Sruthy Sunny, M.Sc.Nursing

1. Hydrocephalus

2. •It is an excessive accumulation of CSF in the ventricles and
subarachnoid space of the brain.
• Hydrocephalus is commonly called “water on the brain.”
•It is a combination of the Greek word “hydro,” ---water and
“cephalus” --- head.

3. What is CSF?
• CSF looks like water, but it contains proteins, electrolytes, and nutrients
that help to keep brain healthy.
• The most important purpose of CSF is to cushion brain and spinal cord
against injury.
• Brain produces 20 ml of CSF per hour and 3-4 lit per day.
• It circulates through a network of tiny passageways in brain, and
ultimately into blood stream where it is absorbed by body.

4. Overview of CSF production
• The choroid plexuses are the
source of approximately 80% of
the CSF
• The blood vessels in the
subependymal regions, and pia
also contribute to the formation
of CSF

5. CSF circulation
Choroid plexus of lateral ventricles
Foramen Monro
Third ventricle
Aqueduct of sylvie
Fourth Ventricle
Foramen of Magendie and
Luschka
Subarachinoid space

6. CSF pressure
• Normal intracranial pressure (ICP) in
an adult is between 2-8 mmHg.
• Levels up to 16 mmHg are considered
normal
• ICP higher than 40 mmHg or lower BP
may combine to cause ischemic
damage

7. ETIOLOGY
• 1. Over production of CSF by choroid plexus
--- Tumor
--- Inflammation
• 2. Obstruction in the passage of CSF
--- Congenital atresia / narrow aqueduct of sylvius
--- Infections – meningitis, encephalitis
--- Tumor / haemorrhage / adhesion
• 3. Inadequate absorption of CSF
--- In extensive subarachinoid haemorrhage

8. CLASSIFICATIONS
I. a. Communicating / Non- Obstructive Hydrocephalus
No blockage between ventricular system,basal cisterns & spinal
arachinoid space.
It is due to --- failure in absorption of CSF. eg. Cavernous sinus thrombosis
--- over production of CSF. eg. choroid plexus papilloma,
pseudotumor of cerebri
b. Non- Communitcating / Obstructive Hydrocephalus
Blockage at any level of CSF pathway
It is due to --- obstructive lesion / inflammation
Obstruction ------- partial
------- intermittent
------- complete

9. • II. A. Congenital Hydrocephalus
Causes:
Intrauterine infection ( TORCH )
Congenital malformation – aqueduct stenosis
Dandy walker syndrome – Congenital septa /membrane block the forth
ventricle outlet
Arnold – chiari malformation – displacement of the brain stem and
cerebellum into upper cervical part of spine through foramen magnum

10. • b. Acquired Hydrocephalus
Causes
Inflammatory meningitis / encephalitis
Traumatic birth injury / head injury/ ICH
ICSOL- tuberculoma, abscess,glioma
Connective tissue disorder

11. PATHOPHYSIOLOGY
Non- communitating hydrocephalus communitating hydrocephalus
Blockage in between the ventricular & increased production / poor
Subarachnoid space absorption of CSF
Interference with the CSF circulation

12. Dilation of ventricles & compression of brain tissue
Enlargement of skull
Increased ICP

13. CLINICAL MANIFESTATIONS
Newborns & Infants
oLarge skull with separated sutures
oAnt fontanel – intense & bulged
oThinning of skull bones
oMacewen sign – cracked pot sound on
percussion
Infants ( later) –
ounequal response to light
oSun setting eyes – visible sclera above iris
oFrontal bossing, sluggish pupils, depressed
eye
Infants ( in general )
• Irritability, shrill ,high pitch cry
• Lethargy, opisthotonos
• Persistent early infantile reflexes
• Change in LOC
• Vomiting
• Lower extremity spasticity
• Difficulty in sucking & feeding

14. Older children
Headache on awakening
Papilledema
Strabismus
Ataxia
Irritability
Lethargy
Confusion
Apathy
Incontinence
Vomiting
Signs of increased ICP & meningeal irritation
Sun setting sign

15. DIAGNOSIS
• History collection & physical examination
• EEG
• CT & MRI
• X- ray
• Pneumoencephalography
• Ophthalmoscopy
• CSF analysis

16. MANAGEMENT
Pharmacological management
Acetazolamide – 50 mg/kg/day ( to decrease CSF production )
Oral glycerol & isosorbide
Antibiotics
Surgical management
Removal of obstruction in CSF flow
Ventriculostomy- destruction of portion of choroid plexus
Shunting of CSF from ventricle to another normal site in CSF pathway
Shunting of CSF from ventricle to an area outside CNS system

17. Types of extra cranial shunts
1. Ventriculoperitoneal shunt –
Common
Through a burr hole in the skull ventricular catheter is inserted into ant.
Portion of lateral ventricle.
A valve unit is tested & attached to the catheter.
An incision is made in the abdomen & through the rectus muscle in to the
peritoneum.
Here CSF is absorbed by tissues in the abdominal cavity

18. 2. Ventriculoatrial shunt
Catheter from lateral ventricle to RA of heart
Here CSF drains into circulating blood.
3. Ventriculoureter shunt
Here CSF drains through ureter & into the urinary bladder
Used in older children / if other two methods fails.
4. Ventriculopleural shunt
Here CSF drains into the pleural cavity.

19. NURSING MANAGEMENT
Preoperative
Assess for any signs of
increased ICP
Monitor head circumference
Assess vital signs frequently
Assess for any signs of
dehydration
Postoperative
Assess vital signs every 15 – 30
mints & monitor I/O chart.
Administer oxygen
Position-bed head elevation 15- 300
Assess for any signs of increased ICP
Assess for LOC & pupillary reactions
Assess patency of the shunt
Assess the nutritional status of the
child
Assess for any complications

20. • Than you