Neuro: Hydrocephalus

Question 1

What is Hydrocephalus?

Answer 1

It is the excess build up of cerebro-spinal fluid within the intracranial space leading to dialtion andventricles, causing increased intracranial presure.

Question 2

What are the two distinctions of Hydrocephalus?

Answer 2

Communicating hydrocephalus

and

Non communicating hydrocephalus

Question 3

What is the pathology of communicating hyrdocephalus.

Answer 3

It starts with problem with reabsorbtion. There is a higher production to reabsorption. (overproduction)

also known as non-obstructive hydrocephalus, is caused by impaired cerebrospinal fluid reabsorption in the absence of any CSF-flow obstruction between the ventricles and subarachnoid space.

Question 4

What is the cause of the overproduction of the CSF that leads to Communicating hydracephalus?

Answer 4

due to functional impairment of the arachnoidal granulations (also called arachnoid granulations or Pacchioni’s granulations), which are located along the superior sagittal sinus and is the site of cerebrospinal fluid reabsorption back into the venous system.

Example is Choroid Plexus Papillomas (grade 1 lesion)

Question 5

What is the signs and symptoms of communicating hydrocephalus in a child whose sutures have not yet fused.

Answer 5

there is disproportional increase in head circumference compared to the rest of the face/body, causing a Failure to thrive.

Question 6

What causes the sighs and symptoms of hydrocephalus in children with fused sutures and adults?

Answer 6

The increased intracranial pressure

Question 7

What is the signs and symptoms of adults with communicating hydrocephalus?

Answer 7

Papilledema

Headache

Nausea/vomiting

Up gaze difficulty

gait disturbance

Question 8

What is the etiology of communicating hydrocephalus?

Answer 8

Infection
Subarachnoid haemorrhage s
Post-operative side effects
Head trauma’s

Question 9

What infection has a high incidence of hydrocephalus?

Answer 9

Meningitis

Question 10

How does subarachnoid haemorrhage lead to acute communicating hydrocephalus.

Answer 10

blood breakdown products cause scarring of arachnoid granulations.

Question 11

Why would acute communicating hydrocephalus, which is where the CSF reabsorption is significantly and suddenly reduced presented as an emergency?

Answer 11

Since it causes neurological decline very rapidly.

Question 12

What can be seen in emergency communicating hydrocephalus?

Answer 12

Patients presents being asleep

Question 13

What occurs in non communicating hydrocephalus?

Answer 13

Occurs whenever there is any physical obstruction to normal flow of CSF before it leaves the ventricles. It can come acutely as results from CSf flow obstruction at any point in the intra-ventricular pathway.

Question 14

The 4 different routes of Non communicating Hydracephalus.

Answer 14

Foramen of Monro obstruction may lead to dilation of one or, if large enough (e.g., in colloid cyst), both lateral ventricles.

The aqueduct of Sylvius, normally narrow to begin with, may be obstructed by a number of genetically or acquired lesions (e.g., atresia, ependymitis, hemorrhage, tumor) and lead to dilation of both lateral ventricles as well as the third ventricle.

Fourth ventricle obstruction will lead to dilatation of the aqueduct as well as the lateral and third ventricles (e.g., Chiari malformation).

The foramina of Luschka and foramen of Magendie may be obstructed due to congenital malformation (e.g., Dandy-Walker malformation).

Question 15

How is Hydracephalos investigated?

Answer 15

Radiography
CT/MR

Question 16

What are the early signs seen in radiography of hydrocephalus?

Answer 16

Dialation of the temporal horns of the Lateral Ventricles.

Question 17

What can be seen in radiography of hydrocephalus?

Answer 17

Third ventricle becomes ballooned

Lateral ventricle size increases

Peripheral sulci erased (enclosure)

Question 18

What diagnostic techniques shows ventriculmomegaly has occurred in a radiography of hydrocephalus?

Answer 18

Evans ratio - the ratio of the maximum width of the anterior horns of the lateral ventricles to the maximum width of the calvarium at the same level of the foramen mono

if greater than 0.3 `(30%) = venticulomegaly

Question 19

What is the surgical treatment for emergency acute hydrocephalus?

Answer 19

External ventricular drain

Question 20

What is the problems with external ventricular drain?

Answer 20

Cannot be maintained indefinitely

Some patients unable to tolerate weaning/clamping of EVD prior to removal

Infection risk is high

Question 21

What is the treatment of communicating hydrocephalus?

Answer 21

Shunt placement: It involves the placement of a ventricular catheter (a tube made of silastic) into the cerebral ventricles to bypass the flow obstruction/malfunctioning arachnoidal granulations and drain the excess fluid into other body cavities, from where it can be resorbed.

• ventriculoperitoneal
• lumbar peritoneal
• ventriculoatrial (if peritoneal failure)

Question 22

When would patients be given a permanent shunt placement?

Answer 22

If patient cannot tolerate EVD or weeks or months after EVD if needed.

Question 23

What is the most frequent shunt?

Answer 23

Ventroperitoneal is most used.

Question 24

What is the problem with lumbar peritoneal drainage.

Answer 24

Overdrainage

Question 25

The indecent of shunt failure is high, what is the common causes?

Answer 25

Mechanical failure from occlusion, disconnection migration

Overdrainage/underdrainage,

Infection and skin erosion

Question 26

What is a sign of shunt failure?

Answer 26

Ist sign is Headache

Question 27

What is the three treatment options for non communicating hydrocephalus?

Answer 27

1. Removal of obstructive lesson
2. Shunt placement
3. Third ventriculostomy: a surgical procedure for treatment of hydrocephalus in which an opening is created in the floor of the third ventricle using an endoscope placed within the ventricular system through a burr hole. This allows the cerebrospinal fluid to flow directly to the basal cisterns, bypassing the obstruction.

Question 28

What is often performed in junction with third ventriculostomy?

Answer 28

Ventriculoperitoneal shunt

Question 29

What is a rare preventable and/or reversible cause of dementia?

Answer 29

Non pressure hydrocephalus

Question 30

What is the classic triad of non pressure hydrocephalus?

Answer 30

WET- Urinary incontinence

WOBBY - Gait disturbance (wide stance, short and shuffle steps)

WACKY - rather quickly progressive dementia

Question 31

What are the 4 investigation of non pressure hydrocephalus?

Answer 31

CT/MRI

Gait assessment

Mini-mental state examination

Lumpar puncture

Question 32

What occurs with lumbar puncture and normal pressure hydrocephalus?

Answer 32

Symptoms improve with CSF removal

Question 33

what is the order of improvement in symptoms in the treatment of non pressure hydrocephalus?

Answer 33

Most likely symptoms to improve Gait > incontinence> memory

Question 34

Why is it important to have an early diagnosis of non pressure hydrocephalus?

Answer 34

Chance of outcome is improved if symptoms have been present for shorter periods of time so failure to recognise delays treatment and lessens their chances.

Question 35

What is non pressure hydrocephalus usually diagnosed as and how is this a problem?

Answer 35

Many patients with NPH to be diagnosed with alzheimers or age related dementia. therefore never seek treatment. Due to signs not always obvious.