Hydrocephalus is an abnormal accumulation of cerebrospinal fluid in the brain ventricles that causes them to expand. It can be caused by obstruction of CSF flow or improper absorption. Common signs include an enlarged head size, bulging fontanelles, downward eye deviation, and irritability. Diagnosis involves imaging tests and lumbar puncture. Treatment is typically with a shunt system to drain excess CSF out of the brain ventricles. Complications can include infection, shunt malfunction, and bleeding.

1. Definition
• Hydrocephalus is an abnormal expansion of
ventricles within the brain, which is caused
by an abnormally large accumulation of
cerebrospinal fluid (CSF).

2. Ventricles

4. Arachnoid/Pia
• Bridges over the sulci
• Arachnoid granulations-
project into venous
sinuses, (where CSF
diffuses into bloodstream)
• Subarachnoid space-
filled with CSF
• Delicate, highly vascular
• Closely covers brain and
spinal cord

5. Meningeal Spaces

6. Production of CSF
Net transport of Na+ and Cl-
across the epithelium results in
the secretion of CSF.
Cl- efflux from the epithelium to
CSF is mediated by a
cotransporter.
The generation of H+ and HCO3
by carbonic anhydrase is
important in the secretion of
CSF.

7. Function of CSF
• Maintenance of a constant external
environment for neurons and glia
• Mechanical cushion to protect the brain and
provide buoyancy to the heavy brain .
• Serves as a lymphatic system and a conduit
for neuropeptides
• pH of CSF regulates pulmonary ventilation
and CBF

8. CSF flow

10. Types of hydrocephalus
• Obstructive hydrocephalus
There is an obstruction in the flow of CSF within the normal pathway.
• Communicating hydrocephalus
There is no block in the flow of CSF, but the CSF is not absorbed
properly back into the bloodstream
• Normal pressure hydrocephalus
Usually occurs in older age groups and is due to a lack of properly
functioning brain structures.
• Secondary hydrocephalus
Usually results from an infection (such as meningitis) or a severe head
injury.

11. CAUSES OF HYDROCHEPHALUS

12. CAUSES Congenital hydrocephalus
TORCH INFECTIONS
(e.g., cytomegalovirus [CMV], toxoplasmosis,
rubella)
congenital malformations
1. Aqueductal stenosis–narrowing of the pathway to
the fourth ventricle
2. Arnold-Chiari malformations–small part of the
cerebellum protrudes into the spinal canal
3. Dandy-Walker syndrome–enlarged fourth ventricle
due to obstruction in pathway
4. Spina bifida–portion of the spinal cord is
pushedthrough an abnormal opening between two
vertebrae

13. Adult Neural Canal Regions

14. Arnold-Chiari

15. Myelomeningocele

16. Diagnosis
Ultrasound
Elevated AFP
95% survival rate

17. Spina Bifida
Bowden &

18. CAUSES-Acquired hydrocephalus
• IC Bleeding (hemorrhage)
• Brain trauma (i.e., result of injury)
• Brain tumor
• Cyst (i.e., a fluid-filled sac)
• Infection (e.g., cerebral abscess,
bacterial meningitis

19. Signs in infants
•An unusually large head
•A rapid increase in the size of the head
•A bulging frontenelle
•Vomiting
•Sleepiness
•Irritability
•Seizures
•Eyes fixed downward (sunsetting of the eyes)
•Developmental delay

20. older children, common signs and
symptoms of hydrocephalus include:
• Headache followed by vomiting
• Nausea
• Blurred or double vision
• Eyes fixed downward (sunsetting of the eyes)
• Problems with balance, coordination or gait
• Slowing or regression of development
• Memory loss
• Confusion
• Urinary incontinence
• Irritability
• Changes in personality

21. • The characteristic Hakim's Triad may be
seen in normal pressure hydrocephalus,
which is found mostly in adults:
• psychiatric disorders, mimicking the
appearances of dementia
• This involves mostly slow and poor quality
ideation and activity, with apathy and
indifference, serious memory and orientation
disturbance, particularly in time, loss of
attention and unawareness of reality.

22. • GAIT DISORDERS, with instability
• This is due to static abnormalities, which may
develop into titubation. The person moves around
slowly and with care and may, occasionally, walk on
the spot. Turning around, or either starting or
stopping suddenly leads to imbalance.
• SPHINCTER DISTURBANCE (incontinence++)
• On occasions, the person is incontinent of urine and
occasionally faeces. It is not clear whether this is due
to inattention, reduced awareness or urgency of
micturition. The patient may pass urine anywhere and
soil his clothing.
•

23. Assessment
• Bulging fontanels
• Split sutures
• Increasing head circumference
• Prominent scalp veins
• Sunset eyes
• Irritability
• Poor feed
• The older child will complain of headache

24. Examination of the Head

25. Infant skull

26. Head Circumference

27. Differences in Children

28. Palpation of fontanels
• Anterior
– diamond shaped, intersection of coronal and
metopic sutures, FT 3-4cm by 1-3cm
• Posterior
– triangular shaped, intersection of sagittal and
lambdoidal sutures, FT 1-3cm wide
• Findings
• normal- soft/flat
• full, bulging
• sunken

29. Palpation of sutures
• Normally should feel slightly mobile when
slight pressure is applied
• Overriding
• Separated
• Craniosynostosis

30. Head circumference
• Occipital-frontal circumference is measured
with the tape placed just above the
eyebrows.
• Factors that can effect measurement:
edema, IV infiltrates in scalp,
cephalhematoma
• Serial measurements over time give you the
most useful information.

31. Head growth
• Preterm: 0.5-1.0cm/week
• Term: 0.5cm/week
• Sick or preterm infants may have slowing
of head growth with subsequent “catch up”
after recovery.

32. Abnormalities of head size
• Macrocephaly
– >90th percentile for gestational age
– potential causes: hydrocephaly, hydrencephaly

33. Head shape
• Effects of labor and
delivery
– molding
• Birth trauma
– cephalhematoma
– caput succedaneum
• Craniosynostosis
• Dolichocephaly of
www.nlm.nih.gov
prematurity

34. Auscultation of fontanel
• Bell of stethoscope is placed over the
fontanels and also may be placed over the
temporal, frontal, and occipital areas.
• Listening for bruits
• Why? Bruits can be heard with
arteriovenous malformations and
aneurysms.

35. Hydrocephalus
Bulging anterior fontanelle
Eyes deviated downward
“Setting” Sun sign

36. Transillumination of Skull
Advanced cases of
Hydrocephaly produces
a glow of light over
the entire cranium.

37. Severe Hydrocephalus

38. Increased ICP; vital signs
1. CEREBRAL ISCHEMIA; CUSHING’S REFLEX
2. SYSTEMIC VASOCONSTRICTION
3. RESPONSE TO INCREASED BP IS TO SLOW
HEART
4. LOW CO2 FROM ACCELERATED CIRCULATION
REDUCED RESPIRATORY RATE
5. AS CIRCULATION TO BRAIN IMPROVES,
RELIEVES ISCHEMIA, VASOCONSTRICTION
RELAXED

39. Vital Sign Changes
Increase in
Blood Pressure
Cushing Triad
Decrease in Pulse Altered Respiratory
pattern

40. Increased ICP; visual signs
PRESSURE ON OCULOMOTOR NERVE
(III) AFFECTS THE SIZE AND
RESPONSE OF THE PUPILS.
IPSILATERAL PUPIL BECOMES FIXED
AND DILATED.

41. Diagnostic tests
• x-ray - a diagnostic test which uses invisible
electromagnetic energy beams to produce images
of internal tissues, bones, and organs onto film.
• computed tomography scan (Also called a CT
or CAT scan.) - a diagnostic imaging procedure
that uses a combination of x-rays and computer
technology to produce cross-sectional images
(often called slices),

42. Lumbar Puncture
Insertion of spinal
needle into
subarachnoid space
between the lower
lumbar vertebrae.
Waley & Wong
Modified sitting position for LP

43. Cerebral Spinal Fluid
• Normal CSF • Abnormal CSF
• Clear odorless • Turbid, cloudy
• WBC’s 0 – 5 • WBC’s 1000 – 2000
• Protein 15 to 45 • Protein 100 – 500
• Glucose 50 – 80 • Glucose lower than
• Pressure 50 to 180 blood sugar
• Pressure 180 or
greater

44. Interventions-shunt

45. Interventions
• The shunt consists of
three parts:
1. a tube that is placed inside of
the ventricular space
2. a reservoir and valve to control
the flow of CSF
3. tubing that is directed under the
skin to the abdomen, or less
commonly to the heart or lung
area

46. SHUNT

47. Assessment of Shunt
• Vomiting
• Headache
• Irritability
• Fever
• Redness along shunt
line
• Fluid around shunt
valve

48. CYTERNOSTOMY

49. Care of shunt
• Frequently check for any redness or
secretion on the skin over the shunt.
• Check the integrity of the skin over the
shunt, wounds or scratches may
conduct to infection..
• Check that the fontanel is leveled or
depressed below the level of the bone.
• Observe for symptoms of shunt
malfunction.

50. complications from the shunts or
surgery
• infection
• shunt malfunction that results in under-
drainage or over-drainage of the CSF
• bleeding