It's about HYDROCEPHALUS TO EXPLAIN ANATOMY OF HUMAN BRAIN TO INTRODUCE HYDROCEPHALUS TO DEFINE HYDROCEPHALUS TO EXPLAIN INCIDENCE OF HYDROCEPHALUS TO EXPLAIN ETIOLOGY OF HYDROCEPHALUS TO EXPLAIN PATHOPHYSIOLOGY OF HYDROCEPHALUS TO EXPLAIN CLINICAL MANIFESTATION OF HYDROCEPHALUS TO ENLIST DIAGNOSIS & DIAGNOSTIC EVALUATION FOR HYDROCEPHALUS TO DESCRIBE MANAGEMENT OF HYDROCEPHALUS TO EXPLAIN COMPLICATION & PROGNOSIS OF HYDROCEPHALUS

1. MISS. BHAWANA SUNIL HAJARE
BSC. NURSING 3rd YEAR
COLLEGE OF NURSING PADHAR HOSPITAL
BETUL

2. TO EXPLAIN ANATOMY OF HUMAN BRAIN
TO INTRODUCE HYDROCEPHALUS
TO DEFINE HYDROCEPHALUS
TO EXPLAIN INCIDENCE OF HYDROCEPHALUS
TO EXPLAIN ETIOLOGY OF HYDROCEPHALUS
TO EXPLAIN PATHOPHYSIOLOGY OF HYDROCEPHALUS
TO EXPLAIN CLINICAL MANIFESTATION OF HYDROCEPHALUS
TO ENLIST DIAGNOSIS & DIAGNOSTIC EVALUATION FOR HYDROCEPHALUS
TO DESCRIBE MANAGEMENT OF HYDROCEPHALUS
TO EXPLAIN COMPLICATION & PROGNOSIS OF HYDROCEPHALUS

4. The human brain-
* Bony skull forms the strongest covering & provides primary protection to brain.
* It is an expansible structure in impels and small children due to incomplete classification of skull
bones.
* Rigid in older children and adolescence.
Parts of brain-
1. The cerebrum cerebral cortex- outermost layer of brain cells.( thinking & voluntary movements).
2. The brain stem is between the spinal cord and the rest of the brain. Basic function like breathing
and sleep are controlled here.
Medulla- sensory & motor tracts, breathing & cardiovascular centers, regulate consciousness &
arousal.
Pans- sensory & motor tracts.
Midd brain- sensory & motor tracts, movements of head, eyes & trunk, response to visual stimuli.
3.The cerebellum is at the base & the back of the brain. The cerebellums' responsible for
coordination & balance.
4.Diencephalon-
Thalamus helps regulate motor function & maintenance of consciousness.
Hypothalamus releasing hormones & control of ANS.
Epithalamus Pinal gland(secrete melatonin).

6. FUNCTIONAL ORGANIZATION OF CEREBRAL
CORTEX
Fontral lobes- Fontral lobes are responsible for problem
solving and judgment and motor function.
Parietal lobes- Parietal lobes Manage sensation, hand
writing and body position.
Temporal lobes- Temporal lobes are involved with
memory and hearing.
Occipital lobes - Occipital lobes contain the brain visual
processing system.

7. BLOOD SUPPLY OF THE
BRAIN
1- INTERNAL CAROTID
ARTERY - Branches into
various brain segment.
2- VOLUME OF BLOOD TO
BRAIN CONSTITUTE 17% of
cardiac output and supplies
brain with 20% oxygen.
ebb

8. CEREBROSPINAL FLUID
• The normal amount of CSF is about 150ml.
• CSF formed by choroid plexus.
• Absorbed by arachnoids villi.
• Normally about 500ml of CSF formed everyday an
equal amount is absorbed.

11. NORMAL CSF CIRCULATION
3rd ventricle
Foramina of
monro Aqueduct
(Sylvius)
4th Ventricle
Central canal of
spinal cord
Subarachnoid
space
Reabsorbed in
venous sinuses by
arachnoids villi

12. HYDROCEPHALUS

13. INTRODUCTION
1. The term hydrocephalus is derived from the greek
word " Hydro" meaning water and cephalus
meaning head As the name implies, it is a
condition in which the primary characteristics is
excessive accumulation of fluid in the brain.
2. Hydrocephalus is the condition cause by an
imbalance in the production and absorption of
CSF in the ventricular system. When production is
grater then absorption, CSF accumulate within the
ventricular system ,usually under increase pressure
,producing passive dilation of the Ventricles

14. 3. The CSF is secreted by the choroid clexus within
the ventricul by ultra filtration and active recretion it
passes from the lateral ventricul to the 3rd & 4th
ventricul and exite from foramen of luschka and
maggendie into the Basal cisterns and then the
cerebral and spinal subarachnoid spaces where it is
absorb via the arachnoid space where it is absorb via
the arachnoid villi(Granelation) into the venous
channels and sinuses. About 20ml of CSF is secreted
in an hour and it's turnover is 3 or 4 time's in a day.

16. DEFINITION
• According to Marlin, " A condition in which
fluid accumulate in the brain, typically in young
children, enlarging the head and sometimes
causing brain damage ".
• According to Parul dutta, " A condition
resulting from imbalance in CSF production and
absorption ".
• According to Ghai, " Hydrocephalus is the
abnormal accumulation of cerebrospinal fluid in
the intracranical spaces ".

17. INCIDENCE
It is found in 1-3 of every 1000 born children in world wide.
Occurs in 80-85% children born with meningomyelocele.
Incidence is equal in males & females.

18. ETIOLOGY
Hydrocephalus results from an imbalance between
production and absorption of cerebrospinal fluid.
There are 2 types:-
1. Communicating Hydrocephalus.
2. Noncommunicating hydrocephalus.

19. 1. Communicating Hydrocephalus
There is no blockage in the CSF pathway but reabsorption may be
affected. Excess CSF may be produced in papiloma of choroid
plexus.
2. Obstruction or noncomminicating Hydrocephalus:-
The block is at any level the ventricular system commonly at the
level of aqueduct or foramina of luschka & magendle.
In obstructive Hydrocephalus, the ventricles are dilated above the
block in cerebral atrophy, Ventricles are dilated but prcssux is not
raised(Hydrocephalus ex vacuo).
o Bleeding inside the brain for eg. If blood leaks over the surface of
the brain ( subarachnoid hemorrhage).
o Blood clots in the brain ( venous thrombosis).
o Meningitis – an infection of the membranes surrounding the brain
& spinal cord.
o Brain tumors.
o Head injury.
o Stroke.

20. Hydrocephalus may occur due to congenital or acquired causes/ etiology-
1.Congenital Hydrocephalus- It occur due to the following
•Intrauterine infections- mainly in rubella , toxoplasmosis cytomegalovirus
•Congenital brain tumor obstructing the CSF flow.
•Intracranial hemorrhage .
•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 villi.
2.Acquired Hydrocephalus- It occurs usually following the conditions.
•Inflammation- Meningitis, encephalitis.
•Trauma- Brain injury, head injury, intracranial hemorrhage.
•Neoplasm- Space occupying lesions like tuberculoma, subdural hematoma
or absorbs, gliomas, ependymoma, astrocutoma, choroid plexus papiloma
pseudo tumor cerrbri.
•Chemical – hypervitaminsis A.
•Connective tissue disorder –hurler syndrome, achondroplasia.
•Degenerative abophy of brain- hydrocephalus ex vaccuo.
•Anterior venous malformation & rapture aneurism, cavernous sinus
thrombosis.

21. PATHOPHYSIOLOGY OF CSF FLUID
1. Impaired absorption.
2. Obstruction of flow through ventricular system.
3. Increased accumulation of CSF .
4. Dilatation of ventricles & cortex can atrophy.
5. Increased CSF in ventricular system.
6. Compress brain against cranium.
7. If this occur before fusion of cranial sutures these can be:
8. Enlargement of skull
9. Dilation of ventricles.
If sutures are previously closed
Sagital suture may become opened.

22. CLINICAL MANIFESTATIONS
Infants- Early
•Abnormally rapid head growth.
•Bulging fontanels (tense. Non pulsatile)
•Dilated scalp veins.
•Separated sutures.
•McEwen sign ( cracked pot sound on percussion of skull near the junction of the fontal,
temporal & parietal bones).
•Thinning of skull bones.
•Poor head control.
Later in infancy
•Fontal enlargement
•Depressed eyes
•When the third ventricle dilates, the child can present with paranoid syndrome (up gaze
palsy with a normal ventricle doll response).
•The sitting sun sign ( paranoid syndrome with lid retraction & increased tonic down
gaze).
•Pupils sluggish.
•Unequal papillary response to light.
Older children
•Headache on awakening
•Nausea & vomiting
•Lethargy
•Apathy.

23. DIAGNOSIS
History collection
Physical finding in infants include the following.
Vital sign-
Bradycordia due to pressure on brain stem.
Systemic hypertension.
Altered respiration & sometimes apnea.
Head
Head enlargement ( HC>2 cm per month in months).
Disjunction of sutures.
Dilated scalp veins.
Tense fontanelle, anterior fontanelle bulging.
In older children
1. Large head- sutures are closed , but chronic increased ICP will lead
to progressive macro cephaty.
2. McEwen sign- A “ cracked pot” sound noted on percussion of the
head( open fontanels).
As long as the anterior fontanel is open i.e. up to 18 months, the test
will be positive.

24. 3. Trans illumination- translucency extending beyond 2.5cm in fontal area or
over 2cm in occipilul are is abnormal.
Eyes
1. Setting-sun sign- in infonts, it is characteristic of increased intracranial
pressure(ICP), Ocular globes are deviated downward, the upper lids are
retracted, and the white sclera may be visible above the iris.
2. Papilledema- If the raised ICP is not treated, this can lead to optic atrophy
& vision loss.
3. Failure of upward gaze.
4. Unilateral or bilateral sixth nerve palsy (abducens) is secondary to
increased ICP.(convergent drabismus).
Upper and lower limbs
 Increased limbs tone –Spasticity preferentially affects the lower limbs.
The cause is stretching of the per ventricular pyramidal tract fibers by
hydrocephalus.
In children
• Unsteady gait – this is related to spasticity in the lower extremities.
• Pyramidal signs in lower limbs due to stretching of pyramidal tract fibers.
• Exaggerated plantar reflex & deep tendon reflexes of lower limbs along
with increased tone of lower limbs.

25. DIGNOSTIC EVALUATION
Lab test
1. Ultrasound
2. Magnetic resonance imaging (MRI)
3. Computerized tomography (CT) scan.
4. X-RAY of skull.
5. Physical examination.
6. Opthalmoscopy.
Lumbar puncture- Insertion of spinal needle into subarachnoid space between the lower lumber vertebrae.
CEREBRAL SPINAL FLUID
Normal CSF
 Clear odorless
 WBC’s 0-5
 Protein 15 to 45
 Glucose 50-80
 Pressure 50 to 180.
Abnormal CSF
 Turbid cloudy
 WBC’S 1000-2000
 Protein 100-500
 Glucose lower than blood sugar.
 Pressure 180 or greater.

31. MANAGEMENT
Management of HYDROCEPHALUS is directed towards.
A. Reducing intracranial pressure.
B. prevention & management of complication.
C. Managing problems caused by the problem.
Medical Management-
Medical management include use of diuretic ( Acetazolamide & furosemide ) this medicine
provide temporary relief.
Surgical management-
A shunt is made up of radio plastic and has ventricular catheter, pressure value, pumping
chamber and distal catheter that directs the flow of CSF from the ventricles to other
areas of body from where it is absorbed.
 Endoscopic third ventriculostomy.
 Choroid plexectomy.
 Ventriculo-peritoneal shunt. ( vp shunt )
 Ventriculatrial shunt.
 Ventriculopleural shunt.
 Ventriculo gall bladder shunt.
 Ventriculostomy & choroid plexectomy have been performed with variable results.
 Surgical shunts are the treatment of choroid at the present time.
 Intracranial or extracranial shunt is done to bypass the obstruction and to divert the CSF
from the ventricular system to other compartment.
 The most commonly performed extracranial shunt is ventriculoperitoneal shunt. (VP
shunt)
 Intrauterine surgical intervention in fetal hydrocephalus has not yet given good results.

33. Nursing management-
1. Explain the family about the management required for the disorder.
2. Pre operative care
 Measure the head circumference daily.
 Palpate the fontanele for evidence of increased intracranial pressure.
 Assess the pupilary response level of consciousness.
 Monitor vital signs regularly.
 Provide calm & quit environment.
 Present the child from nosocomial infection.
 Change the infant position frequently.
3.Post operative care-
 Place the infant in flat position to prevent rapid CSF damage.
 Check vital signs every 15-30 minutes in immediate post- operative period.
 Assess the neurological status.
 Assess the head circumference regularly.
 Oral rehydration must be started after the bowel sound response.
 Check dressing for any drainage.
 Teach parents about care of the child at home .

34. Nursing Diagnosis
Risk for injury related to increased ICP.
Risk for impaired skin integrity related to pressure from physical immobility.
Altered nutrition less than body requirement related to reduce oral intake &
vomiting.
Anxiety related to the abnormal condition & surgical interventions.
Risk for fluid volume deficit related to CSF drainage.
Ineffective family coping related to life- retaining problem of infant.
Complication
1. Seizures
2. Herniation of brain.
3. Persistent increased ICP.
4. Developmental delay.
5. Neurological deficits.
6. Motor & intellectual handicaps.
7. Visual problems ( squint, optic atrophy , field defect ).
8. Aggressive.
9. Delinquent behavior.
10. Depression.

35. Prognosis
1. Prognosis of the children with hydrocephalus depends upon initiation of
management and associated problem.
2. Appropriate medical 7 neurosurgical treatment about 70% of these
patient with infantile hydrocephalus. Live beyond first year of life.
3. Without treatment mortality is as high as 50 to 60 %.
4. Two thirds of the survived children has motor and intellectual
handicapped condition.
5. The long term follow up in a specialized setting may improve the
prognosis.

36. SUMMARY
1. A condition in which fluid accumulates in the brain, typically in
young children renlarging the head & sometimes causing brain
damage.
2. Definition of hydrocephalus, CSF, circulation, type , etiology,
incidence , clinical features, diagnostic evaluation, management,
complication, prognosis of hydrocephalus.

37. BIBLIOGRAPHY