Hydrocephalus

 

Def.: Hydrodynamic disturbance of CSF vol. Of CSF within ventricular System

Types:

with or without concomitant in its tension.

1- Normal pressure hydrocephalus only male.

2- Communicating hydrocephalus

3- Non-communicating hydrocephalus ( obstructive ) : i most common

4- Arrested hydrocephalus

Causes (pathogenesis) :

(A) Hydrocephalus e` ­ CSF pressure:

1- secretion: - choriod plexus ( congestion – tumor )

- vit. A ( hyper – hypo )

- Idiopathic

2- Obstructive : (i commonest)

Congenital	Acquired
A Agenesis of foramen of monro - Arnold chiari type II syndrome	* Post – inflammatory: meningitis. * Post-traumatic * Neoplastic : i commonest post. Fossa tumors
B Bicker Adam's syndrome
C Congenital toxoplasmosis
D Dandy walker malformation

+ Most common : X-linked hydrocephalous ( aqueductal stenosis )

Malformation of vein of gallen ( A.V. fistula – High COP failure – arterial bruit on frontal

& parietal bone auscultation ).

3- Impaired absorption:

* Subarachnold space: ( adhesions – leukemia infiltration ).

* Dural sinus thrombosis.

B- Normal pressure hydrocephalus:

* Congenital cerebral agenesis.

* Diffuse cerebral Atherosclerosis. 

* Dementia as Alzheimer.

C/P

(A) Before closure of ant. Fontanel:

 

Head 

• - head circumference
• - Delayed closure of a. Font.
• - Wide separation ( ) sutures
• - Craniotabes
• - Mc Ewen sign :i cracked pot sound on percussion.
• - Arterial bruit:
• Malf. of vein of gallen.
• - Fore shortened occiput: Arnold chairi syndrome
• - Prominent occiput: dandy walker syndrome

+ Over stretched & glistening scalp.

 

Eye:

• * Sun set appearance.
• * Medial squint.
• * Visual disturbance & optic atrophy & papilledema.

 

Back:

• * Spina bifida.
• * Meningocele

 

Neurological manifestations :

• * No ­ of ICT
• * Late cases:

1. - Mental retardation.
2. - Motor retardation ( spastic paraplegia ).
3. - + ve babinski.
4. - Convulsions.

 

b) After closure of A.F. 

• * Head enlargement less significant
• * Manifest of ICT . . . .
• * Abducent ( 6th ) nerve palsy ( medial squint )
• * Personality change

Investigation :

1- X-ray (plain):

Bfore closure	After closure of A.F.
Cranio-facial disproportion	Signs of ↑ ICT
Wide speta ( ) sutures	Finger print appearance
Thinning of skull bone	Beaten silver appearance

2- CT & MRI: brain ( i best )

3- CSF study : ( cytoalbminous Dissociation )

4- Blood examination.

5- Arteriography

6- U/S : through ant. Fontanel

7- ECG : for convulsions.

 

D.D.: Other causes of macrocephaly:

* Skull causes: rickets – osteogenesis imperfecta Ch. Hemolytic anemia .

* Meningeal causes: subdural hematome – effusion.

* Brain causes : Hydranencephaly , megalocephaly ( neurofibromatosis ).

* Familial.

Treatment:

A- Medical:

* Indication: in cases of CSF production.

* Mech: - Salt & H2O restriction.

- Diamox.

- Isosorbide CSF absorption.

B- Surgical:

1- Choroid plexectomy: in papilloma.

2- Diathermy coagulation: of choroid Plexus.

3- Opening of stenosed aqueduct: high morbidity.

4- Endoscopic fenestration of 3rd ventricular Floor.

5- Excision of brain tumor.

6- Shunt operation:

* I commonest operation.

* Using one way valve ( spitz – halter valve ).

Types	Indications
1- Ventriculo-ureteral 2- Ventriculo-atrial 3- Ventriculo-pleural 4- Ventriculo-peritoneal (most common) 5- Lumbo-peritoneal. 6- Torkilidsen shunt. Complications: Obstruction of tube. Infection . Rejection. Shortening of i tube e` age.	1- Progressive head enlargement. 2- Obstructive hydrocephalus. 3- No: - Eye complication - neurological Manifestation - mental affection - ass e` cong. Malformation

Complications:

Due to hydroceph. Progression	Medical ttt	Surgical ttt
Eye: (Visual dist. – medial squint – papilloedema, optic atrophy – compress on optic chiasma.	- Electrolyte dist. - Metabolic acidosis	1- shunt.... 2- V-P: peritonitis. 3- V-A: endocarditis. 4- L-P: radioculopathy
Neuro: ( MR.- UMNL, gait disturb- convulsions – post. Cerebr. art occlusion

N.B.: CSF.:

* Volume: (adult 120 ml – infant 50 ml ).

* Pressure (180-200 mm H2O = 18 – 20 mm/Hg)

 

This is visual diagnosis case about hydrocephalus