Hydrocephalus Dr Inas A Saad Professor of PediatricsCairo

Hydrocephalus Dr. Inas A. Saad Professor of Pediatrics-Cairo University

Cerebro-spinal fluid �CSF volume: ØInfants=50 cc ØAdults = 150 cc �CSF: ØSecretion: Choroid plexus ØAbsorption: subarachnoid space by the villi

CSF circulation lateral ventricles--> foramen of Monro third ventricle --> aqueduct of Sylvius --> fourth ventricle --> foramina of Magendie and Luschka -> subarachnoid space over brain and spinal cord --> re-absorption into venous sinus blood via arachnoid granulations.

CSF circulation

Hydrocephalus Dilatation of the ventricular system due to imbalance between production and absorption of CSF with or without concomitant increase in CSF pressure

Classification �Obstructive: ventricular dilatation proximal to the obstruction �Communicating: All ventricles are dilated

Etiology Congenital Obstructive Communicating Aqueductal stenosis Arnold-Chiari malformation (Genetic, TORCH, Hge or Tumor) Dandy-Walker malformation Vein of Galen malformation Traumatic Intra-ventricular Hge Subarachnoid Hge Inflammatory Post-meningitic gliosis Neoplastic Posterior fossa tumor Leukemia (mtastatic deposits Others Brain abscess Choroid plexus papilloma

�Dandy-Walker malformation: Ø Obstruction of Foramina of Magendie & Lushka. Ø Cystic expansion of 4 th ventricle. �Arnold-Chiari malformation: Ø Downward displacement of vermis, pons & medulla into cervical canal Ø Obstruction of subarachnoid space around brain-stem Ø Associated with meningocele or myelomeningocele

Inraventricular hge Arnold-Chiari malformation

Clinical picture � In infants: Ø Macrocephally & progressive increase of HC. Ø Wide bulging anterior fontanelle with separated sutures. Ø Stretched shiny scalp skin with dilated veins. Ø Sunset eyes. Ø Prominent forehead & globular face. Ø Late: manifestation of increased ICT

Hydrocephalus in infant

Neurological examination �Delayed mental & motor milestones �Hypertonia �Weakness or paralysis �Hyper-reflexia + pathological reflexes �Optic atrophy (late)

Clinical picture �After partial sutures closure: �Prominent manifestation of increased ICT. �Head enlargement (less prominent). �Same neurological manifestation

Investigations �X-ray: craniofacial disproportion & sutures separation, silver-beaten appearance (older) �Cranial US: before suture closure �CT & MRI: diagnostic �Investigate cause.

Differential diagnosis Causes of macrocephaly: Cranial (skeletal) : {chronic hemolytic anemia, rickets, Achondroplasia and familial} Intracranial: subdural hematoma or effusion and brain tumors}

Treatment �Medical: �Surgical: Acetazolmide Shunt : V-P, V-A or external