CSF, Hydrocephalus, Lumbar Puncture

Question 1

What is Hydrocephalus?

Answer 1

condition whereby there is excess of CSF, pithing itracranial space, specifically, the intraventricular spaces within the brain- causing dilation of the ventricles and a wide range of symptoms.

Question 2

where is CSF produced? Is it a passive or active process?

Answer 2

choroid plexus. active process that requires ATP where sodium pumped into subarachnoid space and water follows into the blood vessels

Question 3

Where is the choroid plexus found?

Answer 3

lateral ventricles, post 3rd ventricle roof, and caudal 4th ventricle roof

Question 4

is production equal to absorption in CSF?

Answer 4

yes

Question 5

How much CSF do we produce, and how much is in our bodies and brain?

Answer 5

we produce between 450-600 ccs of CSF everyday.

Question 6

What is the CSF pathway

Answer 6

1. lateral ventricles (there are 2)
2. Foramen of Monro
3. 3rd ventricle
4. cerebral Aqueduct (of sylvius)
5. 4thventricle.
6. Foramina of Luschka
7. Foramen of Magendie
8. then when leaves 4th ventricles hoes to subarachnoid space and around brain and spinal cord
9. reabsorbed by arachnid granulations

Question 7

How do arachnoid granulations absorb csf?

Answer 7

have arachnoid villi, which function as pressure-dependant one way valves that open when the ICP is 3-5cm greater than dural venous sings to pressure.

Question 8

Is CSF absorption a passive or active process?

Answer 8

passive- needs no ATP.

driven by pressure gradient between the ICP and the venous system

Question 9

2 types of hydrocephalus?

Answer 9

CommunicatingHydrocephalus (non-obstructive)

-Non communicating hydrocephalus (obstructive)

Question 10

Difference between communicating and non communicating?

Answer 10

communicating-csf pathway is open from start to finish- no obstruction
-whilst non-communicative- obstruction

Question 11

communicating hydrocephalus short name?

Answer 11

CoH

Question 12

signs and symptoms of CoH in children?

Answer 12

In young children whose cranial sutures have not yet fused, you can see disproportional increase in head circumference compared to the rest of the face/body or failure to thrive
In children with fused sutures/adults, hydrocephalus manifests with symptoms of increased intracranial pressure;

Question 13

other symptoms of CoH?

Answer 13

H/A, N/V. papilledmea, gait disturbance, 6th cranial nerve palsy, up gaze difficulty

Question 14

aetiology of CoH?

Answer 14

Infection (incidence after bacterial meningitis can approach 30%)
Subarachnoid Hemorrhage (blood and blood breakdown products cause scarring of arachnoid granulations)
Post-operative
Head trauma

Question 15

note form name of Non-communicating Hydrocephalus?

Answer 15

NCH

Question 16

when is it NCH?

Answer 16

when there is ANY physical obstruction to the normal flow of CSF

Question 17

NCH causes?

Answer 17

Aqueductal stenosis
Tumors/Cancers/Masses
Cysts
Infection
Hemorrhage/hematoma
Congenital malformations/conditions

Question 18

NCH symptoms rapid or gradual? and explain

Answer 18

if from process that develops over a longer period of time the symptoms will be gradual.

-but if its from an acute process like an intraventricular bleed- that can cause acute obstruction with rapid status decking

Question 19

What radiography finding indicates hydrocephalus?

Answer 19

dilation of the temporal horns of the lateral vernticle
-in most younger and middle aged patients, these should be invisible.

• third ventricle will become ballooned
• lateral ventricle size increase
• peripheral sulk effaced
• evans ration-> 30%/ ventricular index>50%

Question 20

Treatment for acute hydrocephalus?

Answer 20

reamins surgical
-acute hydrocephalus- whether communicating or not, needs urgent External ventricular Drain (EVD) passed through patients scalp and skull into lateral ventricle, that drains CSF to a collection system at patients bedside.

Question 21

treatment for communicating hydrocephalus?

Answer 21

mainstay treatment is shunt placement.

if its an acute communicating hydrocephalus can be managed with evd and no shunt placements

Question 22

treatment for non-communicating hydrocephalus?

Answer 22

surgical but sometimes shunt can be avoided by removing obstructing lesion

-can do third ventriculostomy

Question 23

If a previously shunted patients presents with a headache does that mean it a shunt malfunction?

Answer 23

No, but it is a differential diagnosis

Question 24

What condition can normal pressure hydrocephalus lead tp?

Answer 24

preventable/or reversible cause of dementia

Question 25

Symptoms of normal pressure hydrocephalus?

Answer 25

WET, WOBBLY, and WACKY
Hakim-Adams Triad
Urinary incontinence
Gait disturbance (usually the first symptom to present) – wide stance; short, shuffling steps
Rather quickly-progressive dementia

Question 26

investigation for normal pressure hydrocephalus?

Answer 26

CT/MRI,
lumbar puncture: normal opening pressure, symptoms improve with CSF removal, gait assessment )time walk and turns) and MMSE

Question 27

NPH treatment?

Answer 27

VP shunt placement

LP shunts tend to overdrawn and are difficult to assess and revise

Question 28

NPH prognosis

Answer 28

Chance of outcome is improved if symptoms have been present for shorter period of time
Meaning that failure to recognize these patients delays their treatment and lessens their chances!
Least likely symptom to improve with shunting is dementia
It’s always a worse sign once mentation gets involved!
Most likely symptom to improve is gait>incontinence>memory

Question 29

What is it important to keep in mind when taking a history of a patients with signs of Alzheimers?

Answer 29

always keep in mind that NCH is a possible differential diagnosis

Question 30

What can you use CSF to diagnose? Through what procedure do you get CSF?

Answer 30

-get css through a lumbar puncture
Meningitis
Meningoencephalitis
Subarachnoid hemorrhage
Malignancy – diagnosis and treatment
Idiopathic Intracranial Hypertension
Other neurologic syndromes
Infusion of Drugs or contrast

Question 31

when do you not do a lumbar puncture? what are the contraindications?

Answer 31

• unstable patient with cardiovascular or respiratory instability
• localized skin/soft tissue infection over puncture site.
• evidence of unstable bleeding disorder. P;latelets<50,000 or clotting factor deficiency
• increase ICP (do a ct scan)
• neuro deterioration can occur if LP bellow level of spinal complete spinal subarachnoid block.

Question 32

Sure for lumbar puncture?

Answer 32

L3-L4 or L4-L5

Question 33

Complication of a lumbar puncture?

Answer 33

headache, apnea, back pain, bleeding or fluid leek around spinal cord
infection, pain, hematoma, subarachnoid epidermal cyst, ocular muscle palsy, nerve trauma, brainstem herniation

Question 34

What his the most common complication of a lumbar puncture?

Answer 34

Spinal headache

Question 35

RF of a spinal headache>

Answer 35

female, age 18-30, lower BMI, hx of HA, prior spinal HA

Bilateral HA, improves when supine
Can last hours to weeks
Supine position for at least 2 hours 
Hydration
Caffeine either PO or IV
Epidural blood patch

Question 36

spinal headache prevention?

Answer 36

Can avoid by:
Passing needle bevel parallel to longitudinal fibers of dura
Replacing stylet before removing needle
Using small diameter needles
Using atraumatic needles
Bed rest or PO intake after LP does not reduce incidence of headache

Question 37

What does nerve root trauma/irritation? Treatment?

Answer 37

can feel electric shocks or dyesthesias. Back pain can persist for months: consider disc herniation.
rarely permanent
withdraw needle immediately.
If pain or motor weakness persists, start corticosteroids.
Electromyogram/ nerve conduction velocity studies should be scheduled off pain persists