Hydrocephalous- Its presentation, Diagnostic Imaging and Management

2. INTRODUCTION

3. A syndrome, or sign, resulting from disturbances in
the dynamics of cerebrospinal fluid (CSF), which may
be caused by several diseases.

4. Occurs in 3-4 of every 1000 births.
Cause may be congenital or acquired.
Congenital- may be due to maldevelopment or
intrauterine infection
Acquired- may be due to infection, neoplasm or
hemorrhage.

5. The CSF volume of an
average adult ranges
from 80 to 160 ml
The ventricular system
holds approximately 20
to 50 ml of CSF
CSF is produced in the
choroid plexuses at a
daily rate of 14-36 ml/hr

6. The choroid plexuses are
the source of
approximately 80% of
the CSF
The blood vessels in the
subependymal regions,
and pia also contribute
to the formation of CSF

7. The majority of CSF is produced from within the
two lateral ventricles. From here, the CSF passes
through the interventricular foramina of monro to
the third ventricle, then the cerebral aqueduct (of
Sylvius) to the fourth ventricle. The fourth ventricle
is an outpouching on the posterior part of
the brainstem. From the fourth ventricle, the fluid
passes through three foramen to enter
the subarachnoid space. It passes through
the Foramen of Magendie on the midline, and
twoForamen of Luschka laterally. The subarachnoid
space covers the brain and spinal cord.

9. Imbalance of csf formation and absorption
resulting in excess of CSF with subsequent increase
in intracranial pressure

10. Hydrocephalus results from:
1. Impaired absorption of CSF within the subarachnoid
space (communicating hydrocephalus), or
2. Obstruction to the flow of CSF through the
ventricular system (non-communicating
hydrocephalus)

11. CLASSIFICATION

12.  CONGENITAL
 ACQUIRED
- COMMUNICATING
- NON- COMMUNICATING

13. Most common category in children
Usually present in infancy
-Hydrocephalus presenting after age of 6
months is less likely to be congenital and neoplasms
must be excluded

14. Aqueduct stenosis
-due
to arnold chiari 1 and 2 malformation
-post infectious
(toxoplasmosis, cytomegalic inclusion disease
rubella, syphilis)
. Obstruction of foreman of Luschka and Magendie
-dandy walker malformation
 Myelomeningocele

15. Noncommunicating hydrocephalus :
 Intra venticular obstruction
Tumor
(posterior fossa tumor ,brain stem glioma ,
tumor of pinael body,choroid plexus)
papilloma,ependymoma,colloid cyst
infection
(cerebral abcess , ventriculitis )
Hemorrhage

16. Communicating hydrocephalus
extra-ventricular obstruction by
- infection (T.b)
-Subarachnoid hemorrhage
- head injury

17. It is characterized by
dilatation of ventricular
system by intermittent rise in
csf pressure
It is most commonly seen in
older adults and is
accompanied by following
symptom
gait disturbance
dementia
urinary incontinence

18. CLINICAL FEATURES

19. Clinical features of hydrocephalus are
influenced by the patient's age, the
cause of the hydrocephalus, the
location of the obstruction, its duration,
and its rapidity of onset.
Symptoms in infants include poor
feeding, irritability, reduced activity, and
vomiting.

20. Symptoms in children and adults include the
following:
•Slowing of mental capacity, cognitive deterioration
•Headaches (initially in the morning)
•Neck pain
•Vomiting, more significant in the morning
•Blurred vision: A consequence of papilledema and,
later, of optic atrophy
•Double vision: Related to unilateral or bilateral sixth
nerve palsy
•Difficulty in walking
•Drowsiness

21. Examination in infants may reveal the following findings:
Head enlargement
Dysjunction of sutures
Dilated scalp veins
Tense fontanelle
Setting-sun sign: Characteristic of increased intracranial
pressure (ICP); downward deviation of ocular globes,
retracted upper lids, visible white sclera above iris
Increased limb tone (spasticity preferentially affects the
lower limbs)

23.  Children and adults may demonstrate the following findings on
physical examination:
 Papilledema
 Failure of upward gaze
 Unsteady gait
 Large head
 Unilateral or bilateral sixth nerve palsy (secondary to increased ICP)
 Children may also exhibit the Macewen sign, in which a "cracked pot"
sound is noted on percussion of the head.

24. NVESTIGATIONS

25.  Ultrasound scan
 Plain skull X-Ray
 CT scan
 MRI

26. IS USUALLY DONE TO DIAGNOSE CONGENITAL
HYDROCEPHALUS.

29. SEPARATION OF SUTURES
EROSION OF SUTURES
INCREASED CONVOLUTIONAL MARKINGS
(SILVER BEATEN APPERANCE)

30. WHAT IS IT?
THESE ARE ROUNDED ZONES OF BONY
ATTENTUATION OF THE CRANIAL BONES
CAUSED BY PRESSURE FROM THE CEREBRAL
CORTICAL GYRI, RESULTING FROM PREMATURE
CLOSURE OF CRANIAL SUTURES IN INFANTS AND
BY EXTENSION, INCREASED INTRACRANIAL
PRESSURE.

33. BOTH TEMPORAL
HORNS ARE
>2MM.
CT SCAN
FINDINGS

39. COMPLICATIONS

40. The severity of hydrocephalus depends on the time of onset
and whether the disease is progressive. If the condition is well
advanced at birth, major brain damage and physical
disabilities are likely. In less severe cases, with proper
treatment, it's possible to have a nearly normal life span and
intelligence.
Other complications of hydrocephalus include:
Intellectual impairment
Neurological damage, such as decreased function, movement
or sensation

41. MANAGEMENT

42. Hydrocephalus (fluid on the brain) is treated with
surgery.
 Babies born with hydrocephalus (congenital) and adults or
children who develop hydrocephalus (acquired) usually
need prompt treatment to reduce the pressure on their
brain. If hydrocephalus isn't treated, the increase in
pressure will cause brain damage.
Both congenital and acquired hydrocephalus will be
treated with either shunt surgery or neuroendoscopy

43. • Shunt surgery
• Shunt surgery involves implanting a thin tube,
called a shunt, in the brain. The excess
cerebrospinal fluid (CSF) in the brain runs
through the shunt to another part of the body,
usually the abdomen. From here, the fluid is
absorbed into your blood stream. The shunt has a
valve inside to control the flow of CSF and ensure
it doesn't drain too quickly. You can feel the valve
as a lump under the skin of your scalp.

44. • A ventriculoperitoneal (VP) shunt is used most commonly. The lateral
ventricle is the usual proximal location. The advantage of this shunt is
that the need to lengthen the catheter with growth may be obviated by
using a long peritoneal catheter.
• A ventriculoatrial (VA) shunt also is called a "vascular shunt." It shunts
the cerebral ventricles through the jugular vein and superior vena cava
into the right cardiac atrium. It is used when the patient has abdominal
abnormalities (eg, peritonitis, morbid obesity, or after extensive
abdominal surgery). This shunt requires repeated lengthening in a
growing child.
• A lumboperitoneal shunt is used only for communicating
hydrocephalus, CSF fistula, or pseudotumor cerebri.
• A Torkildsen shunt is used rarely. It shunts the ventricle to cisternal
space and is effective only in acquired obstructive hydrocephalus.
• A ventriculopleural shunt is considered second line. It is used if other
shunt types are contraindicated.

45. Normal pressure hydrocephalus
Normal pressure hydrocephalus (NPH) can sometimes be treated
with a shunt, although experience has shown that not everyone with the
condition will benefit from shunt surgery.
Due to the risk of complications, you'll need tests to assess whether the
potential benefits of surgery outweigh the risks. A lumbar drainage or
lumbar infusion test, or both, can be used to determine whether shunt
surgery will benefit you.

46. Shunt infection is most serious complication!
Period of greatest risk is 1 to 2 months following
placement.
Staph and strep most common organisms

47. Mechanical difficulties
kinking, plugging, migration of tubing.
Malfunction is most often by mechanical obstruction!
Look for signs of increased ICP; fever, inflammation
and abdominal pain.

48. THANKYOU