Hydrocephalus is a disorder where there is excessive cerebrospinal fluid in the brain ventricles causing increased pressure. It can be congenital due to neural tube defects, infections, or genetic syndromes. Symptoms include headache, vomiting, blurred vision. Diagnosis is made through neuroimaging and lumbar puncture. Treatment involves surgically placing a shunt to drain fluid from the brain to the abdomen. Complications can include infection or shunt malfunction.

1. HYDROCEPHALUS
Presaented by :
Faisal Hussain .
Majid Ahmed .

2. Lecture Objective :
 Definition
 Epidemiology.
 Anatomy and Physiology
 Classification .
 Pathogenesis .
 Etiology .
 Clinical feature .
 Diagnosis
 Management .

3. Definition and Epidemiology :
 Definition :
Hydrocephalus is a disorder in which the cerebral
ventricular system contains an excessive amount of
cerebrospinal fluid (CSF) and is dilated because of
increased pressure.
 Epidemilogy:
The prevalence of congenital and infantile hydrocephalus
has been estimated as 0.48 to 0.81 per 1000 live and
still births

4. Anatomy:

5. Physiology:
 CSF Production:
site: choroid pluxes
Amount : 20ml/h .
Rate: 0.1 to 26 ml/h . wich affected by : age and weight
Total volume : Range from 50 to 150 ml .
CSF produced by active secretion and diffusion.
 CSF Absorption :
CSF is absorbed into the systemic circulation primarily across the
arachnoid villi into the venous channels of the sagittal sinus

6. Classification :
 Non communicating (obstructive )
The obstruction occurs at the Interventricular
foramina, the aqueduct of Sylvius, or the fourth
ventricle and its outlets .
Note: The proximal area of ventricle system is
diliated .
 Communicating (non obstructive);
due to :
1- decrease absorption : inflammation of the
subarachnoid villi .
2- increased secretion .e.g choroid pluxes papilloma

7. Pathology:
 Acute obstruction :
1- causes increased pressure and rapid enlargement of the ventricular
system.
The frontal and occipital horns of the lateral ventricles enlarge first.
Symmetric dilatation of the remainder of the intracerebral CSF-containing
spaces follows.
2-Iflattening of the gyri and compression of the sulci against the cranium,
3-obliterating the subarachnoid space over the hemispheres.
4-The vascular system is compressed, and the venous pressure in the
dural sinuses increases.
5-. contributes to the development of interstitial edema of the
periventricular white matter.
6-Another compensatory mechanism that limits expansion of the
ventricular system in infants is spreading of the cranial sutures.
 chronic hydrocephalus
the force of the fluid is distributed over the greater surface area of the
enlarged ventricular system

8. Etiology :
 Congenital :
A - Neural tube defect : e.g myelomeningocele has the following
1- obstruction of fourth ventricular outflow
2- flow of CSF through the posterior fossa due to the Chiari malformation
3- aqueductal stenosis .
B- Isolated hydrocephalus :
aqueductal stenosis in wich this stenosis may due to malformation or
inflamation .
c- X-linked hydrocephalus :
aqueductal stenosis
D- CNS malformation : 1- Chiari II portions of the brainstem and cerebellum are displaced
caudally into the cervical spinal canal. This obstructs the flow of CSF in the
posterior fossa
2- Dandy Walker syndrome :atresia of the foramine of
Luschka and Magendie
3- Vein of Galen malformation : compression of the cerebral aqueduct .

9. Etiology : continued
 Congenital continued :
E- Intrauterine infection . rubella,
cytomegalovirus,
toxoplasmosis, and syphilis
F- Syndromi Hydrocephalus : 13 ,18 ,9
 Acquired :
1- Infection e.g. meningites and encephalities .
2- Tumor : especially posterior fossa
medulloblastomas,
astrocytomas, and ependymomas.
3- hemorrhage :a- subarachnoid space
b- into the ventricular system

10. Symptoms:
 Symptoms
in infants
1. Poor
feeding
2. Irritability
3. Reduced
activity
4. Vomiting
 Symptoms in children
1. Slowing of mental capacity
2. Headaches (initially in the morning) that are more significant
than in infants because of skull rigidity
3. Neck pain suggesting tonsillar herniation
4. Vomiting, more significant in the morning
5. Blurred vision: This is a consequence of papilledema and
later of optic atrophy
6. Double vision: This is related to unilateral or bilateral sixth
nerve palsy
7. Stunted growth and sexual maturation from third ventricle
dilatation: This can lead to obesity and to precocious puberty or
delayed onset of puberty.(hypothalmous)
8. Difficulty in walking secondary to spasticity: This affects
the lower limbs preferentially because the periventricular
pyramidal tract is stretched by the hydrocephalus.
9. Drowsiness

11. Signs :
 Children
1. Papilledema: if the raised ICP is not
treated, this can lead to optic atrophy
and vision loss.
2. Failure of upward gaze: This is due to
pressure on the tectal plate through the
suprapineal recess. The limitation of
upward gaze is of supranuclear origin.
When the pressure is severe, other
elements of the dorsal midbrain
syndrome (ie, Parinaud syndrome) may
be observed, such as light-near
dissociation, convergence-retraction
nystagmus, and eyelid retraction (Collier
sign).
3. Macewen sign: A "cracked pot" sound is
noted on percussion of the head.
4. Unsteady gait: This is related to
spasticity in the lower extremities.
5. Large head: Sutures are closed, but
chronic increased ICP will lead to
progressive macrocephaly.
6. Unilateral or bilateral sixth nerve palsy is
 Infants
1. Head enlargement: Head
circumference is at or above the
98th percentile for age.
2. Dysjunction of sutures: This can be
seen or palpated.
3. Dilated scalp veins: The scalp is thin
and shiny with easily visible veins.
4. Tense fontanelle: The anterior
fontanelle in infants who are held
erect and are not crying may be
excessively tense.
5. Setting-sun sign: In infants, it is
characteristic of increased
intracranial pressure (ICP). Ocular
globes are deviated downward, the
upper lids are retracted, and the
white sclerae may be visible above
the iris.
6. Increased limb tone: Spasticity
preferentially affects the lower

12. Diagnosis :
 Serial head measurement .
 The diagnosis is confirmed by neuroimaging
In a newborn, ultrasonography is the preferred
technique due to mobility and has no radition .
Infant and children CT and MRI .
 A lumbar puncture (LP) should be performed in
case of meningities or encephalities .

13. Differential Diagnosis :
 Intracranial Hemorrhage
 Intracranial Epidural Abscess
 Epidural Hematoma
 Subdural Empyema
 Subdural Hematoma
 Brainstem Gliomas
 Meningioma
 Pseudotumor Cerebri: Pediatric Perspective
 Pituitary Tumors

14. Management :
 Shunt :
RT lateral ventricle to peritoneum .
The catheter is connected to a one-way valve
system
Complication :
1-Infection: Staphylococcus epidermidis , S.
aureus, enteric bacteria, diphtheroids, and
Streptococcus species.
2- malfunction .

15. Management : continued
 Medical Management :
Diuretics .
Fibrinolytic therapy .
Serial lumbar punctures .