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HYDROCEPHALUS CASE STUDY

Guided by:
Asso. Prof. V. Suganya

Ms. J. Saraswathi, 50% of children with communicating hydrocephalus.

st
1 Year M.Sc (N) Incidence is equal in males and females. Incidence of
Dept. of CHN, human hydrocephalus presents a bimodal age curve;
Narayana College of Nursing, one peak occurs in infancy and is related to the various
Chinthareddypalem, Nellore. fo rms of congenital malformations. Adult
hydrocephalus represents approximately 40% of total
Abstract: Hydrocaphalery is a collection of excessive cases of hydrocephalus.
cerebronspinal fluid. The child presented with the CASE REPORT:
complaints of feeding unable to recognize the parents, Master. Naveed 10 years old boy was admitted in
decreased activity, severe head ache. sunset eyes. The the paediatric ward in the hospital with complaints of
patient undergone ventiliculoperitioneal shunt. poor feeding, unable to recognize the parents,
INTRODUCTION: decreased activity, sunset eye sevear head ache and
Hydrocephalus affects hundreds of thousands diagnosed as congenital hydrocephalus.
of Americans, in every stage of life, from infants to DIAGNOSIS:
the elderly. The term hydrocephalus is derived from  CT scan brain plain: scans have shown that
two words: “hydro,” meaning water, and “cephalus,” cerebrospinal fluid (CSF) is at a higher level than
referring to the head. Hydrocephalus can be defined usual.
broadly as a disturbance of cerebrospinal fluid (CSF)  MRI brain: Which shows ventricles in the brain
formation, flow, or absorption, leading to an increase become blocked or narrowed angle of the frontal
in volume occupied by this fluid in the central nervous horns on coronal view, downward bowing of the floor
system. This condition could also be termed a of the third ventricle, elevation of the corpus callosum.
hydrodynamic CSF disorder.  CSF analysis: protein concentration 6 g/l.
DEFINITION: DISCUSSION:
Hydrocephalus is a condition characterized by an Causes: Congenital abnormalities.
excess of cerebrospinal fluid (CSF) within the CLASSIFICATION:
ventricular and subarachnoid spaces of the cranial There are two types of hydrocephalus:
cavity. 1. Non-communicating: In the non-communicating
Need for the study type of congenital hydrocephalus, an obstruction
Hydrocephalus cases are affecting the entire occurs in the free circulation of CSF.
world every day. 2. Communicating: In the communicating type of
The incidence of congenital hydrocephalus is hydrocephalus, no obstruction of the free flow of the
3 per 1, 000 live births; the incidence of acquired CSF exists between the ventricles and the spinal theca;
hydrocephalus is not known exactly due to the variety rather, the condition is caused by defective absorption
of disorders that may cause it. Incidence of acquired of CSF, thus causing increased pressure on the brain
hydrocephalus is unknown. Shunt dependence occurs or spinal cord.
in 75% of all cases of treated hydrocephalus and in 3. Congenital hydrocephalus: Co ngenit al

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hydrocephalus is present in babies when they’re born babies born prematurely (before week 37 of the
and can be caused by birth defects, such as spine bifida, pregnancy). Some premature babies experience
or as a result of an infection that the mother develops bleeding in their brain, which can block the flow of
during pregnancy, such as mumps or rubella (German cerebrospinal fluid and cause hydrocephalus.
measles). It’s estimated that spine bifida affects one Other possible causes of congenital hydrocephalus
baby in every 1,000 born in Ireland. Most of them include:
will have hydrocephalus.  X-linked hydrocephalus - where the condition
Congenital hydrocephalus carries the risk of long-term occurs as a result of a mutation (change in the genetic
mental and physical disabilities as a result of permanent material) of the X chromosome.
brain damage.  rare genetic disorders, such as Dandy Walker
4. Acquired hydrocephalus: Acquired hydrocephalus malformation.
can affect children or adults. It usually develops after  arachnoid cysts - fluid filled sacs located between
an injury or illness. For example, it may occur after a the brain or spinal cord and the arachnoid membrane,
serious head injury or as a complication of a medical which is one of the three membranes surrounding the
condition, such as a brain tumour. brain and spinal cord
5. Normal pressure hydrocephalus: N o r m a l In many cases of congenital hydrocephalus,
pressure hydrocephalus (NPH) is a poorly understood the cause is unknown. This is medically referred to as
condition that usually affects people over 50 years idiopathic.
old. 3. Acquired hydrocephalus Hydrocephalus that
It can sometimes develop after an injury or a develo ps in adults or children (acquired
stroke, but in most cases the cause is unknown. The hydrocephalus) is usually the result of an injury or
average age of people with NPH is 75. illness that causes a blockage between the ventricles
CAUSES: of the brain.
1. Cerebrospinal fluid and the brain Possible causes of acquired hydrocephalus include:
Hydrocephalus can develop if:  bleeding inside the brain - for example, if blood
 There’s a blockage in one of the ventricles so that leaks out of blood vessels over the surface of the brain
excess fluid can’t move out of the brain. (subarachnoid haemorrhage).
 There’s a problem with the arachnoid villi so that  blood clots inside the blood vessels in the brain
fluid is unable to filter into the blood vessels. (venous thrombosis).
 The brain starts to produce too much cerebrospinal  meningitis - an infection of the protective
fluid. membranes that surround the brain and spinal cord
2. Congenital hydrocephalus  brain tumours
Congenital hydrocephalus, where a baby is  head injury
born with the condition, may be the result of a brain It’s also possible for someone to be born with
defect that restricts the flow of cerebrospinal fluid. narrowed passage ways in their brain that restrict the
For example, the passages that connect the ventricles flow of cerebrospinal fluid, but don’t cause any
in the brain become blocked or narrowed. symptoms until years later.
These defects in the development of the brain 4. Normal pressure hydrocephalus
can be caused by health conditions known to cause Hydrocephalus that develops in older people
birth defects. For example, most children born with (normal pressure hydrocephalus or NPH) can occur
the most serious type of spine bifida will develop after a brain injury, bleeding in the brain or infection.
hydrocephalus. However, in most cases, there’s no clear reason why
Congenital hydrocephalus can also occur in the condition occurs.

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There are several theories to explain what CLINICAL MANIFESTATIONS:
happens to the brain in cases of NPH. Some are Clinical features of hydrocephalus are
outlined below. influenced by the patient’s age, the cause of the
5. Problems with the arachnoid villi, one idea is that hydrocephalus, the location of the obstruction, its
NPH occurs when something goes wrong with the duration, and its rapidity of onset.
arachnoid villi, which is the layer of tissue that allows  Poor feeding: The infant with hydrocephalus has
cerebrospinal fluid to filter into the blood vessels. This trouble in feeding due to the difficulty of his condition.
means that the blood vessels don’t reabsorb the fluid.  Large head: An excessively large head at birth is
This creates a gradual increase in pressure, which can suggestive of hydrocephalus.
cause progressive brain damage.  Bulging of the anterior fontanels: The anterior
6. Underlying health conditions: NPH may be fontanel becomes tense and bulging, the skull enlarges
caused by underlying health conditions that affect the in all diameters, and the scalp becomes shiny and its
normal flow of blood. For example, diabetes, heart veins dilate.
disease or having a high level of cholesterol in the  Setting sun sign: If pressure continues to increase
blood. without intervention, the eyes appear to be pushed
The exact cause is unknown, but conditions downward slightly with the sclera visible above the
that affect blood vessels within the brain or that supply iris- the so-called setting sun sign.
blood to the brain (cerebrovascular disease) may be  High-pitched cry: The intracranial pressure may
linked to NPH. increase and the infant’s cry could become high-
PATHOPHYSIOLOGY: pitched.
Normally, a delicate balance exists between the rate of  Irritability: Irritability is also caused by an increase
formation and absorption of CSF. in the intracranial pressure.
  Projectile vomiting: An increase in the intracranial
In hydrocephalus, this balance is disturbed. pressure can cause projectile vomiting.
 Urinary symptoms
CSF is formed mainly in the lateral ventricles by the choroid The change in the way that you walk is often followed
plexus and is absorbed into the venous system through the by bouts of urinary incontinence, which may include
aarachnoid villi. symptoms such as:
  a frequent need to urinate
CSF circulates within the ventricles and the subarachnoid  an urgent need to urinate
space.  loss of bladder control
 Mental abilities
An obstruction may occur in the free circulation of CSF; this The normal thinking process also starts to slow down.
blockage causes increased pressure on the brain or spinal This can take the form of:
cord.  being slow to respond to questions
  reacting slowly to situations
The site of obstruction may be at the foramen of Monro, the  being slow to process information.
aqueduct of Sylvius, the foramen of Luschka, or the foramen Other symptoms of acquired hydrocephalus include:
of Magendie.  neck pain
  feeling sick
If there is no obstruction, the condition may be caused by  being sick - which may be worse in the morning
defective absorption of CSF, thus causing increased pressure  drowsiness, which can progress to a coma
on the brain or spinal cord.  changes in your mental state, such as confusion

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 blurred vision or double vision 7. Radionuclide cisternography (in NPH). To
 difficulty walking assess the prognosis with regard to possible shunting-
 not being able to control your bladder and in some however, due to its poor sensitivity in predicting shunt
cases, bowel incontinence response when the ventricular to total intracranial
ASSESSMENT AND DIAGNOSTIC FINDINGS: activity (V/T) ratio is less than 32%, this test is no
Examination in infants may include the following: longer commonly used.
CT scan of the brain with hydrocephalus. Black areas 8. ICP monitoring/CSF infusion studies ICP
in the middle of the brain are abnormally large and monitoring and CSF infusion studies are now being
filled with fluid. used more frequently in young patients with mild
1. Computed tomography (CT) scanning. CT scan symptoms and older patients with possible low grade
is used to assess a computerised tomographic (CT) hydrocephalus. ICP monitoring may reveal “B waves”
scan should be undertaken to assess the overall size either at night time alone or throughout the day and
of the ventricles, and to determine if periventricular night. An ICP above 15 mm Hg at frequent intervals
oedema or “lucency” is present. A CT scan is also during the night or day while asleep or resting is
useful to assess the size of the fourth ventricle - if abnormal, and patients with functioning shunts should
large, this suggests a communicating hydrocephalus, normally have an ICP below or near to zero while
whereas a relatively small fourth ventricle implies 45° head up in bed and scans have shown that
obstructive hydrocephalus that might be best treated cerebrospinal fluid (CSF) is at a higher level than
by endoscopic third ventriculostomy rather than a usual.
ventriculo-peritoneal shunt. the size of ventricles and MEDICAL MANAGEMENT:
other structures. The goal of treatment in client s with
2. Magnetic resonance imaging (MRI). MRI is used hydrocephalus is to reduce or prevent brain damage
to assess for Chiari malformation or cerebella or by improving the flow of CSF which may include
periaqueductal tumors. surgery to provide shunting for drainage of the excess
3. Ultrasonography through anterior fontanel in fluid from the ventricles to an extracranial space such
infants. This study assesses for subependymal and as the peritoneum or right atrium (in older children)
intra ventricular hemorrhage; to follow infants for or management with medications to reduce ICP if
possible progressive hydrocephalus. progression is slow or surgery is contraindicated.
4. Skull radiography. To detect erosion of sella Pharmacologic Therapy
turcica, or “beaten copper cranium” or “beaten silver The following medications are used t o treat
cranium” - the latt er can also be seen in hydrocephalus.
craniosynostosis; (after shunt insertion) to confirm Diuretics: Acetazolamide (ACZ) and furosemide
correct positioning of installed hardware. (FUR) treat post hemorrhagic hydrocephalus in
5. MRI cine. To measure CSF stroke volume (SV) in neonates; both are diuretics that also appear to
the cerebral aqueduct; however, such measurements decrease secretion of CSF at the level of the choroid
don’t appear to be useful in predicting response to plexus.
shunting. Anticonvulsants: Helps to interfere impulse
6. Diffusion tensor imaging (DTI). To detect transmission of cerebral cortex and prevent seizures.
differences in fractional anisotropy and mean Antibiotics: Culture and sensitivity dependent for
diffusivity of the brain parenchyma surrounding the shunt infections such as septicemia, ventriculitis,
ventricles; allows recognition of microstructural meningitis, or given as a prophylactic treatment.
changes in periventricular white matter region that Surgical Management
may be too subtle on conventional MRI. Surgical intervention is the only effective means of

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relieving brain pressure and preventing additional Recent shunt operation, 90% of VP shunt infections
damage to the brain tissue. present within three months of a shunt operation,
1. Surgery: Surgical treatment is the preferred Raised C reactive protein, High peripheral and CSF
therapeutic option in patients with hydrocephalus. white cell count, Culture of organism from CSF.
2. Ventriculoperitoneal (VP) shunt: A Over-drainage: The perfect shunt valve has yet to
ventriculoperitoneal (VP) shunt is a medical device be designed and many current models allow over-
that relieves pressure on the brain caused by fluid drainage of CSF due to the siphoning effect. The
accumulation. hydrostatic pressure (25-75 cm CSF) caused by the
3. Ventriculoatrial (VA) shunt: Ventriculoatrial shunt weight of the column of CSF within the distal catheter
placement enables cerebrospinal fluid (CSF) to flow leads to fluid being sucked out of the ventricles in the
from the cerebral ventricular system to the atrium of upright position.
the heart. Subdural hematoma: can occur during the first six
4. Lumboperitoneal shunt: Only used for months after a shunt insertion and has been shown to
communicating hydrocephalus, CSF fistula, or be related to the amount of CSF released at operation.
pseudotumor cerebri. Small collections occur up to 30% of patients after
5. Torkildsen shunt: Effective only in acquired shunt insertion in the elderly, but symptomatic
obstructive hydrocephalus. collections requiring surgery affect only 10–15%. The
6. Ventriculopleural shunt (second-line therapy): symptoms of a shunt related subdural collection
COMPLICATIONS OF SHUNTING include headaches, confusion, hemiparesis, and
Shunt obstruction: Shunt obstruction may occur drowsiness.
proximally in the ventricular catheter as a result of NURSING MANAGEMENT: Managing a child
choroid plexus, red cells, tumour cells, or a high with hydrocephalus warrants skill and compassion for
protein concentration in the CSF. Blockage of the nurses and all the members of the healthcare team.
distal catheter can occur as a result of body growth Nursing Assessment: Accurate information is
(if the shunt was placed during childhood), adhesions essential in the assessment of the child with
within the abdominal cavity, especially when hydrocephalus.
associated with a low grade infection, pregnancy, and  Head circumference: Measurement of the
occasionally constipation. newborn‘s head is essential.
Infection: Shunt infections are usually caused by the  Neurologic and vital signs: Obtaining accurate
patient’s own skin organisms, which gain access to vital and neurologic signs is necessary before and after
shunt tubing during the shunt procedure. Typically surgery.
this contamination will cause an internal shunt  Check the fontanelles: If the fontanelles are not
colonisation where the bacteria settle and grow on closed, carefully observe them for any signs of bulging.
the internal wall of the shunt catheter and valve,  Monitor increase in intracranial pressure:
establishing adherent colonies. However, some Observe, report, and document all signs of ICP.
bacteria set up a ventriculitis without full colonisation  History taking: If the child has returned for
of the shunt, and others cause an external shunt revision of an existing shunt, obtain a complete history
infection (deep wound infection). before surgery from the family caregiver to provide a
The most important clinical features of a shunt baseline of the child’s behavior.
infection are as follows: NURSING DIAGNOSES:
General malaise, Pyrexia, Headaches, Based on the assessment data, the major nursing
vomiting, neck stiffness, Abdominal tenderness or diagnoses are:
distension, Recurrent lower end shunt obstruction, 1. Risk for Injury related to increased ICP:

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Interventions : to understand.
 Monitor the patient. 6. Deficient Knowledge related to the family’s
 Monitor the newborn‘s level of consciousness. understanding of the child’s condition and home
 Check the pupils for equality and reaction. care.
 Monitor the neurologic status, and observe for a  Demonstrate care of the shunt to the family
shrill cry, lethargy, or irritability. caregivers and have them perform a return
 Measure and record the head circumference daily. demonstration.
 Keep suction and oxygen equipment convenient at  Provide them with a list of signs and symptoms
the bedside. that should be reported, and discuss appropriate
2. Risk for Impaired Skin Integrity related to growth and development expectations for the child,
pressure from physical immobility. and stress realistic goals.
Interventions: REFERENCES:
 After a shunting procedure, keep the newborn‘s  Adams RD, Fisher CM, Hakim S, et al. Symptomatic
head turned away from the operative site until the occult hydrocephalus with ‘normal’ cerebrospinal fluid
physician allows a change in position. pressure N Engl J Med 1965;273:117–26. A landmark
 Reposition the newborn at least every 2 hours, as paper in the clinical assessment of hydrocephalus in the
permitted. older age group.
 Inspect the dressings over the shunt site immediately Google Scholar:
after the surgery, every hour for the first 3 to 4 hours,  Hebb AO, Cusimano MD. Idiopathic normal pressure
and then at least every 4 hours. hydrocephalus: a systematic review of diagnosis and
3. Risk for Infection related to the presence of a outcome. Neurosurgery 2001; 49:1166–86. A general
shunt. overview of diagnostic criteria and treatment of older
 Closely observe for and promptly report any signs patients with hydrocephalus.
of infection PubMed Web of ScienceGoogle Scholar
 Perform wound care thoroughly as ordered.  Boon AJ, Tans JT, Delwel EJ, et al. Dutch normal-
 Administer antibiotics as prescribed. pressure hydrocephalus study: prediction of outcome after
4. Risk for Delayed Growth and Development shunting by resistance to outflow of cerebrospinal fluid. J
related to impaired ability to achieve Neurosurg1997;87:687–93. An evaluation of the use of
developmental tasks. lumbar infusion tests in the diagnosis of active
Interventions: hydrocephalus in older adults. A widely quoted paper on
 The newborn needs social interaction and needs to the assessment of normal pressure hydrocephalus.
be talk. PubMed Web of ScienceGoogle Scholar
 Played with, and given the opportunity for activity.  Pople IK, Edwards RE, Aquilina C. Endoscopic
 Provide toys appropriate for his mental and physical management of hydrocephalus treatment. Neurosurg Clin
capacity. N Am2001; 12:719–35... .. An overview of current
5. Anxiety related to the family caregiver’s fear of endoscopic techniques in hydrocephalus treatment.
the surgical outcome. PubMedGoogle Scholar:
Interventions:  Drake JM, Kestle JR, Tuli S. CSF shunts 50 years on
 Explain to the family the condition and the anatomy – past, present and future. Childs Nervous System2000;
of the surgical procedure in terms they can understand. 16:800–4. A useful overview of ventricular shunts for
 Encourage them to express their anxieties and ask hydrocephalus.
questions.
 Give accurate, nontechnical answers that are easy

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