The document discusses hydrocephalus, including its definition, anatomy, types, causes, signs and symptoms, diagnosis, and management. Hydrocephalus is a condition caused by an imbalance in CSF production and absorption, leading to ventricular enlargement. It can be congenital or acquired. Types include communicating, non-communicating, and normal pressure hydrocephalus. Management involves medical treatment or surgical options like shunting procedures or endoscopic third ventriculostomy. An external ventricular drain (EVD) may be used to temporarily treat hydrocephalus by draining excess CSF.

1. HYDROCEPHALUS
Evaluator: Mr L Anand Presenter: Shruti Shirke
[Asso professor, CON AIIMS BBSR] M.Sc Neuroscience Nursing
06-08-2021
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2. Introduction
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Anatomy of brain

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Anatomy of ventricles

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12. About choroid plexus
◦Choroid plexus is present in each ventricles
◦In the lateral ventricles it is only present in the inferior horn
◦Choroid plexus is also located in the interventricular foramina,
the channels between the lateral and the third ventricles. The
choroid plexus in the fourth ventricle is beneath the
cerebellum.
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15. Functions of choroid plexus
Production of CSF as plasma is filtered
from the blood through the epithelial cells.
Choroid plexus is also a major source of
transferrin secretion that plays a part in iron
homeostasis in the brain.
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16. Production of CSF
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17. About Cerebrospinal fluid
◦Production: Choroid plexus
◦Absorption: Arachnoid villi
◦Rate of production: Approximate 0.3-0.5ml/min or
20ml/hr and 450ml/day
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18. About CSF Cont..
◦Turn over: 3 times a day
◦CSF volume: 125-150 ml
◦ICP (adult): 2-8mmhg up to 16mmhg (70-
180mmH2O) is considered normal.
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20. ⱺThe CSF volume and pressure are
maintained every minute by the
systemic circulation.
ⱺICP higher than 40mmhg or lower
bp may combine to cause ischemic
damage to the brain.
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21. Function of CSF
To keep the
brain tissue
buoyant
Vehicle for
delivering
nutrients to
brain
Removal of
waste
Compensate
for changes
intracranial
blood volume
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CSF
Circulation

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26. Definition:
◦“Hydrocephalus is a condition caused by an
imbalance in the production and absorption of
CSF in the ventricular system”.
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27. Incidence:
◦1-2 of every 1000 babies are born with hydrocephalus.
◦Approximately 200,000 cases each year all over world and
12,000 cases of congenital hydrocephalus in India every
year.
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28. Incidence: cont..
◦According to hydrocephalus association
◦It is estimated that up to 5% of all cases of Alzheimer’s,
Parkinson’s, and dementia are actually undiagnosed cases of
NPH.
◦In US currently over 1million individuals are living with
hydrocephalus.
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29. Incidence: cont..
◦Prevalence – over 55 years old 5.5 patient per 100000 of
people, At any age, both man and women, more often in
elderly population between 60-70 (NPH)
◦Congenital hydrocephalus 0.2-0.5/1000 live birth, A higher
incidence is reported in elderly primiparous mother.
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32. Types of hydrocephalus
Communicating
• Congenital and acquired
Non-communicating
• Congenital and acquired
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35. Congenital
hydrocephalus
Acquired
hydrocephalus
Normal pressure
hydrocephalus
Pseudotumor
cerebri
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37. Types of NPH
Idiopathic/
Primary
Secondary/
Hydrocephalus
ex-vacuo
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Hydrocephalus ex-vacuo - Subarachnoid
haemorrhage, head trauma, tumours, infections
in CNS, complication if cranial surgery.

38. Normal pressure hydrocephalus
◦It describes a condition that rarely occurs in patients younger
than 60 years.
◦Enlarged ventricles and normal pressure at lumbar
puncture(LP).
◦It is a type of communicating hydrocephalus.
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39. Normal pressure hydrocephalus
◦Intermittent intracranial
hypertension has been noted during
monitoring of patients in whom
NPH is suspected, usually at night.
◦Headache is NOT a typical
symptom in NPH.
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40. Sign and symptoms of NPH
Gait apraxia
Incontinence
Dementia
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The classic hakim’
triad

41. Gait disturbance – same as Parkinson’s
disease.
Dementia – apathy, forgetfulness, inertia, inattention,
disturbed manipulation of acquired knowledge. (same
as Alzheimer’s )
Incontinence – frontal lobe compression.
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42. Pseudotumor cerebri
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Mostly seen in women (obese, childbearing)
It is also known as idiopathic
intracranial hypertension.
pseudotumor cerebri is a
condition in which the
pressure around brain
increases, causing headache
and vision loss

43. Pseudotumor cerebri
Increased intracranial pressure / intracranial
hypertension
No mass / tumor
#Obstruction of venous drainage & impaired
reabsorption of CSF
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45. Pseudotumor cerebri (sign and symptoms)
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Headache
Nausea
and
vomiting
Vision
problems
Papilledema
Diagnosis
MRI: Normal
MRV: (Magnetic resonance
venography) Stenosis of
transverse sinuses

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47. Etiology:
Congenital Acquired
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48. Congenital causes
◦Intrauterine infections
◦Trauma
◦Congenital malformations: Aqueduct stenosis (30%),
Dandy walker syndrome, Neural tube defect, Congenital
Arachnoid cyst, Arnold Chiari malformations
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49. Aqueduct stenosis
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50. Arachnoid cyst
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52. Dandy walker syndrome
◦Atresia of foramina of magendie, and Luschka.
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53. Arnold-Chiari malformations
◦Portion of cerebellum and brainstem herniating into cervical spinal
canal, blocking the flow of CSF into the posterior fossa.
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58. Atresia of foramen of monro
Myelodysplasia (MDS)
Craniosynostosis
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59. Acquired causes
Tumours
Meningitis or other infection
Haemorrhage
Acquired arachnoid cyst
Traumatic brain injury
Idiopathic
Posterior fossa cyst
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60. Non communicating
◦Aqueduct stenosis
◦Atresia of foramen of
monroe
◦Skull base anomalies
◦Inflammatory ventriculitis
◦Haemorrhage
◦Ruptured arachnoid cyst
◦infection
Communicating
◦Encephalocele
◦Benign cysts
◦Viral infections
◦Craniosynostosis
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61. Pathophysiology
Following subarachnoid hemorrhage, blood in
the subarachnoid space makes it harder for the
CSF to reach the arachnoid villi and slows
down or prevents its absorption.
Following intraventricular hemorrhage, blood
in the ventricles can enter the subarachnoid
space and impair CSF absorption.
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62. Pathophysiology cont..
Exudate from infection (such as meningitis or
encephalitis) can block the cerebral aqueduct and
therefore obstruct CSF flow.
Genetic disorders, such as: aqueduct stenosis
(abnormally narrow cerebral aqueduct); Dandy-Walker
malformation (several abnormal brain structures
including a dilated.
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63. Pathophysiology cont..
Tumors of the choroid plexus, which are
rare, can cause overproduction of CSF.
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Tumors near the third and fourth ventricles
can obstruct CSF flow.

64. Sign and symptoms
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• Head grows to abnormal rate.
• Anterior fontanel is tense, often
bulging, non pulsatile.
• Scalp veins are dilated.
• Macewen’s sign- cracked pot
sound on the percussion of the
skull.
• Frontal bossing with depressed
eyes

65. Sign and symptoms cont..
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Young children:
Acute onset:
• Irritability
• Impaired conscious level
• Vomiting
Gradual onset:
• Mental retardation
• Failure to thrive
Adults:
Acute onset
• Headache
• Vomiting
• Deterioration of conscious level
• Impaired upward gaze (perinaud’s
phenomenon)
Gradual onset
• Dementia
• Gait ataxia
• Incontinence

66. Diagnosis:
Medical history collection
Neurological examination
CT Scan (VH OR VS ratio: less than 0.5 is considered normal)
MRI
MRV
LP
MILLER FISHER TEST
LUMBAR INFUSION TEST
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67. Management of hydrocephalus:
◦Medical management
◦Acetazolamide 25mg/kg/day diminishes CSF production.
◦Oral glycerol
◦Furosemide
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68. Surgical Management
◦The removal of the obstruction (tumour, haemorrhage or cyst) to
the flow of CSF
◦Shunting
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Ventriculoperitoneal shunt.
Ventriculoarterial shunt.
Ventriculopleural shunt.
Lumboperitoneal shunt.
EVD

69. Shunting
◦High pressure: 8-10 cm h2o
◦Medium pressure: 4-7 cm h2o
◦Low pressure: 2-4 cm h2o
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70. MPVP Shunt
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71. Lumboperotoneal shunt
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72. Endoscopic third ventricle
◦Puncture third ventricles to cistern
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73. EVD/ Ventriculostomy
◦Hydrocephalus is temporarily treated by insertion of an EVD.
Also known as an external ventriculostomy, the EVD is a small
soft catheter inserted directly into one of the lateral ventricles
usually of the right hemisphere, to drain excess CSF. The right
hemisphere is the non-dominant hemisphere for language, so
insertion into the right lateral ventricle reduces the risk of
language dysfunction.
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74. Clinical indications for EVD insertion
Monitoring intracranial pressure
Correcting intracranial hypertension.
Administering medication for intraventricular haemorrhage or
ventriculitis, Diverting infected or bloodstained cerebrospinal fluid,
preventing its absorption by the arachnoid villi
Treating hydrocephalus secondary to aneurysmal subarachnoid
hemorrhage or a tumour
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75. Care of the patient with EVD
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◦ Set at zero level - zero corresponds to the pressure where the catheter enters the ventricle, and should always be
horizontally level with the tragus of the patient’s ear.
◦ When the patient is lying on one side, this anatomical reference point becomes the bridge of the nose.
◦ It is a key nursing responsibility to ensure that zero on the pressure scale is level with the patient’s tragus at all times.
◦ The prescribed pressure level must be documented.
◦ The collection chamber must be checked frequently to ensure it is neither too high nor too low.
◦ Touching EVD components, such as the stopcock or drainage bag, must be an aseptic procedure and handling must be
kept to a minimum.
◦ Dressing should only be changed if it becomes soiled or loose.
◦ The drainage bag should be changed when it is three-quarters full, as too much weight could disrupt drainage,
◦ The integrity of the entire EVD system must be checked at a minimum of every four hours, and damage or
disconnection of any of the components reported as an emergency.

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◦ Patients must also be checked every four hours for early signs of infection such as an increase in temperature, pulse
and status of their neurological and vital observations.
◦ Drainage should be turned off while suctioning, walking, physiotherapy and repositioning in bed.

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78. ◦ Humphrey E (2018) Caring for neurosurgical patients with external ventricular drains. Nursing Times
[online]; 114: 4, 52-56.
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Hydrocephalus is temporarily treated by insertion of
an EVD. Also known as an external ventriculostomy
(Hammer et al, 2016), the EVD is a small soft
catheter
inserted directly into one of the lateral ventricles
(Hickey, 2009), usually of the right hemisphere, to
drain excess CSF (Fig 2). The right hemisphere is
the
non-dominant hemisphere for language (Grandhi et
al, 2015), so insertion into the right lateral ventricle
reduces the risk of language dysfunction. Box 1 lists
the clinical indications for EVD insertion