Hydrocephalus
Examine this child head :
1. General observation :
- Position of child , obvious large head , obvious deformity
- Growth : plot weight , height and head circumference in appropriate
growth chart for age and sex.
Can be FTT
Obese in case of dilated 3rd ventricle compress pituitary gland.
- Abnormal features:
achondroplasia ,
stigmata of neurocut. Syndrome
prominent head for dandywalker malformation
flexion deformity of thumb in bicker adam syndrome
obvious deformity in lower limbs (TEV ).
- Equipments : walking aids.
2. Hand : for vital sign for evidence of increase ICP.
PULSE : for bradycardia
BP : for HTN
RR: apnea / irregular breathing.
3. Head examination looking for
- 5 S:
SIZE : big head. We must measure head circumference 3 times and
take largest one
SHAPE : broad forehead., prominent occipt "in dandy walker
malformation".
SCAR : in head and in abd. For VP SHUNT.
SUTURE : wide suture + tense AF.
SHUNT : behind the ear.
- Other signs for hydrocephalus :
Percussion : Macwen sign (crack pot sound ): percuss on ant. Fore
head produced cracked sound on taping it (indicate suture
sepration).
Auscultate for Cerebral bruit (Vein of galen
4. Eye examination :
- Sun setting sign : paralysis of upward gaze (pupils will be downward).
- Papilledema
- Chorioretinitis : ass e TORCH infection.
- 6th nerve palsy : blured vision , double vision , convergent squent
5. Gait examination : either :
Inability to walk – on wheelchair or bed ridden.
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Or Spastic gait.
6. lower limb examination: either :
- Upper motor neuron lesion( b/c pyramidal fibers pass periventricular
which can stretch by hydrocephalus lead to spacity ) : Hypertonia , hyper
reflexia , +ve babinski .
- Lower motor neuron lesion ( in arnlod- chiari malformation= spina bifida +
hydrocephalus) : hyporeflexia , hypotonia ,reduce power.
7. Back examination : either
- Spina bifida or hair tuft .
- Surgical scar (repaired meningomyelocele )
- Scoliosis (meningomyelocele).
8. To complete examination :
- Abdominal examination :
Scar of VP shunt.
Abdominal mass due to constipation.
Distended bladder – urine retention / wearing nappy – urine
incontence.
- Hearing assessment : observe for startle to sound ( may be hearing
impairement).
Discussion
What is hydrocephalus ?
Hydrocephalus is an excessive accumulation of cerebrospinal fluid (CSF) within the
head caused by a disturbance of formation, flow or absorption.
Dd of hydrocephalus :
1. Communicating :
- Post haemorrhagic : Subarachnoid or periventricular .
- Post infection : Meningitis or encephalitis.
- Leukaemic infiltration.
- 1ry ciliary dyskinesia.
2. Non-communicating :
- X-linked bicker adam syndrome.
- Haemrrhge
- Meningitis
- Mumps encephalitis.
- Vein of galen
- Space occupying lesion : Brain tumor , abscess , haematoma .
- Iatrogenic
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- Dandy – walker malformation
- Klipple – feil syndrome.
- Oesteopetrosis
- Achondroplasia.
- Crinocyntosis
- Hypervitaminosis A.
3. Congenital :
- Aqueduct stenosis in 10% of cases.
- Dandy walker malformation
- Arnold- chiari malformation.
- Congenital toxoplasmosis (TORCH).
- Aneurysm vein of galen.
- Achondroplasia can cause perinatal hydrocephalus.
- Huler syndrome.
Investigations :
- Antenataly : Aminocentasis (15-18 weeks) for alpha feto protein
- Chromosomal association : trisomy 13 , 18
- TORCH screening : toxoplasmosis.
- Cranial U/S. : if fontanele still open
Indication of cranial U/S :
Birth weight less than 1500 g.
Sick premature infant
Rapid increase in head circumference.
Signs of increase ICP.
- CT / MRI brain : for CNS anomalies , calcification and site of flow
disturbance.
Management :
1. VP shunt :
- Indications :
For obstructive hydrocephalus .
Some cases of communicating ( over production or poor
absorption of CSF).
- Complication of VP shunt :
Infections. e.g : ventriculitis , peritonitis.( ventriculitis treated by
Fracture or migration of the tube
Occulsion (under drainage ) :
Distal occlusion by chroid plexuses ,fibrin , clot
Distal occlusion from peritoneal adhesion.
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Low pressure "slit ventricle " syndrome (over drainage ) can lead
to microcephaly.
Scalp ulceration
Organ perforation.
Brain : damage , swelling or bleeding.
Rare : intestinal obstruction , peritoneal fibrosis.
2. Serial lumber puncture + acetozolamide :
- For post haemorrhgic communicating hydrocephalus which arrested
within 4 weeks
Prognosis of patient with hydrocephalus
- Epilepsy in 50%
- Hemiplegia due to cause like meningitis ,complication of insertion of
shunt "subdural haemorrhage ".
- Impairement of vision due to optic atrophy
- Normal intelgent.
Why usually VP-shunt in the right side ?
- To avoid dominant hemisphere which in most of the case in the left side.
- To be far from heart side .
What is slit ventricle syndrome ?
- Following overdraiage either from acute or chronic CSF decompression .
it characterize by :
1. Intermittent or chronic headache 2ry to ventricular catheter
obstruction.
2. Slit like Y shaped ventricle as seen in CT scan
3. The valve mechanism is slow to refill.
- Manage ment : use high pressure valve ,steroids , head down position
What is acess CSF device?
- It's device inserted with VP shunt.
What is advantages of access device?
- Measurement of intraventriculer pressure.
- Anylasis of CSF.
What is problem associated ?
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- Infection.
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