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Neurology > CSF & Hydrocephalus > Flashcards

CSF & Hydrocephalus Flashcards

1
Q

What is the mean CSF pressure (ICP) in an adult?

A

10mmHg

14cm of CSF

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2
Q

Above what would be considered an abnormally high value of ICP?

A

> 15mmHg

>20cm CSF

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3
Q

Where is the majority of CSF produced?

A

Choroid plexus - 75%

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4
Q

At what rate of variation is CSF produced?

A

Circadian rhythm

Max production at 2am and minimum at 6pm

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5
Q

CSF secretion _________ with old age?

A

Decreases

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6
Q

What drug reduces the production of CSF by up to 50%?

A

Acetazolamide

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7
Q

Where is the other 25% of CSF produced from?

A

From the brain interstitial fluid

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8
Q

Where is CSF absorbed?

A

Mainly the arachnoid granulations

Olfactory lymphatics

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9
Q

Absorption of CSF is a ______ process which depends of the _ _ _ being greater than the pressure in the ______ ________

A

Passive
Depends on the ICP

Sagittal sinus

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10
Q

What are the main functions of the CSF?

A
  • Buoyancy - reduces brain weight by 96% (1500g becomes 60g)
  • Accommodates physiological changes in vascular volumes i.e. mediator of compliance
  • Ionic homeostasis
  • Provides micronutrients to cerebral tissue
  • Clears some waste products of neuro cell metabolism
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11
Q

Give some examples of micronutrients the CSF supplies the cerebral tissue with:

A

Vitamin C

Thyroxine

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12
Q

What three symptoms are considered the classic triad of normal pressure hydrocephalus?

A
  • Ataxia - (important early sign)
  • Memory decline
  • Incontinence
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13
Q

What are some of the features of normal pressure hydrocephalus ataxia?

A
  • Difficulty rising from a chair
  • Tendency to fall backwards
  • Difficulties initiating gait
  • Broad based, shuffling gait - Early stage sign
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14
Q

Describe some of the clinical features of a child born with hydrocephalus:

A
  • unusual shaped head
  • thin shiny scalp w/ visible veins
  • bulging or tense fontanelle
  • downward looking eyes
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15
Q

A baby born with congenital hydrocephalus may present with:

A
  • Poor feeding
  • Irritability
  • Vomiting
  • Sleepiness
  • Muscle stiffness and spasms in lower limbs
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16
Q

What are the three main physiological causes of ventriculomegaly?

A

Raised pressure
Increased Volume
Impaired absorption

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17
Q

List some common congenital causes of paediatric hydrocephalus:

A
  • Chiari malformation
  • Spina bifida
  • Aqueduct stenosis (X linked)
  • Dandy walker complex
  • Atresia of foramen of munro
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18
Q

List some acquired causes of paediatric hydrocephalus:

A
  • Haemorrhage
  • Infection e.g. meningitis
  • Traumatic head injury
  • Tumour
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19
Q

What are the main categories of valves used in the management of different hydrocephalus?

A
  • Fixed differential pressure
  • Adjustable
  • Switchable
  • Antisyphon
  • Constant flow
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20
Q

What % of valves no longer function after 12 years?

A

80%

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21
Q

List some common complications of shunts:

A 
Over-drainage: 
 - Acute SDH
 - Slit ventricles
Underdrainage:
 - Blockage
 - Displacement 
Infection:
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22
Q

List some ways the risk of infection in a CNS shunt can be reduced:

A
  • Prophylaxis antibiotics
  • Iodine use
  • Silver impregnated shunts
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23
Q

List some less common complications of shunts:

A 
Intracerebral haemorrhage
Seizures
Craniosynostosis
Dissemination of tumour cells
Umbilical fistula
Erosion of abdo viscera
Ascites / hydroceles
Inguinal hernia
Silicone allergies
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24
Q

List some symptoms associated with a blocked shunt:

A

Headache and vomiting
Sunsetting in children
lack of up gaze in adults
Blurred vision

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25
Q

How is a blocked shunt investigated?

A

CT shows hydrocephalus

Can tap the shunt to send CSF to microbiology

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26
Q

What is a good alternative to shunts for certain cases of hydrocephalus?

A

Endoscopic 3rd ventriculostomy

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27
Q

How does a VP shunt work

A

VP = ventriculoperitoneal

shunts CSF from lateral ventricles to the peritoneum

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28
Q

How does an LP shunt work?

A

LP = lumboperitoneal shunt

Shunts CSF from the subarachnoid space into the abdominal cavity

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29
Q

What shunts tend to have a very limited life expectancy?

A

LP shunts

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30
Q

When can ETV be used with good success?

A

70% success with aqueduct stenosis and tumours

50% success with hindbrain hernias

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31
Q

What cases have a high failure rate when treated with ETV?

A

Vascular
Congenital
Post meningitis
Neonates

32
Q

Define normal pressure hydrocephalus;

A

This is an accumulation of CSF which leads to the enlargement of the ventricles of the brain which shows little to no increase in ICP

33
Q

What is significant about Normal pressure Hydrocephalus?

A

It is one of the few potentially reversible / treatable causes of dementia

34
Q

List the main causes of normal pressure hydrocephalus;

A 
Idiopathic (mainly)
Post inflammatory e.g. 
 - SAH
 - Meningitis
 - Trauma 
 - Craniotomy
35
Q

What are some of the clinical features of dementia caused by normal pressure hydrocephalus:

A 
Delay in answering questions
Loss of spontaneity
May progress to akinetic mutism
Fluctuates in severity 
(alongside the triad)
36
Q

List some of the differential diagnosis of normal pressure hydrocephalus:

A

Ataxia:

  • cerebella problems
  • myelopathy

Dementia:

  • Alzheimer’s
  • Cerebrovascular
37
Q

Give some examples of genetic causes of dementia:

A

Huntington’s
Wilsons
Porphyria’s

38
Q

List some degenerative causes of dementia:

A

Alzheimer’s
Fronto temporal
Parkinson’s

39
Q

List some metabolic causes of dementia:

A

Hypothyroidism

Thiamine (alcoholism)

40
Q

List some infectious causes of dementia:

A

Syphilis
Prions
Encephalitis

41
Q

What are the main investigations for a normal pressure hydrocephalus:

A 
CT
MRI
ICP measurement
LP tap test
Lumbar drainage
Infusion studies
Tracer diffusion studies
42
Q

What are the main surgical treatment options for normal pressure hydrocephalus?

A

LP shunt
VP shunt
ETV

43
Q

Idiopathic intracranial hypertension is a disorder of ______ movement in the brain

A

Water movement

44
Q

List some of the conditions / risks associated with IIH

A 
Female
Obesity
Sleep apnoea
Hypothyroidism
Addison's
Uraemia
SLE
Vit A
Antibiotics
Hormones e.g. OCP
Lithium
Steroid withdrawal
45
Q

List the symptoms of an idiopathic intracranial hypertension:

A

Headaches
Visual field loss
Visual acuity loss (you want to step in before this part)

46
Q

list the signs of idiopathic intracranial hypertension:

A

Papilloedema
Constriction of visual fields
Loss of visual acuity (late sign)

47
Q

What are the most appropriate investigations and results for idiopathic intracranial hypertension?

A

LP pressure = >25cm CSF
CSF chemistry /cytology = normal
CT & MRI = normal
NO evidence of venous sinus thrombosis

48
Q

List the main treatment options for idiopathic intracranial hypertension:

A 
WEIGHT LOSS
Diuretics 
Lumbar puncture
LP / VP shunt
Optic nerve sheath fenestration
Venous stents 
Sub temporal decompression
Remove underlying medical disorder e.g. w/heparin
49
Q

List some of the common complications of an LP shunt:

A 
Blockage
Infection
Nerve root irritation
Low pressure headaches
Subdural haemorrhage
Arachnoiditis
Tonsillar herniation
50
Q

What is spontaneous intracranial hypotension (SIH)?

A

Rare condition where the fluid pressure inside the skull is abnormally low which leads to a severe disabling headache

51
Q

List some of the main symptoms of SIH:

A 
Orthostatic headaches
Neck / interscapular / arm pain
Diplopia / VF defects
Dizziness
Thunderclap headache 
Muffled hearing
Galactorrhoea
Symptomatic subdural haematomas
52
Q

What is the ‘classic triad’ of spontaneous intracranial hypotension?

A

Low CSF
Orthostatic headache
Brain sag with parenchymal enhancement

53
Q

What are some of the causes of spontaneous intracranial hypotension?

A

Idiopathic
Collagen disorders
Dural diverticula
Trauma

54
Q

How is SIH treated / managed?

A

Conservative - bed rest, fluids, analgesia
Epidural blood patches
Surgical repair

55
Q

List the most appropriate investigations for SIH:

A 
Head MRI 
LP
CT myelography 
Spinal MRI
Isotope myelography
56
Q

In SIH what might be seen on a cranial MRI

A

Meningeal enhancement
Chronic subdural haematomas
Hindbrain herniation

57
Q

What would be seen on an LP in a patient with SIH?

A

Low pressure
Pleocytosis
Raised protein
Xanthochromia

58
Q

What leads to galactorrhoea in patients with SIH?

A

Low CSF leads to compensatory hyperaemia which can occur in the pituitary leading to galactorrhoea

59
Q

What is the mean age of presentation in a syringomyelia?

A

31-50 y/o

60
Q

Define a syringomyelia:

A

A chronic condition characterised by a fluid filled cavity / cyst known as a syrinx which forms in the spinal cord.
The syrinx can expand over time causing cord compression

61
Q

What is the incidence of a syringomyelia occurring above a spinal fracture site?

A

3-5%

62
Q

Describe the main morphology of a syringomyelia:

A

Dilated central canals
Spindle
Holocord (can affect whole cord)
Tethered conus

63
Q

Which parts of the spinal cord are more commonly affected by a syringomyelia?

A

Cervical

Upper Thoracic

64
Q

List some of the classic presenting features of a syringomyelia:

A 
Dissociated sensory loss
Cuts and burns on hands
Small muscle wasting
Claw hands
Loss of upper limb reflexes
Increased lower limb reflexes
65
Q

What abnormality is a feature of early stage syringomyelia?

A

Hyperhidrosis (excess sweating)

–> it indicated hyperactivity of pre-ganglionic neurons

66
Q

List some of the more rare manifestations / features of syringomyelia:

A 
Segmental myoclonus
Paroxysmal arm posturing
Isolated Horner's
Orofacial pain
limb hypertrophy
Orthostatic hypotension
Reduced intestinal mobility
67
Q

List some of the common presentations of a hindbrain herniation:

A 
Coughing
Sneezing
Straining
laughing
Bending forward
Visual disturbances
Dizziness / tinnitus / hearing loss
Dysarthria / Dysphagia
Somatic sensory disturbance
68
Q

What symptom is common in patients with an abnormality of the craniovertebral junction (CVJ)

A

Sleep apnoea

A common presentation in hindbrain herniation

69
Q

What treatment options are there for syringomyelia?

A

Open up the obstructed CSF channels
Drain syrinx cavity
Lower overall CSF pressure
Conservative management

70
Q

What is meant by communicating hydrocephalus?

A

Obstruction to the outflow of CSF outwith the ventricular system e.g. post SAH or bacterial meningitis

71
Q

What is meant by non-communicating hydrocephalus?

A

Obstruction is occurring from within the ventricular system

e.g. Arnold Chiari malformation

72
Q

What is hydrocephalus ex vacuo?

A

This is when there is a loss of brain parenchyma, leading to ventricular expansion, increasing the CSF volume

73
Q

What is the normal volume of CSF?

A

120-150ml

74
Q

What is the normal protein level in CSF?

A

<0.4g/L

75
Q

What is the normal value for lymphocytes in the CNS?

A

<4cells/ml

76
Q

What are the three most common forms of herniation?

A

Subfalcine
Tentorial
Tonsillar

Neurology (15 decks)

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