Hydrocephalus
Presentation by Pious Musonda for MedTalk
Zambia CNS Series 18.01.23
Objectives of Presentation.
1. Be able to define hydrocephalus
2. Have a basic understanding of Ventricular System and CSF.
3. Be able to classify of Hydrocephalus
4. Understand the pathophysiology of hydrocephalus
5. Under the clinical Presentation- History and Physical
Examination.
6. Know the different tests used for diagnosis.
7. Understand treatment of Hydrocephalus.
Table Of Contents
01 02 03
Clinical
Introduction Pathophysiology
Presentation
❖ Definition ❖ Eitology ❖ History
❖ Review of Ventricular ❖ Physical Examination
System& CSF
❖ Classification
04 05 06
Diagnosis Treatment Conclusion
❖ Medical
❖ Laboratory
❖ Surgical
❖ Imaging
❖ Differentials
Introduction
Hydrocephalus represents a diverse
group of clinical conditions in which
there is disturbance in CSF formation,
flow or absorption resulting in an
increase in volume occupied by CSF in
the Central Nervous System.
Ventricular System
Ventricular System
Ventricles contain cerebrospinal fluid (CSF) - plasma ultrafiltrate
mainly produced by the choroid plexus lining each ventricle.
❖ CSF functions to:
1. Protection.
2. Buoyancy.
3. Provide nutrients.
4. Waste Removal.
Ventricular System
Image from:Cerebrospinal fluid (CSF) - Anatomy of the Brain ([Link])
INTERMISSION….
Walter Edward Dandy: described
❖ the circulation of cerebrospinal fluid in
the brain,
❖ surgical treatment of hydrocephalus.
SALUTE!!!
“Dandy will never do
anything equal to this
again. Few men make
more than one great
contribution to medicine.”
—Someone…
Dandy went on to be one of
those few men. Hope we’ll
all go on to be such men
and women!
CLASSIFICATION
❖ Communicating
❖ Non-communicating
❖ Normal Pressure Hydrocephalus
❖ Hydrocephalus Ex vacuo
Eitology
Communicating Non Communicating
● Decreased absorption: ● Congenital:
1. Inflammation (Meningitis). 1. Dandy-Walker Malformation.
2. Subarachnoid Hemorrhage. 2. Chiari Malformation
3. Congenital absence of arachnoid villi. 3. Congenital stenosis of aqueduct of
sylvius.
4. Intrauterine infections
(Toxoplasmosis- TORCH).
● Increased Production: ● Acquired:
1. Choroid plexus papilloma, 1. Brain tumor (e.g. medulloblastoma)
Eitology
Chiari malformation Dandy-Walker Malformation
Pathophysiology
Image from: Hydrocephalus Pathophysiology And Schematic Diagram ([Link])
Image from: Hydrocephalus Pathophysiology And Schematic Diagram ([Link])
Hydrocephalus Vs. Normal Brain
Pression
Enlarged ventricle Normal ventricle
Clinical Features What ab
out
ex vacuo
e p h a lu s
hydroc
● Features of increased ICP
○ Headache, nausea, and vomiting
○ Papilledema
○ Abnormal gait
○ Impaired consciousness
○ Cushing triad (irregular
breathing, widening pulse
pressure, bradycardia)
○ Abducens nerve palsy
Clinical Features
INFANTS
● Macrocephaly: an enlarged head with a
circumference greater than the average for age and
sex by two standard deviations (as indicated by a
percentile growth chart)
● Tense fontanelle
● Setting sun sign:
● Developmental delays (e.g., psychomotor delays)
● Behavioral changes (e.g., irritability)
● MacEwen sign (cracked pot sign): percussion of
the skull near the junction of the frontal, temporal,
and parietal bones evokes an unusually resonant
sound
Medical History
presenting
ROS- Developmental
Age complaint- s/s
breathing? milestones
above
BIRTH HISTORY
Pre-natal Natal Post natal
Mother have any Any head trauma during Child have any infections?
infections whilst delivery? High pitched cry?
pregnant? Method of delivery? Irritable?
Cats at home?
Medical History Example..
A 12 week old female infant presents to the emergency department with progressive
vomiting, lethargy, and difficulty feeding over the past two days. Her mother reports that
she has been increasingly irritable in the last week and does not appear to be herself.
She has been less interactive, and her cry has become more high-pitched and weak. She
has not been breastfeeding well. Her mother is concerned because she thinks her infant's
head has grown, and the fontanelle appears to be bulging. She thinks that the infant has
felt warm, but she has not measured the temperature with a thermometer. She has had
fewer wet diapers and no bowel movements today. She reports that the infant was born
on time and that there were no prenatal or perinatal complications. The infant was
released after a 48 hour stay in the regular newborn nursery, and had follow-up initially
with her pediatrician about one week after discharge. She has had no further follow-up.
From the previous medical records, it is confirmed that the infant was born at term. There
was poor prenatal care, but the labor and delivery were unremarkable. Mother's prenatal
labs were normal. The infant weighed 2900 grams at birth (25th percentile), measured
47.8 cm in length (10th to 25th percentile), and had a head circumference of 34 cm (25th
percentile).
Physical Examination
Head size and
circumferenc shape of the
e occiput
Babinski's MacEwen's
sign sign
visible scalp
Setting sun
veins
What else would you elicit in Hx and
PE?
Diagnosis
Ultrasonography
Antenatal period, less than 6
months
CT scan
MRI
Supportive
Image from:
Lumbar puncture (NPH),
[Link] FBC/DC etc
Diagnosis
Look like twins?
Image from:
[Link]
Treatment
Shunts
Endoscopic third
Ventriculoperitoneal shunt vetriculostomy
Ventriculoatrial shunt
Establishes an alternative
route for CSF toward the
subarachnoid space. It is
contraindicated in
communicating
Medical hydrocephalus, but can be
used especially with
Decreasing CSF secretion aqueductal stenosis.
by the choroid plexus -
Acetazolamide and
furosemide
What do you think are
some complications
associated with shunt
placement?
References
● AMBOSS (2022). Hydrocephalus [online]. [Link]
● Kliegman [Link] (2011). Nelson’s textbook of Paediatrics . Elsevier
● Koleva. M & De Jesus. O (2022). Hydrocephalus. Statpearls Publishing. [online]
[Link]
● Nelson S (2018). Hydrocephalus. Medscape [online]
● Telano L & Baker (2022). Physiology, Cerebrospinal Fluid. Statpearls Publishing.
Mockup
Thanks!
Do you have any questions?
piousmusonda@[Link]
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