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Hydrocephalus

The normal brain has four pockets, called ventricles, which are filled with fluid called cerebrospinal fluid (or CSF). The CSF is constantly being produced and is responsible for nourishing the brain and spinal cord. The CSF flows through a pathway from the brain, down through the spinal canal and is eventually reabsorbed into the bloodstream. Hydrocephalus is a condition that occurs when either too much CSF is produced, the CSF is not reabsorbed into the bloodstream or the normal flow pathway is blocked.

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.

Hydrocephalus is a condition some infants are born with or may acquire later in life. It is important to determine the cause of hydrocephalus, as the treatment often depends on the cause.

Causes

• Congenital (usually diagnosed during infancy).
• Acquired by tumor, infection, stroke, bleeding into the brain, meningitis or as the result of a severe head injury.

Symptoms

The symptoms of hydrocephalus may vary, according to the age of the patient and the other associated illnesses.

• The head circumference (measurement around the head) of an infant with hydrocephalus will measure larger than the normal infant.
• The infant may have developmental delays, such as delayed sucking, abnormal reflexes, sleepiness, fussiness, nausea or vomiting.
• The older child may complain of headaches, difficulty walking, nausea or vomiting, lack of energy, sleepiness, inattention, blurred vision or dizziness.
• In adult symptoms may consist of headaches, drowsiness, dizziness, nausea or vomiting, difficulty walking and visual changes.
• The elderly person often has symptoms of drowsiness, unsteady walking, loss of control of the bladder and confusion (or dementia).
• The elderly person may not complain of headaches as readily as the younger adult or child.

Diagnostic tests

If your health-care provider suspects you or your child has hydrocephalus, a thorough physical and neurologic evaluation will be performed and the following tests may be recommended:

• CT scan
  This is a special X-ray image of the brain to determine the size of the ventricles, if there is a tumor or obstruction and the size and location of the tumor. The test is performed by having the patient lie on a flat X-ray table which slides into a round, open scanner. The X-ray images are taken as the patient is lying still on the X-ray table. Often, this test involves the injection of a contrast dye to obtain better images of the brain structures (be sure to tell your health-care provider if you are allergic to dye or have ever had a reaction to dye).
• MRI (magnetic resonance imaging)
  This is a special non-X-ray image of the brain to determine the size of the ventricles, if there is a tumor or obstruction and the size and location of the tumor. No X-rays are used in this test. The test is performed by having the patient lie on a flat imaging table, which slides into an enclosed tube. It is important to lie very still while in the scanner, as the pictures are very sensitive to any movement. You will hear a machine-like sound, as the pictures are taken. The space inside the tube is quite snug, therefore, be sure to tell your health-care provider if you are claustrophobic or uncomfortable in very tight places. Because this test is performed with a special high-power magnet, it may not be performed on anyone with a metal implant (ie. artificial limbs, artificial joints, aneurysm clips, shrapnel or metal heart valves). If you are unsure of any metal in your body, please tell the MRI technician before the test begins.
• Cranial ultrasound
  This test is performed on infants only, to determine the size of the ventricles and the amount of fluid flowing within the ventricles.

Treatment

The treatment of hydrocephalus depends on the cause. Some of the treatment options are:

• Lumbar puncture is a temporary measure to drain some of the volume of CSF from the spinal canal. The skin around the low back is cleansed with Betadine (or a surgical soap), and a local anesthetic (numbing medicine) is injected under the skin. A spinal needle then is inserted into the spinal canal, and a volume of CSF is drained out into a sterile container. The spinal needle then is removed and the puncture site closes on its own. This may be only a temporary measure or it may solve the problem until a more permanent solution is completed.
• Shunt is an operation in which a small catheter is placed from the ventricle to the abdomen. The purpose of the operation is to provide an alternate path for the CSF to flow from the brain through the spinal canal. With a shunt in place, the CSF can flow through the normal pathway, which prevents large amounts from accumulating in the ventricle. Although the shunt is a permanent device, it may need to be surgically revised in the infant or child to accommodate for normal growth of the child. A shunt can be placed in a person of any age. The surgical procedure takes approximately 90 minutes and is performed under general anesthesia. The most frequent complications of a shunt are infection (which can generally be treated with antibiotics), obstruction within the catheter or disconnection of the catheter. Your neurosurgeon will discuss the risks and benefits of a shunt when the decision is made to perform the procedure. Symptoms of shunt infection include: fever, lethargy or sleepiness, fussiness in the infant or young child, pain, redness or swelling around the shunt site, headache, nausea or vomiting, unsteady gait and signs that the shunt is not working properly. If any of these symptoms occur, call your health-care provider as soon as possible.
• Surgical removal of a tumor which is causing the obstruction is often the procedure of choice in the adult or elderly person. Your neurosurgeon will discuss the operation and risks involved before the procedure is planned.