Hydrocephalus

Hydrocephalus

CSF
1. Produced by
  1. Choroid plexus (60-80%)
  2. Subependymal regions
  3. Pia
2. Absorption
  1. Mainly an active process done by arachnoid villi
    1. They are mainly in the lumen of the superior sagittal sinus
3. cerebral perfusion pressure
  1. difference between the mean arterial blood pressure minus the intracranial pressure
  2. If you increase intracranial pressure with the same mean arterial blood pressure you will have an ischemia
    1. To compensate you have the Cushing reflex
Clinical presentation
1. Infants
  1. enlargement of the head and less destruction of the brain tissue
2. Adults
  1. increase in intracranial pressure and a rapid destruction of the brain tissue
3. frontal and occipital horns typically enlarge first
  1. Then there is a progressive involvement of white matter, but gray matter is usually well preserved
4. Seizures occur frequently in children
Types
1. According to when the hydrocephalus forms
  1. Congenital
    1. neural tube defects
    2. CNS malformations
  2. Acquired
    1. infections
    2. intraventricular hemorrhage
    3. secondary to intracranial mass (benign or malignant)
2. According to whether the CSF can still circulate through the ventricles
  1. Non communicating
    1. Due to an obstruction
    2. Tetraventricular hydrocephalus
      1. Intraventricular tumors
      2. Inflammatory conditions
    3. Triventricular hydrocephalus
      1. Stenosis at the acqueduct of sylvius
      2. Obstruction
      3. Stenosis or congenital atresia
    4. Biventricular hydrocephalus
      1. Obstruction of both foramina of Monro (like tumors)
    5. Monoventricular hydrocephalus
      1. Single tumor at the foramen of Monro
  2. Communicating
    1. Impaired absorption
      1. Common in leptomeningitis because the CSF can’t reach the villi due to a blockage by scar tissue, in subarachnoid hemorrhage we have blood filling the villi, stopping their function
    2. Overproduction
      1. By a papilloma or ependymal tumor, or due to inflammation
3. According to the length of time of formation
  1. Acute
    1. Very unstable neurological condition
  2. Chronic
    1. We have a bit more time for diagnosis and intervention
4. Normal pressure hydrocephalus
  1. Classical triad of symptoms
    1. Dementia
    2. Gait disturbance
      1. Patient’s steps are very short, the base/stance is broadened and there is a loss of postural stability
      2. Most prominent clinical symptom
      3. Most responsive to surgical treatment
    3. Urinary incontinennce
  2. Secondary to infections or even minor injuries in childhood, intraventricular hemorrhage, or meningitis
  3. Slight and continuous increase in pressure that remains for many years
Typical clinical peatters
1. Infants
  1. Poor feeding
  2. Irritability
  3. Reduced activity
  4. Vomiting
2. Children
  1. Slowing of mental capacity
  2. Headaches
  3. Vomiting
  4. Neck pain
3. Adults
  1. Headaches
  2. Neck pain
  3. Nausea
  4. Vomiting
  5. Cognitive deterioration
Treatment
1. Surgical therapy (the best)
  1. Surgical drainage
  2. Shunt
    1. External
      1. Best to resolve a sudden hydrocephalus
    2. Internal
      1. Collect the CSF into the peritoneum or in the atrium
        Peritoneum is first choice
      2. Only effective in the case of obstructive hydrocephalus
  3. Third ventriculostomy
    1. Putting a hole in the floor of the third ventricle
      1. Direct connection between the intraventricular and extraventricular (subarachnoid) space
    2. Mainly used for obstruction of the cerebral aqueduct, tumors or malformations at the mesencephalon
    3. Endoscopic procedure
    4. Not useful in the case of communicating hydrocephalus
2. Medical therapy
  1. drugs which will decrease CSF production
    1. Furosemide and acetazolamide
Diagnosis
1. Imaging
  1. US
    1. Preferred technique for the initial exam, particularly in children
  2. CT/MRI
    1. Mickey Mouse sign
2. Anamnesis
3. Physical examination
  1. Vital signs (due to distortion of the brainstem)
    1. Bradycardia
    2. Systemic hypertension
    3. Altered respiratory rate
  2. Head
    1. Measure the skull
    2. Check for macrocephaly in infants
    3. Setting sun sign
    4. Frontal bossing
  3. Cranial nerve palsy
    1. Diplopia
  4. Papilledema

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	Created by LewisLewis almost 11 years ago