrhage.

21. Other CSF shunts :
 ventriculoatrial shunts
 ventriculopleural shunts
 lumboperitoneal shunts.

22. Anesthetic consideration for VP Shunt
 The child should be carefully monitored whilst awaiting
surgery for signs of neurological deterioration as this
can occur rapidly.
 If patient suffers resp. arrest or sudden deterioration in
neurological ststus due to raised ICP & tonsillar
herniation, ET intubation & hyperventilation with with
100% O2 should be carried out.
 The goal for induction is to avoid any further rise in ICP
& avoid hypotension. IV or Inhalational induction can
be used in child with normal ICP.
 IV induction allows rapid control of airway in
emergency situations(raised ICP). 22

23.  Gaseous induction is an acceptable alternative with a
non-irritant volatile anesthetic agent such as
sevoflurane or halothane especially when IV cannula is
not in place. However IV induction should be preferred
if child has signs of raised ICP, stupor or delayed
gastric emptying.
 Muscle relaxation can be achieved with the use of a
neuromuscular blocking agent.
 In case of very large head, intubation can be very
difficult. Proper positioning using pad/bolster below the
shoulder can help overcome the problem.
 Anethesia can be maintained with volatile agent & a
mixture of O2 + air.
 Core temperature should be monitored to maintain
normothermia. 23

24. THANK YOU