Hydrocephalus

Question 1

What is hydrocephalus

Answer 1

Excess CSF in the intracranial and intraventricular spaces causing dilatation of the ventricles (ventriculomegaly) superior to obstruction
Due to imbalance between absorption and production

Question 2

What causes absorption of CSF

Answer 2

Passive process by conc gradient so if raised ICP it is disrupted by arachnoid granulations in venous sinus

Question 3

What causes CSF production

Answer 3

Metabolically active process produced by ependymal cells in choroid plexus

Question 4

What affects CSF production

Answer 4

Acidosis
Altitude
Carbonic anhydrase inhibitor drugs

Question 5

What are the non-obstructive / communicating causes of hydrocephalus

Answer 5

Production > resorption
Choroid plexus papilloma = very rare 
Arnold chiairi malformation
Tiny trauma blocks granulations 
Infection - meningitis 
SAH 
Post-op
Trauma 
Drugs

Question 6

What are the obstructive causes of hydrocephalus

Answer 6

Aqueduct stenosis (children) 
Tumours - gradual onset 
Cysts 
Infection
Haemorrhage 
Spina-bifida

Question 7

What are the symptoms in children

Answer 7

Increase in head circumference
Bulging / tense anterior fontanelle 
Failure to thrive 
Frontal bottling
Venous scalp distention
Parinaud syndrome - can't look up
Bradycardia
Seizure

Question 8

What are the symptoms in adults

Answer 8

Raised ICP 
Headache - worse lying down / Valsalva 
N+V
Papilloedema 
Gait disturbance 
6th nerve palsy
Up gaze difficulty 
Coma if severe

Question 9

How do you Dx hydrocephalus

Answer 9

CT head = 1st line
MRI to look in more detail
LP = therepatuic and diagnostic as will reduce pressure

Question 10

When is LP CI

Answer 10

In obstructing hydrocephalus as difference in brain and spinal pressure will cause herniation

Question 11

How do you treat communicating hydrocephalus

Answer 11

Shunt
Ventriculo-peritoneal most common
Ventriculo-atrial if peritoneal failure

Question 12

How do you treat NCH

Answer 12

Remove obstructing lesion

Shunt

Question 13

What are causes shunt malfunction

Answer 13

Skin erosion
Infection
Mecahincal failure
50% will fail in 5 years

Question 14

How do you treat acute hydrocephalus and where

Answer 14

EMERGENCY
External ventricular drain into R lateral ventricle
Huge infection risk

Question 15

What are symptoms of shunt malfunction

Answer 15

Return of original symptoms

Question 16

How much CSF is produced by choroid plexus

Answer 16

500ml

Question 17

What is the approx volume in brain

Answer 17

150ml

Question 18

What is the composition

Answer 18

Glucose - look for this to make sure CSF
Protein
WCC

Question 19

How does CSF circulate

Answer 19

Lateral ventricle
Through foramen of munro
3rd ventricle
Through cerebral aqueduct
4th formane
Through foramen of Magendie / Luscka
Into Subarachnoid space
Reabsorbed

Question 20

What are Arnold chair malformation

Answer 20

Congenital
Acquired through trauma
Cause downward displacement of herniation of cerebellar tonsil through Forman magnum

Question 21

What are the symptoms

Answer 21

NCH
Headache
Synringomyelia (fluid filled cyst within spinal cord)

Question 22

What causes normal pressure hydrocephalus

Answer 22

Secondary to reduced reabsorption at arachnoid villi
Head injury
SAH
Meningitis

Question 23

What are the Sx of normal pressure hydrocephalus

Answer 23

Urinary incontinence
Gait disturbance - wide stance / short shuffle
Quickly progressive dementia

Question 24

How do you Dx

Answer 24

CT / MRI
LP
Gait assessment / MMSE

Question 25

How do you Rx

Answer 25

Programmable VP shunt to change pressure | Gait improves the most then incontinence then memory

Question 26

Complications of shunt

Answer 26

Infection Haemorrhage Seizure

Question 27

What should CSF be on removal

Answer 27

Clear Colourless Opening pressure Glucose, protein and WCC within normal levels

Question 28

Infection

Answer 28

Low glucose

Question 29

GBS

Answer 29

High protein

Question 30

Inflammation

Answer 30

High WCC

Question 31

Bacterial Menignitis

Answer 31

High opening High neutrophil Low glucose

Question 32

Encephalitis / viral

Answer 32

High opening High WCC Normal glucose

Question 33

Lyme's / syphillis

Answer 33

High WCC

Question 34

How do you do LP

Answer 34

Cleanse iodine Anaethetize area 22 gauge needle Pop indicates punctured dura

Question 35

Where do you inset needle

Answer 35

L3/4

Question 36

What position of patient

Answer 36

Lateral debiscus

Question 37

Where does CSF lie

Answer 37

Space between Pia and arachnoid matter

Question 38

What are each tubes for

Answer 38

``` 1 = gram stain and culture 2 = glucose and protein 3 = cell count and differential ```

Question 39

What do you do if procedure fails

Answer 39

USS guided

Question 40

What are indications

Answer 40

Meningitis SAH Malignancy Intracranial hypertension

Question 41

What are CI

Answer 41

``` Unstable SKin infection Bleeding disorder Increased ICP Chiairi malformation ```

Question 42

What are complications

Answer 42

``` Spinal headache Apnoea Back pain Infection Cyst Haemorrhage Nerve root trauma ```

Question 43

What are symptoms of spinal headache

Answer 43

Bilateral Improves supine Typically young female with low BMI

Question 44

How do you treat

Answer 44

IV saline IV caffieine Epidural blood patch

Question 45

What are the symptoms of nerve root trauma

Answer 45

``` Electric shock Back pain Altered mental status CN abnormality Cushings - Brady / hypertension / irregular breathing ```

Question 46

How do you treat

Answer 46

``` Immediately remove needle Raise head to increase venous return Mannitol Intubate Corticosteroid Nerve conduction study ```