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Neurology- Clinical > Hydrocephalus > Flashcards

Hydrocephalus Flashcards

1
Q

What are the three different ways of classifying hydrocephalus?

A

Infantile or childhood/adult, acute or chronic, obstructive or communicating

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2
Q

What are the three causes of hydrocephalus?

A

Something obstructing the flow of CSF, a problem absorbing CSF, too much production of CSF

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3
Q

Describe obstructive hydrocephalus?

A

Hydrocephalus caused by something obstructing the flow of CSF e.g. a blockage in the ventricular system or outflow from the ventricular system

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4
Q

Describe communicating hydrocephalus?

A

Hydrocephalus caused by impaired CSF absorption by the arachnoid granulations

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5
Q

What can obstructive hydrocephalus also be known as? Why is this?

A

Non-communicating hydrocephalus, the CSF in the ventricles does not communicate with the CSF in the subarachnoid space

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6
Q

Hydrocephalus leads to intracranial accumulation of CSF which causes what?

A

Increased ventricular size and raised ICP

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7
Q

How does acute hydrocephalus present?

A

With features of raised ICP: patients develop acute headache with N+V as well as a deterioration in conscious level

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8
Q

What are some extra features of acute hydrocephalus?

A

Irritability in young children and ‘sunsetting’ eyes

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9
Q

What causes a sunsetting gaze?

A

Impairment of upward gaze caused by pressure on the midbrain vertical gaze centres

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10
Q

How does chronic hydrocephalus usually present?

A

Progressive deterioration in higher neurological functions and persistent pressure headache

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11
Q

What are some examples of deterioration in higher neurological function seen in chronic hydrocephalus that may be seen in children?

A

Failure to thrive, developmental delay, worsening school performance

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12
Q

Occasionally, congenital hydrocephalus can be picked up before birth on what investigation?

A

US scan

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13
Q

How may congenital hydrocephalus present?

A

Large head, thin and shiny scalp with visible veins, bulging or tense fontanelle, downward looking eyes

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14
Q

Why does congenital hydrocephalus cause an increase in head circumference?

A

Children < 18 months have skull bones that are still unfused to increased ICP causes the skull to enlarge

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15
Q

As well as the signs on the head, what are some more behavioural features that may be seen in congenital hydrocephalus?

A

Poor feeding, irritability, sleepiness, vomiting, muscle stiffness and spasms in the lower limbs

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16
Q

Some babies have a large head but do not have congenital hydrocephalus. When should you be concerned about this?

A

When the head circumference starts increasing centiles

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17
Q

Does congenital hydrocephalus go away?

A

No, it is usually a lifelong condition

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18
Q

Give an example of a vascular cause of hydrocephalus which is a) obstructive? b) communicating?

A

a) intracerebral haemorrhage b) subarachnoid haemorrhage

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19
Q

Give an example of an infective cause of hydrocephalus which is a) obstructive? b) communicating?

A

a) infective space occupying lesion e.g. abscess b) meningitis

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20
Q

Give an example of a tumour cause of hydrocephalus which is a) obstructive? b) communicating?

A

a) any tumour within or outside the ventricular system b) carcinomatous infiltration of the meninges

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21
Q

Congenital hydrocephalus is usually caused by what? Is this obstructive or communicating?

A

Stenosis of a part of the ventricular system, this is obstructive

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22
Q

What is the first line investigation for hydrocephalus?

A

CT

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23
Q

What will a CT show in obstructive hydrocephalus?

A

Dilation of the ventricle proximal to the site of obstruction

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24
Q

What will a CT show in communicating hydrocephalus?

A

Generalised dilatation of all ventricles

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25
Q

After a CT, further imaging for hydrocephalus may be done with what?

A

MRI

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26
Q

In neonates and infants with an open anterior fontanelle, what investigation can you use to monitor ventricular size?

A

Ultrasound

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27
Q

What is a ventriculoperitoneal shunt?

A

A catheter inserted into the ventricle to drain excess CSF into the peritoneum

28
Q

What % of valves on a VP shunt function well after insertion?

A

80%

29
Q

80% of valves on a VP shunt are no longer functioning after how long?

A

12 years

30
Q

What are 3 common complications of a VP shunt?

A

Overdrainage, underdrainage and infection

31
Q

What is the most common treatment option for hydrocephalus (assuming there is not an underlying cause to be treated)?

A

VP shunt

32
Q

Underdrainage of CSF from a shunt can be caused by what?

A

Blockage or a displaced catheter

33
Q

What can be used to reduce the risk of infection of a VP shunt?

A

Use of an antibiotic, impregnate the shunt with silver, use iodine

34
Q

What are some less common complications of a VP shunt?

A

Intracerebral haemorrhage, seizure, umbilical fistula, erosion into abdominal viscera, ascites, inguinal hernia

35
Q

What features may a blocked VP shunt present with?

A

Features of acute hydrocephalus: headache, vomiting, sunsetting gaze in children/lack of upgaze in adults, blurred vision

36
Q

Why is blurred vision a worrying sign of a blocked VP shunt?

A

Suggests papilloedema which precedes blindness and can be a rapid progression

37
Q

How do you investigate a blockage of a VP shunt?

A

Tap of the shunt or LP to send CSF to microbiology, CT head to show hydrocephalus

38
Q

How is an acute VP shunt blockage treated?

A

Urgent surgery to replace the shunt

39
Q

Aside from a VP shunt, what is another treatment that can be used for hydrocephalus?

A

Endoscopic 3rd ventriculostomy

40
Q

What is endoscopic 3rd ventriculostomy?

A

A minimally invasive technique where a hole is made in the floor of the 3rd ventricle, creating an alternative channel for CSF to flow through to reach the subarachnoid space to be absorbed

41
Q

If endoscopic 3rd ventriculostomy is successful, is a VP shunt needed?

A

No

42
Q

When is endoscopic 3rd ventriculostomy a useful treatment?

A

If there is an obstruction distal to the 3rd ventricle (e.g. aqueduct stenosis or compressing tumours)

43
Q

Is endoscopic 3rd ventriculostomy used for obstructive or communicating hydrocephalus?

A

Obstructive

44
Q

If the VP shunt is overdraining CSF this can lead to collapse of the ventricles and tearing of blood vessels. What can this lead to?

A

Headaches, haemorrhage (subdural haematoma) and slit ventricle syndrome (ventricles decrease in size until they are too small)

45
Q

What are some clinical features of normal pressure hydrocephalus?

A

Enlarged ventricles, normal or intermittently raised ICP, triad of ataxia, memory decline and incontinence

46
Q

Is there potential for NPH to respond to CSF diversion?

A

Yes, but this is not permanent

47
Q

NPH is a condition seen mostly (but not exclusively) in who?

A

Older age groups

48
Q

Why is the diagnosis of NPH especially important?

A

It is one of the few treatable causes of dementia

49
Q

What are some causes of NPH?

A

Primary (idiopathic) or secondary (post-inflammation) after meningitis, SAH, trauma or craniotomy

50
Q

What are some differentials of NPH?

A

Cerebellar pathology and myelopathy (ataxia) as well as Alzheimer’s and vascular dementia

51
Q

How may dementia as a result of NPH present?

A

Delay in answering questions, loss of spontaneity

52
Q

Dementia as a result of NPH may progress to what?

A

Akinetic mutism

53
Q

Does the dementia as a result of NPH stay the same all the time?

A

No, it fluctuates in severity

54
Q

What symptom of NPH is essential to the diagnosis and usually precedes all other symptoms?

A

Ataxia

55
Q

How can ataxia as a result of NPH present?

A

Difficulty rising from a chair, tendency to fall backwards, difficulties initiating gait, broad based shuffling gait

56
Q

When is suspicion of NPH raised?

A

When there is hydrocephalus in association with one or more of the classic triad

57
Q

What are some investigations that should be performed on all patients with suspected NPH?

A

CT, MRI, LP, infusion studies

58
Q

What is an infusion study?

A

Record baseline ICP for a period of time and then challenge absorptive mechanisms with an infusion of saline

59
Q

What would happen in an infusion study of a normal person?

A

After 10 minutes or so of the infusion, a new plateau is reached (usually within 10mmHg of the opening pressure) with a modest increase in pulse pressure

60
Q

What happens in an infusion study of someone with impaired CSF absorption?

A

Amplitude of the pressure wave and the mean pressure increase dramatically

61
Q

What are the 3 treatment options for NPH and how is the treatment decided?

A

VP shunt, LP shunt, endoscopic ventriculostomy: based on radiological appearance and patient preference

62
Q

What is the most likely treatment for NPH?

A

VP shunt

63
Q

How long do shunts last in NPH?

A

About a year

64
Q

How can you tell if a shunt is going to work for a patient with NPH?

A

‘Tap test’ or LP drain both pre and post CSF drainage - if there is an improvement these patients should be shunted

65
Q

What are some predictors of a poor outcome of treatment for NPH?

A

Pronounced dementia, secondary NPH

66
Q

What are some predictors of a good outcome of treatment for NPH?

A

Gait problems predominate, primary NPH

67
Q

With NPH treatment, some specific safeguarding is needed against what? How is this done?

A

Overdrainage and subdural haematoma formation; can be avoided with anti-syphon/adjustable pressure valve

Neurology- Clinical (31 decks)

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