HYDROCEPHALUS

VINAYAKA A.M IST Msc NSG N.H.C.O.N

DEFINITION
Hydrocephalus is a condition caused by an imbalance in the production and absorption of CSF in the ventricular system, when production is greater than absorption. CSF accumulates within the ventricular system, under increased pressure, producing passive dilation of the ventricles.

CSF CIRCULATION

ETIOLOGY
CONGENITAL HYDROCEPHALUS  Intrauterine infections- mainly Rubella, Toxoplasma, Cytomegalovirus.  Congenital malformations like aqueduct stenosis. Amold- chiari malformation ( displacement of the brain stem and cerebellum through formen magneum ) Dandy-walker anomaly ( congenital septum or membrane blocking the out let of 4th ventricle )  Intracranial hemorrhage  Congenital brain tumor  Malformation of arachnoid ventricle

ETIOLOGY (conti)
ACQURIRED HYDROCEPHALUS Inflammation Meningitis, Encephalitis Trauma- Birth injury, head injury, Intracranial hemorrhage. Neoplasm- tuberculoma, subdural hematoma or abscess gliomas, ependymoma asterocytoma, choroid plexus papiloma, pseudo tumor cerebrai.

ETIOLOGY (conti)
Chemical- Hypervitaminosis A Connective tissue disorder- Hurler syndrome achondroplasia. Degenarative atrophy of brain-Hydrocephalus Ex vaculo Arteriovenous malformation, ruptured aneurysms,cuvernous sinus thrombosis etc.

TYPES OF HYDROCEPHALUS

NON COMMUNICATING HYDROCEPHALUS

COMMUNICATING HYDROCEPHALUS

PATHOPHYSIOLOGY
Due to above causes , the ventricular system becomes greatly distended and dilated Increased ICP leads to thinning of cerebral cortex and cranial bones Ependymal lining of ventricles is disrupted resulting in preventricular ooze.
Edema occurs and white matter is compressed, 3rd ventricle compress the optic nerve and dilation of sella turica, atrophy of choriod plexus Enlargement of skull and previously closed sutures lines may become diastatic or open ( especially sagital suture)

CLINICAL MANIFESTATIONS
Depends upon age of child, types and duration of hydrocephalus, closing of anterior fontanel or fusion of cranial sutures. The features may manifest rapidly, slowly, steadly advancing or remittent. INFANCY ( EARLY) Abnormally rapid head growth Bulging fontanels ( anterior) without head enlargement, tense, nonpulsatile. Dilated scalpveins Separated sutures Macewen sign ( cracked pot sound on percussion) Thinning of skull bones.

CLINICAL MANIFESTATIONS ( conti..)

INFANCY ( LATER) Fontal enlargement or bossing Depressed eyes Setting sun sigh ( sclera visible above the eyes) Pupils sluggish, with unequal response to light INFANCY ( GENERAL) Irritability Lethargy Infant crying Normally expected responses fail to appear May display change in level of consciousness Lower extremity spasticity Vomiting

CLINICAL MANIFESTATIONS ( conti..)

 Advanced cases difficulty in seeking and feeding, shrill, brief high pitched cry, cardiovascular embarrassment.

CHIDHOOD  Head ache on awakening, upright posture or emesis  Papilledema  Strabismus  Ataxia  Irritability  Lethargy  Apathy  Confusion  Incoherence  Vomiting  Urinary incontinence  Usually not accompanied by big head as in infancy

INCIDENCE
Not exactly known Acquired hydrocephalus occurs 1 in every 1000 children Some time found to be associated with meningomyelocele

DIAGNOSTIC EVALUATION
Physical examination and neurological examination Increase in head circumference in first 3 months of life, more than 1cm every 15 days and persistent widening of saquamo-partial sutures should arose the suspicion. Typical cracked pot sound (Makmens sign) of the skull bone Ophthalmoscope are important measures. MRI, CT scan, cranial ultrasonography X ray

MEDICAL MANGEMENT
The goal to establish equilibrium between production and absorption. Use of acetazonamide (Diamox), a drug ( 50mg/kg/day) that reduce the production of CSF occasionally Repeated lumber puncture can be done to maintain the pressure in case of acute hydrocephalus or subarachnoid hemorrhage or bacterial meningitis.

SURGICAL MANGEMENT
The removal of the obstruction- For the flow of CSF, through the surgical removal of the tumor. Reduction in the amount of CSF production Through destruction of the portion of choriod plexus ( choriod plexotomy) or a third or fourth ventriculostomy. Shunting the CSF from the ventricle to another site in the normal circulating pathway -For non communicating type. Shunting from the ventricle to an area outside the CNS -Used most commonly for communicating type and non communicating type in infants.

SURGICAL MANGEMENT (conti)

Here radiopaque ventricular catheter used and A one way valve device are used with shunts from the lateral ventricle in order to prevent a backflow of blood or other secretions into ventricles. These valve may be of several types Holter valve system, The Hegar schulte- padenz ventricular catheter,

SURGICAL MANGEMENT (conti)

Several types of extracranial shunt procedure may be used a)Ventriculoperitoneal shunt  Here catheter is inserted into the anterior portion of a lateral ventricle through burr hole in the skull.  An incision is made in the abdomen and through the rectus muscle into the peritoneum.  The proximal end is slipped beneath the skin of the anterior abdominal and chest wall to the neck.

SURGICAL MANGEMENT (conti)

 The ventricular catheter is attached valve unit is then sutured to the peritoneal catheter.  The CSF is absorbed by tissues in the abdominal cavity.  This type of shunt may be obstructed, necessitating revision.

SURGICAL MANGEMENT (conti)

b) Ventriculoaterial shunt (VA) This also widely used. A silicone catheter is inserted into the lateral ventricle and down through the internal jugular vein into the right atrium of the heart. The CSF drains into the circulating blood This type of shunt may be infected easily or obstructed and it must be revised as the child grows.

SURGICAL MANGEMENT (conti)

c) Lateral ventricle or lumber subarachnoid space to ureter This is a seldom used procedure because it necessities the removal of a kidney. It may be used in older children or when other types of shunts have failed. In this type CSF drains through the ureter and into the urinary bladder. Since the There is no reabsorption sodium and chloride may lead to hyponatremic-hypochloremic dehydration. If the levels of these electrolytes become low, additional requirement is required. If the urinary tract infection occurs prompt treatment is taken.

SURGICAL MANGEMENT (conti)

d) Ventriculoplural shunt This type of shunt drains fluid from the lateralventricle to the pleural cavity. Drainage of the CSF may cause hydrothorax necessitating either removal of the shunt or a thoracenthesis The major complications of shunting are Ventriculitis septicemia